Search

Background Balancing the control of SARS-CoV-2 transmission with the resumption of travel is a global priority. Current recommendations include mitigation measures before, during, and after travel. Pre- and post-travel strategies including symptom monitoring, antigen or nucleic acid amplification testing, and quarantine can be combined in multiple ways considering different trade-offs in feasibility, adherence, effectiveness, cost, and adverse consequences. Methods We used a mathematical model to analyze the expected effectiveness of symptom monitoring, testing, and quarantine under different estimates of the infectious period, test-positivity relative to time of infection, and test sensitivity to reduce the risk of transmission from infected travelers during and after travel. Results If infection occurs 0–7 days prior to travel, immediate isolation following symptom onset prior to or during travel reduces risk of transmission while traveling by 30–35%. Pre-departure testing can further reduce risk, with testing closer to the time of travel being optimal even if test sensitivity is lower than an earlier test. For example, testing on the day of departure can reduce risk while traveling by 44–72%. For transmission risk after travel with infection time up to 7 days prior to arrival at the destination, isolation based on symptom monitoring reduced introduction risk at the destination by 42–56%. A 14-day quarantine after arrival, without symptom monitoring or testing, can reduce post-travel risk by 96–100% on its own. However, a shorter quarantine of 7 days combined with symptom monitoring and a test on day 5–6 after arrival is also effective (97--100%) at reducing introduction risk and is less burdensome, which may improve adherence. Conclusions Quarantine is an effective measure to reduce SARS-CoV-2 transmission risk from travelers and can be enhanced by the addition of symptom monitoring and testing. Optimal test timing depends on the effectiveness of quarantine: with low adherence or no quarantine, optimal test timing is close to the time of arrival; with effective quarantine, testing a few days later optimizes sensitivity to detect those infected immediately before or while traveling. These measures can complement recommendations such as social distancing, using masks, and hand hygiene, to further reduce risk during and after travel.

Monkeypox is a rare, sometimes life-threatening zoonotic infection that occurs in west and central Africa. It is caused by Monkeypox virus, an orthopoxvirus similar to Variola virus (the causative agent of smallpox) and Vaccinia virus (the live virus component of orthopoxvirus vaccines) and can spread to humans. After 39 years without detection of human disease in Nigeria, an outbreak involving 118 confirmed cases was identified during 2017-2018 (1); sporadic cases continue to occur. During September 2018-May 2021, six unrelated persons traveling from Nigeria received diagnoses of monkeypox in non-African countries: four in the United Kingdom and one each in Israel and Singapore. In July 2021, a man who traveled from Lagos, Nigeria, to Dallas, Texas, became the seventh traveler to a non-African country with diagnosed monkeypox. Among 194 monitored contacts, 144 (74%) were flight contacts. The patient received tecovirimat, an antiviral for treatment of orthopoxvirus infections, and his home required large-scale decontamination. Whole genome sequencing showed that the virus was consistent with a strain of Monkeypox virus known to circulate in Nigeria, but the specific source of the patient's infection was not identified. No epidemiologically linked cases were reported in Nigeria; no contact received postexposure prophylaxis (PEP) with the orthopoxvirus vaccine ACAM2000.

School-related factors may influence retention in care and adherence to antiretroviral therapy (ART) among adolescents with human immunodeficiency virus (HIV). We analyzed data from in-depth interviews with 40 adolescents with HIV (aged 14 -19 years), 40 caregivers of adolescents with HIV, and 4 focus group discussions with healthcare workers to evaluate contextual factors affecting adherence to ART and clinic attendance among adolescents, with a focus on the school environment. Informed by Anderson’s Model of Health Services Utilization, transcripts were systematically coded and synthesized to identify school-related themes. All groups identified the school environment as a critical barrier to engagement in HIV care and medication adherence for adolescents with HIV. Adolescent participants reported inflexible school schedules and disclosure to school staff as the biggest challenges adhering to clinic appointments and ART. Adolescents described experiencing stigma and discrimination by peers and school staff and would adjust when, where and how often they took ART to avoid inadvertent disclosure. Boarding school students faced challenges because they had limited private space or time. Caregivers were often instrumental in navigating school permissions, including identifying a treatment supporter among school staff. Additional research engaging school staff may guide interventions for schools to reduce stigma and improve adherence and retention.

During the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC implemented travel and border health measures to prevent international spread of the disease, educate and protect travelers and communities, and minimize disruption of international travel and trade. CDC staff provided in-country technical assistance for exit screening in countries in West Africa with Ebola outbreaks, implemented an enhanced entry risk assessment and management program for travelers at U.S. ports of entry, and disseminated information and guidance for specific groups of travelers and relevant organizations. New and existing partnerships were crucial to the success of this response, including partnerships with international organizations, such as the World Health Organization, the International Organization for Migration, and nongovernment organizations, as well as domestic partnerships with the U.S. Department of Homeland Security and state and local health departments. Although difficult to assess, travel and border health measures might have helped control the epidemic's spread in West Africa by deterring or preventing travel by symptomatic or exposed persons and by educating travelers about protecting themselves. Enhanced entry risk assessment at U.S. airports facilitated management of travelers after arrival, including the recommended active monitoring. These measures also reassured airlines, shipping companies, port partners, and travelers that travel was safe and might have helped maintain continued flow of passenger traffic and resources needed for the response to the affected region. Travel and border health measures implemented in the countries with Ebola outbreaks laid the foundation for future reconstruction efforts related to borders and travel, including development of regional surveillance systems, cross-border coordination, and implementation of core capacities at designated official points of entry in accordance with the International Health Regulations (2005). New mechanisms developed during this response to target risk assessment and management of travelers arriving in the United States may enhance future public health responses. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Summary Background Outbreak response efforts for the 2014–15 Ebola virus disease epidemic in west Africa brought widespread transmission to an end. However, subsequent clusters of infection have occurred in the region. An Ebola virus disease cluster in Liberia in November, 2015, that was identified after a 15-year-old boy tested positive for Ebola virus infection in Monrovia, raised the possibility of transmission from a persistently infected individual. Methods Case investigations were done to ascertain previous contact with cases of Ebola virus disease or infection with Ebola virus. Molecular investigations on blood samples explored a potential linkage between Ebola virus isolated from cases in this November, 2015, cluster and epidemiologically linked cases from the 2014–15 west African outbreak, according to the national case database. Findings The cluster investigated was the family of the index case (mother, father, three siblings). Ebola virus genomes assembled from two cases in the November, 2015, cluster, and an epidemiologically linked Ebola virus disease case in July, 2014, were phylogenetically related within the LB5 sublineage that circulated in Liberia starting around August, 2014. Partial genomes from two additional individuals, one from each cluster, were also consistent with placement in the LB5 sublineage. Sequencing data indicate infection with a lineage of the virus from a former transmission chain in the country. Based on serology and epidemiological and genomic data, the most plausible scenario is that a female case in the November, 2015, cluster survived Ebola virus disease in 2014, had viral persistence or recurrent disease, and transmitted the virus to three family members a year later. Interpretation Investigation of the source of infection for the November, 2015, cluster provides evidence of Ebola virus persistence and highlights the risk for outbreaks after interruption of active transmission. These findings underscore the need for focused prevention efforts among survivors and sustained capacity to rapidly detect and respond to new Ebola virus disease cases to prevent recurrence of a widespread outbreak. Funding US Centers for Disease Control and Prevention, Defense Threat Reduction Agency, and WHO.

On May 15, 2014, CDC was notified of two laboratory-confirmed measles cases in the Federated States of Micronesia (FSM), after 20 years with no reported measles. FSM was assisted by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and CDC in investigating suspected cases, identify contacts, conduct analyses to guide outbreak vaccination response, and review vaccine cold chain practices. During February–August, three of FSM’s four states reported measles cases: Kosrae (139 cases), Pohnpei (251), and Chuuk (3). Two thirds of cases occurred among adults aged ≥20 years; of these, 49% had received ≥2 doses of measles-containing vaccine (MCV). Apart from infants aged

During December 2015-January 2016, the American Samoa Department of Health (ASDoH) detected through surveillance an increase in the number of cases of acute febrile rash illness. Concurrently, a case of laboratory-confirmed Zika virus infection, a mosquito-borne flavivirus infection documented to cause microcephaly and other severe brain defects in some infants born to women infected during pregnancy (1,2) was reported in a traveler returning to New Zealand from American Samoa. In the absence of local laboratory capacity to test for Zika virus, ASDoH initiated arboviral disease control measures, including public education and vector source reduction campaigns. On February 1, CDC staff members were deployed to American Samoa to assist ASDoH with testing and surveillance efforts.

Despite elimination of endemic measles in the United States (US), outbreaks associated with imported measles continue to occur. In 2007, the initiation of a multistate measles outbreak was associated with an imported case occurring in a participant at an international youth sporting event held in Pennsylvania.Case finding and contact tracing were conducted. Control measures included isolating ill persons and administering postexposure prophylaxis to exposed persons without documented measles immunity. Laboratory evaluation of suspected cases and contacts included measles serologic testing, viral culture, detection of viral RNA by reverse-transcription polymerase chain reaction, and viral genotyping.The index case occurred in a child from Japan aged 12 years. Contact tracing among 1250 persons in 8 states identified 7 measles cases; 5 (71%) cases occurred among persons without documented measles vaccination. Epidemiologic and laboratory investigation supported a single chain of transmission, linking the outbreak to contemporaneous measles virus genotype D5 transmission in Japan. Of the 471 event participants, 193 (41%) lacked documentation of presumed measles immunity, 94 (49%) of 193 were US-resident adults, 19 (10%) were non-US-resident adults (aged18 years), and 80 (41%) were non-US-resident children.Measles outbreaks associated with imported disease are likely to continue in the US. Participants in international events, international travelers, and persons with routine exposure to such travelers might be at greater risk of measles. To reduce the impact of imported cases, high measles, mumps, and rubella vaccine coverage rates should be maintained throughout the US, and support should continue for global measles control and elimination.

Background Chikungunya virus is a mosquito-borne alphavirus which causes an acute febrile illness associated with polyarthralgia. Beginning in August 2013, clinicians from the Yap State Department of Health in the Federated States of Micronesia (FSM) identified an unusual cluster of illness which was subsequently confirmed to be chikungunya virus disease. Chikungunya virus disease previously had not been recognized in FSM. Methodology/Principal findings Information from patients presenting to healthcare facilities was collected and analyzed. During August 11, 2013, to August 10, 2014, a total of 1,761 clinical cases were reported for an attack rate of 155 clinical cases per 1,000 population. Among residents of Yap Main Island, 3% were hospitalized. There were no deaths. The outbreak began on Yap Main Island and rapidly spread throughout Yap Main Island and to three neighboring islands. Conclusions/Significance Chikungunya virus can cause explosive outbreaks with substantial morbidity. Given the increasing globalization of chikungunya virus, strong surveillance systems and access to laboratory testing are essential to detect outbreaks., Author summary Chikungunya virus can cause large outbreaks with substantial morbidity, especially in places with certain Aedes species of mosquitos and immunologically-naïve populations. In August 2013, chikungunya virus disease was identified for the first time in the Federated States of Micronesia. The explosive outbreak that followed is described in this report. Given the increasing globalization of chikungunya virus, strong surveillance systems and access to laboratory testing are essential to detect outbreaks. When outbreaks occur, a swift vector control response and implementation of prevention measures are important to limit disease spread.

Summary We survey Indigenous health issues across the Pacific with a case study approach that focuses on Australia, New Zealand, Hawai‘i, and US Associated Micronesia. For each case study, we provide an overview of the Indigenous population, its colonial history, and current health and social outcomes. In the discussion that follows, we flag some of the key policy initiatives that have been developed to address Indigenous health disadvantage, albeit within the context of continuing debates about Indigenous rights and policy.

In response to the largest recognized Ebola virus disease epidemic now occurring in West Africa, the governments of affected countries, CDC, the World Health Organization (WHO), and other international organizations have collaborated to implement strategies to control spread of the virus. One strategy recommended by WHO calls for countries with Ebola transmission to screen all persons exiting the country for "unexplained febrile illness consistent with potential Ebola infection." Exit screening at points of departure is intended to reduce the likelihood of international spread of the virus. To initiate this strategy, CDC, WHO, and other global partners were invited by the ministries of health of Guinea, Liberia, and Sierra Leone to assist them in developing and implementing exit screening procedures. Since the program began in August 2014, an estimated 80,000 travelers, of whom approximately 12,000 were en route to the United States, have departed by air from the three countries with Ebola transmission. Procedures were implemented to deny boarding to ill travelers and persons who reported a high risk for exposure to Ebola; no international air traveler from these countries has been reported as symptomatic with Ebola during travel since these procedures were implemented.

An epidemic of Zika virus (ZIKV) illness that occurred in July 2007 on Yap Island in the Federated States of Micronesia prompted entomological studies to identify both the primary vector(s) involved in transmission and the ecological parameters contributing to the outbreak. Larval and pupal surveys were performed to identify the major containers serving as oviposition habitat for the likely vector(s). Adult mosquitoes were also collected by backpack aspiration, light trap, and gravid traps at select sites around the capital city. The predominant species found on the island was Aedes (Stegomyia) hensilli. No virus isolates were obtained from the adult field material collected, nor did any of the immature mosquitoes that were allowed to emerge to adulthood contain viable virus or nucleic acid. Therefore, laboratory studies of the probable vector, Ae. hensilli, were undertaken to determine the likelihood of this species serving as a vector for Zika virus and other arboviruses. Infection rates of up to 86%, 62%, and 20% and dissemination rates of 23%, 80%, and 17% for Zika, chikungunya, and dengue-2 viruses respectively, were found supporting the possibility that this species served as a vector during the Zika outbreak and that it could play a role in transmitting other medically important arboviruses., Author Summary Arthropod-borne viruses (arboviruses) cause significant human morbidity and mortality throughout the world. Zika virus, which is reported to be transmitted by Aedes (Stegomyia) species mosquitoes, caused an outbreak on the island of Yap, in the Federated States of Micronesia in 2007. This was the first described outbreak of Zika in Oceania, which has had several arbovirus outbreaks in the past. Diagnosing the outbreak was difficult due to the similarity in clinical symptoms between disease caused by Zika virus and other viruses. This work describes the efforts to identify the mosquito species that were responsible for transmission of the virus. While no virus was isolated from any species of mosquito collected during the current study, the predominant species found was Aedes hensilli and through the complementary laboratory studies, this mosquito was implicated as a probable vector for Zika virus. In addition, this species was found to be susceptible to both the medically important dengue-2 and chikungunya viruses.

Dengue is a potentially fatal acute febrile illness caused by four mosquito-transmitted dengue viruses (DENV-1–4). Although dengue outbreaks regularly occur in many regions of the Pacific, little is known about dengue in the Republic of the Marshall Islands (RMI). To better understand dengue in RMI, we investigated an explosive outbreak that began in October 2011. Suspected cases were reported to the Ministry of Health, serum specimens were tested with a dengue rapid diagnostic test (RDT), and confirmatory testing was performed using RT-PCR and IgM ELISA. Laboratory-positive cases were defined by detection of DENV nonstructural protein 1 by RDT, DENV nucleic acid by RT-PCR, or anti-DENV IgM antibody by RDT or ELISA. Secondary infection was defined by detection of anti-DENV IgG antibody by ELISA in a laboratory-positive acute specimen. During the four months of the outbreak, 1,603 suspected dengue cases (3% of the RMI population) were reported. Of 867 (54%) laboratory-positive cases, 209 (24%) had dengue with warning signs, six (0.7%) had severe dengue, and none died. Dengue incidence was highest in residents of Majuro and individuals aged 10–29 years, and ,95% of dengue cases were experiencing secondary infection. Only DENV-4 was detected by RT-PCR, which phylogenetic analysis demonstrated was most closely related to a virus previously identified in Southeast Asia. Cases of vertical DENV transmission, and DENV/Salmonella Typhi and DENV/Mycobacterium leprae co-infection were identified. Entomological surveys implicated water storage containers and discarded tires as the most important development sites for Aedes aegypti and Ae. albopictus, respectively. Although this is the first documented dengue outbreak in RMI, the age groups of cases and high prevalence of secondary infection demonstrate prior DENV circulation. Dengue surveillance should continue to be strengthened in RMI and throughout the Pacific to identify and rapidly respond to future outbreaks.

BACKGROUND: Despite high two-dose measles-mumps-rubella (MMR) vaccine coverage, a large mumps outbreak occurred on the U.S. Territory of Guam during 2009–2010, primarily in school-aged children. METHODS: We implemented active surveillance in April 2010 during the outbreak peak and characterized the outbreak epidemiology. We administered third doses of MMR vaccine to eligible students aged 9–14 years in 7 schools with the highest attack rates (ARs) between 5/18/2010—5/21/2010. Baseline surveys, follow-up surveys, and case-reports were used to determine mumps ARs. Adverse events post-vaccination were monitored. RESULTS: Between 12/1/2009—12/31/2010, 505 mumps cases were reported. Self-reported Pohnpeians and Chuukese had the highest relative risks (54.7 and 19.7, respectively) and highest crowding indices (mean: 3.1 and 3.0 persons/bedroom, respectively). Among 287 (57%) school-aged case-patients, 270 (93%) had ≥2 MMR doses. A third MMR dose was administered to 1068 (33%) eligible students. Three-dose vaccinated students had an AR of 0.9/1000 compared to 2.4/1000 among two-dose vaccinated students >1 incubation period post-intervention, but the difference was not significant (p= 0.67). No serious adverse events were reported. CONCLUSIONS: This mumps outbreak occurred in a highly vaccinated population. The highest ARs occurred in ethnic minority populations with the highest household crowding indices. After the third dose MMR intervention in highly affected schools, the AR in three-dose MMR recipients was 60% lower than two-dose vaccine recipients, but the difference was not statistically significant and the intervention occurred after the outbreak peaked. This outbreak may have persisted due to crowding at home and high student contact rates.

Natural disasters such as tsunamis can significantly damage infrastructure and cause morbidity and mortality, home damage, and population displacement. Tsunamis, which can occur following an earthquake, are a series of ocean waves generated by any disturbance that displaces a large water mass.1 Tsunami-related injuries may result from blunt force trauma, and deaths may occur immediately as a result of drowning or injuries sustained in the event aftermath. Illness may occur as a result of water source contamination or increased vector population, and mental health problems may occur because of stress or traumatic experience related to the tsunami.2 The 2004 Asian tsunami, a particularly devastating event, resulted in more than 175 000 deaths, nearly 50 000 missing persons, and more than 1.7 million displaced persons in the Indian Ocean region.3 On September 29, 2009, an earthquake measuring 8.3 on the Richter scale struck 190 km southwest of American Samoa,4 an island territory with a population of 57 291 people.5 The resulting tsunami caused 34 deaths and widespread destruction of coastal homes, mainly in the capitol city of Pago Pago and western coast of Tutuila Island near the town of Leone.6 The waves damaged public utilities, resulting in immediate, widespread loss of water, electricity, and sanitation throughout Tutuila Island. In addition to injuries and deaths, many families were displaced from their homes and potentially exposed to environmental and other public health hazards. The American Samoa Department of Health (ASDOH) requested assistance from the US Public Health Service (USPHS) and the Centers for Disease Control and Prevention (CDC) to assess the public health needs and health status of the affected population. In response, a team from the USPHS and the CDC was deployed to assist in conducting an initial (five days after tsunami) and follow-up (three weeks after the tsunami) Community Assessment for Public Health Emergency Response (CASPER).7 CASPER is a type of needs assessment that uses a two-stage cluster sampling method originally developed by the World Health Organization to assess immunization coverage.8 This methodology has been used previously to assess community needs and health status following natural disasters9,10 and provides household-based estimates of specific needs, injuries, and illnesses after a disaster.11 The objectives of the initial CASPER were to rapidly identify basic public health needs of affected communities, special needs, and vulnerable populations, and environmental and other health hazards that might result in further morbidity and mortality. The follow-up CASPER objectives were to identify ongoing and newly emerged community public health issues and to assess the effectiveness of the public health response following the initial CASPER. This report summarizes and compares the findings of the initial and follow-up CASPERs conducted following the American Samoa earthquake and tsunami.

Background.Healthcare-associated outbreaks and pseudo-outbreaks of rapidly growing mycobacteria (RGM) are frequently associated with contaminated tap water. A pseudo-outbreak ofMycobacterium chelonae–M. abscessusin patients undergoing bronchoscopy was identified by 2 acute care hospitals. RGM was identified in bronchoscopy specimens of 28 patients, 25 of whom resided in the same skilled nursing facility (SNF). An investigation ruled out bronchoscopy procedures, specimen collection, and scope reprocessing at the hospitals as sources of transmission.Objective.To identify the reservoir for RGM within the SNF and evaluate 2 water system treatments, hyperchlorination and point-of-use (POU) membrane filters, to reduce RGM.Design.A comparative in situ study of 2 water system treatments to prevent RGM transmission.Setting.An SNF specializing in care of patients requiring ventilator support.Methods.RGM and heterotrophic plate count (HPC) bacteria were examined in facility water before and after hyperchlorination and in a subsequent 24-week assessment of filtered water by colony enumeration on Middlebrook and R2A media.Results.Mycobacterium chelonaewas consistently isolated from the SNF water supply. Hyperchlorination reduced RGM by 1.5 log10initially, but the population returned to original levels within 90 days. Concentration of HPC bacteria also decreased temporarily. RGM were reduced below detection level in filtered water, a 3-log10reduction. HPC bacteria were not recovered from newly installed filters, although low quantities were found in water from 2-week-old filters.Conclusion.POU membrane filters may be a feasible prevention measure for healthcare facilities to limit exposure of sensitive individuals to RGM in potable water systems.

The U.S.-Affiliated Pacific Islands (USAPI) are composed of three U.S. Territories (American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands) and three independent countries (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau). These three countries are affiliated with the United States through Compacts of Free Association, which enable their citizens to travel to, and live and work in the United States without visas or additional screening.1 These island jurisdictions experience a number of endemic (tuberculosis, Hansen's disease, enteric diseases such as hepatitis A) and introduced communicable disease threats. Since 2000, the region has experienced outbreaks of cholera (2000–01 in the Federated States of Micronesia2 and the Marshall Islands3), measles (2003 in the Marshall Islands4), and a number of emerging vector-borne disease outbreaks, caused by dengue (2004 in FSM, 2011–13 in the Federated States of Micronesia5 and the Marshall Islands), Zika (Federated States of Micronesia in 20076), and chikungunya viruses (Federated States of Micronesia in 2013). The vulnerability to outbreaks in the U.S.-affiliated and other Pacific islands is heightened by limited epidemiologic and laboratory surveillance capacity,7 travel patterns that facilitate disease translocation, geographic remoteness that may delay and limit external assistance, small populations with limited specialized human resources, and health care systems with limited surge and tertiary care capacity. Moreover, the introduction of new pathogens into immunologically naive island populations can result in high attack rates.6 Increasing rates of noncommunicable diseases, including diabetes and associated conditions,8 further threaten the resiliency of these communities to communicable disease threats. The World Health Organization (WHO), the Secretariat of the Pacific Community (SPC), and the U.S. Centers for Disease Control and Prevention (CDC) each support national and territorial health authorities in the USAPI in strengthening detection and response capacity for communicable diseases. A key framework for coordinating technical assistance in the region is the Pacific Public Health Surveillance Network (PPHSN). This network was established in 1996 as a collaborative partnership between 22 Pacific Island countries and territories and technical assistance partners to strengthen communicable disease detection and response capacity.9 SPC, WHO, and CDC representatives currently serve on the PPHSN Coordinating Body, along with members from Fiji National University, the Pacific Island Health Officers Association, and representatives from Pacific Island health ministries and departments. The response to a dengue outbreak in the Republic of the Marshall Islands during 2011–12 highlighted the benefits of enhanced regional coordination among PPHSN and other partners. In October 2011, dengue virus-type 4 was detected by Marshall Islands Ministry of Health (MOH) physicians and laboratory staff. Early detection was enabled by clinical knowledge of dengue and the local availability of dengue rapid diagnostic tests pre-positioned by WHO in public health laboratories throughout the Pacific. Following notification of CDC, WHO, and SPC, daily support conference calls were convened with Marshall Islands health authorities. At the request of the MOH, Hawaii-based CDC staff assumed a coordinating role to guide external partner assistance in support of the extensive MOH outbreak response efforts. A total of 33 formal coordination teleconferences were conducted during October 2011–February 2012. Through these teleconferences, interagency partnerships and assistance from the U.S. Embassy in the Marshall Islands were engaged to coordinate additional support from the U.S. Agency for International Development, U.S. Department of State, U.S. Department of Defense, U.S. Department of Interior, the Association of State and Territorial Health Officers, the Hawaii State Department of Health, U.S. Coast Guard, and the Pacific Island Health Officers Association. The coordinated international and interagency support enhanced the robust Marshall Islands government response to the outbreak. The MOH established dedicated hospital dengue wards, implemented enhanced epidemiologic and laboratory surveillance, and worked with other government agencies and community partners to reduce mosquito breeding sites and conduct community education for preventing and responding to dengue. CDC and WHO staff provided epidemiologic and entomologic technical assistance and conducted dengue clinical management training. CDC provided reference laboratory testing. CDC, WHO, and SPC provided laboratory supplies, including dengue rapid diagnostic test kits. U.S. Naval Medical Research Unit 2 deployed a five-person vector-control team, including personnel from Navy Environmental and Preventive Medicine Unit 6, to support Marshall Islands government pesticide application efforts. The vector-control team was later augmented by three Japan-based personnel from U.S. Army Public Health Command Region-Pacific.10 Epidemiologic investigation guided vector-control activities. U.S. Coast Guard aircraft on unrelated missions transported the Department of Defense vector-control team from Hawaii to the Marshall Islands and assisted with transport of diagnostic specimens. The Hawaii Department of Health donated mosquito larvicide that was transported at no charge by United Airlines. The Association of State and Territorial Health Officials worked with a nongovernmental organization (Direct Relief USA) to facilitate donation and shipping of insect repellents (valued at $100,000) for the Marshall Islands and Federated States of Micronesia (which was experiencing a discrete but concurrent dengue outbreak). Of the more than 1,600 suspected dengue cases reported among persons in the Marshall Islands during this outbreak, 10% were hospitalized and none were fatal. Large disease outbreaks can quickly overwhelm the capacities of small Pacific island health departments and coordination of external organizations and agencies can be a challenge to manage effectively. More than fifteen external organizations and agencies were involved in the RMI dengue outbreak response and, because of the large number of partners, the Marshall Islands MOH requested CDC assistance to coordinate external partner support. The regular teleconference calls between the MOH outbreak response team and all external partners assured that gaps were identified and communicated, facilitated smooth and well-coordinated external partner response activities, and enabled timely external partner updates. When compared to other large disease outbreaks in the Pacific that lacked a dedicated external partner coordination mechanism, the external partner response in Marshall Islands was smooth, effective, and efficient and provides a model for responding to future large outbreaks in the Pacific and beyond.

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key healthcare professionals, hospital administrators and government officials. This article highlights findings of ACT's Assessment of Kosrae State, Federated States of Micronesia. All data were collected in 2004/2005 and have not been updated since it was to establish a baseline for future reference.

The University of Hawai'i Pacific Basin Bioterrorism Curriculum Development Project has developed a problem-based learning (PBL) curriculum for teaching health professionals and health professional students about bioterrorism and other public health emergencies. These PBL cases have been incorporated into interdisciplinary training settings in community-based settings, such as in the small island districts of the U.S.-Affiliated Pacific Islands.Quantitative and qualitative methods have been utilized in the evaluation of the PBL cases, PBL tutorials, and the accomplishment of learning objectives.Evaluation of the PBL tutorials demonstrates that PBL is an educational and training modality appropriate for such settings. Participants found it helpful to learn in interdisciplinary groups. The educational process was modified in accordance with local culture.PBL is a useful educational modality for settings where healthcare staffing and available resources are limited.

The United States-Affiliated Pacific Islands (USAPI) include the U.S. Flag Territories of American Samoa and Guam, the Commonwealth of the Northern Mariana Islands (CNMI) and three Freely Associated States: the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI) and the Republic of Palau. These six jurisdictions span four time zones and are separated by over 4,000 miles of the Pacific. There has been a well documented need for continuing education (CE)for health workers in the USAPI region. This executive summary highlights key points from a series of CE needs assessments conducted in the region in 2004. These reports are presented in their entirety (pages 31-88) in this issue.

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of health care professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key healthcare professionals, hospital administrators, and government officials. This article highlights findings of PACT's Assessment of Pohnpei State, Federated States of Micronesia. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

In 2003, the University of Hawai 'i (UH) Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.- Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key healthcare professionals, hospital administrators, and government officials. This article highlights findings of PACT's Guam Assessment. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

In 2003, the University of Hawai'i Department of Family MedicineCommunity Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healtcare professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key healtcare professionals, hospital administrators, and government officials. This article highlights findings of PACT's American Samoa assessment. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

In 2003, the University of Hawai 'i Department of Family Medicine and Community Health entered a four-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.- Affiliated Pacific Island Nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key healthcare professionals, hospital administrators, and government officials. This article highlights findings of PACT's Assessment of the Commonwealth of the Northern Mariana Islands (CNMI). Meant to establish a baseline for future reference, all data were that collected in 2004/2005 and have not been updated.

Healthcare workers in many parts of the U.S.-Affiliated Pacific Islands (USAPI) have limited access to continuing education. Barriers to traditional on-site continuing education programs include the diversity of educational needs, limited health staffing, the distances between islands and associated high travel costs. A pilot evaluation of distance education modalities was conducted among USAPI healthcare workers.Three distance education modalities (live videoconference, live audioconference and a recorded computer-based format) were evaluated in comparison to live lecture during two separate half-day educational programs in Pohnpei, Federated States of Micronesia, in June 2004. Participants from the USAPI included 59 nurses, doctors, dentists and other healthcare workers who were assigned to different educational modalities for two training modules (diabetes/oral health and metabolic syndrome). We conducted pre-and post-tests and obtained participant feedback.Comparison of pre-test and post-test scores showed statistically significant score increases among the live lecture and videoconference group for the diabetes/oral health module and among all three distance education modalities for the metabolic syndrome module. Participants expressed a high degree of interest in each of the distance education modalities. Computer-based training was well-accepted even by health workers with little prior computer experience.This pilot study validates the ongoing development and evaluation of distance education resources as part of a comprehensive approach to improving continuing education in the USAPI. The results have been used to guide continuing education efforts in the region.

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a four-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of health care professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key health care professionals, hospital administrators, and government officials. This article highlights findings of PACT's Assessment of Chuuk State, Federated States of Micronesia. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

BACKGROUND In 2007, physicians on Yap Island reported an outbreak of illness characterized by rash, conjunctivitis, and arthralgia. Although serum from some patients had IgM antibody against dengue virus, the illness seemed clinically distinct from previously detected dengue. Subsequent testing with the use of consensus primers detected Zika virus RNA in the serum of the patients but no dengue virus or other arboviral RNA. No previous outbreaks and only 14 cases of Zika virus disease have been previously documented. METHODS We obtained serum samples from patients and interviewed patients for information on clinical signs and symptoms. Zika virus disease was confirmed by a finding of Zika virus RNA or a specific neutralizing antibody response to Zika virus in the serum. Patients with IgM antibody against Zika virus who had a potentially cross-reactive neutralizing-antibody response were classified as having probable Zika virus disease. We conducted a household survey to estimate the proportion of Yap residents with IgM antibody against Zika virus and to identify possible mosquito vectors of Zika virus. RESULTS We identified 49 confirmed and 59 probable cases of Zika virus disease. The patients resided in 9 of the 10 municipalities on Yap. Rash, fever, arthralgia, and conjunctivitis were common symptoms. No hospitalizations, hemorrhagic manifestations, or deaths due to Zika virus were reported. We estimated that 73% (95% confidence interval, 68 to 77) of Yap residents 3 years of age or older had been recently infected with Zika virus. Aedes hensilli was the predominant mosquito species identified. CONCLUSIONS This outbreak of Zika virus illness in Micronesia represents transmission of Zika virus outside Africa and Asia. Although most patients had mild illness, clinicians and public health officials should be aware of the risk of further expansion of Zika virus transmission.

Rapidly increasing tobacco use in developing countries will result in a large and increasing burden of tobacco-related illnesses as their populations age. The Republic of the Marshall Islands (RMI) is an island nation in the Pacific with a 1999 census population of 50,840, of whom more than fifty percent were under twenty years of age. There are limited data on the prevalence of smoking among youth in the RMI. A school survey of 3,294 RMI students in grades 5 through 12 was conducted in 2000. Urban and outer atoll schools were included in the sample. Demographic data and information on tobacco use and risk factors were collected. The overall smoking rate in this school sample was 10.6%. There were significantly higher smoking rates in the high school age group; the rate of smoking among 18 year olds was 33.5%. Smoking rates were higher among males compared to females (18.7% vs. 3.4%) and higher among outer atoll students compared to urban students (14.5% vs. 9.4%). The most prominent risk factors for smoking were: age, male gender, receiving or wearing tobacco-labeled equipment or clothing and willingness to participate in other high-risk behaviors. The survey provides an estimate of smoking rates among Marshallese school students and identifies and quantifies significant risk factors for smoking. This information can assist in guiding a comprehensive tobacco control strategy in the Republic of the Marshall Islands.

The purpose of this study was to use a low-cost method of estimating prevalence of diabetes mellitus for a small island population receiving medical care from a single facility. A suitable sample of 692 (16.4%) from a total of 4,223 medical records of Ebeye Island Marshallese adult outpatients 30 or more years of age was reviewed in July and August 2000 for evidence of diabetes mellitus. Diagnosed diabetes was defined as having a diagnosis of diabetes noted in the chart. In patients without a diagnosis of diabetes, undiagnosed diabetes was defined as one fasting whole blood glucoseor = 70 mmol/l (126 mg/dl) or one random whole blood glucoseor = 11.1 mmol/l (200 mg/dl). Impaired fasting glucose was defined as one fasting whole blood glucose 6.1-7.0 mmol/l (110-125 mg/dl). For this population of adults 30 or more years in age, the crude prevalence of diabetes [diagnosed cases 13% (confidence interval, CI = 10-15%) and undiagnosed cases 6.9% (CI = 5.0-8.8%)] was 20% (CI = 17-23%). As the population of Ebeye is younger than the world population, adjustment to a standard world population gives an age-adjusted prevalence of diabetes in adults 30 or more years of age of 27%, and an age-adjusted prevalence in adults 20 or more years of age of 20%. In comparison, the crude prevalence of diagnosed and undiagnosed diabetes in the U.S. in adults 20 or more years of age is 8.3%, and the worldwide prevalence in adults 20 or more years of age is 4.0%. Limitations of our methodology include lack of randomization, lack of access to proper laboratory equipment, and passive case-finding, necessitating revision of standard diagnostic criteria. Prevalence rates of diabetes in Marshallese outpatients are thus significantly higher than US or worldwide rates. In addition, there are many cases of undiagnosed diabetes in the RMI. Recommended are a cross-sectional serosurvey of a large age- and gender-stratified population, increased resources to care for people with diabetes, and public health interventions to improve nutrition and facilitate physical activity in order to lower the prevalence of diabetes. The large-scale social forces that lead to diabetes need to be addressed accordingly.