Department of Health and Human Services

The Department of Health and Human Services supports and conducts Arctic health research through the Centers for Disease Control and Prevention and the National Institutes of Health.

Centers for Disease Control and Prevention

Arctic research programs of the Centers for Disease Control and Prevention (CDC) are conducted by the National Center for Infectious Diseases (NCID), the National Center for Environmental Health, the National Center for Injury Control and Prevention, and the National Institute of Occupational Safety and Health. These programs represent an excellent example of interagency cooperation and collaboration with the State of Alaska Division of Public Health, the Alaska Native Medical Center (ANMC), the Alaska Area Native Health Service (AANHS) of the Indian Health Service (IHS), local and regional Native health corporations, universities and other state and local agencies and organizations.

National Center for Infectious Diseases

The Arctic Investigations Program (AIP) located in Anchorage, Alaska, is one of the field stations operated by the National Center for Infectious Diseases (NCID). The mission of AIP is the prevention of infectious diseases among residents of the Arctic and sub-Arctic, with a focus on diseases of high incidence and concern among the indigenous populations of these regions and more recently emerging and re-emerging diseases. Research on the prevention and control of infectious diseases in these remote and widely scattered populations with limited resources is accomplished through the development of partnerships with local communities; local regional and Native health organizations; universities; other divisions, programs and centers within CDC; the National Institutes of Health; the Alaska Area Native Health Service; the Alaska Native Medical Center (ANMC); and the State of Alaska. To further increase the participation of American Indian and Alaska Native community members in infectious disease prevention research, priority setting and training opportunities, the first emerging infectious diseases cooperative agreement program was initiated in Alaska in 1997.

The prevention and control of infectious disease uses a strategy that includes the application of traditional and innovative epidemiologic and laboratory methods to determine the etiology of disease, the establishment of surveillance systems to determine diseases rates in the affected population, the identification of risk factors for disease acquisition and transmission, the evaluation of established or new intervention methods, and the implementation, promotion and long-term monitoring of successful prevention and control programs. This approach has been successfully used by AIP for the prevention and control of hepatitis B and Haemophilus influenzae type b in the Alaska Native population. This strategy serves as a model for the prevention and control of other diseases of high incidence in Alaska. As one of CID's three field stations in the U.S., AIP is uniquely positioned to facilitate or augment the development of emerging infections prevention programs, not only in Alaska but also within Arctic populations residing in other circumpolar countries. Priority diseases currently targeted for prevention by AIP in the Arctic include those caused by hepatitis A, B and C, Haemophilus influenzae type b, Streptococcus pneumoniae, respiratory syncytial virus and Helicobacter pylori.

Hepatitis A
Hepatitis A virus (HAV) infection is a major disease problem for Alaska Natives. The disease typically follows a pattern of cyclic recurrences every 10-12 years. The latest statewide epidemic began in late 1986 and peaked in 1988-89. By the end of 1990 the epidemic included over 1100 documented cases of disease in Alaska Natives. However, during 1992 the incidence of disease was again increasing in several areas throughout the state, and the disease peaked again in 1993, with a steady decline since then. The recurrence of village outbreaks depends on the presence of a young susceptible population.

The focus of AIP's HAV Arctic research program has been to understand and describe the population of Alaska Natives susceptible to HAV infection and to test candidate HAV vaccines in the population. Testing of banked serum samples from previous statewide serosurveys for antibody to HAV has enabled assessment of susceptibility to HAV infection. In conjunction with the ANMC and private industry, a study demonstrated the usefulness of one dose of vaccine without concurrent immune globulin in an outbreak setting. In addition, a safety and immunogenicity study of a candidate hepatitis A vaccine was conducted among Alaska Native preschoolers and adults and non-Native adults, and the vaccine is currently undergoing trials in Alaska Native infants. This study has allowed comparisons of various vaccination schedules in children, examination of potential age trends in response to vaccine in Alaska Native adults, and comparisons of Native adults with non-Native adults. A six-year follow-up of this group will enable assessment of antibody persistence.

Hepatitis B
Infection with the hepatitis B virus (HBV) is a serious health problem in many parts of the world. In the Alaska Native population the prevalence of hepatitis B has been very high. In 1982 a collaborative AIP, ANMC and State of Alaska Division of Public Health statewide program was instituted to immunize all susceptible Alaska Natives. Between 1982 and 1987 over 52,000 Alaska Natives were screened for hepatitis B markers, and over 43,000 susceptibles were identified and vaccinated. In the one region of Alaska where surveillance was established prior to the hepatitis B control program and where 90% of susceptibles were vaccinated, the incidence of acute symptomatic hepatitis B cases decreased from 215 cases per 100,000 population to 6 per 100,000 within five years and subsequently has fallen to less than 1% in 1996-97. This demonstrated that community-based mass immunization can effectively reduce acute symptomatic hepatitis B virus infection in at least 90% of susceptible persons in a hyperendemic population.

The hepatitis B control program in Alaska became the first successful program to halt the spread of hepatitis B in a large geographic area. Since it has greatly decreased the number of acute cases of hepatitis B, it is likely that the long-term sequelae such as vasculitis and hepatocellular carcinoma will also decline in this population over time. The strategy used in this program has been integrated into control programs in other countries. The alpha fetoprotein screening program for hepatitis B carriers is a model for hepatocellular carcinoma control in other parts of the world, and the information gathered on the long-term efficacy of the hepatitis B vaccine is being used to develop policies for revaccination schedules. A recent study in conjunction with other divisions of NCID and an Alaska Native corporation determined the prevalence of hepatitis B in six villages in southwest Alaska where routine hepatitis B vaccination was implemented ten years previously. The prevalence of hepatitis B carriage was zero in children 2 to 10 years of age compared to 15% of age-matched controls tested in 1983. This demonstrates that similar results could be accomplished in other endemic areas using childhood vaccination programs. Current research is focusing on long-term follow-up of infants and adults immunized with hepatitis B vaccine and responses to booster immunizations, which will allow recommendations to be developed regarding revaccination schedules.

Hepatitis C
Hepatitis C virus (HCV) is an important cause of morbidity and mortality in the U.S. and many other parts of the world. The prevalence of hepatitis C in the general U.S. population is between 1 and 2%. HCV has also been associated with hepatocellular carcinoma (HCC). Anti-HCV was found in 65, 75 and 86% of patients with HCC, respectively, from Italy, Spain and Japan, areas with a moderate prevalence of HCV in the general population. More importantly, HCC has been associated with end-stage cirrhosis. In the U.S., HCV-associated cirrhosis is the number one reason for liver transplant (OLT). In Alaska Natives, HCV-associated cirrhosis is also the prime reason for referral for OLT. The Alaska Native Medical Center (ANMC) laboratory has identified over 500 persons who are positive for anti-HCV.

In collaboration with the ANMC and the University of Washington Molecular Biology Laboratory, AIP is studying the natural history of HCV in Alaska Natives. The risk factors associated with acquiring HCV and the factors associated with the progression of liver disease are being identified. These factors relate to both the host and the infecting microorganism. The investigation of the HCV virus includes such properties as the viral genotype and the level of virus in the blood. To enable this investigation a retrospective serum bank search is being performed for consenting patients. The earliest and most recent sera that are positive for anti-HCV are sent for testing for HCV-RNA and genotype. In addition, a prospective analysis of patients with HCV will be performed to determine the rate of development of complications such as cirrhosis and hepatocellular carcinoma. In another study, persons with HCV who might benefit by currently licensed anti-viral therapy are being identified. Currently 300 persons are enrolled.

Helicobacter pylori
Helicobacter pylori, one of the most common infections of humans, causes chronic active gastritis and primary duodenal and gastric ulcers. In the general U.S. population the seroprevalence of IgG antibodies to H. pylori is 30-40%, with the rate of seroconversion estimated at 0.5% per year. What appears to be the increasing frequency of seropositivity in older adults in developed countries is mostly due to the cohort effect, with the prevalence of antibody in adults actually reflecting acquisition of disease earlier in life. In developing countries and in lower socioeconomic classes, there is a higher prevalence of infection; seroprevalences often approach 100%, with most persons in these circumstances becoming infected before 10 years of age. Increased transmission of infection occurs in these disadvantaged socioeconomic groups because of crowding or poor hygiene. Although the actual route of transmission is unknown, oral-oral or fecal-oral transmission is suspected. The contamination of drinking water may play a role. Man is the only known reservoir.

Attention focused on H. pylori in Alaska Natives when it was discovered that anemia due to fecal blood loss appeared to be associated with H. pylori. High rates of iron deficiency anemia had been observed among Alaska Natives dating back to the 1950s, despite adequate intake of nutrients offering optimum iron nutrition. Therefore, gastrointestinal blood loss was examined as a cause of anemia, leading to the discovery that 99% of those with increased fecal blood loss had chronic active gastritis due to H. pylori. To determine the prevalence of H. pylori in Alaska Natives, over 2000 serum samples collected in the 1980s in Alaska Native communities were assessed for H. pylori IgG antibodies. Overall, 75% were positive for H. pylori, with rates increasing from 32% among 0- to 4-year-olds up to 86% in those 20 years or older. There was a marked regional variation, which was most pronounced among the youngest children (0-4 years), where rates ranged from 5% in south-central (Anchorage vicinity) to 65% in interior Alaska. Ferritin determinations on the same samples supported an association between H. pylori infection and iron deficiency, especially in those under 20 years of age.

The high rates of anemia, gastritis and gastric cancer in Alaska Natives are likely related to the high rates of infection with H. pylori. The overall impact in terms of the potential health and economic costs resulting from chronic H. pylori infection in this population is still unknown, but it could be substantial. Current research is focused on establishing laboratory-based surveillance systems that allow evaluation of diagnostics, monitoring antimicrobial resistance, determining rates of re-infection following treatment, and determining the extent and clinical impact of this infection on the residents of Alaska.

Streptococcus pneumoniae
Alaska Natives have experienced unprecedented rates of invasive disease due to Streptococcus pneumoniae that are among the highest reported in the world. In southwest Alaska, for example, the annual incidence of invasive pneumococcal disease from 1980 through 1986 was 108 per 100,000 persons per year, and in those over 59 years the age-specific rate was 145 per 100,000. The highest rate was in children under the age of 2 years: 1195 per 100,000. This attack rate in the children under 2 years is twice as high as in Alaska Native children the same age living elsewhere and 20 times the rate for Alaska non-Natives. The incidence and mortality rates of invasive pneumococcal disease among all age groups of Alaska Natives are five times higher than among Alaska non-Natives.

Pneumococcal serotypes associated with invasive disease are also reflected in the organisms carried by healthy individuals. This held true in a 1992 survey of nasopharyngeal carriage isolates from healthy children that were representative of the invasive strains in the region. In addition, the proportion of invasive organisms that were resistant to at least one drug did not differ from the nasopharyngeal isolates from asymptomatic children. Twenty-nine percent of pneumococcal isolates from the nasopharynx of asymptomatic children 5 years old were intermediate or resistant to penicillin. The capsular serotype 6B organism was the etiology of 22% of the invasive disease in infants under 24 months of age from 1982 to 1991, a substantial proportion (77%) of which had intermediate levels of penicillin resistance compared to an expected 4.7% in the U.S. population. Also, all of the multiple-drug-resistant organisms were type 6B.

The case-fatality rate for Alaska Natives with invasive pneumococcal disease is relatively low (8%), the same as the Alaska non-Native rate, and compares favorably with rates of 5-33% elsewhere in the U.S. This is noteworthy considering that the proportion of pneumococcal cases with pneumonia and meningitis is high in Alaska Natives and that this is a remote, isolated population living in a harsh environment with difficult travel.

The reason for the unprecedented rates of pneumococcal disease in the Alaska Native population is not entirely clear, but there appear to be several contributory factors, such as crowded living conditions, poor ventilation and exposure to smoke, which are common conditions in rural Alaska. The emerging type 6B pneumococcus, which exhibits multiple resistance to commonly used antibiotics, coupled with increased use of antibiotics, confers extra risk to the pneumococcal infection problem.

There are potential opportunities for controlling pneumococcal disease in this population by vaccination and by limiting the prescription of antibiotics to those of proven effectiveness. The groups at high risk for invasive pneumococcal disease are at both ends of the age spectrum. Alaska Natives over the age of 55 years are now routinely offered a 23-valent pneumococcal polysaccharide vaccine. However, effective pneumococcal vaccines are not licensed for the high-risk group under 2 years of age. Research is in progress on promising new conjugate pneumococcal vaccines in the Alaska Native population. Research is also underway in educating providers and consumers in the appropriate use of antibiotics to see if this can impact carriage rates of resistant pneumococcal strains.

Haemophilus influenzae
In the 1960s and 1970s Alaska Native children had the highest endemic rates of meningitis in the U.S. Haemophilus influenzae type b (Hib) was the leading cause of the meningitis and of the other invasive infections in these children. The AIP began conducting statewide surveillance for Hib disease in 1980, when the rate of Hib meningitis and all invasive Hib disease in Alaska Native children under 5 years of age was 264 per 100,000 and 601 per 100,000, respectively, and the rate of invasive disease in those under 1 year was 1,700 per 100,000. Subsequent AIP studies have characterized the epidemiology of Hib disease in Alaska. Although the Native population represented only 16% of the population, they experience 51% of all invasive Hib disease in Alaska. The rate of invasive Hib disease in Alaska Native infants in southwestern Alaska was ten times that of non-Natives in Alaska and in the rest of the U.S. Early and intense exposure to Hib increased the risk of Hib disease in the Alaska Native population, and breastfeeding offered protection. The disease was more likely to occur in younger infants, with 25% of all Hib disease and 35% of meningitis occurring before six months of age, compared to 15% and 17%, respectively, in Alaska non-Natives. Alaska Native children also suffered greater neurological morbidity as a result of Hib meningitis than non-Native children.

Believing that active immunization of infants was the most promising way of preventing disease, AIP conducted immunogenicity trials of various Hib vaccines among Alaska Natives beginning in the 1970s, which yielded valuable information on the response to vaccines in this high-risk population. In 1991, universal active Hib vaccination of infants was begun with a Hib conjugate vaccine (PRP-OMP) that AIP had shown to be superior to other Hib conjugate vaccines. It was the only vaccine that induced a response after the first dose, and it also remained the most immunogenic after two doses. Since the age distribution of Hib infections was much younger in Alaska Natives than in the U.S. population, the AIP-generated immunogenicity information was especially important in helping the AANHS and the state choose an appropriate vaccine for routine use. The incidence of invasive Hib disease in Alaska Native children under 5 years, which had reached 75 per year in the 1980s, began to decline dramatically, and by the mid-1990s, incidence had decreased to two to three annually.

In January 1996 the statewide vaccine program replaced the PRP-OMP vaccine, which had been used for five years, with a new combination vaccine of a Hib conjugate component (HbOC) with DTP. Because of the dramatic drop in Hib disease, it was postulated that the decrease was partially attributable to a decrease in nasopharyngeal Hib carriage, and Alaska could safely switch to a different Hib conjugate vaccine. Studies in the U.S. and Finland showed a dramatic decrease in Hib carriage from a prevaccine rate of 3-5% to 0% in Finland and 0.3% in Georgia. In the prevaccine era in Alaska, Hib colonization was as high as 7% in one region and fell to 2% in 1992 in the same region. From 1992 to 1996 there were one to three invasive Hib infections per year in Alaska Native children under 5 years of age. However, between May and June of 1996 there were five cases of invasive Hib disease in Alaska Native children. In response to the increase in invasive Hib disease, AANHS, in consultation with CDC's Division of Bacterial and Mycotic Diseases, recommended that the IHS offer the PRP-OMP Hib conjugate vaccine as an initial dose for Alaska Native infants in high-risk regions, a practice that was also recommended to the American Academy of Pediatrics (AAP) Committee on Native American Child Health. Between January 1, 1996, and September 1997, there were 16 cases of Hib disease in Alaska Native infants. A carriage study was performed in six villages of southwestern Alaska. Among children under 5 years the carriage rate of Hib was 9.5%, indicating that in this highly immunized population, conjugate vaccines had not reduced oropharyngeal carriage of Hib. This study has implications for Hib disease prevention in other countries with high rates of invasive disease caused by Hib.

Respiratory syncytial virus
Respiratory syncytial virus (RSV) is the most important cause of acute lower respiratory infections in infants in the U.S. It occurs in annual outbreaks that usually peak in February and is responsible for one-fourth to one-third of all pediatric hospitalizations for pneumonia and one-half of the hospitalizations for bronchiolitis. Native American children suffer from greater morbidity and mortality from acute respiratory infections in general than other children in the U.S. The mortality from pneumonia for all Native American infants is twice that of infants in the general U.S. population.

Hospitalization rates for RSV disease for Alaska Native children from 1986 through 1992 were ten times higher than for other U.S. populations. An intense review of hospital records for Alaska Native infants from Anchorage and southwestern Alaska helped characterize the epidemiology of the Alaska Native RSV disease. The hospitalized Anchorage infants appeared more similar to those in the general U.S. population than did the infants from the southwest region. For Anchorage infants the peak age of hospitalization was 4.5 months, similar to the U.S. peak age of 2-5 months, but the peak for the southwestern region infants was 2 months. Sixteen percent of the hospitalized children from the southwest were less than 1 month of age, compared to less than 5% for Anchorage Alaska Native and U.S. infants. The more severe disease also occurred in younger infants. Despite the similarities of Anchorage Native infants to the U.S. population, the hospitalization rate for these infants was 33 per 1000, among the highest reported in the world. The rate was even higher in southwestern Alaska, with one in ten infants requiring hospitalization for RSV.

There are known risk factors for serious RSV disease. Young age, prematurity, cardiac disease, chronic pulmonary disease or immunodeficiency increase the risk of complications. Since the dis-ease itself provides limited protective immunity, repeated infections can also occur. Certain environmental conditions also place young infants at increased risk. Environmental smoke has been well documented as a risk factor. The presence of a wood-burning stove increases the risk of Navajo children to lower respiratory illnesses. Passive smoke is also an important risk factor for Alaska Native infants, since 50% of Alaska Native men and women smoke, which usually occurs indoors and especially during the winter months. Another risk factor is crowded households.

A prospective case-control study among Alaska Native infants in southwestern Alaska, carried out by AIP, AANHS, an Alaska Native health corporation, and Johns Hopkins University, has confirmed the increased severity of RSV disease associated with young age and pre-existing medical conditions. The study also demonstrated that the hospitalization for any viral respiratory illness is a risk factor for hospitalization with RSV within the same year. The study also demonstrated that some protection against RSV is afforded by breastfeeding. Assessment of antibody levels suggest a trend that maternal antibody may provide some protection to the younger infant.

National Institute of Occupational Safety and Health

The National Institute of Occupational Safety and Health (NIOSH) found that for the ten-year period between 1980 and 1989, Alaska experi-enced 34.8 worker deaths for every 100,000 workers employed in the state, a rate approximately five times the national rate of 7.0 per 100,000. After identifying Alaska as the highest-risk state in the U.S. for job-related traumatic fatalities, NIOSH responded by establishing a research field station, as part of its Division of Safety Research, in Anchorage in 1991.

The major research questions addressed by the project are:

• How many severe occupational injuries occur in Alaska?
• In which Alaskan industries and occupations do severe occupational injuries occur?
• What risk factors are identifiable for these events?
• Which of these risk factors can be eliminated or mitigated?
• How can this most effectively be accomplished?

The objectives of the program are:

• To characterize and reduce occupational risks in workplaces and industries by using epidemiologic surveillance and analytic methods and engineering hazard and task analysis techniques;
• To establish and refine statewide occupational injury and fatality reporting systems;
• To conduct prevention-oriented research addressing high-risk operations and populations (for example, commercial fishing, air transport and logging);
• To use the on-site location as a "living laboratory" for conducting state-of-the-art injury surveillance, intervention trials and demonstration projects; and
• To promote worker injury prevention technology transfer to and from Alaska.

The NIOSH Alaska Field Station designed and implemented a comprehensive surveillance system for fatal and non-fatal occupational injuries, the Alaska Occupational Injury Surveillance System (AOISS). AOISS obtains risk factor information and permits quantitative epidemiologic analyses to be used for sound public health and prevention planning. The AOISS database contains over 500 fatality records, as well as over 2400 non-fatal injury records from the Alaska Trauma Registry (which is partially supported by Alaska Field Station funds).

The Alaska Field Station has established strong relationships with many other Federal, state, municipal and non-governmental agencies that are engaged in detecting, investigating and/or preventing occupational injuries and fatalities. Included in this group are the jurisdictional agencies overseeing the highest-risk industries in Alaska. These relationships, formalized within the Alaska Interagency Working Group for the Prevention of Occupational Injuries, have fostered injury surveillance, a broader understanding of occupational injuries in the state, and an opportunity to effectively influence the immediate response to emerging occupational injury problems (such as helicopter logging fatalities, drowning from man-overboard events, and occupational homicides) in the state. In addition to surveillance and investigation activities, in-depth studies have been focusing on identifying and reducing risks associated with commercial fishing, logging and air transport in Alaska.

Between 1990 and 1996, 508 Alaskan workers died, an average of one every five days, from job-related injuries, including 160 commercial fishermen, 82 pilots, 44 military personnel, 23 fish processors and 21 loggers. The leading causes of these deaths were drowning (175), aircraft crashes (162), being crushed (44), falls (22), motor vehicle crashes (22) and homicide (21). Many of the deaths were among young people, resulting in over 14,500 worker-years of potential life lost before age 65. The dollar cost to society in lost future productivity (wages) due to these 508 premature, work-related deaths is estimated to be $536,320,000.

Progress
The combined efforts of many agencies and individuals have resulted in the following: Alaska experienced a 30% decline in work-related deaths in 1996 compared to 1991; commercial fishing deaths in 1996 were down 33% from 1991; in 1996, 89% of commercial fishermen survived vessel sinkings/capsizing, whereas in 1991 only 73% survived. NIOSH published Commercial Fishing Fatalities in Alaska: Risk Factors and Prevention Strategies in September 1997 to foster further progress in this area.

For the 18-month period of January 1, 1992, to June 30, 1993, helicopter logging pilots had the highest-risk occupation in Alaska. In July 1993 NIOSH facilitated an interagency intervention that resulted in a marked decrease in helicopter-logging-related fatalities.

As a result of epidemiologic and process analysis of severe injury events, the Alaska Field Station has proposed a number of technological innovations (such as log truck stake extensions and fishing vessel retrofit sponsons) and procedural innovations (such as redundant or fail-safe communications in logging transport operations and encouraging the wearing of personal flotation devices during commercial fishing operations) to improve worker safety in Alaskan industries.

The surveillance technology developed by the NIOSH Fatality Assessment and Control Evaluation (FACE) program has been transferred to the Alaska Department of Health and Social Services (ADHSS), Division of Public Health, Section of Epidemiology, Occupational Injury Prevention Program via the state-based FACE program, with technical assistance and collaboration by the Alaska Field Station.

Alaska Trauma Registry
The following data are for the industry in which hospitalized injuries occurred, as recorded in the Alaska Trauma Registry. In January 1997 the occupation field in the registry was reworked to NIOSH specifications, which will permit future classifications of injuries by occupation as well.

Special Populations: Alaska Natives
Alaska Natives have a drowning rate that is more than 17 times the national average. The NIOSH Alaska Field Station has worked in conjunction with the Alaska Area Native Health Service (AANHS) of the Indian Health Service (IHS) to set up a surveillance system for drowning in Alaska. As part of this effort, Alaska death certificates are reviewed annually to abstract demographic information. Follow-up reports are requested from the state troopers, police departments and medical examiner offices to collect risk factor information such as personal flotation device usage and alcohol involvement. The data from this system are used by the AANHS to evaluate their "floatcoat" programs in the different service units. Alaska Natives have a high drowning rate (particularly young adult males) because the rivers are used as highways in bush Alaska. Dozens of Alaska Natives drown each year, mostly from boating incidents and from breaking through the ice while traveling via snowmobiles. A paper pertaining to drowning in Alaska for 1988-1992 was published in the November/December 1996 issue of Public Health Reports.

The NIOSH Alaska Field Station, in conjunction with the AANHS, has developed a surveillance definition for subsistence activities, including hunting, fishing and trapping. This case definition is being used by the Alaska Field Station, working with the AANHS, to gather subsistence-related injury and fatality information for Alaska Natives. This surveillance for severe subsistence-related injuries and their risk factors in Alaska is forming the basis for future prevention strategies for these events. During 1991-1995, there were 82 subsistence-related injuries requiring hospitalization of Alaska Natives occurring in the following settings: 47 during subsistence hunting, 28 during subsistence fishing, 4 during subsistence whaling, and 3 during subsistence gathering activities. The causes of these injuries included the use of tools and implements such as knives (24), guns (18) and snowmobiles (7), as well as exposure to cold (5). These data have been recently shared with the Alaska Native Epidemiology Center and will be used by AANHS injury practitioners in community-based injury prevention activities.

International and Circumpolar Collaboration
NIOSH Alaska continues its active international collaboration in circumpolar health research through direct interagency relationships and via the Injury Prevention and Occupational Safety and Health Working Groups of the International Union for Circumpolar Health. This collaboration led to a special session on cold injury and hypothermia at the Tenth International Congress on Circumpolar Health in Anchorage in May 1996. From May through August 1996, Juhani Hassi, Director, Oulu Regional Institute, Finnish Institute for Occupational Health (FIOH), was a visiting scientist in the Alaska Field Station. He continued his own research on cold-related injury during his stay. Also, the FIOH began a collaborative effort with the Alaska Field Station to provide technical assistance in occupational injury and hazard surveillance and prevention to the Barents Sea region of northwestern Russia and northern Norway, Sweden and Finland. This led to George Conway, Chief of the NIOSH Alaska Field Station, being detailed to the FIOH for August 1997 to provide technical assistance in injury surveillance and prevention activities and to collaborate in the development of a Barents surveillance agenda and comparative mortality projects. Dr. Conway also provided training in surveillance and epidemiologic techniques to a group of Finnish, Russian and Norwegian scientists in Haukipudas, Finland, in late August 1997. NIOSH has also participated as a co-sponsor in planning for the International Symposium on Problems with Cold Work, held in Stockholm in November 1997.

Conferences and Workshops
The NIOSH Alaska Field Station sponsored helicopter logging safety workshops in 1995, 1996 and 1997 in response to an epidemic of helicopter-logging-related deaths. The workshop proceedings were published and disseminated widely.

The NIOSH Alaska Field Station conducted the Second Fishing Industry Safety and Health (FISH II) Workshop in Seattle, Washington, on November 21-22, 1997. The two-day workshop consisted of presentations from scientists, researchers, regulators, educators, health care providers and commercial fishermen, and from working groups tasked with identifying root causes of specific injuries (fatal and non-fatal) and corresponding countermeasures. The FISH II Workshop presentations and working group recommendations will be published and disseminated through a proceedings volume.

National Center for Environmental Health

Fetal Alcohol Syndrome
Between 1991 and 1995 the National Center for Environmental Health (NCEH), the AANHS and the ADHSS entered into formal agreements to establish the Alaska Fetal Alcohol Syndrome Prevention Project. The project's purpose was to develop a surveillance methodology for fetal alcohol syndrome (FAS) that could be used by other states and countries to provide the epidemiologic data for developing and implementing prevention efforts.

The project, staffed by NCEH personnel, worked closely with ADHSS epidemiologists to link multiple data sources and evaluate the usefulness of each for purposes of FAS surveillance. In all, 16 data sources were used, including data from the Alaska Native Medical Center and from two Alaska Native regional health corporations. Other sources included state programs for children with special needs and state data sets such as Medicaid and vital statistics. The project was also provided access to the hospital discharge data from the state's two largest private hospitals and to the files of two pediatricians in private practice who are considered referral physicians for FAS.

Of the 630 potential cases identified, 568 had medical charts available for review, of which 248 had a chart notation of "FAS," which included "possible FAS," "probable FAS" and "suspect FAS." NCEH and ADHSS epidemiologists used a five-criteria surveillance case definition to ascertain cases. The findings indicate a high prevalence among Alaska Natives; the observed rate is 3.0 per 1000 live births for five-criteria cases and 5.2 per 1000 live births for FAS-noted cases for Alaska Native children born between 1977 and 1992. The 1977-1992 rates for the state's non-Native population were 0.2 per 1000 live births for five-criteria cases and 0.3 per 1000 live births for FAS-noted cases. Project epidemiologists found substantial under-reporting of FAS in each of the 16 data sources examined, indicating that multiple data sources and active screening programs are needed to enhance case ascertainment.

Project staff obtained birth certificate data for 102 cases, which showed that 63% of FAS mothers were not married at the time of delivery, 41% had not completed high school, and 69% had either no prenatal care (33%) or began prenatal care after the first trimester (36%). These mothers are older women, many of whom had previous children. Medical charts and birth certificates documented an average maternal age of 29 +/- 5. In addition, project staff documented that 14 of the mothers gave birth to more than one FAS case, averaging 2.3 FAS children each.

The results of the project's activities have been widely disseminated in Alaska and were presented at the Xth Congress of the International Union for Circumpolar Health in Anchorage in 1996. An FAS Working Group was formed through the International Union after the IXth Congress in 1993. The Working Group received a grant from NCEH to offer a workshop on diagnosing FAS at the Xth Congress to improve case ascertainment among circumpolar nations. In addition, the project's results have been accepted for publication in the Journal of the American Public Health Association.

The state's DHSS commissioner has established a statewide coordinator for the prevention of FAS. The associated risk factors for FAS as documented by the project will be used in developing prevention strategies.

In 1997, NCEH awarded DHSS a five-year cooperative agreement (one of five awarded nationwide) for conducting enhanced surveillance for FAS. In developing the request for proposals for the FAS surveillance cooperative agreements, NCEH addressed the constraints to surveillance documented by the Alaska project. All recipients are required to link multiple data sources and to use the same surveillance case definition. NCEH has also awarded ADHSS a three-year cooperative agreement to develop an Alaska Birth Defects Registry. Enabling legislation has been passed to require reporting specified birth defects, among them FAS, to public health officials. NCEH is providing both financial and direct assistance under the cooperative agreement.

Endocrine Disrupters
The NCEH epidemiologists collaborated with the Indian Health Service, the National Cancer Institute and the Alaska Area Native Medical Center to study the health effects among Alaska Native women exposed to environmental chemicals such as organochlorines, which may act as endocrine disrupters. Some of these chemicals have the potential to mimic female hormones and thus have been theorized to increase women's risks for breast cancer. This was an ideal population for such a study because endocrine disrupters tend to concentrate in colder climates, and many of the women in the study consumed a subsistence diet rich in fish, which contain high levels of several endocrine-disrupting chemicals. For the study, serum samples were analyzed that had been previously collected and stored in the Arctic Investigations Serum Bank. The results of this study will soon be published in the scientific literature.

National Institutes of Health

The National Institutes of Health (NIH) is one of eight health agencies of the Public Health Service, which is part of the Department of Health and Human Services. Comprising 24 institutes, centers and divisions, NIH is headquartered in Bethesda, Maryland, and has satellite facilities in North Carolina, Montana and New Mexico. The NIH's mission is to uncover new knowledge that will lead to better health for everyone. NIH supports research on Arctic-related health issues through grants and contracts to non-Federal scientists and through the projects carried out by scientists in NIH laboratories.

National Institute on Aging

In FY 97 the National Institute on Aging (NIA) initiated funding of a five-year center core grant to establish and maintain the Native Elder Research Center (NERC). The center will be located within the Division of American Indian and Alaska Native Programs of the Department of Psychiatry, School of Medicine, at the University of Colorado Health Sciences Center in Denver. It will serve to incorporate American Indian (AI) and Alaska Native (AN) members and culturally relevant priorities into local systems of health care and aging research processes. The center will also recruit and equip AI/AN investigators for successful research careers at the interface of aging, health and culture. The expected outcome is improved health status and access to care for this special population.

National Institute on Alcohol Abuse and Alcoholism

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is the lead Federal agency responsible for supporting and conducting biomedical and behavioral research on the causes, consequences, treatment and prevention of alcohol-related problems affecting the Nation's health. The NIAAA continues to support research projects in Alaska. In 1994 a five-year grant was awarded to the University of Connecticut Health Center to conduct a collaborative study with the University of Alaska Anchorage to examine the genetic, biological and behavioral characteristics of Native Alaskans receiving treatment for alcoholism. The project has begun its fourth year and has met several objectives. Research assistants who are Alaska Natives have been trained in procedures using standardized methods to obtain clinical assessment and laboratory data. To date, 330 subjects (168 women and 162 men) have been recruited into the study. Preliminary analyses of data collected to date indicate that subjects are typically affected with a very severe form of alcohol dependence. The age of onset of DSM-III-R (alcohol dependence) ranges from 12 to 49 years of age. However, most males have an onset around 18, while the onset age for females is about 20 years of age.

The clinical assessment battery used in this study is identical to that used in the Collaborative Study on Genetics of Alcoholism (COGA), which will contain a sample of approximately 10,000 subjects collected at six sites in the continental U.S. The COGA sample represents a range of alcohol problems and contains a sufficient number of Hispanic and African-American subjects for comparison across different ethnic groups. Comparisons with the sample of Native Alaskans can help to determine if there are specific differences in the development of alcohol problems among these groups.

A second project was supported by a grant awarded to the Prevention Research Center in 1997 to determine whether alcohol availability control can change alcohol-related outpatient visits at the area hospital in an isolated geographic community. Findings from this project, Impact of Banning Alcohol on Outpatient Visits in Barrow, Alaska, were recently published in the Journal of the American Medical Association. During a 33-month period, possession and importation of alcohol were legal, banned, legal again and banned again. Based on review and analyses of outpatient records, there was a substantial decrease in alcohol-related visits during the ban periods. When the ban was lifted, alcohol-related visits showed a substantial increase. In a geographically isolated community, control of alcohol availability may be an effective public health intervention in reducing problems associated with alcohol abuse.

National Institute of Arthritis and Musculoskeletal and Skin Diseases

From 1989 to 1996 the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) supported research on spondyloarthropathies (SpA) in circumpolar populations, through an interagency agreement with the Indian Health Service (IHS) in Anchorage, Alaska. The SpA include Reiter's syndrome, ankylosing spondylitis, reactive arthritis, arthritis associated with inflammatory bowel disease, psoriatic spondylitis, idiopathic seronegative enthesopathy and arthropathy syndrome in children, and undifferentiated SpA. The etiology and pathogenesis of the SpA are poorly understood, although it is clear that both genetic and environmental factors are involved. All spondyloarthropathic diseases appear to be associated to some degree with Class I histocompatibility antigen HLA-B27; some are clearly triggered by infection.

Collaborative studies were conducted with Russian investigators from the Institute of Rheumatology of the Russian Academy of Medical Sciences in Moscow. Over a period of five years, U.S. investigators from the NIAMS and the IHS collected cross-sectional data from Inupiat and Yupik Eskimos in four Alaskan regions, and Russian investigators collected data from four settlements of Siberian Eskimos and Chukchi Indians on the Chukotka Peninsula. Both groups of investigators used the same data collection methods and disease criteria.

The objectives of this project were:

• To determine the prevalence of SpA disorders in circumpolar populations, which are known to have a high frequency of HLA-B27;
• To describe the spectrum of SpA disease, including clinical manifestations, natural history, sequelae and severity; and
• To lay the groundwork for investigating the role of specific genetic and environmental factors in the pathogenesis and expression of the disease.

The prevalence and spectrum of SpA were found to be similar in the U.S. and Russian study populations, and no predisposition to a particular form of spondyloarthropathy was observed. Among adults who were positive for the presence of HLA-B27, the prevalence of all types of SpA was estimated to be 4.5% for all the populations combined, and the prevalence of ankylosing spondylitis was estimated to be 1.6%. In these circumpolar populations the risk of developing ankylosing spondylitis for persons with HLA-B27 appears to be much lower than the rates that have been observed in other Indian populations in different geographic regions. No difference in disease frequency was found between men and women, although women tend to have slightly milder diseases. More research is needed in other defined populations to determine the difference in prevalence for the entire spectrum of spondyloarthropathic diseases.

National Cancer Institute

The National Cancer Institute coordinates the National Cancer Program, which conducts and supports research, training, health information dissemination and other programs with respect to the cause, diagnosis, prevention and treatment of cancer, rehabilitation from cancer and the continuing care of cancer patients and the families of cancer patients. Through a variety of programs, NCI:

• Supports and coordinates research projects conducted by universities, hospitals, research foundations and businesses throughout this country and abroad through research grants and cooperative agreements;
• Supports education and training in fundamental sciences and clinical disciplines relating to cancer through career awards, training grants and fellowships;
• Supports research projects in cancer control;
• Supports a national network of cancer centers;
• Collaborates with voluntary organizations and other national and foreign institutions engaged in cancer research and training activities;
• Encourages and coordinates cancer research by industrial concerns where such concerns evidence a particular capability for programmatic research; and
• Collects and disseminates information on cancer.

Surveillance, Epidemiology and End Results Program
The Surveillance, Epidemiology and End Results (SEER) program is an important component for epidemiologic and surveillance research at the NCI and across the U.S. The SEER program collects and publishes cancer incidence and survival data from ten population-based cancer registries. The geographic areas comprising the SEER program's database represent approximately 14% of the U.S. population. Currently 25% of the American Hispanic population, 41% of the Asian/Pacific Islanders population (43% of all Chinese Americans and 60% of all Japanese Americans), 27% of American Indian and Alaska Native populations, and 12% of the African American population reside in SEER areas.

Over the past several years NCI has funded two interagency agreements with the Indian Health Service, one for the support of the Alaska Native Tumor Registry for the surveillance of the cancer burden among Alaska Natives and an earlier, more complex project to describe not only cancer incidence and mortality in Alaska Natives and American Indians but also the patterns of care, risk factors and cultural entities that form barriers to early detection and treatment. SEER investigators have provided technical assistance to the registry.

The SEER program has recently completed a monograph entitled Racial/Ethnic Patterns of Cancer in the United States 1988-1992, which provides a concise description of the occurrence of the major cancers among most racial/ethnic groups in the U.S. Age-adjusted incidence rates are shown graphically by age group and sex for Alaska Native, American Indian (New Mexico), Black, Chinese, Filipino, Hawaiian, Hispanic, Japanese, Korean, Vietnamese, White (total), White Hispanic, and White non-Hispanic populations. Age-adjusted mortality rates are also shown for these groups, with the exception of Koreans and Vietnamese, for whom national data are not yet available. The SEER program uses mortality data from the National Center for Health Statistics (NCHS) to compare with SEER incidence data.

EBV Expression in Nasopharyngeal Carcinoma
The University of North Carolina Chapel Hill is conducting research to determine the role of the Epstien-Barr virus (EBV) in the etiology of nasopharyngeal carcinoma (NPC), an epithelial malignancy that develops with high incidence in southern China, in northern Africa and among Eskimos. The viral genes that are expressed in NPC include the latent membrane proteins LMP1 and 2 and a new family of mRNAs, transcribed through the BamHI A fragment. Glutathionein transferase fusion proteins will be synthesized to produce monospecific antisera to identify the proteins in transfected cell lines and in NPC tumor tissues. The proteins will be tested for interactions with cellular proteins and for transactivation of the LMP1 promoter. To investigate the high incidence in specific populations and to explore a possible genetic contribution to NPC, additional NPC samples will be obtained from Chinese, Caucasian, Black and possibly Inuit Americans.

Community Clinical Oncology Program
The Virginia Mason Research Center (VMRC) Community Clinical Oncology Program (CCOP) has a component in Anchorage, Alaska. This component allows Alaskans with cancer to have access to the NCI Clinical Trial Network. The VRMC CCOP brings the advantages of state-of-the-art cancer treatment and cancer control trials to patients in metropolitan Seattle and in smaller communities in western Washington and Alaska by strengthening and expanding both the core institution participation in the activities of the CCOP and their relationship with the component institutions, Valley Medical Center (Renton, WA), Evergreen Medical Center (Kirkland, WA), Olympic Memorial Hospital (Pt. Angeles, WA) and Providence and Humana Hospitals (Anchorage, AK), and the physicians who practice in these hospitals.

Data-Based Cancer Intervention Research
The State of Alaska Department of Health and Social Services has entered into a cooperative agreement with NCI to develop a project that will serve as a model of data use in planning and evaluating statewide cancer prevention and control interventions. The specific goals of this project are to:

• Reduce Alaska's age-adjusted cancer mortality rate by 50% by the year 2000;
• Develop and institutionalize a comprehensive cancer prevention and control program in the Alaska Division of Public Health; and
• Assure a mechanism to implement state-of-the-art techniques to translate research findings into public and private practice and to assure that services are available to prevent and control cancer.

Extending over a seven-year period, the project will be accomplished in four phases: data appraisal, planning, implementation of model interventions and evaluation. Priority areas for the initial phase of this project are cessation and prevention of tobacco use, cervical cancer detection and breast cancer detection.

Cancer Risk Assessment
NCI is supporting research at the Mayo Foundation examining the origins of colon cancer among Alaskans. Alaskans have the highest incidence and the highest mortality of colon cancer of any racial/ethnic group in the U.S., and colorectal cancer is one of the leading causes of cancer mortality in the U.S. today. Although the underlying etiology is still not fully understood, it is increasingly apparent that genetic susceptibility plays a prominent role in a subset of these patients. Hereditary non-polyposis colon cancer (HNPCC) may account for the majority of the inherited forms of colon cancer, and it is estimated that as many as 1 out of every 200 individuals in the general population may be a carrier. This frequency makes HNPCC one of the most common inherited genetic disorders in humans. Until recently a strong family history of cancer was the only measure available to the clinician to decide which patients were at great risk. However, two types of molecular genetic markers have recently been identified that may enhance the ability to define colon cancer risk for families and individuals. These include the demonstration of tumor microsatellite instability ("mutator phenotype"), which is indicative of defective DNA mismatch repair, and the direct analysis of the genetic susceptibility loci responsible for this particular phenotype. One of the goals of this research is to determine the frequency of tumor microsatellite instability in an Alaska Native population.

Exposure to Organochlorines in Alaskan Native Females
Recent studies have reported associations between breast cancer and elevated levels of organochlorines (such as DDT and PCBs) in adipose tissue and serum. Alaska Natives may be at increased risk of exposure because their diets are disproportionately high in protein and fat from marine sources established as having high concentrations of organochlorines. Alaskan Natives are covered by a cancer registry and are further defined by the existence of a banked serum repository of samples collected since 1967 in conjunction with a variety of health investigations. NCI, in collaboration with the Centers for Disease Control and Prevention, the Alaska Area Native Health Service and the Indian Health Service, has initiated a pilot study to assess the Alaska Native population, the variability of organochlorine levels in the serum, and the extent and quality of data in the Indian Health Service medical records on known breast cancer risk factors. Components of the pilot study include analyses of previously collected serum samples and a medical records review for 60 breast cancer cases and 60 controls; new collections of serum, urine and adipose tissues from Alaska Native women undergoing breast biopsy/surgery at the Alaska Native Medical Center; and a quality assessment/quality control evaluation beneficial to the Alaska Area Native Health Service. Sera that participating women may have stored in the Indian Health Service/CDC Serum Bank will be acquired and used. These data will be analyzed to determine if the amount of organochlorine chemicals in a woman's serum and adipose tissue is associated with biopsy outcome. Data collected in this pilot project will guide decisions regarding a proposed future full-scale investigation of breast cancer among Alaskan Natives.

National Institute of Child Health and Human Development

The National Institute of Child Health and Human Development (NICHD) continues to support research at the Institute of Arctic Biology, University of Alaska, on the role of the endocrine system in hibernating mammals and on mechanisms by which Arctic ground squirrels spontaneously adopt subzero body temperatures without freezing. Investigations have explored the role of the reproductive endocrine system in influencing the seasonal timing of hibernation, the neural substrates of this system in influencing the seasonal timing of hibernation, and the neural substrates of this system and the role of the circadian clock in controlling the weekly and daily timing of hibernation. The most recent work focused on how decreased brain temperatures in ground squirrels and black bears influence the kinetics of sleep regulation. These studies are the first ever done that make continuous physiological and neurological measurements on bears during hibernation.

National Institute of Diabetes and Digestive and Kidney Diseases

The National Institute of Diabetes and Diges-tive and Kidney Diseases (NIDDK) supports two research grants addressing the health of residents in the Arctic. One is being conducted by the University of Alaska Anchorage. This collaborative research project, entitled Diabetes Prevention in Yupik Eskimos, is designed to determine to what extent intervention can decrease the prevalence of diabetes, hyperinsulinemia and cardiovascular risk factors among Yupik Eskimos living on St. Lawrence Island and the west coast of Alaska. The project would also investigate dietary patterns, physical activity levels and anthropometric data and attempt to correlate these with the occurrence of diabetes, cardiovascular risk factors, diabetes complications and insulin levels. As part of the ongoing Alaska-Siberia Medical Research Program, identical baseline data are being gathered in the population of Yupik Eskimos across the Bering Straits on the Chukotka Peninsula in Siberia.

The age-adjusted prevalence of non-insulin-dependent diabetes mellitus (NIDDM) among Alaska's Eskimos, Indians and Aleuts overall increased 11%, from 15.7 to 17.4 per 1000 over the two-year period from 1985 to 1987. Rates in 1987 varied from 6.7 to 40.8 per 1000 in various Indian Health Service units in Alaska. These estimates are based only on clinically recognized cases. Comparing preliminary rates to Chukotka Natives 15 years and older, the St. Lawrence Island rate is 9.7 per 1000, while the Chukotka rate is 1 per 1000. Since Siberian Yupik Eskimos of Chukotka and Alaska are genetically closely related, one hypothesis is that dietary and lifestyle differences account for the difference in diabetes prevalence. This represents a unique opportunity for research since these populations were essentially one until 1948, when contact ceased due to political reasons, and lifestyles diverged as a result.

A second grant is to the University of Alaska Fairbanks, titled Sympathetically Mediated Gene Activation in Brown Fat. Several factors contribute to the onset of obesity, including molecular imbalances in energy metabolism. Mammals in their native environments are protected from obesity and the cold by adaptive thermogenic survival mechanisms. The objective of this research is to further delineate the relationship between thermogenesis, energy imbalance and obesity by elucidating the control mechanisms underlying the activation of thermogenesis in brown adipose tissue. The major effector of thermogenesis is the brown-adipose-tissue-specific mitochondrial uncoupling protein. The working hypothesis is that several DNA-binding proteins control the onset of thermogenesis following cold exposure by regulating the rate of mitochondrial uncoupling protein gene transcription in brown adipose tissue. By elucidating the signaling mechanisms controlling thermogenesis and energy expenditure, this research will result in a better understanding of defective energy expenditure, energy imbalance and obesity.

National Institute on Drug Abuse

NIDA supports over 85% of the world's research on behavioral, psychological, biological, medical and sociological aspects of drug abuse and addiction, including the correlates and consequences of drug abuse, such as HIV and other infectious diseases, violence and crime.

From 1991 to 1997, NIDA funded a cooperative agreement with the University of Alaska Anchorage (UAA) as part of its AIDS community-based outreach/intervention research program. The objectives of this research project were to monitor the HIV status of injecting drug users and crack cocaine users in Alaska and to evaluate the effectiveness of an innovative, culturally sensitive program in reducing AIDS risk behaviors among drug users relative to the NIDA standard intervention (which consists of four components: street-based outreach, HIV risk reduction education and counseling, HIV antibody testing, and post-test or booster counseling and education). This project extended beyond HIV and studied other medical conditions such as hepatitis and Streptococcus pneumoniae (S. pneumoniae).

Drug users are at high risk for HIV, as well as S. pneumoniae, which can cause pneumonia and meningitis. Drug users participating in the study were encouraged to take the S. pneumoniae vaccine, which can greatly reduce their chances for developing an opportunistic infection if they contract AIDS. The vaccine can also prevent S. pneumoniae in non-HIV-positive drug users.

Important findings from the UAA cooperative agreement project include:

• Female drug users (including Alaska Natives, Whites and Blacks) are at especially high risk of HIV infections, as indicated both by high levels of certain diseases, such as hepatitis B (HBV), and also by various high-risk sexual behaviors.
• With female study participants, for every increase of five sex partners, a woman was 1.4 times as likely to report having had HBV.
• Women with a history of trading sex for money or for drugs were also more likely to report a history of HBV.
• Among women, Alaska Natives were more likely than either Black or White women to report having had gonorrhea or chlamydia.
• Alaska Native women report significantly less use of condoms than any other sex/race group.
• The unique combination of Alaska Native women with White men (a frequent sexual pair in Anchorage) is associated with less condom use.

This latter finding is of particular interest given that the White men (independent of any other sex/ethnic group) being studied are more likely to be injecting drug users (IDUs) and that Alaska Native women have the highest percentage of sex partners who are IDUs.

More recently NIDA funded several new research initiatives at the UAA. These include:

• A study to develop interventions for reducing HBV, HCV and HIV. This is both an efficacy study and a feasibility study design of a two-group randomized clinical trial in which IDUs are assigned to a syringe exchange condition or a pharmacy sales condition. Data to be monitored include the results of urine testing for amphetamines, cocaine metabolites and morphine, as well as serological testing. It is estimated that approximately 80-85% of current injectors are positive for hepatitis C (HCV). Estimates are not yet available regarding the HBV status of current injectors.
• A new fellowship grant that deals with the relationship of HCV and depression among drug users will help to provide a foundation on which effective HCV treatment, intervention and prevention policies can be developed.
• A First Independent Research Support and Transition grant has been awarded to UAA to study the ecologies of risk in order to develop a model to predict and identify subgroups of women and their risk behaviors relative to the use of drugs and condoms.

The NIDA-supported research at UAA has also benefited from UAA's Telemedicine Project, which helps to bridge the great geographic expanse of Alaska in a series of "research at a distance" projects. These projects use desktop video teleconferencing technology to investigate the transformation of epidemiological and health-related research from a model based on physical proximity to one that can be shared over great distances. In collaboration with the NIDA-supported research, the Telemedicine Project is continuing to explore the uses of narrow-band telecommunications and information technology to improve the delivery of health care to all citizens of Alaska.

In other Arctic-related research matters, NIDA staff, in conjunction with National Institute of Allergy and Infectious Diseases staff and Russian counterparts, organized the first U.S.-Russian meeting on Emerging and Reemerging Infectious Diseases (EREIDS). The meeting was held in St. Petersburg, Russia, in December 1996 with the express purpose of developing joint EREIDS research teams comprising scientists from the U.S. and the former Soviet Union (FSU). Support for the meeting was provided by the U.S. (the Fogarty International Center and the NIH Office of AIDS Research), the Civilian Research and Development Foundation for the FSU, and the Russian Ministry of Science. The meeting and collaborative process that came out of it were recognized as an important part of the Vice President Gore/Premier Chernomyrdin accords for greater cooperation between the U.S. and the FSU. The St. Petersburg meeting was also recognized as helping to implement the Presidential Decision Directive on EREIDS, which was released in June 1996 by Vice President Gore and which emphasized greater focus on EREIDS, including focus in an international context. FSU participants at the St. Petersburg meeting included researchers from Siberia and the Russian Far East. Discussions included, but were not limited to, Arctic EREIDS research and future U.S. and FSU collaborations.

Future NIDA Arctic research plans include expanding the substance abuse and health and social consequences research portfolio, including infectious diseases, violence and crime.

National Institute of Environmental Health Sciences

The National Institute of Environmental Health Sciences (NIEHS) supports studies relating to the mechanisms, diagnosis, treatment and prevention of diseases and disorders caused by environmental chemicals and other factors. NIEHS has instituted a number of activities that address the potential human health consequences of environmental contamination for the Alaska Native population. Projects directly related to health include a survey program to identify prenatal exposure to environmental pollutants, a study of the health consequences of methyl mercury exposure, and an environmental justice grant program to establish an environmental awareness program for Alaskan Natives living in the Yukon Flats. In addition, beginning in FY 97, NIEHS has been planning a conference, under the auspices of the Arctic Monitoring and Assessment Program, on environmental biomarkers that will address new methodology for detecting the effects of environmental pollutants in the Arctic and approaches for integrating such measurement into public health programs.

Prenatal Exposure to Environmental Pollutants
The NIEHS is supporting a survey of umbilical cord blood for environmental pollutants among Alaska Natives. Environmental pollutants of major concern among Native people of Alaska are persistent organic pollutants (POPs) and toxic metals, particularly prenatal exposure to methyl mercury. Exposure to the pollutants is from the consumption of traditional foods, particularly marine mammals. The pollutants are persistent in body fats and cross the placenta, resulting in fetal exposure, and they may impair neurological development. The blood samples are collected by the Alaska Department of Health, and analyses are done through an interagency agreement between the NIEHS and the CDC with funding from the NIEHS National Toxicology Program. Analyses of 50 umbilical cord blood samples from a fish-eating population in southeast Alaska to date show increased levels of DDE, a degradative product of the pesticide DDT, in 100% of the samples and increased levels of hexachlorobenzene in 60% of the samples. Other POPs were below the limits of detection. Analyses of these samples is still in progress. Additional umbilical cord blood samples will be obtained in FY 98. Analyses will include POPs, chlorinated hydrocarbons and toxic metals, particularly methyl mercury and lead, both of which are developmental neurotoxicants. Cadmium is also a concern because it accumulates in the kidneys and may produce nephrotoxicity later in life.

The objective of the studies is to determine if prenatal exposure to these toxins is at levels that may impair development. Related NIEHS-supported research projects are focused on determining minimal toxic levels of these pollutants, data that will be applied in evaluating the health risks to Alaska Native children.

Support for Scientists in Alaska
NIEHS has provided the University of Washington Environmental Health Sciences Center with supplemental funding to enable scientists in Alaska to perform mercury analyses of biological samples. This project will equip laboratories with state-of-the-art instrumentation in Fairbanks, train Alaskan investigators in its use and design a population-based study to evaluate hair mercury levels in a subgroup of Alaska Natives. Native peoples of Alaska are at risk from methyl mercury because of their consumption of marine mammals and fish and because of mercury contamination of streams and river sediments as a consequence of gold mining.

Environmental Justice Grant to the University of Alaska
A grant has been awarded to the Council of Athabascan Tribal Governments as part of the NIEHS Environmental Justice Program to establish an environmental awareness program in the Yukon Flats. This area contains 1500 rural residents in scattered, isolated villages distributed over 55,000 square miles. This population is composed of Alaska Natives (Eskimo, Aleut and Indian) who rely on traditional hunting, fishing and trapping for survival. Environmental concerns include radioactive and hazardous wastes at military and mining sites, landfills, and oil spill contamination. This project is surveying communities to form an inventory of environmental health concerns and preparing a community profile for each village. The program provides continuing training for local regional health care providers and environmental health planning and training workshops in the communities' schools. It is also planned to establish a geographic information system for the region to compile existing data on environmental health hazards and develop a capacity to monitor potential hazardous environmental conditions locally. The overall aims are to form partnerships among community members, village-based health providers and environmental health researchers and to empower the villages to conduct assessments and develop and implement prevention strategies.

Conference on Biomarkers
NIEHS, in association with the Arctic Monitoring and Assessment Program (AMAP-2), has proposed an international conference on the role of biomarkers in identifying susceptibility to the health effects of environmental pollutants, especially among Alaska Native populations. The conference will integrate environmental medicine and epidemiology with newer technologies in molecular biology as an approach to identifying the various environmental, cultural and genetic factors that determine the health status of inhabitants of the Arctic.

Arctic populations provide an opportunity to apply new molecular technologies to identify health factors not presently recognized. As Arctic lifestyles undergo change, it is important to identify and pursue research opportunities inherent in this population. There are unique factors in the Arctic climate that enhance exposure and susceptibility to pollutants. While many of the pollutants in the Arctic are common in other climates, the role of subsistence diets is important as a route of exposure, particularly toxic metals and persistent organic pollutants. Nutritional deficiencies may alter susceptibility to health effects. The conference will introduce molecular biomarkers that may be used in epidemiological studies for early detection of health effects and identify genetic polymorphism that has enabled these populations to adapt to the extreme climate and traditional diets. Application of the evolving molecular tools may provide insight as to whether past adaptive changes will influence risk to future lifestyle changes.

National Heart, Lung, and Blood Institute

The National Heart, Lung, and Blood Institute (NHLBI) conducts research on matters relating to the cause, prevention, diagnosis and treatment of heart, blood vessel, lung and blood diseases; the use of blood and blood products and the management of blood resources; and sleep disorders. NHLBI has made an Academic Career Award to the University of Washington Pacific Medical Center to develop and improve the clinical, educational and research activities relating to pulmonary vascular disease in Alaska and the Pacific Northwest. A comprehensive clinical program for the care of patients with primary and secondary pulmonary hypertension will be based in a focused clinic at the University of Washington Medical Center, with multispecialty care facilitated by a nurse coordinator.

University and community physicians are developing local clinical practice guidelines for the evaluation and care of patients with primary pulmonary hypertension and pulmonary hypertension secondary to airflow obstruction and for the prevention, evaluation and treatment of pulmonary thromboembolism. At the School of Medicine, new curriculum elements are proposed, including a problem-based learning exercise in pulmonary hypertension for second-year students and a clinical decision making analysis of prevention of pulmonary thromboembolism in hospitalized patients for third-year students. Opportunities to pursue a project in pulmonary vascular science are also being provided for students involved in the school's Medical Student Research Training Program.

Educational programs are also directed toward housestaff and fellowship trainees at the affiliated hospitals and community physicians throughout the Washington-Alaska-Montana-Idaho region. A regional newsletter is distributed emphasizing progress in pulmonary vascular science and current patient management issues. Communication is increased among individuals conducting clinical and basic research relating to pulmonary vascular disease from several disciplines and affiliated institutions. Pulmonary vascular research is also highlighted annually at a new regional meeting, The John Butler Symposium in Pulmonary Vascular Science, honoring the memory of the founding Pulmonary Division head at the University of Washington and an international figure in the study of the pulmonary circulation.

National Institute of Mental Health

NIMH supports a variety of research projects that have an impact on Arctic populations. The Institute's goals and objectives include support of mental health services research as it relates to Arctic, ethnic, minority and other rural populations. Many of the Arctic mental health research activities supported by NIMH are part of general American Indian and Alaska Native programs. They include:

• Continued support of an American Indian and Alaskan Mental Health Research Center;
• Support of a five-year, large-scale assessment of the prevalence rates for major mental disorders among Native Americans, their mental health service utilization patterns, the impact on psychiatric morbidity of selected risk factors, and the cross-cultural generalization of the results;
• The D/ART (Depression/Awareness, Recognition and Treatment) program; and
• Program announcements on Research on Mental Disorders in Rural Populations and American Indian, Alaska Natives and Native Hawaiian Mental Health Research.

The D/ART program, a public and professional education campaign sponsored by NIMH in collaboration with private organizations and citizens, is based on over 40 years of research on the diagnosis and treatment of depressive disorders. Its goals include the alleviation of symptoms through early intervention and effective treatment for individuals who suffer from depressive disorders. Through a variety of information sessions, health fairs, screenings, referrals and consultation, the program directly reaches approximately 4000 Alaskans each year. Media activities reached an estimated 109,000,000 people. Activities during 1997 included lectures to faculty, Alaska Community Mental Health Services Association, leaders of Anchorage's human service agencies, a grandparents club, church groups, and staff of a senior home health care program. A statewide video teleconference sponsored by the Alaska Mental Health Board featured D/ART and its success in establishing local community support groups. An innovative "talking circle" video conference on women's issues, which involved 181 schools across Alaska, was hosted through the University of Alaska Anchorage. Depression information and screening were part of the conference program.

D/ART staff participated in health fairs at a major business firm and the Mat-Su Community Mental Health Center and sponsors ongoing weekly support groups for people with depression. Depression screening programs and workshops, important elements in D/ART's Alaska-based activities, are offered on National Depression Screening Day and throughout the year, with special efforts planned in the deep winter months following the holiday season. For additional rural outreach, people from rural Alaska received depression information by mail and were referred to local mental health centers for screening. Education materials were shared with village health aides and village priests as well as primary care physicians. Also, a media blitz expanded depression education efforts through television and radio public service announcements, live interview, print articles and print ads that reached over 110,000,000 people.

National Library of Medicine

The mission of the National Library of Medicine (NLM) is to aid in the advancement of medicine and to improve public health through effective dissemination of the results of research. As part of this broad mission, during FY 96 and 97, NLM continued to index and catalog the published reports of health-related Arctic research. In 1996, NLM published a Current Bibliographies in Medicine on American Indian and Alaska Native Health, with over 2000 citations, including many relevant to Arctic health. NLM continued to enhance access by Arctic health researchers and practitioners to the relevant health literature via on-line database services. In June 1997, NLM initiated free access to Medline via NLM's web site, with the intent of improving availability of such information, especially in rural and remote areas such as the Arctic. NLM continued its support of the National Network of Libraries of Medicine, which includes the Pacific Northwest Regional Medical Library at the University of Washington in Seattle and the Alaska Health Sciences Information Service at the University of Alaska Anchorage. Both have a mandate to serve health professionals in Arctic areas.

During FY 96 and 97, NLM supported the University of Washington's Alaska outreach subcontract with the University of Alaska. This project includes ongoing efforts to train Alaskan health professionals in rural and remote areas, including the Arctic, on accessing and using health and medical information resources from a variety of sources. The emphasis is on the use of Internet-based access from remote villages and some regional medical centers and includes site visits as well as telephone and on-line consultation. The villages selected for outreach include Arctic and sub-Arctic sites such as Talkeetna, Healy, Galena, Bethel, Nome and Barrow. Also, the University of Alaska outreach staff participated in the Tenth International Conference on Circumpolar Health and the Sixteenth International Polar Libraries Colloquy, both held in Anchorage.

NLM has initiated two additional projects, through the University of Washington, that will also benefit Arctic Alaska. These include a project that is intended to develop and test a resource book for planning and conducting outreach to health information professionals and users, and a tribal connections project that will analyze and upgrade Internet connectivity in selected American Indian reservations and Alaska Native villages. These projects will help improve the information access training and the Internet connections available to rural health professionals in remote and Arctic Alaska. These will in turn enable health practitioners and researchers in remote areas to communicate more effectively with colleagues throughout the region, the country and the world. Finally, NLM is supporting telemedicine projects at the University of Washington and the University of Alaska. These projects will develop, test and evaluate the use of telecommunications and computers for delivery of medical care and consultations at remote locations, including rural Alaska.

Indian Health Service

The mission of the Alaska Area Native Health Service (AANHS) of the Indian Health Service is to raise the health status of Alaska Natives to the highest possible level. The AANHS is primarily a health care organization. As such, research is clinically oriented, designed to investigate identified problems, and almost always undertaken with other governmental agency and tribal collaborators. Additional activities just getting underway include:

• A pilot study of 50 umbilical cord blood specimens from Alaska Native infants in western Alaska to assess the level of exposure to persistent organic pollutants (POPs) via subsistence food contamination;
• A long-term monitoring program to examine maternal and umbilical cord blood in a yearly sample of Alaska Native residents on the Arctic and Bering Sea coasts to follow trends in POPs and heavy metals and to examine the data for association with child health outcomes; and
• A joint proposal from AANHS, ANEC, the Arctic Slope Native Association and the Institute for Circumpolar Health Studies of the University of Alaska to operate a Children's Environmental Health Center to investigate the health effects of environmental pollutant exposure including prenatal exposure on Alaska Native infants born to residents of the Arctic coast.