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Background Many developing countries are experiencing the epidemiological transition, with the majority of deaths attributed to cardiovascular disease, cancer, Type 2 diabetes (T2DM) and others. In some countries, large proportional mortality attributed to diabetes is evident in official mortality statistics, with Mauritius and Fiji rated as the highest in the world. Methods This study investigates trends in recorded diabetes and cardiovascular disease mortality in Mauritius and Fiji under coding from the International Classification of Diseases (ICD) versions 9 and 10, using mortality data reported from these countries to the World Health Organization (WHO). Results In Mauritius over 1981–2004, T2DM proportional mortality varied between 4% and 7% in males (M) and 5% and 9% in females (F). In 2005 there was a sudden increase to M 20% and F 25%, which continued to M 25% and F 30% by 2012. Over 1981–2004 the proportion of circulatory disease mortality rose from 44% to 49% in males, and from 46% to 57% in females. In 2005, circulatory disease mortality proportions fell precipitously to 34% in males and 37% in females, and declined to 31% and 34% by 2013. ICD–10 coding was introduced in 2005. In Fiji, sharp rises in proportional T2DM mortality from 3% in both sexes in 2001 to M 15% and F 20% in 2002 were followed by more gradual trend increases to M 20% and F 26% by 2012–13. Circulatory disease proportions fell steeply from M 57% and F 53% in 2001 to M 44% and M 38% by 2004, with subsequent less steep declines to M 39% and F 30% by 2012. ICD–10 coding was introduced in 2001. Conclusions Large, abrupt changes in diabetes and circulatory disease proportional mortality in Fiji and Mauritius coincided with the local introduction of ICD–10 coding in different years. There is also evidence for diabetes-related misclassification of underlying cause of death in Australia and the USA. These artefacts can undermine accurate monitoring of cause of death for evaluation of effectiveness of prevention and control, especially of circulatory disease mortality which is demonstrably reversible in populations.

Background Fiji, a Pacific Island nation of 884,887 (2017 census), has experienced a prolonged epidemiological transition. This study examines trends in mortality and life expectancy (LE) in Fiji by sex and ethnicity over 1996–2017, with comparisons to published estimates. Methods Trends in infant mortality rates (IMR), under-5 mortality (U5M), adult mortality (probability of dying), LE (at birth) and directly age-standardised death rates (DASRs) by sex and ethnicity, are calculated (with 95% confidence limits) using unit death records from the Fiji Ministry of Health and Medical Services. The LE gap between populations, or within populations over time, is examined using decomposition by age. Period trends are assessed for statistical significance using linear regression. Results Over 1996–98 to 2014–17: IMR and U5M for i-Taukei and Fijians of Indian descent declined; U5M decline for i-Taukei (24.6 to 20.1/1000 live births) was significant ( p  = 0.016). Mortality (15–59 years) for i-Taukei males was unchanged at 27% but declined for Indians 33 to 30% ( p  = 0.101). Mortality for i-Taukei females increased 22 to 24% ( p  = 0.011) but declined for Indians 20 to 18% ( p  = 0.240). DASRs 1996–2017 were lower for i-Taukei (9.3 to 8.2/1000 population) than Indian males (10.6 to 9.8/1000). DASRs declined for i-Taukei (both sexes, p  < 0.05), and for Indians (both sexes, p  > 0.05). Over 22 years, LE at birth increased by 1 year or less ( p  = 0.030 in male i-Taukei). In 2014–17, LE (years) for males was: i-Taukei 64.9, Indians 63.5; and females: i-Taukei 67.0 and Indians 68.2. Mortality changes in most 5-year age groups increased or decreased the LE gap less than 10 weeks over 22 years. Compared to international agency reports, 2014–17 empirical LE estimates (males 64.7, females 67.8) were lower, as was IMR. Conclusions Based on empirical data, LE in Fiji has minimally improved over 1996–2017, and is lower than some international agencies report. Adult mortality was higher in Indian than i-Taukei men, and higher in i-Taukei than Indian women. Exclusion of stillbirths resulted in IMRs lower than previously reported. Differing mortality trends in subgroups highlight the need to collect census and health data by ethnicity and sex, to monitor health outcomes and inform resource allocation.

Post-licensure studies to evaluate vaccine impact are an important component of introducing new vaccines. Such studies often rely on routinely collected data but the limitations to these data must be understood. To validate administrative data for use in 10-valent pneumococcal conjugate and rotavirus vaccine impact evaluations we have audited the two electronic database capturing hospital admissions in Fiji for completeness and consistency. Hospital admission data for one week per year between 2007–2011 and 2014–2015 was collected from ward registers for selected hospitals. Ward registers were defined as the reference standard and compared to data captured in electronic databases. Data quality was assessed for completeness of admissions data (percentage of admissions in the electronic database, expressed as sensitivity), consistency of complete reporting (determined by identifying variables associated to complete reporting), and completeness of coding (percentage of admissions in the electronic database with an assigned ICD-10-AM code). Over all hospitals and years, the sensitivity for completeness of admission data was 83% (95% CI: 81.3, 84.6). Consistency of complete reporting varied and was highest at tertiary hospitals using the electronic database (sensitivity: 89.1%, 95% CI: 87.4, 90.7). The overall completeness of coding at tertiary hospitals was 90.8% (95% CI: 90.5, 91.1) with annual and hospital variation. The administrative data in the electronic databases in Fiji are of reasonable quality for the vaccine impact evaluation. This quantification of the missing data can be used to adjust the vaccine impact estimates.

Introduction Food insecurity is associated with inadequate nutrition and increased rates of chronic disease. The primary aim of this study was to assess self-reported food insecurity and the perceived impact of COVID-19 on food security, in two regional districts of Central Fiji, as part of a broader program of work on strengthening and monitoring food policy interventions. The secondary aim was to explore the relationship between food insecurity and salt, sugar and fruit and vegetable intake. Methods Seven hundred adults were randomly sampled from the Deuba and Waidamudamu districts of Viti Levu, Fiji. Interview administered surveys were conducted by trained research assistants with data collected electronically. Information was collected on demographics and health status, food security, the perceived impact of COVID-19 on food security, and dietary intake. Food insecurity was assessed using nine questions adapted from Fiji’s 2014/5 national nutrition survey, measuring markers of food insecurity over the last 12 months. Additional questions were added to assess the perceived effect of COVID-19 on responses. To address the secondary aim, interview administered 24-hour diet recalls were conducted using Intake24 (a computerised dietary recall system) allowing the calculation of salt, sugar and fruit and vegetable intakes for each person. Weighted linear regression models were used to determine the relationship between food insecurity and salt, sugar and fruit and vegetable intake. Results 534 people participated in the survey (response rate 76%, 50.4% female, mean age 42 years). 75% (75.3%, 95% CI, 71.4 to 78.8%) of people reported experiencing food insecurity in the 12 months prior to the survey. Around one fifth of people reported running out of foods (16.8%, 13.9 to 20.2%), having to skip meals (19.3%, 16.2 to 22.9%), limiting variety of foods (19.0%, 15.9 to 22.5%), or feeling stressed due to lack of ability to meet food needs (19.5%, 16.4 to 23.0%). 67% (66.9%, 62.9 to 70.7%) reported becoming more food insecure and changing what they ate due to COVID-19. However, people also reported positive changes such as making a home garden (67.8%, 63.7 to 71.6%), growing fruit and vegetables (59.5%, 55.6 to 63.8%), or trying to eat healthier (14.7%, 12.0 to 18.0%). There were no significant associations between food insecurity and intakes of salt, sugar or fruit and vegetables. Conclusion Participants reported high levels of food insecurity, exceeding recommendations for salt and sugar intake and not meeting fruit and vegetable recommendations, and becoming more food insecure due to COVID-19. Most participants reported making home gardens and/or growing fruit and vegetables in response to the pandemic. There is an opportunity for these activities to be fostered in addressing food insecurity in Fiji, with likely relevance to the Pacific region and other Small Island Developing States who face similar food insecurity challenges.

Background: Global stroke epidemiology is changing rapidly. Although age-standardized rates of stroke mortality have decreased worldwide in the past 2 decades, the absolute numbers of people who have a stroke every year, and live with the consequences of stroke or die from their stroke, are increasing. Regular updates on the current level of stroke burden are important for advancing our knowledge on stroke epidemiology and facilitate organization and planning of evidence-based stroke care. Objectives: This study aims to estimate incidence, prevalence, mortality, disability-adjusted life years (DALYs) and years lived with disability (YLDs) and their trends for ischemic stroke (IS) and hemorrhagic stroke (HS) for 188 countries from 1990 to 2013. Methodology: Stroke incidence, prevalence, mortality, DALYs and YLDs were estimated using all available data on mortality and stroke incidence, prevalence and excess mortality. Statistical models and country-level covariate data were employed, and all rates were age-standardized to a global population. All estimates were produced with 95% uncertainty intervals (UIs). Results: In 2013, there were globally almost 25.7 million stroke survivors (71% with IS), 6.5 million deaths from stroke (51% died from IS), 113 million DALYs due to stroke (58% due to IS) and 10.3 million new strokes (67% IS). Over the 1990-2013 period, there was a significant increase in the absolute number of DALYs due to IS, and of deaths from IS and HS, survivors and incident events for both IS and HS. The preponderance of the burden of stroke continued to reside in developing countries, comprising 75.2% of deaths from stroke and 81.0% of stroke-related DALYs. Globally, the proportional contribution of stroke-related DALYs and deaths due to stroke compared to all diseases increased from 1990 (3.54% (95% UI 3.11-4.00) and 9.66% (95% UI 8.47-10.70), respectively) to 2013 (4.62% (95% UI 4.01-5.30) and 11.75% (95% UI 10.45-13.31), respectively), but there was a diverging trend in developed and developing countries with a significant increase in DALYs and deaths in developing countries, and no measurable change in the proportional contribution of DALYs and deaths from stroke in developed countries. Conclusion: Global stroke burden continues to increase globally. More efficient stroke prevention and management strategies are urgently needed to halt and eventually reverse the stroke pandemic, while universal access to organized stroke services should be a priority.

Background: World mapping is an important tool to visualize stroke burden and its trends in various regions and countries. Objectives: To show geographic patterns of incidence, prevalence, mortality, disability-adjusted life years (DALYs) and years lived with disability (YLDs) and their trends for ischemic stroke and hemorrhagic stroke in the world for 1990-2013. Methodology: Stroke incidence, prevalence, mortality, DALYs and YLDs were estimated following the general approach of the Global Burden of Disease (GBD) 2010 with several important improvements in methods. Data were updated for mortality (through April 2014) and stroke incidence, prevalence, case fatality and severity through 2013. Death was estimated using an ensemble modeling approach. A new software package, DisMod-MR 2.0, was used as part of a custom modeling process to estimate YLDs. All rates were age-standardized to new GBD estimates of global population. All estimates have been computed with 95% uncertainty intervals. Results: Age-standardized incidence, mortality, prevalence and DALYs/YLDs declined over the period from 1990 to 2013. However, the absolute number of people affected by stroke has substantially increased across all countries in the world over the same time period, suggesting that the global stroke burden continues to increase. There were significant geographical (country and regional) differences in stroke burden in the world, with the majority of the burden borne by low- and middle-income countries. Conclusions: Global burden of stroke has continued to increase in spite of dramatic declines in age-standardized incidence, prevalence, mortality rates and disability. Population growth and aging have played an important role in the observed increase in stroke burden.

Background: Accurate information on stroke burden in men and women are important for evidence-based healthcare planning and resource allocation. Previously, limited research suggested that the absolute number of deaths from stroke in women was greater than in men, but the incidence and mortality rates were greater in men. However, sex differences in various metrics of stroke burden on a global scale have not been a subject of comprehensive and comparable assessment for most regions of the world, nor have sex differences in stroke burden been examined for trends over time. Methods: Stroke incidence, prevalence, mortality, disability-adjusted life years (DALYs) and healthy years lost due to disability were estimated as part of the Global Burden of Disease (GBD) 2013 Study. Data inputs included all available information on stroke incidence, prevalence and death and case fatality rates. Analysis was performed separately by sex and 5-year age categories for 188 countries. Statistical models were employed to produce globally comprehensive results over time. All rates were age-standardized to a global population and 95% uncertainty intervals (UIs) were computed. Findings: In 2013, global ischemic stroke (IS) and hemorrhagic stroke (HS) incidence (per 100,000) in men (IS 132.77 (95% UI 125.34-142.77); HS 64.89 (95% UI 59.82-68.85)) exceeded those of women (IS 98.85 (95% UI 92.11-106.62); HS 45.48 (95% UI 42.43-48.53)). IS incidence rates were lower in 2013 compared with 1990 rates for both sexes (1990 male IS incidence 147.40 (95% UI 137.87-157.66); 1990 female IS incidence 113.31 (95% UI 103.52-123.40)), but the only significant change in IS incidence was among women. Changes in global HS incidence were not statistically significant for males (1990 = 65.31 (95% UI 61.63-69.0), 2013 = 64.89 (95% UI 59.82-68.85)), but was significant for females (1990 = 64.892 (95% UI 59.82-68.85), 2013 = 45.48 (95% UI 42.427-48.53)). The number of DALYs related to IS rose from 1990 (male = 16.62 (95% UI 13.27-19.62), female = 17.53 (95% UI 14.08-20.33)) to 2013 (male = 25.22 (95% UI 20.57-29.13), female = 22.21 (95% UI 17.71-25.50)). The number of DALYs associated with HS also rose steadily and was higher than DALYs for IS at each time point (male 1990 = 29.91 (95% UI 25.66-34.54), male 2013 = 37.27 (95% UI 32.29-45.12); female 1990 = 26.05 (95% UI 21.70-30.90), female 2013 = 28.18 (95% UI 23.68-33.80)). Interpretation: Globally, men continue to have a higher incidence of IS than women while significant sex differences in the incidence of HS were not observed. The total health loss due to stroke as measured by DALYs was similar for men and women for both stroke subtypes in 2013, with HS higher than IS. Both IS and HS DALYs show an increasing trend for both men and women since 1990, which is statistically significant only for IS among men. Ongoing monitoring of sex differences in the burden of stroke will be needed to determine if disease rates among men and women continue to diverge. Sex disparities related to stroke will have important clinical and policy implications that can guide funding and resource allocation for national, regional and global health programs.

To assess the performance of an early warning, alert and response system (EWARS) developed by the World Health Organization (WHO) - EWARS in a Box - that was used to detect and control disease outbreaks after Cyclone Winston caused destruction in Fiji on 20 February 2016. Immediately after the cyclone, Fiji's Ministry of Health and Medical Services, supported by WHO, started to implement EWARS in a Box, which is a smartphone-based, automated, early warning surveillance system for rapid deployment during health emergencies. Both indicator-based and event-based surveillance were employed. The performance of the system between 7 March and 29 May 2016 was evaluated. Users' experience with the system was assessed in interviews using a semi-structured questionnaire and by a cross-sectional survey. The system's performance was assessed using data from the EWARS database. Indicator-based surveillance recorded 34 113 cases of the nine syndromes under surveillance among 326 861 consultations. Three confirmed outbreaks were detected, and no large outbreak was missed. Users were satisfied with the performance of EWARS and judged it useful for timely monitoring of disease trends and outbreak detection. The system was simple, stable and flexible and could be rapidly deployed during a health emergency. The automated collation, analysis and dissemination of data reduced the burden on surveillance teams, saved human resources, minimized human error and ensured teams could focus on public health responses. In Fiji, EWARS in a Box was effective in strengthening disease surveillance during a national emergency and was well regarded by users.

Metodos Inmediatamente despues del ciclon, el Ministerio de Salud y Servicios Medicos de Fiji, con el apoyo de la OMS, comenzo a aplicar el sistema EWARS in a Box, que es un sistema de vigilancia de alerta temprana automatizado y basado en telefonos inteligentes para un despliegue rapido durante las emergencias sanitarias. Se recurrio tanto a la vigilancia basada en indicadores como en eventos. Se evaluo el funcionamiento del sistema entre el 7 de marzo y el 29 de mayo de 2016. La experiencia de los usuarios con el sistema se evaluo en entrevistas mediante un cuestionario semiestructurado y una encuesta transversal. El rendimiento del sistema se evaluo utilizando datos de la base de datos EWARS.