Background Effective emergency care (EC) reduces mortality, aids disaster and outbreak response, and is necessary for universal health coverage. Surge events frequently challenge Pacific Island Countries and Territories (PICTs), where robust routine EC is required for resilient health systems. We aimed to describe the current status, determine priority actions and set minimum standards for EC systems development across the Pacific region. Methods We used a prospective, multiphase, expert consensus process to collect data from PICT EC stakeholders using focus groups, electronic surveys and panel review between August 2018 and April 2019. Data were analysed using descriptive statistics, consensus agreement and graphic interpretation. We structured the research according to the World Health Organisation EC Systems and building block framework adapted for the Pacific context. Findings Over 200 participants from 17 PICTs engaged in at least one component of the multiphase process. Gaps in functional capacity exist in most PICTs for both facility-based and pre-hospital care. EC is a low priority across the Pacific and integrated poorly with disaster plans. Participants emphasised human resource support and government recognition of EC as priority actions, and generated 24 facility-based and 22 pre-hospital Pacific EC standards across all building blocks. Interpretation PICT stakeholders now have baseline indicators and a comprehensive roadmap for EC development within a globally recognised health systems framework. This study generates practical, context-appropriate tools to trigger further research, conduct evidence-based advocacy, drive future improvements and measure progress towards achieving universal health access for Pacific peoples. Funding Secretariat of the Pacific Community (partial)

IntroductionWhilst more than 90% of injury related deaths are estimated to occur in low-and-middle-income countries (LMICs), the epidemiology of fatal and hospitalised injuries in Pacific Island Countries has received scant attention. This study describes the development and piloting of a population-based trauma registry in Fiji to address this gap in knowledge.MethodsThe Fiji Injury Surveillance in Hospitals (FISH) system was an active surveillance system designed to identify injuries resulting in death or a hospital admission in Viti Levu, Fiji. During the pilot conducted over five months in 2005, Accident and Emergency registers, admission folders and morgue registers from 8 of Viti Levu's 12 hospitals, and an additional 3 hospitals in other parts of the country were reviewed by hospital staff and medical students to identify cases and extract a minimum data set that included demographic factors; the mechanism, nature and context of injury; substance use; and discharge outcomes. The system was audited to identify and redress difficulties with data quality in a manner that also supported local capacity development and training in injury surveillance and data management.ResultsThis pilot study demonstrated the potential to collect high quality data on injuries that can pose a significant threat to life in Fiji using a mechanism that also increased the capability of health professionals to recognise the significance of injury as a public health issue.ConclusionThe injury surveillance system piloted provides the opportunity to inform national injury control strategies in Fiji and increase the capacity for injury prevention and more focused research addressing risk factors in the local context.

IntroductionPublished studies investigating the role of driver sleepiness in road crashes in low and middle-income countries have largely focused on heavy vehicles. We investigated the contribution of driver sleepiness to four-wheel motor vehicle crashes in Fiji, a middle-income Pacific Island country.MethodThe population-based case control study included 131 motor vehicles involved in crashes where at least one person died or was hospitalised (cases) and 752 motor vehicles identified in roadside surveys (controls). An interviewer-administered questionnaire completed by drivers or proxies collected information on potential risks for crashes including sleepiness while driving, and factors that may influence the quantity or quality of sleep.ResultsFollowing adjustment for confounders, there was an almost six-fold increase in the odds of injury-involved crashes for vehicles driven by people who were not fully alert or sleepy (OR 5.7, 95%CI: 2.7, 12.3), or those who reported less than 6 h of sleep during the previous 24 h (OR 5.9, 95%CI: 1.7, 20.9). The population attributable risk for crashes associated with driving while not fully alert or sleepy was 34%, and driving after less than 6 h sleep in the previous 24 h was 9%. Driving by people reporting symptoms suggestive of obstructive sleep apnoea was not significantly associated with crash risk.ConclusionDriver sleepiness is an important contributor to injury-involved four-wheel motor vehicle crashes in Fiji, highlighting the need for evidence-based strategies to address this poorly characterised risk factor for car crashes in less resourced settings.

BackgroundOver 90% of injury deaths occur in low-and middle-income countries. However, the epidemiological profile of injuries in Pacific Islands has received little attention. We used a population-based-trauma registry to investigate the characteristics of all injuries in Viti Levu, Fiji.MethodThe Fiji Injury Surveillance in Hospitals (FISH) database prospectively collected data on all injury-related deaths and primary admissions to hospital (≥12 hours stay) in Viti Levu during 12 months commencing October 2005.ResultsThe 2167 injury-related deaths and hospitalisations corresponded to an annual incidence rate of 333 per 100,000, with males accounting for twice as many cases as females. Almost 80% of injuries involved people aged less than 45 years, and 74% were deemed unintentional. There were 244 fatalities (71% died before admission) and 1994 hospitalisations corresponding to crude annual rates of 37.5 per 100,000 and 306 per 100,000 respectively. The leading cause of fatal injury was road traffic injury (29%) and the equivalent for injury admissions was falls (30%). The commonest type of injury resulting in death and admission to hospital was asphyxia and fractures respectively. Alcohol use was documented as a contributing factor in 13% of deaths and 12% of admissions. In general, indigenous Fijians had higher rates of injury admission, especially for interpersonal violence, while those of Indian ethnicity had higher rates of fatality, especially from suicide.ConclusionsInjury is an important public health problem that disproportionately affects young males in Fiji, with a high proportion of deaths prior to hospital presentation. This study highlights key areas requiring priority attention to reduce the burden of potentially life-threatening injuries in Fiji.

Typhoid fever is endemic in the South Pacific. We investigated an outbreak in Nauru. Through interviews and medical records, we identified 50 persons with onset between 1 October 1998 and 10 May 1999, of fever lasting > or = 3 days and one other symptom. Salmonella Typhi was isolated from 19 (38%) cases. Thirty-two (64%) patients were school-aged children, and 17 (34%) were in four households. Case-control studies of (a) culture-confirmed cases and age- and neighbourhood-matched controls; and (b) household index cases and randomly selected age-matched controls implicated two restaurants: Restaurant M (matched OR [MOR] = 11, 95% confidence interval [CI] = 1.3-96) and Restaurant I (MOR = 5.8, 95% CI = 1.2-29). Food-handlers at both restaurants had elevated anti-Vi antibody titres indicative of carrier state. The annual incidence was 5.0/1000 persons. Outbreak-associated costs were $46,000. Routine or emergency immunization campaigns targeting school-aged children may help prevent or control outbreaks of typhoid fever in endemic disease areas.