INTRODUCTION AND BACKGROUND

Among the highest COVID-19-associated morbidity and mortality rates in the United States are found in non-Native Hawaiian Pacific Islanders (PI), defined as the indigenous people of the three territories of the U.S. Affiliated Pacific Islands (Guam, Commonwealth of the Northern Mariana Islands, and American Samoa) and persons of the sovereign nations that have a Compact of Free Association treaty with the U.S. (the Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau). PI also suffer from higher rates of medical co-morbidities (obesity, hypertension, diabetes, cardiovascular disease) known to increase the risk of poor COVID-19 outcomes. Moreover, PI suffer from poor access to health care, lack medical insurance, live in multi-generational, overcrowded housing, and have low-paying service jobs that put them in frequent contact with the infected public. Hawaii is now experiencing another surge in COVID-19, with a doubling of positive SARS-CoV-2 diagnostic tests from 1% to 2%. From the very onset of COVID-19 in Hawaii, PI have been disproportionately affected, leading all other ethnic groups. The latest figures, available from the Hawaii Department of Health on May 3, 2021, show that while PI comprise only 4% of the State’s population, they account for 20% of COVID-19 cases (Fig. 1), 29% of COVID-19 hospitalizations (Fig. 2), and 22% of COVID-19 deaths (Fig. 3). Of great concern is that many of the COVID-19 cases are among individuals younger than 50 years of age (Fig. 4). On Guam, indigenous CHamoru and immigrant Micronesians represent the majority of COVID-19 cases. These underserved PI communities are in urgent need of culturally appropriate COVID-19 response measures.

Long before the COVID-19 pandemic, PI have been largely invisible and overlooked in the socio-economic fabric and healthcare infrastructure in Hawaii. They have suffered generations-long historical trauma from discrimination, implicit bias, colonialism and poverty. Alarmingly, in recent COVID-19 response efforts, a National Academies draft document on COVID-19 vaccine allocation strategies aimed at racial/ethnic disparities groups does not even mention PI (T. Nguyen, personal communication, 2020). In Hawaii (population, 1,455,271), PI communities have disproportionately borne the brunt of COVID-19. On Guam (population, 168,775), the western-most U.S. territory in the Pacific, the COVID-19 has also predominantly affected the indigenous CHamoru and immigrant Micronesians.

OBJECTIVE AND SPECIFIC AIMS

Our long-term goal is to reduce COVID-19 disparities in PI communities and to protect PI communities against COVID-19. The overall objective of our study is to use culturally derived community engagement strategies to increase the reach, access, acceptance, uptake and sustainability of COVID-19 testing to better understand SARS-CoV-2 infection patterns among PI in Hawaii and on Guam. Our central hypothesis is that the leveraging of culturally appropriate and linguistically correct strategies will increase uptake of COVID-19 testing among PI, resulting in more precise SARS-CoV-2 infection and seroprevalence rates. Our multi-disciplinary investigative team comprises physicians and community health workers who provide care for Samoans, Tongans, Tokelauans, Fijians, Chuukese, Kosraean, Marshallese, Palauans, Pohnpeians, and Yapese in Hawaii and the healthcare workforce who care for CHamoru and Micronesians on Guam; community-engaged researchers from the University of Hawaii (UH) and University of Guam (UOG); and basic and applied scientists from UH and the Department of Public Health and Social Services on Guam. The objective will be achieved by the following specific aims.

Specific Aim 1. Develop and evaluate culturally tailored community-engaged strategies to increase COVID-19 testing among PI in Hawaii and Guam.

Hypothesis: A culturally relevant community-engaged strategy, which addresses psycho-social and cultural barriers, will result in 50% or more uptake of COVID-19 testing among PI who are initially hesitant or refuse.
Approach: (a) Engage PI communities to jointly design a community-tailored strategy with culturally and linguistically appropriate content and materials to promote COVID-19 testing; (b) Implement the strategy through PI community health workers and evaluate if the strategy increases COVID-19 testing participation.

Specific Aim 2: Determine SARS-CoV-2 infection patterns in asymptomatic PI in Hawaii and Guam.

Hypothesis: SARS-CoV-2 infection rate and seroprevalence are higher among PI than other ethnic groups in Hawaii and on Guam.
Approach: (a) Nasopharyngeal swab (NPS) or nasal swab (NS) from asymptomatic adult PI will be tested by RT-PCR and results reported within 48 hours to the study participant and the health authorities in Hawaii and on Guam for contact tracing; community field coordinators will assist COVID-19 test-positive participants to obtain food and temporary shelter; (b) Serum samples will be tested for SARS-CoV-2-specific IgG and IgM.

This RADx-UP community-engaged Testing Research Project will design culturally relevant strategies to mitigate COVID-19 disparities among PI. To recruit people to be screened, we will use Respondent Driven Sampling (RDS), a community-engaged method we have used successfully in PI communities for cancer-screening promotion in Hawaii and Guam. The research team has expertise in diagnostic testing, including sample collection, processing, and analyzing COVID-19 nucleic acid and antibodies. Also, our community-engaged strategies will be implemented using CDC recommended physical distancing and personal protective equipment (PPE) use. Study results will be used as iterative fashion to inform culturally and linguistically relevant strategies to increase COVID-19 testing uptake. And project evaluation results will inform the feasibility, acceptability and scalability of the community-engagement strategies. Strong support letters from the CSAB members, the Lieutenant Governor of the State of Hawaii, the Governor of the Territory of Guam, and the Dean of the medical school attest to the urgency of the project.