89: Fighting COVID-19 in the Pacific

Karl Ensign, ASTHO’s Vice President of Territorial Support, shares lessons learned fighting COVID-19 in the U.S. territories; Kelly Wroblewski, Director of Infectious Disease Programs at the Association of Public Health Laboratories, says labs are...

Karl Ensign, ASTHO’s Vice President of Territorial Support, shares lessons learned fighting COVID-19 in the U.S. territories; Kelly Wroblewski, Director of Infectious Disease Programs at the Association of Public Health Laboratories, says labs are following the increase in the use of at-home COVID-19 test kits; ASTHO has a new blog article detailing steps members have taken to curb housing instability in their jurisdictions; and Jim Blumenstock, ASTHO’s Senior Vice President of Pandemic Response and Recovery, announces his retirement.

Website: Association of Public Health Laboratories

ASTHO Blog Article: Reflections From the Field – Pacific and Atlantic Jurisdictions Remain Resolute Amid Adversity

ASTHO Blog Article: Factoring Housing Into Federal and State Policies to Improve Community Health

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This is Public Health Review Morning Edition for Tuesday, December 21st, 2021. I'm Robert Johnson.

Now, today's news from the Association of State and Territorial Health Officials.


Public health professionals in the territories have been working hard to keep COVID-19 at bay in their island jurisdictions, knowing an outbreak could be tougher to fight in a remote location.

Recently, ASTHO CEO Mike Fraser and Karl Ensign, ASTHO's vice president of territorial support, visited some of the Pacific islands. Ensign tells us what they learned in today's morning conversation.

Why is a robust COVID response so important in a region like the U.S.-affiliated Pacific islands?


Yeah, I think there's several reasons for that in addition to the basic equity issue, that these territories do have U.S. citizens in them, and the Freely Associated States have citizens with a close affiliation with the U.S.—they come here frequently for work without visa restrictions to see family, et cetera.

But really the primary reasons are the significant health disparities within these populations. We have obesity rates that are very high—basically three in four suffer from obesity, and diabetes can approach 30% some of these jurisdictions. So, these co-morbidities put them at really increased odds of negative health consequences associated with COVID-19 and other infectious and non-infectious diseases.

We see that in some of the statewide data in Arkansas, where there's significant numbers of Pacific Islanders: the statewide average death rate per 100,000 was just 11 high; but within Pacific Islanders, it was approaching 2000 per 100,000 people. So, it's clear that these folks really have increased co-morbidities that put them at risk of negative health outcomes.

And thirdly, there's just a limited health infrastructure within these jurisdictions. At the best of times, they struggle to provide just a basic set of services—you have to realize not all jurisdictions can offer basic services, like hemodialysis. They really are struggling with respect to care facilities, equipment, trained personnel; and all specialized services are really provided off-island. And, of course, we know that when people get severely sick with COVID, in a hospital setting they need a specialized services and need them quickly. So, it was really important to have a robust response. I heard one leader say that if COVID were to take off in his jurisdiction, it would be just like tinder—I mean, there there'd be no stopping it. It would burn through the population with really bad consequences.


What lessons have we all learned from the response so far?


Well, I think there's several.

Really what stands out is the importance of regional cooperation and collaboration. We know that infectious disease does not respect geographic boundaries, and we also know that the USAPI entered into a distinct and rather historic collaboration between them, federal agencies, trusted partners, meeting, you know, multiple times per week to not only maintain situational awareness, but put in place some really interesting practices—like a double quarantine, for instance, where they jointly rented hotel space in Honolulu to quarantine folks there before they came into region for another set of quarantine.

So, the goal was really to keep COVID out of the region—that could only be done collectively—and then to pursue effective strategies within region. So, there was the strength that was engendered by working together.

We also learned that just basic prevention-medication strategies are highly effective. I just got back from traveling in the USAPI, and I can tell you mask adherence is extremely high, really approaching 100%. With surges, they are quick to limit gatherings, close schools. They have high vaccination rates. Palau, for instance, is one example of close to 100%. And when we do have surges, such as happened with CNMI and in Guam, we can get on top of it quickly with ongoing surveillance. We can show that community transmission, we can do the contact tracing, we can isolate those individuals, and tamp it down quickly. So, I think just the basic preventative and mitigation strategies, in addition to the regional collaboration, really stand out.


We don't have those sorts of success rates here in the lower 48, for sure.

So, how could this response that you're noting in the islands help others across the states and territories as they continue to wrestle with the virus?


Yeah, you know, that's a really good question, and I think there's a lot to be gained here from looking at them as a case study—the USAPI as a case study—and figuring out where we could improve. And certainly, as you said, the proof is in the pudding. Many of these jurisdictions have remained relatively COVID-free. And when they did experience surges, such as in Guam and Commonwealth of Northern Mariana Island, they responded quickly and effectively.

So can we just say that they're different somehow? Yes and no.

I mean, I think we also have to realize that these jurisdictions are highly dependent on tourism as a basic support for their economy, and that tourism took tremendous hits during this time when many of the jurisdictions effectively closed down or limited their intake of tourists into the jurisdiction. In that sense, the economic hit that these jurisdictions took—that was also a kind of a fear mirrored here in the states, it's very similar—but what we don't see is the politization.

There are differences of opinion about how far these measures should go—and the politics in the USAPI can be severe—but when it comes to basic science about what underlies all of this, there's broad agreement that this is a real threat that needs to be addressed effectively.

And so, you have that undergirding of agreement and being on the same page, too, down in the lower 48. And I think we just need to keep studying what's effective out there and what we can transport here and really realize that some of the basic strategies around the mitigation efforts—prevention and mitigation efforts that public health has been preaching—are, in fact, correct, and they work. And the regional collaboration and setting standards at the federal or national level can be effective as well.


Ensign has written a blog article about the challenges and successes facing the territories during the pandemic.

You can read it using the link in the show notes.


Demand for at-home COVID-19 test kits is growing as the Omicron variant spreads across the U.S. Access to kids has been a priority for the Biden administration.

Kelly Wroblewski is director of infectious disease programs at the Association of Public Health Laboratories. She says labs are following the increase in home testing volume.


It's interesting, and I think time will tell in terms of what the specific impact is. A lot of the president's plan is really focused on home testing or point-of-care testing, and that is not the kind of testing that's typically done in public health labs. So, there is this potential that public health labs could see a decrease in volume.

However, I don't think that's likely. I think we will see some increases in circulation of COVID, and that that will likely lead to still strong testing volumes in public health labs and for lab-based testing. But the home testing is an important development in increasing the frequency with which everybody can be tested.



Officials today also keeping tabs on the impact housing instability has on public health. In January, more than 580,000 Americans were homeless. Even before the pandemic, 18.2 million households were spending more than half of their incomes on housing.

ASTHO has a new blog article on this topic. It includes examples of actions ASTHO members have taken to address aspects of the problem. There's a link to the article in the show notes.


Finally, this morning, after a public health career spanning five decades, Jim Blumenstock, ASTHO's senior vice president of pandemic response and recovery, is retiring. In a recent email to ASTHO members and staff, he express thanks for those who taught and guided him along the way, and appreciation for the opportunity to serve alongside his colleagues. Blumenstock was part of the ASTHO team for 16 years.

Congratulations, Jim, and best wishes for your next adventure.


That'll do it for today's report.


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We're taking the rest December off for the holidays, but we're back in two weeks on Tuesday, January 4th. Be sure to join us then for more ASTHO news and information.


I'm Robert Johnson. You're listening to Public Health Review Morning Edition. Happy holidays.

Karl Ensign

Vice President for Territorial Support, ASTHO

Kelly Wroblewski

Director, Infectious Diseases, Association of Public Health Laboratories