Prevalence of HPV infection and other risk factors in a Fijian population.

BACKGROUND: Cancer is among the leading contributors to morbidity and mortality in the Pacific, but the magnitude of the problem and the potential for prevention have not been comprehensively studied. Over the past decade, cervical cancer has been the most common cancer among women in Fiji with an age standardised cervical cancer incidence rate of 51 per 100,000. This rate is among the highest in the South Pacific region and in the world. This high cervical cancer incidence rate is likely linked to the low cervical screening rate, but it points also to the possibility of a high burden of human papillomavirus (HPV) infection. METHODS: We conducted a population-based survey in Fiji to provide information on human papillomavirus (HPV) prevalence, and the distribution of individual HPV types in a Fijian health-sub-district. We included 1,261 women aged between 16 and 64 years. A general primer GP5+/6+ mediatedpolymerase chain reaction (PCR) assay was used for HPV testing of 44 HPV types. RESULTS: The crude HPV prevalence in 1,244 women with an adequate HPV sample was 24.0% (95% confidence interval (CI), 21.7-26.4%) and the corresponding age standardised prevalence was 25.5% (95% CI, 23.1-28.1%). The prevalence of high-risk HPV types was 13.6% (95% CI, 11.8-15.6%). Among 1,192 women with adequate cytological results, 13 (1.1%) showed cervical abnormalities, the majority of which were high-grade intraepithelial lesions or worse. HPV prevalence declined from 35.8% in women aged <25 years to 18.6% in those aged 55-64 years of age. After adjustment, the only variables significantly associated with HPV-positivity were age (ranging from odds ratio (OR) 0.57 (95% CI, 0.36-0.89) for 25-34 year-old-women to OR 0.43 (95% CI, 0.20-0.89) for 55-64 year-old-women) and 'husband's extramarital sexual relationships' (OR 1.69; 95% CI, 1.17-2.34). CONCLUSION: These findings on HPV provide key information for future policy decisions on the most appropriate methods of cervical cancer prevention in Fiji and in the Pacific region

Acceptability of human papillomavirus self-sampling for cervical-cancer screening in under-screened Māori and Pasifika women: a pilot study.

AIM: To assess whether self-sampling for cervical-cancer screening is acceptable to New Zealand women. METHODS: Māori, Pacific and Asian un- or under-screened women aged 30-69 years were asked to: 1) examine three self-sampling devices; 2) complete a questionnaire on demographics and experiences with the devices; and 3) take a self-sample. Samples were tested 'off-label' using the cobas® 4800 human papillomavirus (HPV) test (Roche Diagnostics NZ). RESULTS: Thirty-one Pacific, 12 Māori, nine Asian and four women of other ethnicities participated (mean age, 39.5 years). Before trying any devices, 78% indicated a preference to self-sample, compared to 22% who preferred a physician-collected sample (PCS). After trying a device (HerSwab™, 91%; Delphi Screener™, 14%; cobas Swab, 13%; 12.5% used >1 device), fewer women (66%) preferred to self-sample next time, fewer (16%) preferred a PCS, while 18% expressed no preference. One of 32 samples with valid results (35 were tested) was positive for HPV 'other' oncogenic types. CONCLUSIONS: This was the first New Zealand study to invite women, including Māori women, to take a self-sample for cervical-cancer screening. The pilot study suggests that un- and under-screened women generally find self-sampling acceptable and all sample types are suitable for use with the cobas HPV test

Epidemiology of asthma in selected Pacific countries : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Epidemiology at Massey University, Wellington, New Zealand

In this thesis, I describe a series of studies of the prevalence, causes, and management of asthma in the Pacific. The core study of the thesis is Phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). The ISAAC study is the largest worldwide epidemiological study on asthma prevalence and was established partly in response to the increases in asthma prevalence in most parts of the world over the last two to three decades. The ISAAC Phase I study found large variations in asthma prevalence globally, but no Pacific countries were involved. Thus, the situation in the Pacific was relatively unknown due to lack of standardised studies on prevalence and time trends. The burden and impact of other non-communicable diseases such as cardiovascular and other metabolic disorder on the other hand have been the target of various studies in the Pacific for the past few decades The ISAAC Phase III study was therefore conducted in eight Pacific countries to address the above issues, as well as to enhance Pacific participation and contribution to international research on the causes and control of asthma. The collaboration also served the purpose of encouraging and strengthening health research capacity in the Pacific. The ISAAC Phase III study was followed by an asthma self-management intervention trial conducted in Tonga by the ISAAC Tonga study team. Methods The work presented in this thesis involved: (i) the conduct of the ISAAC Phase III study in the six Pacific islands of Tokelau, Samoa, Fiji Islands, Tonga, Niue and the Cook Islands, as well as the incorporation into the analysis of data that had already been collected in French Polynesia and New Caledonia; (ii) analysis of the data from an environmental asthma risk factor questionnaire which was included in the ISAAC survey in three countries (Samoa, Fiji and Tokelau); (iii) the conduct of the Tonga Asthma Self-management Study which was intended to assess whether the introduction of asthma education, including asthma self-management plans, would reduce morbidity from asthma. Results A total of 20,876 13-14 year olds, in the eight countries involved, participated in the ISAAC Phase III survey, with an overall response rate of 92%. The survey showed that there was considerable variation in the prevalence of asthma symptoms between the eight countries, ranging from 5.8% for current wheeze in Samoa to 16.2% in Tonga. Tokelau reported the highest prevalence (19.7%) for current wheeze, but the number of participants was relatively small. The prevalences of asthma symptoms among Pacific children in the Pacific were lower than those reported for Pacific, Māori and European children living in New Zealand from a previous study (ISAAC Phase I) conducted ten years earlier using the same methodology. The prevalence of 'asthma ever' in Pacific children living in the Pacific was also lower than that found among Pacific, Māaori and European children in New Zealand. The ISAAC Phase III environmental questionnaire data was collected in Samoa, Fiji and Tokelau. The analyses indicated that the major factors associated with current wheeze (across the three countries) were paracetamol use in the previous year (odds ratio (OR) = 1.36, 95% CI 1 15-1.61), the use of open fires for cooking (OR = 1.34,95% CI 1.13-1.58), lack of physical activity as indicated by television viewing more than 3 hours per day (OR = 1.24,95% CI 1.04-1.47), regular meat consumption (OR = 1.30,95% CI 1.09-1.54) and regular cereal consumption (OR = 1.29,95% CI 1.07-1.54). However, these risk factors were not particular strong, and did not account for a large proportion of asthma cases (i.e. they had relatively low population attributable risks). The asthma self-management plan intervention study resulted in significant improvements in asthma morbidity and the management of asthma among individuals and the service provision. The success of the introduction of the self-management plan, in the context of an asthma clinic, was reflected by improvement in measures of asthma morbidity, such as peak expiratory flow rates and nights woken with asthma or coughing. There was also a reduction in the requirement for acute medical treatment, indicated by a decrease in emergency department hospital visits for asthma and hospital admissions. The programme was so successful that the intervention study evolved into a full regular asthma clinic for the main island of Tonga. It is now intended that the asthma self-management programme will be extended throughout the rest of Tonga, through the primary health care system. Conclusions The ISAAC Phase IIII survey has shown that, although there is a significant level of morbidity, asthma prevalence in Pacific countries is lower than those among Pacific people in New Zealand. Together with the large variations in prevalence between the six Pacific countries that participated, this further lends support for the role of environmental risk factors in asthma. The availability of data on eight countries using a standardised methodology also provides useful information on the burden of asthma in the Pacific that is comparable to other countries regionally and internationally as well as forming a basis for ascertaining trends in the future. The crucial role of asthma self-management plans in asthma management is supported by the findings of the Tonga study, and its implementation is essential in the resource-scarce Pacific health setting. The collaborative nature of ISAAC in the Pacific has further raised awareness of the need for capacity building and creating networks and environments that enhance health research in areas other than asthma. The study has also nurtured an environment and network that encourages and strengthens the establishment of health research as one of the vital tools for achieving better health

Prevention and control of diabetes in Pacific people

Diabetes is a major problem worldwide. Among Pacific people, prevention and control of diabetes lies in counteracting rapid changes in lifestyle and must take account of political and economic factors and social structur

Prevalence and causes of diabetes in Pacific people.

Diabetes is approaching epidemic proportions among Pacific people both in their traditional homelands as well as in metropolitan centres of their newly adopted Western countries. Although the risk factors associated with diabetes among individuals are reasonably well understood, the "upstream" causes needs to be critically appraised. While individual interventions and health education has its role, there is an urgent need to intervene at the upstream causes of diabetes and other ill health including social, trade, economic and political at the population, state and international level. Attempts to control diabetes in a vacuum without reference to socioeconomic and political context is a convenient vehicle that has contributed to and will continue to fuel calories to the diabetes epidemic

Health research in the Pacific.

The Pacific Island countries are geographically scattered, with contrasting environmental, social, and political systems, and in varying stages of economic development, but all are going through a rapid epidemiological transition. Processes that took place over thousands of years in Western countries have been very much compacted in time in the Pacific. These processes have produced major changes in environment and lifestyle, which have produced epidemics of non-communicable disease. While it is important to consider non-communicable diseases as a group, it is also important to conduct research into their specific causes. There has been a great deal of research into cardiovascular disease and diabetes in the Pacific, but it is only recently that the importance of cancer as a major source of mortality and morbidity in the Pacific has been recognised, even though it appears to carry a similar burden of morbidity and mortality. It is therefore important that research into the causes and control of cancer in the Pacific is conducted. However, it is also crucially important that this research both learns from the successes and avoids the mistakes of the past. In particular, it is crucial that cancer research in the Pacific is not another opportunity for "research colonialism," but instead provides opportunities for Pacific-training of Pacific health researchers and the conduct of Pacific-led research