Northern Mariana Islands Research Articles

Opioid misuse and suicide among youth remain pressing public health challenges. This scoping review examined studies published between 2020 and 2024 on associations between opioid misuse and suicidal ideation, suicide attempts, or non-suicidal self-injury (NSSI) among adolescents and young adults aged 12–30, emphasizing sex and racial or ethnic differences. Guided by Arksey and O’Malley’s framework and PRISMA-ScR, we searched MEDLINE (PubMed), PsycINFO, Scopus, Embase, and CINAHL for peer-reviewed cross-sectional studies in English. Eligible studies assessed nonmedical prescription or illicit opioid use and excluded clinical or incarcerated samples and those with older participants. Seventeen studies met the inclusion criteria. Fifteen analyzed U.S. national or state data, one examined youth in the Northern Mariana Islands, and one used Canadian data. Sixteen studies identified a positive association between opioid misuse and suicide-related outcomes, while one showed a recency gradient, with current misuse carrying the highest risk. Other findings showed that frequent misuse increased risk, multiple substance use heightened danger, and females and youth from racial and ethnic minority groups were more vulnerable. Opioid misuse is strongly associated with suicide risk. Integrated, sex- and culturally responsive prevention strategies are needed, alongside further research clarifying mechanisms and protective factors.

Many baleen whale vocalizations are species-, or even population-specific and can be used to monitor their occurrence. Although baleen whale occurrence has been well studied in parts of the Pacific Ocean, little is known about the seasonal distribution of blue and fin whales in the Western Pacific. Since 2010, a more concerted visual and acoustic survey effort has occurred around a very remote region of the western Pacific Ocean: the Northern Mariana Islands. Passive acoustic data were collected at two locations in the Northern Mariana Islands, Saipan and Tinian, from 2015–2017 and they were analyzed for call characteristics and occurrence of blue whale and fin whale calls. Low levels of Central North Pacific blue whale tonal calls were detected year-round with peaks in the winter (December) and summer (June). There was a clear seasonal pattern in fin whale calls (20 and 40 Hz calls), with the majority of detections occurring during winter and spring. Moreover, two unknown low-frequency sounds were detected, one tonal and one pulsed. The former was more common at Tinian and the latter at Saipan. By providing their acoustic features and occurrence patterns, we aim to facilitate future identification of their source. Additionally, the observed seasonal patterns in blue and fin whale call occurrences may offer insights into their movement patterns in this remote region.

The Micronesian Games began in 1969 and have been held every four years since 1990. Participants include five small states (Marshall Islands, Kiribati, Naura, Palau, and the Federated States of Micronesia) and two non-sovereign territories (Guam and the Northern Mariana Islands). These comprise seven of the 50 smallest states in the world, with a combined population of roughly 500,000 people. The Games are a modern, multi-sport event in the Olympic tradition but also represent a microcosm of history, culture, and society in wider Oceania: the programme includes traditional games, for example, coconut tree climbing and va’a canoeing. They are a space for cultural exchange, the maintenance of regional identity, and the building of collaborative diplomatic relations. Importantly, the Games also offer a point of reflection on island societies in the midst of the twin existential crises of climate change and cultural homogenization. Through an island studies approach, we engage with the Micronesian Games to contextualize what sport is and is not in the small island states of Oceania and to argue that the oceanic connectivity of these islands helps promote appreciation of common heritage, presents and futures.

Breast, cervical, and colorectal cancer screening prevalence in the US-Affiliated Pacific Islands.

According to the U.S. Census Bureau (2020), over 1.5 million people identify as Pacific Islander, which establishes this group as one of the fastest growing cultural groups in the United States. However, this population remains underrepresented in discussions about mental health (Borrero et al., 2012) despite their overrepresentation in unaddressed mental health concerns (Seaton et al., 2019). Within this population, there is an absence of literature regarding the mental health perceptions of the Indigenous Pacific Islanders of the Northern Mariana Islands, the CHamoru people. Further, little is known about how CHamoru people use their community strengths to promote wellness. This qualitative study explores the perceptions of mental health and the unique community strengths that exist within the CHamoru community. Utilizing a grounded theory approach, a thematic analysis was conducted with data gathered from 10 semistructured interviews with eight women and two men (Mage = 34.6 years) who identified as adults of CHamoru descent. Participants identified six key themes that are central to their culture and promote overall well-being: (a) embracing historical knowledge, (b) connection to land and language, (c) cultural value of inafa'maolek, (d) cultural value of respetu, (e) spirituality, and (f) ethnic identity exploration. Our findings provide insight about the perceptions of mental health and cultural strengths among CHamoru people, providing a needed foundation for understanding how to deliver mental health services to this population. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

The age-based life history of two commercially important parrotfishes (Labridae: tribe Scarinae) and one goatfish (Mullidae) were characterized based on the commercial nearshore fishery in Saipan, Commonwealth of the Northern Mariana Islands. Age, growth, reproduction, and mortality were derived from fishery-dependent samples using sagittal otoliths and gonads for the stareye parrotfish Calotomus carolinus, pacific bullethead parrotfish Chlorurus spilurus, and yellowfin goatfish Mulloidichthys vanicolensis. All three species had short lifespans of 10 years or less, with a maximum age of 4 years for C. carolinus, 10 years for C. spilurus, and 7 years for M. vanicolensis. All three species had a fast initial growth to terminal body sizes, early maturation, and spawned throughout the year. The age-based demographic information presented here can be used to inform future stock assessments, fisheries management, and population models.

Suicide rates are high in United States (U.S.) Pacific Island Territories, where large numbers of Veterans reside. Yet knowledge of suicidal self-directed violence (SSDV) among Veterans in this region is limited. We examined the feasibility of surveying Veterans in Guam, the Commonwealth of the Northern Mariana Islands (CNMI), and American Samoa regarding suicidal ideation (SI) and non-fatal SSDV, and examined SI and non-fatal SSDV prevalence and associations with SI. Of 3,000 Veterans invited to participate (2022), 566 completed the survey (21.6% response rate). Population-based SI estimates were 35.86% (95% CI: 28.34, 43.39) for lifetime and 15.68% (95% CI: 10.91, 20.44) for past year. The prevalence of post-military and past-year SI was significantly higher among Veterans ages 18–34. SI prevalence was also significantly higher among American Indian/Alaska Native Veterans and was significantly lower among Samoan Veterans. The prevalence of SI and suicide attempts (lifetime and during military service) appeared to be higher among Veterans residing in U.S. Pacific Island Territories, compared to among Veterans in all 50 states, DC, and Puerto Rico; however, these differences were not statistically significant. The most common methods considered during past-year SI were motor vehicle crash (32.77%; 95% CI: 19.38, 46.16), overdose/poisoning (26.12%; 95% CI: 15.02, 37.22), and gunshot (24.30%; 95% CI: 11.98, 36.62). Lifetime prevalence was 11.84% (95% CI: 11.05, 12.62) for preparatory behavior(s), 11.96% (95% CI: 7.88, 16.05) for interrupted attempts, and 9.86% (95% CI: 6.36, 13.37) for suicide attempts. Inclusion of Veterans from Pacific Island Territories in suicide prevention surveillance and research is feasible and vital to inform suicide prevention in this region. Prevention efforts targeted to Veterans ages 18–34 are also warranted.

e18138 Background: Lip, oral, and pharyngeal cancers (LOPC) are significant contributors to the global cancer burden, with notable disparities across regions. Despite advancements in prevention and treatment, global trends indicate a slight overall increase in age-standardized mortality rates (ASMR). In order to address the increasing incidence of these malignancies in susceptible areas and close the healthcare gap causing these disparities, our study highlights the critical need for targeted, region-specific strategies. Methods: The GBD 2021 study's data was analyzed for 204 countries and territories. Age-standardized mortality rates (ASMRs), years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life years (DALYs) were the metrics used. Average annual percent changes (AAPC) values were calculated using linear regression to assess temporal trends. Results: With a global annual percentage change (AAPC) of 0.42(95%CI: 1.25 to -0.42), the global age-standardized mortality rate (ASMR) for lip, oral, and pharyngeal malignancies shows a small increase overall. Cabo Verde (AAPC 8.52), Northern Mariana Islands (AAPC 4.37), and American Samoa (AAPC = 4.15) are the countries with the steepest increase. Nonetheless, Ghana (AAPC = -4.08), Afghanistan (AAPC = -2.84), and France (AAPC = -1.76) are among the countries with a declining pattern. With an AAPC of 0.16 and 0.14, the global DALY and YLL rates showed an increasing trend. The countries with the largest rises were Cabo Verde (DALY: 8.814, YLL: 8.805), American Samoa (DALY: 3.863, YLL: 3.860), while Ghana (DALY-4.263, YLL: -4.268), Afghanistan (DALY: -2.354, YLL: -2.3543) and France (DALY -2.284, YLL: -2.284) recorded the greatest decline. With an AAPC of 1.43, the global YLDs showed an increasing trend; the countries with the greatest increases were Cabo Verde (9.39), the Republic of Korea (4.91), Romania (4.16), and Albania (4.11), while Ghana (AAPC -3.84) and Afghanistan(AAPC -2.36) demonstrated improvement. Conclusions: Despite a minor increase in the worldwide burden of LOPC, regional differences highlight the necessity of focused treatments in high-burden nations. Regional discrepancies are particularly noticeable in African countries; for example, ASMR rates in Ghana and Cabo Verde vary significantly, presumably due to disparities in healthcare access and resource allocation. To lessen the increasing burden in areas that are already at risk, comprehensive policies that address modifiable risk factors, early diagnosis, and equitable access to healthcare are essential. ASMRs, DALYs, YLLs and YLDs for global burden of lip, oral, and pharyngeal cancers (LOPC) between 1990 and 2021. Outcome Global AAPC(95% CI) P-value ASMRs 0.42(1.25to -0.40) 0.31 YLLs 0.14(0.88 to -0.59) 0.70 DALYs 0.16(0.91 to -0.57) 0.65 YLDs 1.43(2.59 to 0.29) 0.015

5109 Background: Prostate cancer (PC) is the most prevalent non-skin cancer among males, and it is increasingly diagnosed in those under 55. This younger demographic often faces more aggressive disease progression and a higher risk of metastasis, driven by genetic predispositions, family history, and racial factors. Methods: Data were systematically collected from the GBD-2021 covering key metrics such as incidence, prevalence, death rates, Disability-Adjusted Life Years (DALY), Years of Life Lost (YLL), and Years Lived with Disability (YLD) across the age group of 20-54 years. Global estimated and stratified data based on 204 regions were further analyzed to assess average annual percentage changes (AAPC) and 95% confidence interval (CI) from 1990 to 2021. Results: There were 2,06,612 deaths due to prostate cancer among those aged 20-54 from 1990-2021. Between 1990 and 2021, the global PC incidence in individuals aged 20-54 increased from 0.82 to 1.55 per 100,000, with an AAPC of 2.03 (CI: 1.65-2.41, p<0.0001). The highest incidence was recorded in Lithuania, Bermuda, and Australia, while Vietnam, Bhutan, and Algeria reported the lowest. Notable AAPC increases were observed in Cabo Verde (7.26, CI: 6.80-7.72, p<0.0001), followed by the Republic of Korea and Vietnam. Conversely, Somalia experienced a significant decline (-1.73, CI: -2.04 to -1.43, p<0.0001). During the same period, the global prevalence of PC rose from 7.18 to 13.94 per 100,000, with an AAPC of 2.13 (CI: 1.75-2.54, p<0.0001). Prevalence trends across countries were similar to incidence trends. Between 1990 and 2021, the global mortality rate for prostate cancer in individuals aged 20-54 rose slightly from 0.37 to 0.41 per 100,000, with an AAPC of 0.20 (CI: 0.07-0.32, p=0.003). Significant increases were observed in Cabo Verde (AAPC 4.24, CI: 3.89-4.58, p<0.0001) and the Northern Mariana Islands. Conversely, Sweden and Luxembourg showed declines, with AAPCs of -2.55 (CI: -3.11 to -1.98) and -2.28 (CI: -2.49 to -2.06), respectively. The highest increases across DALY, YLD, and YLL were observed in Cabo Verde, Zambia, and the Republic of Korea, while Somalia, Sweden, and Luxembourg observed significant declines. Conclusions: There has been a rise in mortality rates among young prostate cancer patients aged 20-54, along with increasing morbidity indicators such as YLD, DALY, and YLL. African countries have consistently noted significant rises in both incidence and mortality rates, while a decline was noted in European countries. This could be attributed to the lack of screening protocols and the inadequacy of treatment. The global incidence and prevalence of prostate cancer in this age group have nearly doubled over the past 30 years. Future research should focus on regional disparities and develop strategies to reduce the impact of this disease on younger populations.

Abstract Introduction Saipan, the largest island in the U.S. Commonwealth of the Northern Mariana Islands (NMI) and home to a predominantly native Pacific Islander population, has a high prevalence of obesity and chronic conditions which increase obstructive sleep apnea (OSA) risk. OSA often goes unrecognized and untreated, especially in minority communities. Additionally, unique craniofacial structures in this population influence the prevalence of OSA and pose challenges for effective management. No prior study has looked at the frequency and characteristics of OSA in this population. We aimed to fill this gap by looking at age, BMI, and sex differences in sleep architecture and OSA frequency. Methods Retrospective cross-sectional analysis of polysomnographic data was collected between 2009-2020, in adults aged 18-82, from the only sleep testing center on the island. Variables including sleep architecture, respiratory variables, demographic data, and Epworth Sleepiness Scale scores were assessed. Statistical analyses included descriptive statistics, group comparisons, and logistic regression. Results Severity and prevalence of apnea was greater in men than women (94 vs 86%). Obstructive apnea index was 3 times higher in men vs women. Mean oxygen saturation was also lower in men vs women. We also redemonstrated the age impact on OSA severity in women with higher AHIs in older women particularly rising around 50 – 59 years old. Conclusion Our findings reveal that males tend to experience more severe forms of OSA compared to females; however, OSA severity in females increases with age, likely due to hormonal fluctuations. This study lays the groundwork for future research to further explore and address OSA in this unique population. Support (if any)

Mitochondrial DNA (mtDNA) analysis is a key tool for defining population structure in marine turtles, due to their strong natal homing behavior, which leads to genetic differentiation among rookeries. However, the widespread occurrence of common haplotypes across large geographic areas, has limited the ability to resolve fine-scale population structure, particularly in the western Pacific. Understanding these population dynamics is crucial for effective conservation and management, as distinct nesting populations may face different threats. This study evaluates the use of whole mitochondrial genome sequencing to improve genetic resolution of population structure and enhance the accuracy of mixed stock analysis (MSA). We analyzed 197 nesting green turtles from six Pacific rookeries, representing two common mtDNA haplotypes (CmP20.1 and CmP22.1). Using mitochondrial capture enrichment and MSA simulations, we detected significant genetic differentiation between the rookeries in Guam and the Commonwealth of the Northern Mariana Islands (CNMI), which were previously considered a single genetic stock based on traditional control region sequencing. Our findings demonstrate that whole mitochondrial genome sequencing enhances stock resolution, improves the accuracy of MSA, and strengthens the ability to determine connectivity between nesting and foraging populations throughout the region. Refining genetics baselines using whole mitogenome sequencing will support more precise conservation strategies, allowing for targeted protection of genetically distinct populations, improved assessments of bycatch impacts, and better-informed management of critical foraging and nesting habitats.

The global burden of mesothelioma and its association with asbestos bans, 1990-2021: a population-based study.

We aimed to present an updated epidemiological overview of headache disorders among children and adolescents, utilizing the latest data from the Global Burden of Disease (GBD) 2021. Large-sample epidemiological studies on headache disorders in children and adolescents have been limited due to their demographic uniqueness, with previous GBD studies rarely focusing on this age group, until the GBD 2021 study provided a significant update. A secondary analysis of headache disorder data from the GBD 2021 for individuals aged 0-<20 years was conducted. The analysis focused on estimating the prevalence, incidence, and disability-adjusted life-years (DALYs), as well as the estimated annual percentage changes (EAPCs). Data from 204 countries and regions, stratified by sociodemographic index (SDI), were included to assess variations in headache disorder metrics across different age groups, sexes, and socioeconomic settings. Between 1990 and 2021, the global prevalence, incidence, and DALYs of headache disorders in children and adolescents rose by 22.79% (95% uncertainty interval [UI] 21.68-23.82%), 5.21% (95% UI 4.26-6.10%), and 24.27% (95% UI 20.35-26.91%) per 100,000 population, respectively. In 2021, 545,824,485 (95% UI 448,777,920-641,644,106) children and adolescents were affected, with a prevalence of 20.71% (95% UI 17.03-24.34%). Migraine affected 205,729,235 (95% UI 158,825,540-265,306,014) with a prevalence of 7.81%, and tension-type headache (TTH) affected 394,543,039 (95% UI 300,611,322-499,598,953) with a prevalence of 14.97%. The DALYs totaled 8,102,465 (95% UI 716,310-19,266,508), with migraine at 7,515,775 (95% UI 486,575-18,715,548), and TTH at 586,690 (95% UI 94,646-2,924,761). The 15-19 years age group had the highest prevalence (41.38%, 95% UI 32.73-50.58%), while the 10-14 years age group had the highest incidence (12.75%, 95% UI 9.09-16.72%). High SDI regions had the highest prevalence and DALYs; however, low-middle SDI regions experienced the fastest growth. Brazil had the highest prevalence (30.55%, 95% UI 26.44-34.65%); India had the most DALYs (1,716,049, 95% UI 138,743-4,051,479); the Northern Mariana Islands had the largest prevalence increase (EAPC 0.97, 95% confidence interval [CI] 0.67-1.26), and Norway had the highest DALYs increase (EAPC 1.31, 95% CI 0.98-1.64). Headache disorders in children and adolescents are emerging as critical public health challenges, especially in regions where resources are limited. It is essential to strengthen public health education and advocate for evidence-based strategies to reduce the burden.

Dissolved metal concentrations in coastal seawater and groundwater in Saipan, Commonwealth of the Northern Mariana Islands, USA.

BackgroundCanine vector-borne diseases (CVBDs) are illnesses caused by pathogens transmitted by blood-feeding arthropods such as ticks and mosquitoes. Many CVBDs, including dirofilariosis, anaplasmosis, and ehrlichiosis, are globally distributed and may cause a variety of clinical signs in dogs. Several CVBD agents are zoonotic, making epidemiological surveillance a joint veterinary and public health effort. In this study, we determined the seropositivity of four pathogens from dogs on Saipan, Northern Mariana Islands, a US Commonwealth located in the western Pacific Ocean.MethodsBlood samples (n = 443) were collected from client-owned, owner surrendered, and shelter dogs that participated in an island-wide spay-and-neuter event in 2023. All samples were assessed using a commercial, point-of-care enzyme-linked immunosorbent assay (ELISA) test (SNAP® 4Dx® Plus, IDEXX Laboratory, Westbrook, Maine, USA) to detect the Dirofilaria immitis antigen and antibodies against Ehrlichia spp., Anaplasma spp., and Borrelia burgdorferi sensu lato. Risk factors were assessed for each pathogen through a univariate analysis, followed by a multivariable logistic regression.ResultsOverall, 66.1% (n = 300/443) of the dogs tested positive for at least one pathogen, with the highest prevalence observed for Ehrlichia spp. (58.0%; n = 246/443), followed by Anaplasma spp. (43.1%; n = 184/443) and D. immitis (14.8%; n = 63/443). Among the dogs with a single pathogen detected (30.9%; n = 137/443), Ehrlichia spp. was most prevalent (64.9%; n = 89/137), followed by Anaplasma spp. (23.3%; n = 32/137) and D. immitis (11.6%; n = 16/137). For co-detection of two or more pathogens (36.7%; n = 163/443), Ehrlichia spp. + Anaplasma spp. presented the highest frequency (70.5%; n = 115/163), followed by Ehrlichia spp. + D. immitis (6.7%; n = 11/163), Anaplasma spp. + D. immitis (3.6%; n = 6/163), and Ehrlichia spp. + Anaplasma spp. + D. immitis (19.0%; n = 31/163). Age (P = < 0.001), residing district (P = 0.001), and ownership status (P = < 0.001) were significantly associated with D. immitis positive status in a univariable analysis. Age (P = < 0.001), residing district (P = 0.177), and ownership status (P = 0.014) were significant in a univariable analysis with Ehrlichia spp. as an outcome. Finally, Anaplasma spp. had a significant association with ownership status (P = < 0.001) as a risk factor in a univariable analysis.ConclusionsThis study shows high seropositivity for CVBPs in a dog population living in a poorly studied area. The results of this study suggest that strategies for the prevention and control of these CVBDs should be reinforced on the Island of Saipan.Graphical

The Children's Healthy Living Center of Excellence (CHL Center) conducted a food cost survey (CHL FCS) in the United States Affiliated Pacific Region (USAPR) that was modified from the United States Department of Agriculture Community Food Security Assessment Toolkit (CFSAT). The CFSAT is based on the 1999 United States Department of Agriculture (USDA) Thrifty Food Plan (TFP). The TFP estimates the cost of consuming a healthy, cost-conscious diet at home and is based on food cost, nutrients in food, nutrition guidance and What We Eat in America (WWEIA). The USAPR is not included in the WWEIA survey. The CFSAT's 87 food items were included in the CHL FCS. The purpose of this study is to describe the availability of the food items in stores within the USAPR and what items were locally produced. In March 2021, food cost data were collected from 92 stores in the jurisdictions of Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawai'i. Most CHL FCS food items were available in at least 1 store in each jurisdiction with a range from 0 to 14 items missing from all stores. The presence of local food items was limited across jurisdictions, ranging from 8 to 27 items. Geographic isolation and small populations affect the availability of food items. Inclusion of the region's cultural and dietary practices in national nutritional guidance is crucial in preserving local food cultures, and the production and consumption of local foods.

The purpose of this study is to determine which countries were the top destinations for laundered funds by Australian-based money launderers between 2000 and 2020. A quantitative methodology using a regression research design was used to assess the attractiveness of each country to Australian-based money launderers during the 2000–2020-time frame. The model findings indicate that Australia, Bermuda, Cayman Islands, French Polynesia, Iceland, Japan, Liechtenstein, Luxembourg, Monaco, New Zealand, Northern Mariana Islands, Norway, Qatar, Singapore, Switzerland, and the United Kingdom were the most appealing countries for Australian money launderers between 2000 and 2020. The results of this inquiry contribute to the existing information on global money laundering patterns by applying the revised Walker-Unger model to ascertain which countries money launderers based in Australia used as funding destinations between 2000 and 2020 and whether there were any changes in the ranks during times of economic slowdown. The revised Walker-Unger model is among the limited number of instruments that can gauge money laundering levels.

Abstract Background and objective Esophageal cancer (EC) is the seventh most prevalent cancer globally and the sixth leading cause of cancer-related mortality. This study aimed to provide an updated stratified assessment of rates in EC incidence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2021 by sex, age, and Socio-demographic Index (SDI) at global, regional, and national levels, as well as to project the future trends of EC both globally and regionally. Methods Data about age-standardized rates (ASRs) of incidence (ASIR), mortality (ASDR), probability of death (ASPoD) and DALYs (ASDALYRs) of EC were obtained from the 2021 Global Burden of Disease (GBD) study. Estimated annual percentage changes (EAPCs) and average annual percentage changes (AAPC) were calculated over certain periods to describe the temporal trends of EC burdens. The analyses were disaggregated by sexes, GBD super-regions and regions, nations/territories, age-groups, and SDI quintiles. A Bayesian age-period-cohort (BAPC) model was constructed to project the global and regional EC ASRs in 2022–2035. Results Despite global reductions in EC ASRs, with ASIR, ASDR, and ASDALYR in 2021 of 6.65 [5.88, 7.45] (95% uncertainty interval), 6.25 [5.53, 7.00], and 148.56 [131.71, 166.82], decreasing by 24.9%, 30.7%, and 36.9% in 1990–2021, respectively, the absolute burden numbers were increased from 1990 to 2021, probably because of population growth and aging. Global newly diagnosed cases, deaths, and DALYs of EC increased to 576,529 [509,492, 645,648], 356,263 [319,363, 390,154], and 12,999,265 [11,522,861, 14,605,268] in 2021, by 62.53%, 51.18%, and 33.28% compared to records in 1990. The geographical pattern of EC was consistent: locations with the highest EC incidence and mortality rates were predominantly located in the Asian Esophageal Cancer Belt and African Esophageal Cancer Corridor, with East Asia, Southern Sub-Saharan Africa, and Eastern Sub-Saharan Africa as the GBD regions with the heaviest EC burdens, and Malawi, Eswatini, Mongolia, Zambia, and Zimbabwe with the most EC ASRs in 2021. However, owing to the population size, China, India, the United States, Japan, and Brazil had the heaviest absolute EC burdens. More pronounced alleviations of ASRs were observed in locations with high SDI levels, indicated by their lower AAPC values compared to those of low-SDI locations, while Sub-Saharan Africa regions had increasing EC ASRs, especially in Chad (114.76% in ASDR, for example), Sao Tome and Principe (97.93%), Togo (92.53%), Northern Mariana Islands (84.32%), Liberia (82.33%), etc. Smoking remained the leading contributor to EC ASDALYR globally and across most GBD super-regions in 2021. The EC burden is significantly heavier for males, with incidence and mortality in males in 2021 being 2.89 and 2.88 times higher, respectively, than in females. Across all age groups, EC posed an increasingly significant threat to men aged &gt; 75 years. From 2022 to 2035, the ASR projections show only modest decrease in both global and regional EC burdens, and the absolute burden numbers are expected to increase globally and in nearly all GBD super-regions. Conclusion EC burden remains significant, with disparities across sexes, age groups, and regions. Region-specific and age-targeted measures are crucial to addressing these inequalities, especially in light of increasing EC burdens in older men and in African regions. Efforts should be taken in finding more solid attributions to risk factors for EC burdens and to better identify high-risk populations to inform targeted prevention and screening, and ultimately reduce the EC burden in an efficient and cost-effective way. Graphical Abstract

Abstract: The United States (US)-China relationship is complicated and economically intertwined. Guam and the Commonwealth of the Northern Marianas (CNMI), two territories of the United States, are caught at the crossroads of the current competition between two great powers—the United States and China. The CNMI is a commonwealth, whereas Guam is an unincorporated territory of the United States. Currently, the US military controls approximately 30 percent of Guam's land, with three major military bases located in the northern and southern parts of Guam. The opposite is true in the CNMI, which has minimal US military presence. Therefore, people framed Guam as the "Tip of the Spear" of the United States in the Western Pacific. These two neighboring US autonomies have different relationships with China. Before the COVID-19 pandemic, the central pillar of the CNMI economy was the tourism industry, significantly driven by the Chinese market. Chinese companies are heavily invested in the CNMI, from mom-and-pop stores to luxurious hotels and casinos. China views Guam as a security threat due to the presence of US military bases. The deteriorating US-China relations will further change the landscape: Chinese propaganda presents China's intention to invade Guam should a China-Taiwan military conflict materialize. The US Senate recently questioned CNMI's close economic ties with China. How will these two US territories align themselves in the US-China conflict? Do Guam and the CNMI have a choice in their positioning? In this article we argue that the current US-China competition serves to reduce the territorial autonomies of Guam and CNMI potentially.

Current literature lacks a recent global analysis of scabies. This study aims to analyze the burden and epidemiological characteristics of scabies using data from the Global Burden of Disease (GBD) 2021 study. The analysis assessed disability-adjusted life years (DALYs), prevalence, and incidence of scabies from 1990 to 2021, stratified by geographic location, socio demographic index (SDI), gender, and age. In 2021, scabies caused 5.3 million DALYs, 206.6 million prevalence, and 622.5 million incidence, primarily affecting children and young people. The burden was heaviest in middle SDI regions and lowest in high SDI regions. Oceania, Tropical Latin America, and East Asia ranked as the top three regions in global scabies burden. Nationally, Fiji, Guam, Tonga, Tuvalu, and Northern Mariana Islands had the highest age-standardised DALY rates. From 1990 to 2021, global age-standardized rates (ASRs) of DALYs, prevalence, and incidence for scabies declined, while the absolute numbers increased. These ASRs showed an upward trend in high and high-middle SDI regions, with significant increases in Central Latin America and high-income North America. Larger burden increases were observed in Sri Lanka, the United States of America, and Mexico compared to other countries and territories. In terms of age, these ASRs increased from 40, particularly for women and the elderly. The global scabies burden was higher in tropical regions, particularly among children and young people, in 2021. Between 1990 and 2021, the burden increased in higher SDI regions, Central Latin America, and high-income North America, warranting focused attention. Additionally, the rising burden among adults over 40, particularly women and the elderly, highlighted the need for targeted interventions.