USVI Public Records

Document text

Community Health Assessment UNITED STATES VIRGIN ISLANDS | DEPARTMENT OF HEALTH MAY 2020 The 2020 United States Virgin Islands Community Health Assessment was produced by the USVI Department of Health in collaboration with community partners and other territorial agencies. This report was produced with funding by the Centers for Disease Control and Prevention (CDC) and technical assistance by the Association of State and Territorial Health Officials (ASTHO). Suggested Citation United States Virgin Islands Department of Health. (April 2020.) 2020 United States Virgin Islands Community Health Assessment. Christiansted, USVI. For More Information Visit doh.vi.gov Photos in this report are within the public domain or licensed for use. USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands St. Croix: (340) 718-1311 | St. Thomas: (340) 774-9000 | St. John: (340) 776-6400 Preface May 2020 We are proud to share with our community members, partners, and the public at large the results of our United States Virgin Islands 2020 Community Health Assessment. This report is the result of the labors of many hands, several conversations, and countless hours of deliberate preparation. A community health assessment presents a comprehensive view of the health of a single community, defined by geography. These pages are full of numbers that describe our people—our Virgin Islander community. Numbers that describe who we are demographically, the health conditions we have, and our context for seeking a healthier life. But we know we are much more than a number on a page. We are a diverse, vibrant people. We care for one another and the people who come to visit our home. The data presented in this report is both cause for celebration and a signal for initiating improvement. Our residents are generally healthy, but we are also a population that is aging. This brings new health challenges to our shores. While we have among the lowest smoking rates in the United States, we also have high rates of obesity among some of our residents. While we have few incidents of violence overall, we have some of the highest rates of homicide and violence, particularly among young men. While our mothers and their infants experience healthy pregnancies and outcomes, disparities by race still persist for black mothers. This report is a starting point to build a better future for every Virgin Islander. By looking back at our experiences and outcomes, we can build a healthier community supported by a robust health care system. Building that future begins now. Sincerely, Justa E. Encarnacion United States Virgin Islands Health Commissioner and Chief Public Health Officer Table of Contents CHAPTER 1 Introduction Background ........................................ 2 Methods ............................................. 4 Contributors ....................................... 9 CHAPTER 2 Public Health & Health Care Systems About the USVI ................................. 13 About the USVI DOH ........................ 13 Access to Care ................................. 16 Funding & Workforce ........................ 19 Preface Health Profile ...................................... i CHAPTER 6 Health Status & Chronic Disease Health Status .................................... 57 Chronic Disease Conditions .............. 58 Cancer .............................................. 62 Cardiovascular Health ....................... 66 Health Behaviors ............................... 66 CHAPTER 4 Births & Reproductive Health Fertility & Births ................................. 34 Healthy Pregnancy ............................ 38 Deliveries & Birth Outcomes ............. 39 CHAPTER 5 Child & Adolescent Health Where Children Live .......................... 45 Child Immunizations .......................... 48 School Readiness & Participation ...... 49 Youth Health Conditions.................... 51 Child & Adolescent Mortality ............. 52 CHAPTER 7 Trauma, Injury & Mental Health Child Maltreatment ............................ 72 Accidents .......................................... 73 Violence ............................................ 75 Suicide .............................................. 77 Mental Health .................................... 78 Appendix ......................................... 107 CHAPTER 9 Mortality & Hospital Care Mortality Trends ................................ 98 Life Expectancy ............................... 102 Premature Mortality ......................... 102 Hospitalizations & Emergency Care . 103 CHAPTER 8 Infectious Diseases Food- & Vector-borne Diseases ......... 83 HIV/AIDS ........................................... 87 Sexually Transmitted Diseases .......... 90 Hepatitis ........................................... 92 Vaccinations ..................................... 93 Emerging Pathogens ......................... 93 CHAPTER 3 Population Characteristics Population Change ........................... 23 Demographic Identity ........................ 25 Socioeconomic Position .................... 29 USVI 2020 CHA | i Health Profile GEOGRAPHY A United States territory since 1917, the U.S. Virgin Islands (USVI) are a group of islands in the Caribbean Sea: St. Croix, St. Thomas, St. John, and Water Island. The USVI is about twice the size of Washington, D.C., totaling 133 square miles. Tourism, trade, and service industries account for three-fifths of the USVI’s gross domestic product. The USVI receives between 2.5 – 3 million visitors each year. Category 5 Hurricanes Irma and Maria, devastated the USVI in 2017 causing extensive damage. POPULATION CHARACTERISTICS The residents of the USVI are a demographically and socioeconomically diverse people. The number of residents, our demographic identities, and our socioeconomic position all influence our health—now and in the future. Population Change The USVI population increased between 1980 – 2000, peaking at 108,642, before declining to an estimated 106,631 in 2019. The percent of residents age 65 and older increased by 37.6% while residents under 20 decreased by 31.6% between 2005 – 2015. AGE TOTAL POPULATION 792.2 Number of people per square mile in 2010 37.8 Median age in 2015 Under 20 31.0% 21.2% 65 or older 12.5% 17.2% 2005 2015 99,636 108,642 106,631 95,000 100,000 105,000 110,000 USVI Community Health Assessment 2020 USVI 2020 CHA | ii Sociodemographics One in five (16.0%) residents identify as Hispanic, and three in four Hispanics (76.4%) report they are of Black race. The number of Black residents decreased from 90,758 in 2005 to 80,559 in 2015, an 11.2% decrease. Unemployment almost doubled from 5.8% in 2008 to 9.9% in 2018 and varied by island. Hispanic residents who also identify as Black 2015 Residents whose primary household language is Spanish 2015 Place of birth | 2015 Completed high school education or more | 2015 UNEMPLOYMENT RACE HEALTHY PEOPLE 2020 LEADING HEALTH INDICATORS The United States tracks progress toward high-priority health indicators. The USVI has made progress toward achieving a healthier community.* Obesity Diabetes Tobacco Smoking Colonoscopy *U.S. and USVI data are 2016 data from the Behavioral Risk Factor Surveillance System 76.4% 14.8% Native 49.9% Mainland US 9.5% Puerto Rico 4.4% Other Carribean 34.3% Elsewhere 2.0% 87.1% 70.2% US USVI 8.8% 7.9% 12.5% 6.9% 15.1% 8.1% 5.9% 4.9% 12.1% 8.6% 0.0% 10.0% 20.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Median St Croix St. Thomas and St. John White 9,995 11,672 Black 90,758 80,559 2005 2015 30.1% 32.2% 30.5% US USVI HP 10.5 % 16.8 % 16.2 % 17.0 % 5.6% 12.0 % 63.3 % 49.9 % 70.5 % USVI 2020 CHA | iii PUBLIC HEALTH & HEALTH CARE SYSTEMS The health and wellness of a population is tied to the capacity and quality of its public health system and its partner: the health care system. Most residents (81.5%) have a source of health insurance, whether public or private, and some (16.4%) delay medical care due to lack of insurance. The USVI is a Geographic High Needs Health Professional Shortage Area. HEALTH INSURANCE DELAYED MEDICAL CARE Number of federally qualified health centers 72 Primary care providers Number of HRSA National Health Service Corps certified sites 78 Dentists BIRTHS & REPRODUCTIVE HEALTH Healthy communities promote healthy pregnancies supported by timely prenatal care and access to appropriate care to minimize pregnancy and delivery complications. USVI birth rates are decreasing in every age group, and teen births dropped by 48.8% in the USVI from 2006 to 2016. Preterm births are trending downward from 15.2% in 2006 to 10.2% in 2016. Births with no prenatal care 2017 Deliveries by caesarean section 2018 TEEN BIRTH RATE PRE-TERM BIRTHS 89.8% 81.5% US USVI 12.1% 16.4% 16.6% 33.0% 41.1 US 20.3 49.6 59.3 USVI 25.4 0.0 30.0 60.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 15.6% 10.2% US 12.8% 9.9% 2006 2016 USVI 2020 CHA | iv CHILD & ADOLESCENT HEALTH Children need support to become healthy adults. Children who grow up in poverty or do not finish high school are more likely to have poor health as adults. Children in the USVI have the lowest rate of measles, mumps, and rubella vaccination in the United States, at 70.5%. The percent of high school students who dropped out of school increased from 5.9% in the 2007-2008 school year to 9.2% in the 2017-2018 school year. Children living in poverty 2015 Children 19 to 35 months with recommended vaccines 2016 MUMPS, MEASLES, RUBELLA IMMUNIZATION HIGH SCHOOL DROPOUT RATE HEALTH STATUS & CHRONIC DISEASE Resident health varies across a number of socioeconomic characteristics, reflecting our diversity and disparities in how healthy we are as a community. Most USVI residents report being in good or better health (79.4%), and a majority (75.7%) engage in health promoting behaviors such as physical activity. Not all adults receive recommended cancer preventive screening. Women aged 50-74 with a mammogram 2016 Adults with good or better health status 2016 Adults with arthritis 2016 476 Number of new cancer cases in 2016 75.7% Adults with physical activity in the past 30 days (2016) 29.6% 45.7% 70.5% 85.7% 91.1% USVI Puerto Rico US 5.9% High School Dropout 9.2% 0.0% 20.0% 2007 - 2008 2008 - 2009 2009 - 2010 2011 - 2012 2012 - 2013 2013 - 2014 2014 - 2015 2015 - 2016 2016 - 2017 2017 - 2018 83.3% 79.4% US USVI USVI 2020 CHA | v TRAUMA, VIOLENCE & MENTAL HEALTH Maintaining positive psychological health and wellness is an important determinant of our physical health. People who experience trauma are at risk for poor health. The rate of death by suicide among adult USVI men has increased by 351.3% over 2005. More than half (59%) of all teen deaths and two-thirds (67%) of male teen deaths are caused by firearms. Adults with self-reported depression 2016 36.0 years Average age at death from motor vehicle accident 2017 PERCENT OF TEEN DEATHS CAUSED BY GUNS SUICIDE RATE PER 100,000 INFECTIOUS DISEASES Remaining free from infectious disease is a major determinant of how healthy we are as a community. Keeping pathogens out of the USVI is a challenge due to our tropical climate and tourism. Zika Disease There was an epidemic of Zika virus beginning in early 2016 that resulted in 2,017 confirmed Zika fever cases, the majority occurring on St. Thomas. ZIKA CASES 5.2% 59% 25% 67% All Female Teens Male Teens 0.0 Female 1.8 3.9 Male 17.6 1.8 All 9.3 0.0 5.0 10.0 15.0 20.0 2005 2006 2007 2008 2009 2010 2011 2012 2015 2016 2017 USVI 2020 CHA | vi HIV/AIDS & Sexually Transmitted Diseases The rate of HIV infection diagnosis decreased by 80.4% from a high of 42.8 per 100,000 people in 2010 to a low of 8.4 per 100,000 people in 2018. The incidence of chlamydia cases in the USVI decreased by 43.7% from a high of 757.2 per 100,000 people in 2011 to 430.7 per 100,000 people in 2017. HIV INCIDENCE CHLAMYDIA INCIDENCE MORTALITY Examining how we die provides clues into how healthy we are as a community. Trends in mortality also tell us how well our health care system is working. The four leading causes of death in the USVI in 2016 were heart disease, cancer, homicide, and unintentional injuries. In 2017, the top cause of premature death in the USVI was homicide, with 2,341.3 years of potential life lost before the age of 75 per 100,000 residents. 78.6 Life expectancy 45 Number of residents who died by homicide in 2016 HOMICIDE RATES OF COUNTRIES WITH HIGHEST RATES YEARS OF POTENTIAL LIFE LOST 28.6 42.8 USVI HIV Diagnosis 8.4 19.5 US HIV Diagnosis 11.4 - 10.0 20.0 30.0 40.0 50.0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 120.6 757.2 Chlamydia 430.7 0 100 200 300 400 500 600 700 800 83.1 56.5 56.3 47.0 44.7 El Salvador Honduras Venezuela, RB Jamaica US Virgin Islands 2,341.3 1,080.8 786.1 515.1 445.6 271.9 207.4 177.7 168.7 77.4 Homicide Heart disease Cancer Perinatal Motor vehicle accidents Suicide Cerebrovascular Diabetes Hypertension Chronic lower respiratory disease USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov USVI 2020 CHA | 1 USVI Community Health Assessment 2020 CHAPTER 1 Introduction BACKGROUND | METHODS | CONTRIBUTORS USVI 2020 CHA | 2 Introduction A health assessment is a snapshot in time of the health status and needs of a community. The community could be a geographic place, like the United States Virgin Islands. But a community is also a group of people with a shared identity. These identities include characteristics like age, race, ethnicity, cultural values, and lived experiences. This chapter presents the process the USVI Department of Health and its partners developed and use to create this assessment. This report is part of a larger effort to improve the health of USVI residents over the next five years. Background What is a Community Health Assessment? One of the primary responsibilities of a public health department is to assess the health of the people it serves. A community health assessment (CHA) is a tool to help public health departments pull together information from many different sources and paint a picture of the health of its community across the many identities of its people. The result is not a complete picture, but a comprehensive look at what we know right now about the health of the community. CHAs review the health of a community at a population level. How many babies were born to all mothers last year? How old were first-time mothers on average? What percentage of mothers delivered their babies full-term, and is that a trend we see in the past few years? These are just some of the questions asked and answered in this report. The answers to these questions not only help our whole community understand ourselves and who we are, but they also tell us where challenges in health might be. This information helps public health and health care professionals pinpoint where intervention and resources might be best targeted to improve community health and wellness. CHAs also examine health and wellness of the population across the lifespan. Assessments of population health almost always include a review of our most basic health indicators: births and deaths. But what happens to us in between? What injuries, diseases, or conditions do we experience? Do we have access to health care services? What kinds of behaviors do we engage in that could help or harm how healthy we are? Because we know health is influenced by so much more than genetic or biological factors, assessments like these also look at health from social, environmental, and economic perspectives. For example, how much education do residents have? Has unemployment changed over the past decade? USVI 2020 CHA | 3 CHA reports are not just written for “professionals.” The information presented in reports like this one belongs to the people who are described within its pages. Reports like this one are intended to be a tool for the community and, in particular, organizations and leaders within those communities who work to improve health. The United States Virgin Islands 2020 Community Health Assessment is a starting place for creating change—change that will enable all Virgin Islanders to pursue their own health regardless of background or socioeconomic circumstance. Assessment Purpose The purpose of the USVI 2020 Community Health Assessment is to inform public health and health care planning and improvement efforts of the USVI Department of Health (DOH) and its partners— including sister government agencies, federal agencies, and local organizations with roles in improving resident health and wellness. Improving the health of our people, including residents and visitors, requires an understanding of how they live and the challenges they face in their daily lives. It also requires we examine what information we might need to better assess the health of our people in the future so that we can improve our data collection and reporting work in the future. Past Assessments The USVI 2020 Community Health Assessment is the first health assessment developed by the DOH in over a decade. In addition to brief surveillance reports, DOH has collaborated with the Centers for Disease Control and Prevention (CDC) and the Federal Emergency Management Agency (FEMA) to assess the needs of residents. The most recent DOH assessment was conducted in partnership with FEMA to assess the impact of Hurricanes Irma and Maria and was published in 2019. A community needs assessment funded by the Community Foundation of the Virgin Islands and conducted by researchers at the Caribbean Exploratory Research Center at the University of the Virgin Islands examined, among other factors, the health needs of children and families in the USVI post Hurricanes Irma and Maria. However, these reports do not review the full spectrum of resident health needs because their purpose is different (e.g., facilitating recovery efforts, impacts of hurricanes). The USVI DOH utilized data collected by the Eastern Caribbean Center (ECC) to assess aspects of resident health and wellness. As the lead for the U.S. Census, the ECC produces the Virgin Islands Community Survey on an annual basis. This survey includes estimates of information included in the American Community Survey. The most recent VICS report presents sociodemographic information about USVI residents from 2015. How to Use This Report The USVI 2020 Community Health Assessment is part of a trio of documents that are intended to set a foundation for a long-term health improvement process, including this report, the USVI DOH Strategic Plan (2020-2025), and the USVI 2020 Community Health Improvement Framework. During that five-year process, it is expected that programs within DOH and their supporting partners USVI 2020 CHA | 4 will refer to and build upon the information presented in this report. We invite our partners to use parts of the reports to facilitate actions such as debate or decision-making. Here are some suggestions for that use: TOPIC-BASED CHAPTERS | The majority of topic areas—births and reproductive health, wellness and disability, infectious disease, etc.—begin with a one-page summary describing the importance of the topic and the major highlights from the assessment. These “one-pagers” can be pulled out of the report and used as briefs to inform public policy debate and decision-making. HEALTH PROFILE | This five-page summary section is a snapshot of all the findings in the USVI 2020 Community Health Assessment. The profile includes visualizations that are infographic in style and are meant to be understood by non-technical audiences. This section can be pulled out and presented to inform discussion in the community. DATA VISUALS | The USVI 2020 Community Health Assessment contains over 100 visuals describing public health and health care data. These visuals are meant to be shared. We invite our partners and members of the community to share them via social media or in community presentations. The USVI 2020 Community Health Assessment will be made available in these shorter formats on the USVI DOH website: doh.vi.gov/cha. Methods Vision Fulfilling the purpose of the USVI 2020 Community Health Assessment is a first step toward reaching DOH’s vision of the future of health in the Virgin Islands: Trusted systems supporting healthy people in healthy communities for a healthy Virgin Islands. This vision, developed collaboratively by leaders and staff from the DOH and vetted by community representatives, is a statement about what we as public health leaders want to achieve for all Virgin Islanders. That vision includes building an integrated public health and health care system that is trusted by those who are supported by it and use its services. Trust begins with transparency, and for the DOH, that means sharing the data we collect on behalf of our residents and the people who visit our shores. USVI 2020 CHA | 5 Guiding Frameworks The overarching framework for the health planning process is the Mobilizing for Action through Planning and Partnerships (MAPP) framework, a community-driven strategic planning process for improving community health developed by the National Association of County and City Health Officials (NACCHO). MAPP is a six-phase process that emphasizes partnership with community representatives and close collaboration with organizations and agencies with responsibility for improving the health and wellness of communities. The MAPP framework was adapted to a territorial context (Figure 1.1). For example, the USVI Department of Health does not have a traditional local public health system with separate local public health departments. Instead, the DOH operates as two health districts: St. Croix and St. Thomas/St. John/Water Island. DOH assessments are generally territorial and less frequently by health district. Figure 1.1 | Framework for the USVI Health Planning Process SOURCE | USVI Department of Health, Adapted from National Association of County and City Health Officials The DOH also considered territorial progress toward meeting the Healthy People 2020 national objectives in the assessment process. The DOH grounded its selection of health indicators using the Leading Health Indicators framework of Healthy People 2020. Leading health indicators are a USVI 2020 CHA | 6 subset of measures that track high-priority health issues that are part of Healthy People 2020. Where data was available, the DOH opted to examine progress toward achieving the 26 leading health indicators across its 12 topic areas of focus: access to health services; clinical preventive services; environmental quality; injury and violence; maternal, infant, and child health; mental health; nutrition, physical activity, and obesity; oral health; reproductive and sexual health; social determinants; substance abuse; and tobacco. Community Health Assessment Process The DOH began working in partnership with the CDC in 2019 to develop a year-long health planning process that would lead to the development of this assessment, a strategic plan, and a framework for community health improvement. As part of this effort, the DOH engaged the Association of State and Territorial Health Officials (ASTHO), a national nonprofit organization that represents and supports public health agencies, to develop a health planning approach and facilitate a series of in- person health planning meetings beginning in October 2019. Territorial Health Commissioner Justa Encarnacion appointed Deputy Commissioner Janis Valmond to lead the health planning process. Commissioner Encarnacion also chartered three workgroups to carry out health planning: the Data Team, the Strategic Planning Workgroup, and the Improvement Workgroup. The Data Team was charged with creating the USVI 2020 Community Health Assessment report, a process which began with an all-day meeting in October 2019 to select health indicators. A timeline of CHA development is presented in Figure 1.2. Between November 2019 and mid-January, the Data Team gathered data for preliminary review of trends. The Data Team began visualizing data and developing the report in February 2020. A draft of the USVI 2020 Community Health Assessment report was reviewed by the Data Team and other key members of DOH staff in March 2020. The Data Team finalized the report in April 2020, and the DOH began sharing its findings with partners and the wider community in early May 2020. Figure 1.2 | USVI 2020 Community Health Assessment Timeline SOURCE | USVI Department of Health *Due to the global COVID-19 pandemic, communication of results of the CHA may be delayed beyond May 2020 USVI 2020 CHA | 7 Health Indicator Selection The Data Team selected data for inclusion in the CHA by engaging in a deliberate process. First, the Data Team created a health indicator inventory of available public health data collected by the DOH, sister territorial agencies, external partner organizations, and national sources. Given the accelerated timeframe of the health planning process, the Data Team prioritized data sources that were accessible by the end of February 2020. The health indicator inventory was prioritized to include the most recent data available within the past 10 years, data quality, alignment with Healthy People 2020’s Leading Health Indicators, and whether there were programs that rely on that health indicator for performance monitoring and quality improvement. The Data Team ranked the initial list of health indicators and then selected five to seven indicators per topic area. The initial topic areas included: Sociodemographics, Maternal and Child Health, Environmental Health, Infectious Disease, Chronic Disease, Mental Health and Addiction, and Trauma and Injury. The final list of health indicators was reviewed and approved by the DOH executive team. Data Sources The CHA contains quantitative data from a variety of sources. The DOH houses the primary public health surveillance information system, which collects information on diseases, conditions, health care utilization, health behaviors among other indicators. Because health is also determined by social and economic factors, many other territorial agencies and organizations collect information that helps us understand the health and wellness of Virgin Islanders. This report synthesizes those collective data sources to tell a comprehensive story about the health of the USVI. Major sources of data used to create this assessment include: U.S. CENSUS AMERICAN COMMUNITY SURVEY The U.S. Census Bureau conducts a census of all U.S. territories every 10 years. Data is published on the U.S. Census Bureau website and is also included in a resource called the International Data Base. This report includes data comparisons with national estimates. There is limited information on the U.S. territories after 2015 except total population estimates. VIRGIN ISLANDS COMMUNITY SURVEY (VICS) The Eastern Caribbean Center at the University of the Virgin Islands conducts the VICS survey as part of the U.S. Census. This includes calculating mid- year annual population estimates by sociodemographic characteristics. The last decennial census occurred in 2010. This assessment includes annual population estimates through 2015. Later data is unavailable due to delays related to Hurricanes Irma and Maria. USVI 2020 CHA | 8 NATIONAL VITAL STATISTICS SYSTEM The USVI DOH maintains an office dedicated to collecting vital statistics information including birth and death certificates. This data is transmitted to the National Vital Statistics System at the National Center for Health Statistics. BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS) The USVI DOH participates in the BRFSS, a series of telephone surveys about health-related risk behaviors, chronic health conditions, and use of preventive services by U.S. residents. COMMUNITY ASSESSMENT FOR PUBLIC HEALTH EMERGENCY RESPONSE (CASPER) The Community Assessment for Public Health Emergency Response is a rapid cross-sectional survey that provides household-level information to public health leaders and emergency managers. The USVI has conducted six CASPERs in the wake of the 2017 Hurricanes Irma and Maria. YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM (YRBS) The USVI does not participate in the national survey that assesses a range of priority health risk behaviors among representative samples of high school students at the national, state, and local levels. However, a survey was conducted in 2018 using the 2017 Youth Risk Behavior Survey and following CDC guidelines for survey implementation. In addition to DOH surveillance and national public health databases, secondary sources of data utilized for this report include:  A post-hurricane needs assessment conducted by the Caribbean Exploratory Research Center and the Community Foundation of the Virgin Islands (February 2019)  The USVI KIDS COUNT Data Book published by the Community Foundation of the Virgin Islands (2019)  The USVI Healthcare Facilities Readiness Assessment (July 2019)  Annual labor and economic statistics published by the USVI Bureau of Economic Research (1990 and beyond) Data Analysis and Interpretation The Data Team gathered measures for each health indicator, examining the most recent data and annual trends as available. Where possible, data is reported by sociodemographic characteristics such as race/ethnicity, age, sex, income, education, and health insurance status in order to assess disparities. Geographic comparisons by islands are made throughout the report, but it should be noted that geographic data is sometimes collected by health district (e.g., St. Croix and St. Thomas/St. John) rather than by island. Data is also compared to national data, where available, and the Healthy People 2020 targets for the leading health indicators. USVI 2020 CHA | 9 Any differences between data comparisons are not statistically significant unless explicitly stated. Data collected through national surveys, such as the BRFSS, are typically subjected to statistical significance testing. However, for this report, we analyzed raw BRFSS data without any adjustment or assessment of statistical significance. As such, the reader should interpret differences across data with caution. Definitions for each indicator are noted by footnote in each figure. The Appendix includes a Glossary of Terms and a key of Abbreviations. This report in general does not interpret the drivers of trends that may be present for a specific health measure. The intent of the report is to provide information so that USVI DOH and its partners can discuss and interpret data together to uncover drivers and develop strategies for improvement. Data Quality One of the major reasons the DOH conducted this assessment was to assess its current surveillance capacity as part of a larger environmental scan. The Data Team gathered available data for the assessment based on the indicators selected and then reviewed gaps. It was expected that there would be some gaps in recent data due to Hurricanes Irma and Maria, which caused extensive structural damage and residential displacement in late 2017. The Data Team also expected there to be additional gaps due to other drivers, including factors such as workforce and technical capacity. Where relevant, the assessment notes these gaps and the effect of missing information on the interpretation of data presented. Some of the major gaps in available data are in vital statistics (2013 and 2014 data), environmental health, trauma and injury, and mental health/addiction. The DOH will use the results of this assessment to inform strategic planning efforts. It is expected that at least one of the strategic priorities for the USVI DOH Strategic Plan, 2020-2025 will focus on enhancing data-driven decisioning-making which will require improvement in public health surveillance capacity and reporting. Contributors A community health assessment is a collaborative effort requiring input and labor from many experts. The DOH is grateful to the following individuals for their participation in the Data Team and for their important contribution to creating the USVI 2020 Community Health Assessment report: Kathleen Arnold-Lewis Director, Chronic Disease and Prevention Lorraine Benjamin-Matthew Director, Vital Records Vernita Bicette Director, Behavioral Health Donna Christensen Public Health Advisor USVI 2020 CHA | 10 Radmur Downing Assistant Director, Vital Records Ruth Dublin Program Administrator, Community Health Clinic, St. Croix Brett Ellis Director, Public Health Laboratory Esther Ellis Territorial Epidemiologist Kathleen Greenaway Director, Maternal and Child Health Wanson Harris Director, Environmental health Jason Henry Director, Infectious Disease Marc Jerome Medical Director/Director, Family Planning Aniah John Executive Assistant, Office of the Commissioner John Orr Program Manager/Data Analyst, Chronic Disease Prevention Program Tesha Plunkett Confidential Aide, Office of the Commissioner Janesta Ritter Director, Public Relations Veronica Rivera-Lopez Certified Tumor Registrar Margaret Sheahan Territorial Coordinator, Family Planning Program Janis Valmond Deputy Commissioner Berlina Wallace Berube Director, Primary Care Office Athenia Williams-Smith Program Administrator, Community Health Clinic, St. Thomas USVI 2020 CHA | 11 USVI Community Health Assessment 2020 CHAPTER 2 Public Health & Health Care Systems ABOUT THE USVI | ABOUT THE USVI DEPARTMENT OF HEALTH ACCESS TO CARE | FUNDING & WORKFORCE USVI 2020 CHA | 12 Public Health & Health Care Systems Five Things You Should Know in 2020  The Department of Health functions as both the state health regulatory agency and the territorial public health agency for the USVI.  In 2016, 81.5% of USVI adults reported having health insurance compared to 89.8% of U.S. adults.  In 2016, 16.4% of USVI adults reported delaying medical care compared to 12.1% of U.S. adults.  Forty-two percent of territory-funded positions and 30% of DOH’s 165 federally- funded positions are vacant.  The USVI is a Geographic High Needs Health Professional Shortage Area. USVI By the Numbers 48 Number of health care facilities in the USVI 26 Number of public health programs run by DOH 2 Number of tertiary care centers 2 Number of federally-qualified health centers 12 Number of certified National Health Services Corps facilities 6,000 Number of clients seen in community health clinics on St. Croix in 2018-2019 72 Number of primary care providers 78 Number of dentists USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 13 Public Health & Health Care Systems The health and wellness of a population is tied to the capacity and quality of its public health system and its partner: the health care system. The USVI is unique compared to mainland U.S. states in that the USVI Department of Health provides both public health and some health care services. This dual role means DOH has a close partnership with health care providers and is responsible for facilitiating access to health care services for residents. This chapter provides a snapshot of the features and capacities of this unique system. About the USVI The United States Virgin Islands (USVI) has been a U.S. territory since 1917. Part of the Leeward Islands of the Lesser Antilles, the USVI are a group of islands situated in the Caribbean Sea 1,100 miles south of Miami, Florida and 43 miles east of Puerto Rico. The USVI is about twice the size of the District of Columbia with a total of 133 square miles and four islands: St. Croix, St. Thomas, and St. John which are the three major islands, and the smaller Water Island. Most of the USVI population lives on either St. Croix, which is the largest of the three major islands, or St. Thomas. Tourism, trade, and service industries account for about three-fifths of the USVI's gross domestic product, and government accounts for about one-fifth. The USVI receives between 2.5 – 3 million visitors each year. The USVI’s geographic position makes its susceptible to climate change and natural disasters. Historically, the USVI experiences a major hurricane every three years. Most recently in September 2017, the USVI was hit by two Category 5 hurricanes, Irma and Maria, within a two-week period. About the USVI Department of Health The USVI Department of Health derives its authority to provide public health services to the people of the Virgin Islands from Title 3, Title 19, and Title 27 of the Virgin Islands Code. The Department of Health functions as both the state health regulatory agency and the territorial public health agency for the USVI. In addition to providing oversight of 26 public health programs, as the lead agency for Emergency Services Function 8 (ESF-8), the department also oversees hospitals during a declared emergency or disaster. USVI 2020 CHA | 14 The DOH’s services are aligned with the Ten Essential Public Health Services which allow the department to fulfill the three core functions of public health: assessment, assurance, and policy development (Figure 2.1). Figure 2.1 | Ten Essential Public Health Services SOURCE | USVI Department of Health Health Facilities There are 48 health care facilities in the USVI (Figure 2.2). There are two main hospitals that serve the needs of Virgin Islanders: the Juan F. Luis Medical Center in St. Croix and the Schneider Regional Medical Center in St. Thomas (Figure 2.3). The Myrah Keating Community Health Center on the island of St. John is affiliated with the Schneider Regional Medical Center on the island of St. Thomas. The DOH provides services from four locations within the territory: The Community Health Clinic at the Schneider Regional Medical Center and the Dr. John S. Moorehead Municipal Hospital Complex in St. Thomas; The Morris F DeCastro Clinic in St. John; and, the Charles Harwood Complex-Modular Buildings in St. Croix. There are two federally-qualified health centers (FQHC) in the USVI. Twelve health care facilities are National Health Service Corps (NHSC) certified by the Health Resources and Services Administration. NHSC certification allows those facilities to apply for USVI 2020 CHA | 15 federal funding to support health care worker training and enables primary care workers to receive subsidies for school loans. Figure 2.2 | USVI Health Care Facilities by Type, 2019 SOURCE | USVI Department of Health, Healthcare Facilities Readiness Report, July 2019 NOTE | FQHC refers to federally qualified health centers; ‘Other’ refers to a private health clinic. Figure 2.3 | Number of USVI Health Care Facilities by Type, 2020 SOURCE | USVI Department of Health NOTE | NHSC refers to a National Health Service Corps certified site; FQHC refers to federally qualified health centers. There is one FQHC on St. Croix, and that FQHC has multiple sites. Several of the NHSC sites are clinical programs within the DOH. 12 2 2 27 2 2 1 NHSC Site Mental Health Residential Facility Hospital Clinics FQHC Dialysis Center Substance Use Disorder Treatment Facility USVI 2020 CHA | 16 Health Programs The DOH operates several public health programs to meet the health needs of Virgin Islanders. These programs include:  Mental Health, Alcoholism, and Drug Dependency Services  Communicable Diseases  Vital Records and Statistics  Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)  Infants and Toddlers Program  Family Planning  Maternal and Child Health & Children with Health Care Needs  Chronic Disease and Prevention  Environmental Health  Professional Licenses and Certificates  Public Health Preparedness  Emergency Medical Services  Epidemiology and Disease Reporting  Public Health Laboratory  Community Health Services  Primary Care Office  Vector Control Program  Immunization More information about the specific services provided by each program is available on doh.vi.gov. Access to Care Health Insurance A majority of USVI adults report having a source of health insurance. In 2016, 81.5% of USVI adults reported having health insurance compared to 89.8% of U.S. adults (Figure 2.4). The percent of adults reporting health insurance coverage was highest for residents who were female, White, non- Hispanic, older age, higher income, and more educated. As of January 31, 2020, 30,493 residents were insured by Medicaid. USVI 2020 CHA | 17 Figure 2.4 | USVI Adults with Health Insurance, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Delayed Medical Care A minority of USVI adults reported that they have had to delay medical care because of cost. In 2016, 16.4% of USVI adults reported delaying medical care compared to 12.1% of U.S. adults (Figure 2.5). The percent of adults reporting delayed medical care was highest for residents who were female, Black, non-Hispanic or Hispanic, age 25 to 34, lower income, and with less education. 81.5% 89.8% 79.1% 83.0% 88.3% 81.4% 74.7% 62.7% 68.2% 69.7% 74.6% 78.9% 94.9% 65.4% 70.3% 83.8% 89.9% 95.7% 72.9% 75.3% 81.3% 92.6% USVI US Male Female White, non-Hispanic Black, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 18 Figure 2.5 | USVI Adults Who Delayed Care Because of Cost in the Past Year, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Community Health Services and Outreach During fiscal year 2018-2019, approximately 6,000 clients were seen in the community health clinics on St. Croix. As of April 30, 2019, when the community health clinic began administration of adult vaccines, approximately 72 clients were served. Clinic staff responded to seven requests for outreach services through the mobile health van, reaching approximately 500 individuals. Additionally, during the 2018 and 2019 agricultural fairs, over 700 individuals were screened, for a total of approximately 7,272 individuals being screened both in clinic and at outreach events. 16.4% 12.1% 14.8% 17.5% 10.4% 15.7% 24.9% 9.4% 32.7% 29.6% 21.6% 18.4% 6.3% 35.0% 20.7% 10.4% 13.3% 7.0% 25.3% 19.1% 16.1% 9.0% USVI US Male Female White non-Hispanic Black non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 19 Funding & Workforce Funding The USVI DOH is funded by both territorial and federal sources. In fiscal year 2020, the USVI DOH proposed a $ 51,591,446 budget, 39.4% of which included federal funds (Figure 2.6). Figure 2.6 | Sources of USVI Department of Health Funding, Proposed Fiscal Year 2020 Budget SOURCE | USVI Department of Health Public Health Workforce Maintaining a trained public health workforce is an ongoing challenge for many of our nation’s public health departments. The DOH’s Fiscal Year 2020 Budget included 401 funded positions, and 235 of those positions are funded by the territorial government. Forty-two percent of territory-funded positions are vacant as of the writing of this report. In addition, just over 30% of DOH’s 165 federally funded positions are vacant. Turnover due to resignations, retirements, and transfers to other agencies have driven vacancies. Long-term vacancies have the potential to affect the agency’s capacity to provide core public health services such as communicable disease prevention, treatment and surveillance. Health Care Workforce Before September 2017, the U.S. Health Resources and Services Administration (HRSA) designated the U.S Virgin Islands as a Geographic High Needs Health Professional Shortage Area (HPSA), indicating a shortage of health providers and services. Currently, the USVI is served by a number of General Fund 54.3% Health Revolving Fund 5.0% Non-Appropriated Funds 1.4% Federal Funds 39.4% USVI 2020 CHA | 20 health care professionals including 72 primary care providers (Figure 2.7). There are 78 dentists and 32 dental hygienists licensed in the USVI. Figure 2.7 | Number of USVI Health Care Professionals by Specialty, 2019 SOURCE | USVI Department of Health 34 22 16 35 19 21 24 9 9 9 5 78 32 Family Medicine Internal Medicine Pediatrics Chiropractor Psychologists Obstetrics & Gynecology Optometry Psychiatry Radiology Surgery Cardiology Dentists Dental Hygenists Primary Care Ancillary Specialty Dental USVI 2020 CHA | 21 USVI Community Health Assessment 2020 CHAPTER 3 Population Characteristics POPULATION CHANGE | DEMOGRAPHIC IDENTITY SOCIOECONOMIC POSITION USVI 2020 CHA | 22 Population Characteristics Five Things You Should Know in 2020  The number of USVI residents peaked at 108,642 in 2000 but declined to an estimated 106,631 residents (-1.9%) by 2019.  The median age of USVI residents increased by 34.0%, from 28.2 years in 1990 to 37.8 years in 2015, following the national trend.  The number of Black residents decreased from 90,758 in 2005 to 80,559 in 2015, an 11.2% decrease.  The overall unemployment rate almost doubled from 5.8% in 2008 to 9.9% in 2018.  A majority of our residents had a high school education or more (70.2%) in 2015 compared to 87.1% of U.S. adults. USVI By the Numbers 4 Number of major inhabited islands 3 in 4 Hispanics who identify as Black Hispanic 11.2% Amount the Black population has decreased between 2005 – 2015 14.8% People whose primary language is Spanish 792.2 Number of people per square mile 49.9% People who were born in USVI 37.8 Median age in 2015 9.9% Unemployment rate in 2018 USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 23 Population Characteristics The health of a place is defined by the character of its people and the spirit of that people in the face of challenges. The people of the United States Virgin Islands are in a state of recovery following two Category 5 hurricanes, but we are striving to thrive and move into the future. This chapter defines our basics—our number, our demographic identities, and our socioeconomic position. It is a beginning to understanding who we are, our resiliency, and our potential for a bright future. Population Change Population Size The residential population of the U.S. Virgin Islands has changed in number over the course of the last thirty years. The USVI population has occasionally been affected by the occurrence of natural disasters and other significant historical events. Since 1980, there has been a 7.0% overall increase in the USVI population size. There was a 9.0% increase in population alone between 1980 – 2000 despite the devastation caused by Hurricane Hugo in 1989 (Figure 3.1). The number of USVI residents peaked at 108,642 in 2000 but declined to an estimated 106,631 residents (-1.9%) by 2019. This decrease in population after 2000 occurred after two major events in USVI history: the closure of the St. Croix Hovensa-owned refinery in early 2012 and Hurricanes Irma and Maria in late 2017. Figure 3.1 | Estimated Number of USVI Residents, 1980-2019 SOURCE | U.S. Census Bureau, International Data Base 99,636 108,642 106,631 95,000 100,000 105,000 110,000 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 USVI 2020 CHA | 24 Following overall population trends, the number of residents living on each island has remained consistent over the last several decades. St. Croix, which at 84.17 square miles is the largest of the USVI’s four main islands, is home to almost half of all residents with an estimated 48,502 residents living there in 2015 (Figure 3.2). St. Thomas is physically smaller than St. Croix (32.00 square miles) but has a similar number of residents (48,425 in 2015). At 19.61 square miles, St. John had an estimated 3,841 residents in 2015. Water Island, the youngest of the USVI’s four islands having been transferred to the local government in December 1996, is also the smallest island at just 491.5 acres and a population of fewer than 200 people. Figure 3.2 | Estimated Number of USVI Residents by Island, 1990-2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Population Density In 2010, the USVI had an overall population density of 792.2 people per square mile, with 53.4% of residents living in rural settings. The most populated city is the capital city of Charlotte Amalie on St. Thomas with an estimated 10,354 residents in 2010. St. Thomas Island had the highest population density among the four islands, at 1,649.1 people per square mile in 2010 (Figure 3.3). Between 2000 – 2010, the population of St. Thomas’ Northside subdistrict increased by 15.3% while the Tutu subdistrict decreased in population by 16.2%. During the same time period, all subdistricts in St. Croix and St. John decreased in population except St. Croix’s East End subdistrict (+4.8%) and St. John’s Central subdistrict (+4.4%). St. Croix 50,139 48,502 St. Thomas 48,166 48,425 St. John 3,504 3,841 - 25,000 50,000 75,000 100,000 125,000 1990 1995 2000 2005 2010 2015 USVI 2020 CHA | 25 Figure 3.3 | Population Density by USVI Subdistrict, 2010 SOURCE | U.S. Census Bureau, American Community Survey Demographic Identity Age and Sex Our population has become increasingly older. Over the past decade, the percent of individuals who are age 65 and older increased by 37.6% (from 12.5% in 2005 to 17.2% in 2015) while the percent of children and young adults (under 20) decreased by 31.6% (from 31.0% in 2005 to 21.2% in 2015) (Figure 3.4). The median age of USVI residents increased by 34.0%, from 28.2 years in 1990 to 37.8 years in 2015, following the national trend but more quickly (Figure 3.5). The distribution of age in the USVI population in 2019 was similar between males and females (Figure 3.6). USVI 2020 CHA | 26 Figure 3.4 | Number of USVI Residents Under 20 Years v. 65 Years and Older, 2005 v. 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Figure 3.5 | USVI Resident Median Age, 1990-2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Under 20 31.0% 21.2% 65 or older 12.5% 17.2% 0.0% 25.0% 50.0% 2005 2015 US 32.9 37.8 USVI 28.2 44.5 - 10.0 20.0 30.0 40.0 50.0 1990 1995 2000 2005 2010 2015 USVI 2020 CHA | 27 Figure 3.6 | Estimated Number of USVI Residents by Age Group, 2019 SOURCE | U.S. Census Bureau, International Data Base Race and Ethnicity The USVI has a racially diverse population. A large majority of our residents identify as Black (79.9%) followed by 11.6% White and 8.5% Other (data not shown). One in five (16.0%) residents identifies as Hispanic, and three in four Hispanics (76.4%) report they are of Black race (Figure 3.7). The number of Black residents decreased from 90,758 in 2005 to 80,559 in 2015, an 11.2% decrease (Figure 3.8). 3,306 3,541 3,615 2,912 2,866 3,205 3,476 3,498 3,057 3,710 3,839 4,081 3,799 3,541 3,104 2,063 1,273 889 0 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 plus 3,488 3,728 3,761 2,890 2,589 2,788 2,887 3,102 2,632 3,254 3,639 3,718 3,420 2,908 2,722 1,829 961 530 Female Male USVI 2020 CHA | 28 Figure 3.7 | Percent of USVI Residents Identifying as Hispanic by Race, 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Figure 3.8 | Estimated Number of USVI Residents by Race or Ethnicity, 2005 v. 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center 16.0% 7.4% 76.4% 53.9% Percent of All ISVI Residents Identifying as Hispanic Hispanic Identifying as White Hispanic Identifying as Black Hispanic Identifying as Other Race White 9,995 11,672 Black 90,758 80,559 Other Races 10,718 8,537 2005 2015 All Hispanic 28,054 16,080 White Hispanic 1,969 869 Black Hispanic 17,904 8,918 Other Races Hispanic 8,182 6,293 2005 2015 USVI 2020 CHA | 29 Primary Language Most USVI residents speak English as a primary language, but there is a growing number of residents who speak other languages. In 2015, 75.2% of our population spoke English as their primary language in the home (Figure 3.9). The percent of residents who speak Spanish as their primary language was 14.8%. Figure 3.9 | Percent of USVI Residents by Primary Language, 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Nativity About half of USVI residents were born here. In 2015,49.9% of the population was born in the USVI, 9% were born on mainland US, 4.4% were born in Puerto Rico, and 34.3% were born in another part of the Caribbean (Figure 3.10). Only 2% of residents were born outside of the United States and Caribbean. St. Thomas and St. John had a higher percent of residents from other places in the Caribbean than St. Croix. Socioeconomic Position Unemployment The economic outlook in the USVI shifted dramatically in the aftermath of the September 2017 Category 5 Hurricanes Irma and Maria. For example, air arrivals decreased from 771,517 in 2017 to 385,959, a 50% loss. Changes in tourism stemming from the hurricanes, along with a general downward trend in the economy, have had an impact on the service industry, which is the largest source of private sector employment in the USVI. The overall unemployment rate almost doubled from 5.8% in 2008 to 9.9% in 2018 (Figure 3.11). Compared to 2018, unemployment has increased over a low of 2.8% in 1990. The unemployment rates by island district have been consistent over the past decade, and historically the rate has been higher in St. Croix. Only English 75.2% French, Patois, Creole 8.8% Spanish 14.8% Other 1.3% USVI 2020 CHA | 30 Figure 3.10 | Percent of USVI Residents by Place of Birth, 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Figure 3.11 | Percent of Unemployed Adult USVI Residents by Island District, 2000-2018 SOURCE | USVI Office of the Governor, Bureau of Economic Research Native 49.9% Mainland US 9.5% Puerto Rico 4.4% Other Carribean 34.3% Elsewhere 2.0% All USVI Native 52.5% Mainland US 7.4% Puerto Rico 7.4% Other Carribean 30.9% Elsewhere 1.7% St. Croix Native 47.4% Mainland US 11.3% Puerto Rico 1.6% Other Carribean 37.4% Elsewhere 2.3% St. Thomas and St. John Median 8.8% 12.5% 6.9% 15.1% St Croix 8.1% 4.9% 12.1% St. Thomas and St. John, 8.6% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 USVI 2020 CHA | 31 Educational Attainment A person’s education is a major determinant of future health. The majority of residents had a high school education or more (70.2%) in 2015 compared to 87.1% of U.S. adults (Figure 3.12). Some USVI adults have pursued higher education and 20.0% have obtained a degree: 5.2% earned an Associate’s degree, 11.3% earned a Bachelor’s degree, and 3.4% earned a graduate or professional degree. Figure 3.12 | Percent of USVI Adults by Educational Attainment, 2015 SOURCE | Virgin Islands Community Survey, Eastern Caribbean Center Looking Ahead USVI residents are a diverse people who have experienced a lot of change, both environmentally and economically, over the past decade. The closure of the Hovensa-owned refinery and the impact of Hurricanes Irma and Maria are reflected in the decline in population. The doubling of unemployment in the past 15 years is a worrisome trend that could have many health ramifications. While a majority of residents are high school graduates, 30% are not. Education, along with income, are major social determinants of health that have long-lasting consequences. In addition, an aging population means that the health needs of residents will shift toward a higher burden of chronic disease. The USVI DOH examined population characteristics using some data that pre-dates the recent hurricanes and economic changes. Having more current census data and additional information, such as the housing people live in and their transportation needs, would be helpful in developing a stronger foundation for improvement. 12.1% 17.7% 38.7% 11.5% 5.2% 11.3% 3.4% 5.5% 7.3% 27.6% 20.7% 8.2% 19.0% 11.6% Less than 9th Grade9th to 12th grade, no diploma High school graduate (or GED) Some college, no degree Associate degree Bachelor degree Graduate or professional degree USVI US USVI 2020 CHA | 32 USVI Community Health Assessment 2020 CHAPTER 4 Births & Reproductive Health FERTILITY & BIRTHS | HEALTHY PREGNANCY | DELIVERIES & BIRTH OUTCOMES USVI 2020 CHA | 33 Births & Reproductive Health Five Things You Should Know in 2020  USVI birth rates are decreasing in every age group except women aged 30 to 34. The percentage of pregnant women who initiate prenatal care in the first trimester decreased from 78.5% in 2015 to 63.2% in 2017. Preterm births are trending downward from 15.2% in 2006 to 10.2% in 2016. Black, non-Hispanic mothers in the USVI have a higher rate of delivering low birthweight babies than average, but the disparity is not as wide as the national average. Infant mortality is low, with 56 infant deaths occurring between 2010 – 2017, and a majority caused by extreme prematurity. USVI By the Numbers 21.0% Fertility rate between 2006 – 2016 29.0% Birth rate between 2006 – 2016 3 in 4 Births to unmarried women in 2016 48.8% Teen birth rate between 2006 – 2016 18.9% First trimester prenatal care initiation between 2006 – 2016 26.9% Babies delivered by caesarean section in 2016 976 Number of deliveries to USVI women in 2018 34.6% Percentage of preterm births between 2006 – 2016 9 Average number of infant deaths per year between 2010 – 2017 0 Number of maternal deaths between 2015 – 2018 USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 34 Births & Reproductive Health The health of a community can be measured by the health of its mothers and the children they bear. Healthy communities promote healthy pregnancies supported by timely prenatal care and access to appropriate obstetric intervention to minimize pregnancy and delivery complications. Public health departments monitor poor birth outcomes such as preterm birth, low birthweight, and maternal and infant mortality to assess how well we care for and support women as they become mothers. In this chapter, we describe our maternal and infant health—the USVI’s foundation for a healthy future. Fertility & Births Fertility Rate The overall fertility rate among USVI women aged 15 to 44 has decreased over the past decade, decreasing from 76.1 births per 1,000 women in 2006 to 60.1 births per 1,000 women in 2016 (Figure 4.1). This ten-year 21.0% decrease in fertility rate follows the national trend. Figure 4.1 | Number of Births per 1,000 USVI Women Aged 15 to 44, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality NOTE | Vital statistics information for the USVI is not available for 2013 and 2014. 68.5 US 62.0 76.1 USVI 60.1 - 30.0 60.0 90.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 35 Birth Rate In 2018, 976 babies were delivered in USVI health care facilities, with 15 of those infants transferred to facilities outside of the USVI due to severe prematurity or pregnancy complications (data not shown). The overall birth rate in the USVI is similar to the U.S. rate, which is decreasing but stagnant. In the ten-year period between 2006 – 2016, the birth rate in the USVI declined by 29.0% from 15.5 live births per 1,000 women to 11.0 live births per 1,000 women (Figure 4.2). Figure 4.2 | Number of Live Births per 1,000 USVI Women, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality NOTE | Vital statistics information for the USVI is not available for 2013 and 2014. In the USVI, the majority of live births occur to mothers who are age 25 to 29 years with a rate of 117.6 live births per 1,000 women in 2016 (Figure 4.3). In the United States during the same year, the highest birth rate occurred for women who were age 30 to 34, with a rate of 102.7 live births per 1,000 women. Overall birth rate is either flat or trending downward for all age groups except women age 35 to 39 (Figure 4.4). 14.2 US 12.2 15.5 USVI 11.0 0.0 15.0 30.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 36 Figure 4.3 | Number of Live Births per 1,000 USVI Women by Maternal Age, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality NOTE | Births among mothers older than 44 is not presented due to the small number of cases. Figure 4.4 | Number of Live Births per 1,000 USVI Women by Maternal Age, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality NOTE | Births among mothers older than 44 is not presented due to the small number of cases; Vital statistics information for the USVI is not available for 2013 and 2014. 25.4 87.6 117.6 61.5 53.4 13.7 - 20.3 73.8 102.1 102.7 52.7 11.4 0.9 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 USVI US 49.6 15-19 25.4 135.6 20-24 87.6 156.3 25-29 117.6 103.0 30-34 61.5 47.6 35-39 53.4 9.9 40-44 13.7 15.5 All Births 11.0 - 30.0 60.0 90.0 120.0 150.0 180.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 37 Almost three in four live births that occur in USVI health care facilities occur to women who are unmarried (71.8% of live births in 2016) (Figure 4.5). This percentage is dramatically higher than the U.S. level, which was 39.8% in 2016. The disparity between the USVI and U.S. proportions of live births attributed to unmarried mothers occurs in mothers of all races and ethnicities. The largest difference is in Hispanic unmarried mothers, who accounted for 76.6% of live births by women who are unmarried in the USVI 2016 in contrast to 52.6% of live births nationally. The smallest difference is in the percent of live births to Black, non-Hispanic women in the USVI, who are similar to the national level (74.7% in the USVI versus 69.8% nationally). Figure 4.5 | Percent of USVI Live Births to Unmarried Women by Race/Ethnicity, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality Teen Birth Rate The teen birth rate in the USVI is trending downward after trending upward from 2006 to a high point in 2011 of 59.3 live births per 1,000 women aged 15 to 19 (Figure 4.6). Overall, live births occurring to women aged 15 to 19 decreased by 48.8% in the USVI from 2006 to 2016—from 49.6 to 25.4 live births per 1,000 women aged 15 to 19. While the number of births occurring to teen mothers is higher in the USVI than in the United States overall, the USVI trend in teen birth is going in the same downward direction as the national trend. 71.8% 40.7% 74.7% 76.6% 39.8% 28.5% 69.8% 52.6% All births White, Non-Hispanic Black, Non-Hispanic Hispanic USVI US USVI 2020 CHA | 38 Figure 4.6 | Number of Live Births per 1,000 USVI Women Aged 15 to 19, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality NOTE | Vital statistics information for the USVI is not available for 2013 and 2014. Healthy Pregnancy Prenatal Care Most pregnant women in the USVI initiate prenatal care in the first trimester, but the percent of pregnant women who do so has declined by 18.9% from 78.5% in 2015 to 63.7% in 2017 (Figure 4.7). At the same time, the percent of pregnant women with no prenatal care has increased — up 33.3% from 11.0% of pregnant women in 2015 to 16.6% of pregnant women in 2017. Figure 4.7 | Percent of USVI Women with Prenatal Care, 2015-2017 SOURCE | USVI Department of Health, Maternal and Child Health Program 41.1 US 20.3 49.6 59.3 USVI 25.4 0.0 30.0 60.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 78.5% First trimester prenatal care 63.7% 11.0% No prenatal care 16.6% 10.5% Limited prenatal care 19.7% 0.0% 25.0% 50.0% 75.0% 100.0% 2015 2016 2017 USVI 2020 CHA | 39 Deliveries & Birth Outcomes Caesarean Sections A lower percent of USVI women deliver their babies via caesarean section than U.S. women, regardless of risk level. In 2016, 16.8% of caesarean section deliveries to USVI women were low risk compared to 25.7% of U.S. women overall (Figure 4.8). The trend in percent of USVI women having caesarean sections was flat between 2006 – 2016, as was the national trend (Figure 4.9). In 2018, the percent of deliveries in the USVI occurring through cesarean section was 33.0%. Hispanic mothers had the highest percent of caesarean section deliveries in 2016 (29.7%) and White, non-Hispanic mothers had the lowest (21.5%) (Figure 4.10). Figure 4.8 | Percent of Live USVI Births Delivered by Cesarean Section by Risk Level, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality Figure 4.9 | Percent of Live USVI Births Delivered by Cesarean Section, 2006 v. 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality 26.9% 16.8% 31.9% 25.7% Total cesarean deliveries Low-risk cesarean deliveries USVI US USVI 26.3% 26.9% US 31.1% 31.9% 2006 2016 USVI 2020 CHA | 40 Figure 4.10 | Percent of USVI Live Births Delivered by Cesarean Section by Race/Ethnicity, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality Preterm Birth and Low Birthweight USVI mothers deliver babies pre-term at approximately the same rate as the nation. In 2016, 10.2% of USVI births were preterm—or occurred before 37 weeks gestation—compared to 9.9% of U.S. mothers (Figure 4.11). USVI late-term births—or births occurring 34 to 36 weeks gestation—were similar to U.S. births overall: 7.3% compared to 7.1% of U.S. mothers. The percent of preterm births in the USVI decreased by 34.6% from 15.6% in 2006 to 10.2% in 2016 (Figure 4.12). In 2018, 87% of USVI births were full-term, averaging 38 weeks in gestation (data not shown). The percentage of births that are low birthweight—or weighing less than five pounds, eight ounces—is higher than the national level. In 2016, 9.9% of babies born to USVI mothers had low birthweight compared to 8.2% of babies born to U.S. mothers (Figure 4.11). The percentage of USVI low birthweight births decreased from 10.4% in 2006 to 9.9% in 2016 (Figure 4.12). Disparities in birth outcomes among Black, non-Hispanic mothers are an alarming trend nationally. However, while Black, non-Hispanic mothers in the USVI have higher rates of poor birth outcomes than other mothers, the differences are not as marked as those seen nationally. For example, in 2016 the percent of babies of low birthweight born to USVI Black, non-Hispanic mothers was 11.0% versus 9.9% of babies born to all mothers (Figure 4.11). In contrast, 13.7% of babies born to U.S. Black, non-Hispanic mothers were low birthweight compared to 8.2% of babies born to all mothers. 26.9% 21.5% 26.4% 29.7% All Deliveries White, Non-Hispanic Black, Non-Hispanic Hispanic USVI 2020 CHA | 41 Figure 4.11 | Percent of Live USVI Births that were Pre-Term, Late Pre-Term, or Low Birthweight, All Mothers v. Black, Non-Hispanic Mothers, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality Figure 4.12 | Percent of Live USVI Births that were Pre-Term or Low Birthweight, 2006 v. 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System, Natality Maternal and Infant Mortality The USVI has a very low rate of pregnancy-associated mortality. Between 2015 – 2018, there was only one maternal death (data not shown). Similarly, very few infants die in the USVI annually. Between 2010 – 2017, 56 infants died in the USVI (data not shown). The top five leading causes of 10.2% 7.3% 9.9% 9.9% 7.1% 8.2% 11.2% 8.0% 11.0% 13.8% 8.8% 13.7% Preterm Late preterm Low birthweight All USVI All US Black, Non-Hispanic USVI Black, Non-Hispanic US USVI 15.6% 10.2% US 12.8% 9.9% 2006 2016 Pre-term Birth USVI 10.4% 9.9% US 8.3% 8.2% 2006 2016 Low Birthweight USVI 2020 CHA | 42 infant death between 2010 – 2017 included extremely low birthweight or extreme immaturity (17.9%), sudden unexpected infant death syndrome (10.7%), respiratory distress of newborn (8.9%), birth asphyxia (5.4%), and hydrops fetalis not due to hemolytic disease (5.4%) (Figure 4.13). Figure 4.13 | Leading Causes of USVI Infant Mortality, 2010-2017 SOURCE | USVI Department of Health, Maternal and Child Health Program NOTE | Vital statistics information for the USVI is not available for 2013 and 2014; top causes reflect data from 2010-2012 and 2015- 2017; Birth asphyxia refers to a medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm; Hydrops fetalis refers to a serious fetal condition defined as abnormal accumulation of fluid in two or more fetal compartments. Looking Ahead Births in the USVI are decreasing with the national trend, except among older mothers aged 30 to 34. Understanding this shift in birth rate helps our hospitals and providers educate and support women to have a healthy pregnancy. Prenatal care initiation in the first trimester is trending downward, signaling an opportunity to educate pregnant women about the benefits of prenatal care. Preterm births are also decreasing, a positive outcome that indicates babies are born healthier. Black, non-Hispanic mothers in the USVI have a higher rate of delivering low birthweight babies than the average, but the disparity is not as wide as the national average. While this is good news, it is important for the USVI DOH to continue to support Black, non-Hispanic pregnant women and mothers to ensure equity in birth outcomes. While the data presented in this chapter is comprehensive, the assessment is missing both 2013 and 2014 vital statistics birth and fetal death data. There have been several challenges in collecting and analyzing data for those years. In the future, the USVI DOH will need to complete its set of birth statistics for improved analysis and identificatiosn of improvement opportunities. 17.9% 10.7% 8.9% 5.4% 5.4% Extremely low birthweight or extreme immaturity Sudden infant death syndrome Respiratory distress of newborn Birth asphyxia Hydrops fetalis not due to hemolytic disease USVI 2020 CHA | 43 USVI Community Health Assessment 2020 CHAPTER 5 Child & Adolescent Health WHERE CHILDREN LIVE | CHILD IMMUNIZATIONS SCHOOL READINESS & PARTICIPATION | YOUTH HEALTH CONDITIONS | CHILD & ADOLESCENT MORTALITY USVI 2020 CHA | 44 Child & Adolescent Health Five Things You Should Know in 2020  The percentage of children living in poverty has largely remained the same since 2006, at 29.6% of USVI children. Children in the USVI have the lowest rate of measles, mumps, and rubella vaccination in the US, at 70.5%. More than half of children entering kindergarten in 2015-2016 were between six months to over a year behind developmentally. The percent of high school students who dropped out of school increased from 5.9% in the 2007-2008 school year to 9.2% in the 2017-2018 school year. The teen death rate of 60 per 100,000 is higher than the national rate of 48 deaths per 100,000 teens. USVI By the Numbers 58.2% Children living in families headed by female single parents in 2015 82.8% Children living in families receiving SNAP benefits in 2015 160.7% Percent increase in children living in poverty who live in St. John from 2014 – 2015 12.3% How much the median income has increased from 2006 – 2015 45.7% Children aged 19 to 35 months with recommended vaccines in 2016 10 Grade with the highest dropout rate in 2015-2016 school year USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 45 Child & Adolescent Health The USVI is home to almost 20,000 children and youth, all of whom need support to become healthy adults. Research shows that children who grow up in poverty, do not finish high school, or experience violence are more likely to have poor health as adults. This chapter describes our children and youth—where they live, their educational attainment, and the foundations built for a healthy future. Where Children Live The number of children and adolescents living in the USVI has declined from 30,917 in 2005 to 19,730 in 2015, a 36.2% decrease (data not shown). In 2015, over two-thirds of the USVI’s children lived in single-parent headed households, with 58.2% living in female single-parent households and 10.2% living in male single-parent households (Figure 5.1). The percent of children living in female single-parent households increased by 43.7% between 2006 – 2015. The percent of children living in poverty has remained largely the same since 2006, at 29.6% of USVI children in 2015 (Figure 5.2). Children living in female single-parent households have higher poverty rates than the average, a rate that decreased from 39.6% in 2006 to 34.1% in 2015. Poverty rates have decreased in both St. Croix and St. Thomas, but the poverty rate among St. John families with children increased from 14.0% in 2014 to 36.5% in 2015 (Figure 5.3). USVI families have a median income well below the $68,000 median U.S. family income (data not shown). The median income of USVI families was $43,731 in 2015 up from $38,914 in 2006, a 12.3% increase (Figure 5.4). A large percentage of USVI children live in families receiving benefits from public programs such as Temporary Assistance for Needy Families (TANF), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Supplemental Nutrition Assistance Program (SNAP). In 2015, 82.8% of USVI children were living in families receiving SNAP benefits, an increase of 75.8% from 2009 when 47.1% of children were living in families receiving SNAP benefits (Figure 5.5). The percentage of children living in families receiving TANF benefits has remained consistent at around 6% between 2009 – 2015. USVI 2020 CHA | 46 Figure 5.1 | Percent of Children Living in USVI Families, By Household Structure, 2006-2015 SOURCE | VICS via KIDS COUNT Database Figure 5.2 | Percent of USVI Children Living in Poverty, By Household Head, USVI, 2006-2015 SOURCE | VICS via KIDS COUNT Database NOTE | No data is available for 2011. 35.5% Married Couple Families 23.4% 40.5% Single-Parent Female 58.2% 15.3% Single-Parent Male 10.2% 0.0% 25.0% 50.0% 75.0% 100.0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 29.5% All Families 29.6% 39.6% Female-Headed Families 34.1% 0.0% 25.0% 50.0% 75.0% 100.0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 USVI 2020 CHA | 47 Figure 5.3 | Percent of USVI Children Living in Poverty, By Island, 2006-2015 SOURCE | VICS via KIDS COUNT Database Figure 5.4 | Median Income of USVI Families with Children, 2009-2015 SOURCE | VICS via KIDS COUNT Database NOTE | No data is available for 2011. Data by race unavailable for 2010. $38,914 All Families $43,731 $38,072 Black $43,296 $57,802 White $59,877 $- $25,000 $50,000 $75,000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 USVI 2020 CHA | 48 Figure 5.5 | Percent of Children Living in USVI Families Receiving Public Assistance, 2009-2015 SOURCE | VICS via KIDS COUNT Database Child Immunizations Child Immunization Rate Children in the USVI have among the lowest vaccination rates1 in the United States. According to the National Immunization Survey, in 2016 45.7% of USVI children aged 19 to 35 months were vaccinated according to the recommended national immunization schedule, representing a decline of 10.4% since 2009 when 51.0% of USVI children aged 19 to 35 months received all recommended vaccines (Figure 5.6). In comparison, 64.4% of children aged 19 to 35 months received their recommended vaccines in Puerto Rico and 70.4% nationally in 2016. Less than half of USVI two- year-olds received the complete Haemophilus influenzae type b (Hib) series in 2016 (48.6%), but this level of Hib vaccination was an improvement over 41.6% of two-year-olds in 2009. Measles is an infectious disease with serious health consequences, including pneumonia, brain damage, and death. Children in the USVI have the lowest documented rate of MMR (measles, mumps, rubella) vaccination in the United States. Compared to 91.1% nationally and 85.7% in Puerto Rico, 70.5% of USVI children were vaccinated against measles, mumps, and rubella in 2016 (Figure 5.7). This means that 29.5% of USVI children were at risk for measles, mumps, and rubella as of 2016. 1 Data after 2016 is unavailable because the National Immunization Survey was suspended during 2017 due to the severity of the hurricane season and did not occur at all in 2018. 6.0% TANF 5.8% 63.0% WIC 86.8% 47.1% SNAP 82.8% 0.0% 25.0% 50.0% 75.0% 100.0% 2009 2010 2011 2012 2013 2014 2015 USVI 2020 CHA | 49 Figure 5.6 | Percent of Children Receiving U.S. Recommended Immunizations, 2009-2016 SOURCE | National Immunization Survey NOTE | Data refer to the percent of children aged 19 to 35 months who received the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV. The Hib vaccine series prevents Haemophilus influenzae type b (Hib) disease in children. Per CDC recommendations, infants will usually get their first dose of Hib vaccine at two months of age and will usually complete the series at 12-15 months of age. Figure 5.7 | Percent of Children with Measles, Mumps, and Rubella Immunization, 2016 SOURCE | National Immunization Survey School Readiness & Participation School Readiness In the 2015-2016 school year, half (49%) of children entering kindergarten were six months to over a year behind developmentally compared to 55% of children entering school for the 2013-2014 school year (Figure 5.8). Approximately one-third of children entering kindergarten for the 2015- 2016 school year did not have adequate cognitive skills (34%), a decrease from 40% in the 2013- 51.0% USVI All Recommended Immunizations 45.7% 41.6% USVI Hib Series 2 Year Olds 46.8% 0.0% 25.0% 50.0% 75.0% 100.0% 2009 2010 2011 2012 2013 2014 2015 2016 70.5% 85.7% 91.1% USVI Puerto Rico US USVI 2020 CHA | 50 2014 school year (data not shown). In 2015, 6.2% or 1,230 USVI children under age 18 were identified as developmentally delayed or at risk of delay (data not shown). Figure 5.8 | Percent of USVI Children Ready for School Developmentally and Cognitively, 2013- 2016 SOURCE | KIDS COUNT Database High School Graduation Children and youth who dropped out of school before completing high school graduation have higher rates of poor health and social outcomes such as unemployment and utilization of public assistance. During the 2015-2016 school year, 1.6% of 2,122 students enrolled in seventh or eighth grade dropped out of school (data not shown). The percent of high school students (grades 7 through 12) who dropped out of school increased from 5.9% in the 2007-2008 school year to 9.2% in the 2017-2018 school year (Figure 5.9). Students in grade 10 had the highest percent of dropouts in the 2015-2016 year at 8.2% (data not shown). 49% 34% 55% 40% 6 Months to a Year or more developmentally behind Lack cognitive skills 2015-2016 2013-2014 USVI 2020 CHA | 51 Figure 5.9 | Percent of USVI Public High School Dropouts, 2007-2018 SOURCE | KIDS COUNT Database Youth Health Conditions Adolescents living in the USVI have a variety of health conditions. Among high school students, 37.2% classified as overweight (16%) or obese (21.2%), based on body mass index (BMI) and CDC growth charts for age and gender (Overweight: 85th ≤ BMI < 95th percentile; Obese: BMI ≥ 95th percentile) (Figure 5.10). In 2017, 16.9% of high school students reported ever being told they had asthma by a doctor; the proportion was slightly lower among 7th and 8th graders at 15.9% (data not shown). Figure 5.10 | Percent of High School Students by Weight Status, 2017 SOURCE | USVI 2017 Youth Risk Behavior Survey NOTE | USVI Weight status is based on body mass index and CDC growth charts and was defined as follows: Underweight: BMI<5th percentile; Normal weight: 5th ≤ BMI<85th percentile; Overweight: 85th ≤ BMI < 95th percentile; Obese: BMI ≥ 95th percentile. 5.9% High School Dropout 9.2% 0.0% 20.0% 2007 - 2008 2008 - 2009 2009 - 2010 2011 - 2012 2012 - 2013 2013 - 2014 2014 - 2015 2015 - 2016 2016 - 2017 2017 - 2018 5.8% 57.1% 16.0% 21.2% Underweight Normal weight Overweight Obese USVI 2020 CHA | 52 Some high school and middle school students also struggle with depressive symptoms. In 2017, when asked if they ‘felt so sad or hopeless almost every day for two or more weeks in a row that they stopped doing some usual activities’ in the past year, 32.5% of 7th and 8th grade students said yes (data not shown). Among the high school students, 35.5% reported feeling sad or hopeless almost every day for two weeks or more in a row (Figure 5.11). Female high school students and 11th grade students reported the highest rates of sadness or hopelessness. Figure 5.11 | Percent of High School Students Reporting Feeling Sad or Hopeless Almost Every Day for Two Weeks or More in a Row, by Sex and Grade, 2017 SOURCE | USVI 2017 Youth Risk Behavior Survey Child & Adolescent Mortality A death of a child or teenager is an indicator of poor health in a community. Nationally, motor vehicle accidents are the leading cause of death of children. Other causes vary and include safety, poor parental health or substance use, level of adult supervision, neighborhood factors, and health care access. Few deaths of children and adolescents occur in the USVI each year. In 2015, two children aged one to 14 years died in the USVI at a rate of 13 deaths per 100,000, a rate lower than the national rate of 16 deaths per 100,000 children (Figure 5.12). In 2015, three teenagers aged 15 to 19 years died in the USVI at a rate of 60 per 100,000 teens, a rate higher than the U.S. rate of 48 deaths per 100,000 teens. 35.5% 46.0% 23.7% 31.7% 35.4% 40.8% 35.3% All High School Students Female Male 9th Grade 10th Grade 11th Grade 12th Grade USVI 2020 CHA | 53 Figure 5.12 | Number of USVI Child and Teen Deaths Per 100,000, 2006-2016 SOURCE | USVI Department of Health, Vital Statistics Program Looking Ahead The health of our children, from their birth until adulthood, is essential in ensuring a healthy USVI in the long term. While our children are generally free from health conditions that affect adults, this assessment shows that many of our families live in difficult circumstances that may affect child and adolescent health. Children living in poverty, for example, are at risk for many poor outcomes as they mature into adults. There is evidence that some of our youth experience negative health outcomes, including premature death. As a territory, we must address the social factors that enable these poor outcomes, including educational attainment. Our high school dropout rate has almost doubled over the past decade, a factor that we know disadvantages our young people from achieving their dreams. We know that about 30% of our two-year-olds are not receiving MMR immunization, and that about half of all 19- to 35- month-olds do not receive all the U.S. recommended vaccines. The data also shows that about 37.2% of high school students are classified as overweight or obese and that approximately 17% suffer from asthma. These statistics are a starting point for urgent action. We need to better educate our families about the importance of immunizations in preventing infectious diseases and ensure their access to this life-saving measure. Further, it is well documented that health conditions present in adolescence often track into adulthood. Therefore, investing in interventions aimed at prevention and improvement of health outcomes in children and adolescents have the potential to improve overall health outcomes in adulthood. It was not possible to examine data from the immunization program more closely for this assessment. Additionally, while the data 31 Children Aged 1-14 13 117 Teens Aged 15-19 60 - 50 100 150 200 250 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 54 on middle and high schools students was available for 2018, the USVI does not routinely conduct health surveillance among children and adolescents, making it difficult to assess any trends in health related behaviors and health status of youth in the USVI. Overall, health-related surveillance among child and adolescent populations in the territory is an important next step in determining a plan for population health improvement. USVI 2020 CHA | 55 USVI Community Health Assessment 2020 CHAPTER 6 Health Status & Chronic Disease HEALTH STATUS | CHRONIC DISEASE CONDITIONS | CANCER CARDIOVASCULAR HEALTH | HEALTH BEHAVIORS USVI 2020 CHA | 56 Health Status & Chronic Disease Five Things You Should Know in 2020  The percent of adults in the USVI who report a current asthma diagnosis is about half of the national percentage (4.6% in the USVI versus 9.1% nationally). The number of Black males with diabetes who went to a DOH clinic in fiscal year 2018 increased by 179% over the previous year. Almost half (49.9%) of USVI adults aged 50 to 75 reported having a colonoscopy in the past 10 years. Prostate cancer is the most common cancer in men in the USVI. In women, the top cancer is breast cancer. In 2016, 5.6% of USVI adult residents reported current tobacco smoking—61.7% lower than the national level (17.0% of U.S. adults) and 53.3% lower than the Healthy People 2020 target. USVI By the Numbers 1 in 4 Residents with arthritis 30.1% Adults with a body mass of 30.0 or higher (obese) in 2016 476 Number of new cancer cases in 2016 3 in 4 Number of women aged 50 to 74 who received a mammogram in 2016 16.8% Adults with diabetes in 2016 #1 Ranking of breast cancer incidence among all cancers affecting USVI women in 2016 3.1% Persons who were told they had a heart attack in 2016 75.7% Adults who have done some physical activity or exercise during the past 30 days (2016) USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 57 Health Status & Chronic Disease How well we feel and our health behaviors affect our overall health. USVI residents are largely healthy, but many people live with chronic diseases. Resident health varies across several socioeconomic strata, reflecting our diversity and disparities in how healthy we are as a community. This chapter reviews our general health status and the prevalence of chronic diseases. including cancer, among our residents. Health Status Perceived General Health Most residents report being in good or better health. Compared to 83.3% of U.S. residents, 79.4% of USVI residents say they enjoyed good or better health in 2016 (Figure 6.1). Figure 6.1 | Percent of USVI Adults Reporting Good or Better Health, 2016 SOURCE | Behavioral Risk Factor Surveillance System, 2016 79.4% 83.3% 80.5% 78.8% USVI US Male Female Overall Sex USVI 2020 CHA | 58 Chronic Disease Conditions Arthritis One in four USVI adults reported having a diagnosis of arthritis in 2016, a proportion similar to the U.S. level (Figure 6.2). Among persons of different race-ethnicity, White, non-Hispanic people had the highest percent of reported arthritis (30.5%). Figure 6.2 | Percent of USVI Adults Reporting Ever Being Diagnosed with Arthritis, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Asthma Asthma is a respiratory disease that causes inflammation of the airways and difficulty breathing. Adult asthma rates are low in the USVI. The percent of adults in the USVI in 2016 who report a current asthma diagnosis is about half of the national percent (4.6% in the USVI versus 9.1% nationally) (Figure 6.3). The percent of Hispanic adults reporting current asthma is almost three times the percent of other races/ethnicities. The number of patients presenting with asthma at a DOH-operated clinic between August 2016 – September 2018 was 104 (data not shown). 24.9% 25.5% 30.5% 24.7% 19.1% USVI US White only, non-Hispanic Black only, non-Hispanic Hispanic Overall Race/Ethnicity USVI 2020 CHA | 59 Figure 6.3 | Percent of USVI Adults Reporting a Current Asthma Diagnosis, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Obesity Obesity is a complex medical condition requiring lifelong intervention and support. In the USVI in 2016, 32.2% of adults reported a body mass index2 of 30.0 or higher, compared to 30.1% of U.S. adults—short of the Healthy People 2020 Target (Figure 6.4). A higher percentage of females (36.6%) and persons who were not White, non-Hispanic reported being obese in 2016. Diabetes Diabetes is a metabolic condition that causes higher than normal blood sugar levels and can have dire complications if not treated. For adults presenting at DOH clinics with diabetes, the number of Black males who presented with diabetes in FY2018 increased by 179% over the previous year (data not shown). In 2016, 16.8% of USVI adults reported ever being told they had diabetes. compared to 10.5% of U.S. adults — on par with the Healthy People 2020 Target (Figure 6.5). Those reporting the highest percent of diabetes diagnosis were Black, non-Hispanic, older in age, lower in income, and had less education. 2 Body mass index is s a measure of body fat based on height and weight. It is calculated by taking a person's weight in kilograms divided by the square of height in meters. 4.6% 9.1% 3.9% 3.6% 9.1% USVI US White only, non-Hispanic Black only, non-Hispanic Hispanic USVI 2020 CHA | 60 Figure 6.4 | Percent of USVI Adults with Obesity, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System NOTE | Obesity is defined as a body mass index of 30.0 or higher. 32.2% 30.1% 30.5% 25.2% 36.6% 19.6% 34.4% 36.5% 14.0% 42.7% 45.1% 41.0% 34.6% 22.9% 30.0% 33.1% 30.7% 33.5% 30.2% 28.3% 39.0% 33.0% 28.2% USVI US Healthy People 2020 Target Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 61 Figure 6.5 | Percent of USVI Adults Ever Told They Had Diabetes, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System NOTE | Data is self-reported; U.S. comparison presents the median response percentage using crude prevalence; USVI data is the raw percentage across all survey respondents. 16.8% 10.5% 16.2% 15.9% 17.3% 5.8% 18.8% 14.6% 0.0% 4.5% 7.1% 10.4% 18.1% 26.2% 22.7% 20.1% 17.6% 15.2% 9.2% 27.4% 19.3% 11.8% 9.2% USVI US Healthy People 2020 Target Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 62 Cancer Cancer Incidence and Prevalence In 2016, there were 476 new cases of cancer: 235 in St. Croix, 221 in St. Thomas, and 20 in St. John (data not shown). The top cancers in men were prostate cancer, colon cancer, and cancer of the blood and lymph nodes, while the top cancers in women were breast cancer, uterine cancer, and colon cancer (data not shown). In 2016, 6.0% of adults reported ever having been told they had cancer, compared to 6.7% of U.S. adults (Figure 6.6). Figure 6.6 | Percent of USVI Adult Ever Told They Had Cancer, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System 6.0% 6.7% 7.5% 5.1% 10.5% 6.0% 1.7% 0.0% 2.7% 1.0% 3.4% 2.5% 12.5% 7.1% 0.9% 4.8% 4.6% 7.2% 3.2% 8.6% 8.0% 5.1% 3.9% 7.4% USVI US Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Sex Race/Ethnicity Age Health Insuranc e Income Education USVI 2020 CHA | 63 Cancer Screening Cancer screening is an important public health measure that identifies cancer early and prevents morbidity and premature mortality. The U.S. Preventive Services Task Force recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every three years, biennial screening mammography for women aged 50 to 74 years, and colonoscopy screening for adults starting at age 50 years and continuing until age 75 years. For men aged 55 to 69 years, the U. S. Preventative Services Task Force (USPSTF) recently changed its guidelines on screening for prostate cancer to support patients making the decision to screen for prostate-specific antigen (PSA) together with their provider. USVI adult women generally have cancer screening rates on par with the rest of the United States. In 2016, 78.7% of adult USVI women aged 21 to 65 had a pap test, an important screening to detect cervical cancer (Figure 6.7). The percent of women who report having a pap test was lowest among older women, women with no health insurance, women with lower income, and women with a high school education. Figure 6.7 | Percent of USVI Adult Women Aged 21-65 with a Pap Test in the Past Three Years, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System NOTE | * Sample size was too small for the income bracket of $25,000 to less than $35,000 78.7% 79.7% 79.6% 78.9% 81.7% 81.9% 74.0% 84.7% 58.0% 70.0% 80.3% 81.1% 86.9% 72.3% 86.5% 82.0% USVI US Black only, non-Hispanic Hispanic Age 25 to 34 Age 45 to 54 Age 55 to 64 Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Graduated High School Attended College or Technical School Graduated from College or Technical School Females Aged 21-65 Race/Et hnicity Age Health Insuranc e Income Education * USVI 2020 CHA | 64 About three in four (72.5%) women aged 50 to 74 in the USVI in 2016 received a mammogram in the past two years, an important screening to detect breast cancer (Figure 6.8). The percent of women who report having a mammogram was lowest among White, non-Hispanic women, women aged 55 to 64, women without health insurance, women with lower income, and women with lower levels of education. Figure 6.8 | Percent of USVI Adult Women Aged 50-74 with a Mammogram in the Past Two Years, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Fewer than half (49.9%) of USVI adults aged 50 to 75 reported having a colonoscopy in the past 10 years, an important diagnostic tool in detecting early colon cancer (Figure 6.9). This percent falls 72.5% 77.5% 69.8% 73.5% 75.0% 72.1% 70.2% 75.1% 78.1% 42.4% 60.9% 61.3% 72.7% 80.0% 80.7% 60.0% 72.1% 75.0% 77.5% USVI US White only, non-Hispanic Black only, non-Hispanic Hispanic Age 50 to 54 Age 55 to 64 Age 65 or older Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Females Aged 50- 74 Race/Ethnicity Age Health Insurance Income Education USVI 2020 CHA | 65 short of the Healthy People 2020 Target of 70.5% and is lower than the U.S. level (63.3%). Report of colonoscopy is lowest among males, people who are not White, non-Hispanic, and younger age, and people without health insurance, with lower income, or with lower levels of education. Figure 6.9 | Percent of USVI Adults Aged 50-75 with a Colonoscopy in the Past 10 Years, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Prostate cancer is the most common cancer in men in the USVI. In 2016, just over half of men aged 40 or older had a prostate-specific antigen (PSA) test compared to 39.7% of adult U.S. males of the same age (Figure 6.10). A lower percent of White, non-Hispanic men aged 40 years or older reported ever having a PSA test than Black, non-Hispanic men aged 40 years or older. 49.9% 63.3% 70.5% 47.7% 51.2% 61.4% 49.4% 49.4% 33.7% 45.8% 59.3% 53.8% 27.4% 35.0% 38.7% 57.0% 60.0% 56.8% 37.0% 44.6% 61.0% 56.2% USVI US Healthy People 2020 Target Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 45 to 54 Age 55 to 64 Age 65 or older Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Adults Aged 50-75 Sex Race/Ethnicity Age Health Insurance Income Education USVI 2020 CHA | 66 Figure 6.10 | Percent of USVI Men Aged 40+ Years Who Had a PSA Test, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Cardiovascular Health Heart Attack and Stroke A small percent of adults in the USVI reported ever being told they had a heart attack or myocardial infarction in 2016 (3.1% versus 4.4% of U.S. adults) (data not shown). A higher percent of males and White, non-Hispanic persons reported being told they had a heart attack. In 2016, only 2.5% of USVI adults reported ever being told they had a stroke, compared to 3.0% of U.S. adults (data not shown). A higher percent of Hispanic persons reported being told they had a stroke compared to other races/ethnicities. Health Behaviors Physical Activity USVI prevalence of physical activity is high and similar to national levels. In 2016, 75.7% of adults reported doing physical activity or exercise in the past 30 days (other than their regular job) compared to 76.7% of U.S. adults (Figure 6.11). Physical activity levels were highest among men, persons identifying as White, non-Hispanic, aged 45 to 54 years, persons with a household income of $50,000 or more, and persons who graduated from college or technical school. 54.3% 39.7% 49.2% 63.8% USVI Males 40+ US Males 40+ White only, non-Hispanic Black only, non-Hispanic USVI 2020 CHA | 67 Figure 6.11 | Percent of USVI Adults Reporting Physical Activity in Past 30 Days, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Current Smoking USVI prevalence of smoking tobacco is among the lowest in the nation. In 2016, 5.6% of USVI adult residents reported current smoking—61.7% lower than the national level (17.0% of U.S. adults) and 53.3% lower than the Healthy People 2020 target (Figure 6.12). Current smoking levels among women are less than half the prevalence among men (3.6% in women versus 9.0% among men). Similarly, current smoking levels among Black, non-Hispanic residents are half those of White, non- Hispanic and Hispanic residents. 75.7% 76.7% 78.1% 74.2% 86.4% 75.6% 70.2% 71.7% 68.2% 73.7% 78.0% 76.9% 76.2% 68.1% 70.7% 74.5% 76.6% 83.8% 68.1% 69.8% 79.1% 84.4% USVI US Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 68 Figure 6.12 | Percent of USVI Adults who Currently Smoke Tobacco, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Looking Ahead The USVI met or exceeded the diabetes and current smoking Healthy People 2020 leading indicators by 2016, according to the most recent data collected by the USVI for the Behavioral Risk Factor Surveillance System. These are important successes for Virgin Islanders, but there are several areas that can be improved. Just under half of USVI adults receive the recommended screening for colonoscopy, preventive care that can detect colon cancer early and prevent 5.6% 17.0% 12.0% 9.0% 3.6% 8.7% 4.2% 8.0% 1.9% 5.7% 5.2% 6.8% 7.1% 4.4% 7.7% 5.9% 5.2% 5.7% 4.3% 6.2% 5.1% 7.1% 5.1% USVI US Healthy People 2020 Target Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 69 premature death. Over 30% of USVI adults are obese, a health condition that can lead to other chronic diseases and poor cardiovascular treatment. The USVI DOH has an opportunity to update risk factor screening data collection and to examine more recent data. Identifying current behaviors and health conditions among residents will help the department develop better health communication and educational programs. USVI 2020 CHA | 70 USVI Community Health Assessment 2020 CHAPTER 7 Trauma, Injury & Mental Health CHILD MALTREATMENT | ACCIDENTS | VIOLENCE | SUICIDE USVI 2020 CHA | 71 Trauma, Injury & Mental Health Five Things You Should Know in 2020  The child maltreatment rate has decreased from 13.5 per 1,000 children in 2013 to 11.0 per 1,000 children under age 18 in 2015. The overall trend in number of deaths from motor vehicle accidents of all age groups has been increasing—from 4 deaths in 2005 to 11 deaths in 2017. Homicide and felony assault decreased between 2017 – 2019, but rape has increased (from 19 to 31). The rate of death by suicide among adult USVI men has increased by 351.3% over 2005 (3.9 per 100,000 men in 2005 compared to 17.6 per 100,000 men in 2017). USVI adults have lower reported depression levels than the United States, with 5.2% of USVI adults reporting having ever been told they had a form of depression compared to 17.3% of U.S. adults. USVI By the Numbers 32 Number of residents who died from accidental causes in 2017 218 Number of child maltreatment referrals to DHS in 2015 36.0 Average age at death from a motor vehicle accident in 2017 57 Number of children placed in foster care 93.5% Percent of adults reporting always using their seat belt 26 Number of teen deaths caused by guns between 2010 – 2017 #5 Country rank in homicide rate globally 5.2% Percent of adults reporting depression in 2016 USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 72 Trauma, Injury & Mental Health Maintaining positive psychological health and wellness is an important determinant of our physical health. People who experience trauma—whether it is psychological or physical—are at risk for poor health. Children who experience trauma in the form of neglect or physical or sexual abuse have higher rates of divorce, depression, anxiety, and suicide. Communities who experience natural disasters go through both a physical and mental recovery that can take several years. This chapter describes trauma and its impact on our communities. Child Maltreatment Every year, the USVI experiences cases of child maltreatment, which includes physical abuse, sexual abuse, and neglect. Child maltreatment can result in poor mental health, challenges in development, and even death. In 2015, the child maltreatment rate was 11.0 per 1,000 children under age 18, a decrease from 2013 (13.5 per 1,000 children) (data not shown). The rate of child maltreatment in the USVI is higher than the U.S. rate of 9.2 per 1,000 children. Among the 218 cases of maltreatment referred to USVI Department of Human Services in 2015, 46.8% were referred for physical abuse, 11.5% were referred for sexual abuse, and 41.7% were referred for neglect (Figure 7.1). A higher percentage of St. Croix’s cases of child maltreatment were for physical abuse compared to St. Thomas and St. John combined. In 2015, 57 children were removed by DHS from a parent or caregiver due to maltreatment and placed in foster care (data not shown). Figure 7.1 | USVI Child Maltreatment Case Referrals by Case Type and Island, 2015 SOURCE | KIDS COUNT Database 46.8% 48.8% 44.3% 11.5% 10.7% 12.4% 41.7% 40.5% 43.3% USVI St. Croix St. Thomas/St. John Physical Abuse Sexual Abuse Neglect USVI 2020 CHA | 73 Accidents Accidental Death Several USVI residents die annually due to accidental causes such as drowning and motor vehicle accidents. In 2017, a total of 32 USVI residents died from accidental causes, including 11 from motor vehicles accidents and nine from accidental drowning and submersion (Figure 7.2). Figure 7.2 | Number of Accidental Deaths by Cause, USVI, 2017 SOURCE | USVI Department of Health Motor vehicle accidents caused 40,100 deaths in the United States in 2017 (data not shown). Motor vehicle accidents may be attributed to many causes including sleep deprivation, road conditions, and substance use. The USVI has a low number of deaths from motor vehicle accidents each year. The overall trend in number of deaths due to motor vehicle accidents of all age groups has been increasing since 2005, although there is variation across years. Between 2005 – 2017, there was a low of four deaths due to motor vehicle accidents (in 2005) and a high of 17 deaths due to motor vehicle accidents (in 2008) (Figure 7.3). It should be noted that USVI drivers use the left side of the road, a practice established under Danish control of the territory before the USVI became part of the United States. Tourists may be confused about which side of the road to drive on, potentially leading to accidents. 5 7 9 11 Water, air and space, and other and unspecified transport accidents Other and unspecified nontransport accidents Accidental drowning and submersion Motor vehicle accidents USVI 2020 CHA | 74 Figure 7.3 | Number of USVI Deaths Due to Motor Vehicle Accidents, 2005-2017 SOURCE | USVI Department of Health, Vital Statistics NOTE | No vital statistics data is available for 2013 or 2014. Safe Driving Behaviors USVI adults report high utilization of their seat belt in a motor vehicle. In 2016, 93.5% of USVI adults reported always using a seat belt, which was similar to the national level (94.0%) (Figure 7.4). Seat belt use was above 80% across all subgroups, with the lowest reported percentage being adults aged 25 to 34. The average age of death for persons who die after motor vehicle accidents in the USVI was 36.0 years in 2017 (data not shown). 4 17 Motor Vehicle Deaths 11 - 2 4 6 8 10 12 14 16 18 20 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 USVI 2020 CHA | 75 Figure 7.4 | Percent of USVI Adults Reporting Always Using Seat Belts, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System 93.5% 94.0% 90.6% 95.3% 98.6% 92.8% 92.9% 86.5% 81.6% 93.8% 94.5% 94.0% 96.4% 95.1% 86.5% 90.8% 90.5% 92.3% 92.8% 97.5% 89.4% 91.6% 96.9% 95.8% USVI US Male Female White, non-Hispanic Black, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Have health insurance Do not have health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Health Insurance Income Education USVI 2020 CHA | 76 Violence Violence is a significant threat to one’s personal health and wellness. In the USVI, several rapes and assaults occur annually, including homicides. The USVI has the highest murder rate per capita in the United States and has the fifth highest rate of homicides worldwide. The number of homicides has declined from 55 in 2017 to 43 in 2019 (Figure 7.5). Felony assaults have also decreased from 688 in 2017 down to 359 in 2019. Rapes have increased from 19 in 2017 to 31 in 2019. Figure 7.5 | Number of USVI Homicides, Rapes, and Felony Assaults, USVI, 2017-2019 SOURCE | USVI Police Department USVI youth are also at risk of violence. Among middle school students in 2017, 16.2% reported having ever carried a weapon to school and 65.1% said they had been in a physical fight (data not shown). Among high school students, 9.4% reported not wanting to go to school because they did not feel safe there and 7% reported having been threatened with a weapon at school in the past year (data not shown). Among the 44 teen deaths that occurred between 2010 – 2017, 32 were caused by homicide (72.7%) (data not shown). Among the 32 teen homicide deaths, 26 (81.3%) were caused by firearms; a majority of the 26 teen homicide deaths occurred to males (Figure 7.6). Figure 7.6 | Number of USVI Teen Homicide Deaths Caused by Firearm Discharge, 2010-2017 SOURCE | USVI Department of Health, Vital Statistics 55 19 688 45 20 398 43 31 359 Homicide Rape Felony Assault 2017 2018 2019 26 2 24 All Teen Homicide Deaths by Firearm Female Teen Homicide Deaths by Firearm Male Teen Homicide Deaths by Firearm USVI 2020 CHA | 77 Suicide Adult men have higher rates of death by suicide compared to women in the USVI. In 2017, the suicide rate among USVI men was 17.6 suicides per 100,000 compared to 1.8 suicides per 100,000 among women (Figure 7.7). The rate of death by suicide among adult USVI men has increased by 351.3% over 2005 (3.9 per 100,000 men in 2005 compared to 17.6 per 100,000 men in 2017). The annual U.S. suicide rate increased by 23.8% between 1999 – 2014, from 10.5 to 13.0 suicides per 100,000 people, the highest rate recorded in 28 years. About one in five (22.5%) middle school students in the USVI in 2017 thought seriously about suicide compared to 17.0% of high school students (Figure 7.8). Among middle school students, 14.3% made a suicide plan and 8.5% attempted suicide. Among high school students, more females (18.1%) than males (8.6%) made a suicide plan (data not shown) and one in ten (10.3%) high school students attempted suicide. Figure 7.7 | Age-Adjusted Suicide Rate per 100,000 USVI Adults, 2005-2017 SOURCE | USVI Department of Health, Vital Statistics Figure 7.8 | Suicidal Thoughts and Behaviors among USVI Middle and High School Students, 2017 SOURCE | USVI Youth Risk Behavior Survey 0.0 Female 1.8 3.9 Male 17.6 1.8 All 9.3 0.0 5.0 10.0 15.0 20.0 2005 2006 2007 2008 2009 2010 2011 2012 2015 2016 2017 22.5% 17.0% 14.3% 13.6% 8.5% 10.3% Middle School High School Thought seriously about suicide Made a plan Attempted suicide USVI 2020 CHA | 78 Mental Health Post-Hurricane Mental Health Residents of the USVI experienced two traumatic hurricanes in late 2017 that destroyed many peoples’ homes and took at least four lives. The USVI utilized the CASPER system several times to assess resident needs, including mental health after the hurricane. Almost two years after Hurricanes Irma and Maria, 40.9% of surveyed USVI residents reported suffering from one or more mental health concern, down from 61.3% in November 2017 (Figure 7.9). Figure 7.9 | Percent of USVI Adults Reporting Mental Health Concerns After Hurricanes Irma and Maria, 2017-2019 SOURCE | CDC CASPER Hurricane Recovery Surveys Depression Residents of the USVI report having low rates of depression. In 2016, 5.2% of USVI adults reported having ever been told they had a form of depression compared to 17.3% of U.S. adults (Figure 7.10). A higher percent of adults reporting depression were female (5.5%), White, non-Hispanic (9.1%), age 18 to 24 (7.5%), had a household income of less than $15,000 (8.7%), and did not graduate high school (6.8%). 61.3% 24.2% 41.4% 26.8% 12.5% 21.9% 10.7% 3.7% 40.4% 16.9% 15.1% 14.9% 11.1% 10.7% 7.8% 2.7% Experienced 1 or more* Difficulty concentrating* Trouble sleeping* Agitated behavior* Witness violence Loss of appetite* Increased alcohol Increased drug use Nov-17 Oct-19 USVI 2020 CHA | 79 Figure 7.10 | Percent of USVI Adults Reporting Diagnosis of Depression, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Looking Ahead There have been improvements in instances of trauma and injury over the past few years, such as reduced cases of child maltreatment, number of homicides, and assaults. However, there is an alarming trend among USVI adult men who die by suicide. Data also reveal that youth homicides are largely caused by firearms, particularly among young men. The number of rapes that occur in the USVI has also increased. The root causes of violence and intentional injury relate to social factors including family structure, racism, lack of economic opportunity, and other social determinants of health. These trends, particularly in men, require deeper assessment and 5.2% 17.3% 4.8% 5.5% 9.1% 3.5% 7.3% 7.5% 6.4% 5.1% 4.3% 5.6% 4.9% 8.7% 5.0% 5.8% 3.8% 3.5% 6.8% 3.6% 6.1% 5.6% USVI US Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Income Education USVI 2020 CHA | 80 conversation in our community. The USVI DOH has an opportunity to partner with the USVI Police Department and community leaders to dig deeper into the challenges facing young men and to develop strategies to reduce violence and suicide. The data also show that, on average, Virgin Islanders are mentally well and have lower rates of reported depression compared to the United States. However, data collected through the BRFSS provides only a snapshot of depressive symptoms and clinical depression and may not reveal the true impact of depression in the USVI. Mental health has also improved in the aftermath of Hurricanes Irma and Maria. These numbers are heartening but may not reflect the mental health of all our residents. It is important that the USVI DOH continue to support resident mental health. This report does not include data on mental health service utilization due to lack of availability. Understanding patterns of mental health service use by residents will enable the USVI DOH to assess its programs and to develop new strategies to enhance post-hurricane community recovery. USVI 2020 CHA | 81 USVI Community Health Assessment 2020 CHAPTER 8 Infectious Diseases FOOD & VECTOR-BORNE DISEASE | HIV/AIDS | SEXUALLY TRANSMITTED DISEASES | HEPATITIS | VACCINATIONS | EMERGING PATHOGENS USVI 2020 CHA | 82 Infectious Diseases Five Things You Should Know in 2020  There was an epidemic of Zika virus beginning in early 2016 that resulted in 2,017 confirmed Zika fever cases, the majority occurring on St. Thomas.  DOH tested 3,583 pregnant women for Zika virus in 2016, and 8.1% (292) were positive.  The rate of HIV infection diagnosis decreased by 80.4% from a high of 42.8 per 100,000 people in 2010 to a low of 8.4 per 100,000 people in 2018.  The incidence of chlamydia cases in the USVI decreased by 43.7% from a high of 757.2 per 100,000 people in 2011 to 430.7 per 100,000 people in 2017.  Less than half (41.7%) of adults aged 65 and older received the pneumococcal vaccine compared to 73.4% of adults nationally in 2016. USVI By the Numbers 68 Number of confirmed foodborne and diarrheal illnesses between 2014 – 2018 83 Number of Norovirus cases during an outbreak in 2017 621 Number of people living with HIV/AIDS at the end of 2017 1,494 Number of CDC-funded HIV tests in 2017 49.5% Adults who report ever having an HIV test in 2016 75 Number of Hepatitis cases from all causes between 2014 – 2018 65.9% Households with pets vaccinated against rabies in 2017 0 Number of primary and secondary syphilis cases in 2017 USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 83 Infectious Diseases Remaining free from infectious disease is a major determinant of how healthy we are as a community. As an island culture, we enjoy a warm climate that attracts thousands of visitors each year. With our geography and economy comes a responsibility to be vigilant about screening for and protecting ourselves from pathogens, including new and re-emerging diseases such as Zika virus. This chapter examines the burden of infectious disease on the health of USVI residents. Food- & Vector-borne Disease As a popular tourist destination with a tropical climate, the USVI experiences occasional outbreaks of both food- and vector-borne disease. Between 2014 and the end of 2017, the USVI experienced outbreaks from exposure to viral and bacterial pathogens including Norovirus, Chikungunya, Leptospirosis, Meliodosis, Dengue Fever, and Zika (Figure 8.1). In addition, 41 people were made ill by exposure to the pesticide Methyl Bromide in late 2014 and early 2015. Figure 8.1 | Timeline of Major Food- and Vector-Borne Disease Outbreaks, USVI, 2014-2017 SOURCE | USVI DOH, Epidemiology and Disease Reporting Division Foodborne and Diarrheal Disease Between 2014 – 2018, there were 68 confirmed cases of foodborne and diarrheal illnesses in the USVI. The majority of these cases (45 total) were salmonellosis, a bacterial disease affecting the intestinal tract that is caused by consuming water or food contaminated with salmonella bacteria (Figure 8.2). There were 15 cases of giardiasis, a diarrheal disease caused by the Giardia parasite, during the same period. During late 2016 and early 2017, there was an outbreak of norovirus that affected 83 people. USVI 2020 CHA | 84 Figure 8.2 | Percent of USVI Foodborne and Diarrheal Disease Cases by Type, 2014-2018 SOURCE | USVI DOH, VI-National Electronic Disease Surveillance System Zika Virus and Other Arboviral Diseases As an island community situated in a tropical climate, there are often cases of disease caused by viruses spread to people by the bite of infected insects such as mosquitoes and ticks. These arboviruses tend to be transmitted during warmer months of the year when their vectors are more active. USVI residents often develop symptoms aligned with flavivirus infection, a family of viruses that include West Nile virus, dengue virus, tick-borne encephalitis virus, and yellow fever virus. However, the number of confirmed cases is often much lower than suspected cases. Between 2016 – 2019, the top arboviruses were all mosquito-borne and included Zika, Dengue, Chikungunya, and other unspecified flavivirus (e.g., West Nile, etc.). Zika virus infection rarely causes physical symptoms, but it does have dire effects in pregnant women. Pregnant women infected with Zika virus are at increased risk of birth defects such as microcephaly. An epidemic of Zika virus beginning in early 2016 resulted in 2,017 confirmed Zika fever cases (Figure 8.3). The majority of cases occurred on St. Thomas, peaking at 1,305 confirmed cases on the island in 2016 (Figure 8.4). St. Croix and St. John were not as affected by Zika virus as St. Thomas. Figure 8.3 | Number of USVI Confirmed Cases of Mosquito-Bourne Disease, 2016-2019 SOURCE | USVI DOH, VI-National Electronic Disease Surveillance System 1% 22% 66% 6% 4% Cryptosporidosis Giardiasis Salmonellosis Shigellosis Staphyloccocal Enterotoxin 2,017 18 2 1 3 Zika Dengue Fever Chikungunya Flavivirus USVI 2020 CHA | 85 Figure 8.4 | Number of USVI Annual Confirmed Cases of Zika Fever, 2016-2019 SOURCE | USVI DOH, VI-National Electronic Disease Surveillance System In 2016, the USVI DOH in collaboration with its health care partners tested 3,583 pregnant women for Zika virus. Ultimately 8.1% (292) of pregnant women tested were positive for the Zika virus and were followed closely by medical providers. A total of 66 mothers positive for Zika virus delivered at DOH health care facilities between 2016 – 2017, and the highest number of births occurred in late 2016 (Figure 8.5). A total of 156 infants born to Zika-positive mothers were monitored after birth for signs of abnormalities during the 2016 – 2018 period. No information about the health status of those infants, their mothers, or other Zika-positive pregnant women was available at the time of publication of this report. Following the hurricanes of 2017, there was increased concern about vector-borne diseases among USVI residents. According to the Community Assessment for Public Health Emergency Response (CASPER) surveys conducted between 2017 – 2019, concern about Dengue fever, Chikungunya, and Malaria grew between November 2018 – May 2019 but decreased by October 2019 (Figure 8.6). Concern about Zika virus grew less sharply and did not wane over the same time period. USVI 2020 CHA | 86 Figure 8.5 | Number of USVI Zika Virus Positive Mothers Delivering in DOH Facilities by Month, 2016-2017 SOURCE | USVI DOH, VI-National Electronic Disease Surveillance System Figure 8.6 | Trend in Household Concern about Contracting Mosquito-borne Disease After Hurricanes Irma and Maria, USVI, 2017-2019 SOURCE | CDC, CASPER Survey System 0 0 1 0 2 2 1 1 7 13 17 9 0 0 2 2 1 1 3 0 2 1 0 1 0 2 4 6 8 10 12 14 16 18 Dengue 29.6% 45.6% Malaria 4.8% 7.6% Other/Don't know 44.4% 14.1% Zika 28.9% 35.5% Chikungunya 23.1% 27.5% Nov 2018 May 2019 Oct 2019 USVI 2020 CHA | 87 HIV/AIDS HIV/AIDS Incidence and Prevalence HIV/AIDS infection rates in the Caribbean are among the highest in the world, second only to Sub- Saharan Africa. The USVI has consistently ranked among the top states and territories in terms of HIV incidence and prevalence. At the end of 2007, the USVI’s estimated HIV rate was 641.3 adults and adolescents per capita living with HIV, the second highest HIV rate per capita in the United States at the time. In the past decade, the rate of HIV infection diagnosis has decreased by 80.4% from a high of 42.8 per 100,000 people in 2010 to a low of 8.4 per 100,000 people in 2018 (Figure 8.7). In 2018, the USVI ranked 33 among states and territories in terms of HIV prevalence with a rate of 7.9 per 100,000 people (data not shown). Figure 8.7 | HIV Incidence Among USVI Residents, 2008-2018 SOURCE | CDC, Division of HIV/AIDS Prevention, Annual HIV Surveillance Report By the end of 2017, there were 270 people living with HIV and 351 living with AIDS in the USVI, a total of 621 residents (Figure 8.8). The number of persons living with HIV infection (not AIDS) increased from 237 people in 2005 to 270 people in 2017, a 13.9% increase. The number of persons living with HIV infection ever classified as AIDS increased from 296 people in 2005 to 351 people in 2019, a 18.6% increase (data not shown). A majority of persons living with AIDS in the USVI are Black or African-American (52.5%) or Hispanic (37.3%) (Figure 8.9). Cumulatively since the beginning of the HIV/AIDS epidemic, there have been 808 cases of AIDS among adults and adolescents and 21 among children living in the USVI (data not shown). The prevalence of AIDS in 28.6 42.8 USVI HIV Diagnosis 8.4 19.5 US HIV Diagnosis 11.4 - 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 USVI 2020 CHA | 88 the USVI has decreased from 12.7 per 100,000 people in 2008 to 4.7 per 100,000 people in 2018, falling below the U.S. rate for the second year in a row (Figure 8.10). Figure 8.8 | Number of Persons Living with HIV/AIDS in the USVI, 2007-2017 SOURCE | CDC, Division of HIV/AIDS Prevention, Annual HIV Surveillance Report Figure 8.9 | Percent of USVI AIDS Cases by Race and Ethnicity, 2018 SOURCE | CDC, Division of HIV/AIDS Prevention, Annual HIV Surveillance Report 235 HIV Cases (Not AIDS) 270 335 AIDS Cases 351 570 Total 621 - 100 200 300 400 500 600 700 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 52.5% 37.3% 8.5% 1.7% Black or African-American Hispanic White Other USVI 2020 CHA | 89 Figure 8.10 | Prevalence of AIDS Among USVI Residents, 2008-2018 SOURCE | CDC, Division of HIV/AIDS Prevention, Annual HIV Surveillance Report HIV Testing Almost half the USVI adult population has been tested for HIV. In 2016, 49.5% of USVI adults reported ever having a test for HIV compared to 35.7% of adults nationally (Figure 8.11). Persons identifying as Hispanic, and of younger age, without health insurance, with high income, or with more education had the highest prevalence of HIV testing. In 2017, the USVI administered 1,494 CDC-funded HIV tests (data not shown). HIV/AIDS Treatment DOH provides medication assistance to 54 individuals through the AIDS Drug Assistance Program (ADAP) and insurance co-pay. ADAP and co-pay assistance is funded through the Ryan White Program from the Health Resources and Services Administration (HRSA). The average cost for medications for an individual living with HIV can be very expensive. However, DOH receives a significant discount on HIV medication as a HRSA 340B eligible entity. On an average, DOH spends $32,999 a month for ADAP medications and $3,400 for insurance co-pay assistance at the 340B rate. 12.7 21.6 USVI AIDS 4.7 12.3 US AIDS 5.2 - 5.0 10.0 15.0 20.0 25.0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 USVI 2020 CHA | 90 Figure 8.11 | Percent of USVI Adults Tested for HIV, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Sexually Transmitted Diseases Chlamydia, a curable sexually transmitted infection caused by the bacteria chlamydia trachomatis, is the most common sexually transmitted infection in the United States. The incidence of chlamydia nationally has been increasing steadily for the past two decades, from 251.2 per 100,000 people in 2000 to 524.6 per 100,000 people in 2017 (data not shown). The USVI mirrored the national trend over most of the same period, peaking in 2011 with a high of 820 cases (data not shown). The incidence of chlamydia cases in the USVI has decreased by 43.7% from a high of 757.2 per 100,000 49.5% 35.7% 49.3% 49.6% 48.6% 49.2% 59.1% 85.3% 75.8% 65.5% 49.8% 24.6% 48.4% 54.4% 47.1% 48.4% 51.1% 52.3% 52.6% 40.2% 48.3% 55.9% 55.3% USVI US Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Health Insurance Income Education USVI 2020 CHA | 91 people in 2011 to 430.7 per 100,000 people in 2017 (Figure 8.12). Following national trends, female USVI residents have the highest incidence of chlamydia at 571.2 per 100,000 among females compared to 277.1 per 100,000 among males in 2017 (data not shown). Chlamydia incidence was also highest in the 20- to 24-year age group in 2017 at 2,818.8 per 100,000 people, a rate similar to the national level of 2,853.7 per 100,000 people (Figure 8.13). USVI teens aged 15 to 19 years had the second highest chlamydia incidence rate in 2017 (1,637.2 per 100,000 people). Gonorrhea is a curable sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae. Like chlamydia, the incidence of gonorrhea has increased nationally from 98.2 per 100,000 people in 2000 to 170.6 per 100,000 people in 2017 (data not shown). The USVI has few cases of gonorrhea annually, with a recorded 17 cases in 2017, although the number of cases did experience an upward trend between 2000 – 2011 (data not shown). The gonorrhea incidence rate decreased by 87.7% from 128.4 per 100,000 in 2011 to 15.8 per 100,000 people in 2017 (Figure 8.12). Syphilis, a curable sexually or congenitally transmitted disease caused by the bacterium treponema pallidum, is one of the least common sexually transmitted infections in the United States. There were no cases of primary or secondary syphilis in the USVI in 2017. Between 2000 – 2017, the USVI DOH recorded a total of 23 cases of primary or secondary syphilis with the last confirmed cases occurring in 2015 (eight cases) (data not shown). The last cases of congenital syphilis were recorded in 2001 (data not shown). Figure 8.12 | Incidence of Chlamydia and Gonorrhea, USVI, 2000-2017 SOURCE | CDC, Division of STD Prevention 120.6 757.2 Chlamydia 430.7 13.8 128.4 Gonorrhea 15.8 0 100 200 300 400 500 600 700 800 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 USVI 2020 CHA | 92 Figure 8.13 | Chlamydia Incidence by Age Group, 15-34, USVI, 2000-2017 SOURCE | CDC, Division of STD Prevention Hepatitis Hepatitis refers to inflammation of the liver, which is often caused by a virus, but can also be caused by alcohol consumption or drug use. The three most common types of Hepatitis are A, B, and C. Hepatitis A and B are vaccine-preventable diseases. There is no vaccine for Hepatitis C, but appropriate treatment can clear the infection and cure the disease. There are very few cases of Hepatitis annually in the USVI. Between 2014 – 2018, there were 78 cases of Hepatitis A, B, and C combined (data not shown). The majority of those cases were chronic Hepatitis C, with 43 cases. 526.1 3,322.0 15-19, 1,637.2 933.3 4,548.2 20-24, 2,818.8 250.1 2,304.5 25-29, 1,521.7 110.9 1,186.6 30-34, 642.0 - 1,000.0 2,000.0 3,000.0 4,000.0 5,000.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 USVI 2020 CHA | 93 Vaccinations Influenza Vaccination Influenza is sporadic in the USVI, with a total of 182 suspected (and 14 confirmed) cases of influenza reported during the entire 2014 – 2018 period. Despite the low incidence of influenza, the USVI DOH aggressively promotes CDC’s guidelines to vaccinate all people six months and older. In 2016, 20.1% of adults reported receiving the influenza vaccine compared to 58.2% of adults nationally (Figure 8.14). Those USVI residents with the highest influenza vaccination rates included persons aged 18 to 24 years, persons aged 65 or older, persons identifying as White, and higher income or education. Pneumococcal Vaccination Pneumococcal disease is a vaccine-preventable illness caused by the bacteria Streptococcus pneumoniae (pneumococcus) and leads to 150,000 hospitalizations annually in the United States. The effects of pneumococcal disease are wide-ranging and include sinus infections and pneumonia. In some cases, severe illness can result in death. There were approximately 3,600 deaths nationally in 2017 due to pneumococcal disease. The CDC recommends pneumococcal vaccination for all children younger than two years old and all adults 65 years or older. In 2016, 41.7% of adults aged 65 and older received the pneumococcal vaccine compared to 73.4% of adults nationally (Figure 8.15). Pet Rabies Vaccination Rabies is a fatal viral infection that infects the central nervous system, causing brain inflammation in humans and other mammals. Due to widespread vaccination of companion animals, transmission of rabies to humans is very low in the United States with an average of two to three cases per year. An estimated 52.3% of households in the USVI have pets. In the aftermath of Hurricanes Irma and Maria, there was concern in the USVI about ensuring adequate pet rabies vaccination coverage among domestic animals. Among households with pet, 65.9% reported in the CASPER survey that their pets were vaccinated for rabies. Emerging Pathogens The USVI has relatively low incidence of many diseases commonly seen in other parts of the Caribbean and the mainland United States. However, there are a handful of infectious diseases that the USVI DOH is monitoring due to recent outbreaks. For example, there was an outbreak of antibiotic-resistant Enterobacteriaceae at a health care facility in March 2017 resulting in eight confirmed cases occurring between March 4 – March 31, 2017. USVI 2020 CHA | 94 Figure 8.14 | Percent of USVI Adults Who Received the Influenza Vaccine, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System Figure 8.15 | Percent of USVI Aged 65+ Who Received the Pneumococcal Vaccine, 2016 SOURCE | CDC, Behavioral Risk Factor Surveillance System 20.1% 58.2% 19.1% 20.7% 30.6% 18.5% 20.3% 23.1% 8.7% 9.3% 15.0% 18.0% 29.1% 22.2% 11.5% 13.6% 20.7% 21.2% 18.2% 24.2% 19.0% 14.8% 22.3% 24.3% USVI US Male Female White only, non-Hispanic Black only, non-Hispanic Hispanic Age 18 to 24 Age 25 to 34 Age 35 to 44 Age 45 to 54 Age 55 to 64 Age 65 or older Had health insurance No health insurance Less than $15,000 $15,000 to less than $25,000 $25,000 to less than $35,000 $35,000 to less than $50,000 $50,000 or more Did not graduate High School Graduated High School Attended College or Technical School Graduated from College or Technical School Overall Sex Race/Ethnicity Age Health insuranc e Income Education 41.7% 73.4% USVI Aged 65+ US Aged 65+ USVI 2020 CHA | 95 A new virus called SARS-CoV-2 has emerged as a potential threat to the United States and its territories. SARS-CoV-2 is spread person to person and causes a respiratory infection referred to as coronavirus disease 2019 (COVID-19). On March 11, 2020, the World Health Organization described SARS-CoV-2 as a pandemic. As of the publication of this report, there were a number of confirmed cases of COVID-19 in the USVI as well as some deaths. Because there is no vaccine for SARS-CoV-2 and identifying effective treatment is ongoing, the USVI is monitoring this situation closely and will update this assessment with continued surveillance. Numbers are sure to rise and will need a long term, sustained, public health response. Looking Ahead The USVI has a history of outbreaks of food- and vector-borne diseases, owing to its geographic location in the Caribbean and its position as a tourist destination. Its most recent outbreak of the Zika virus affected over 2,000 people in the USVI, including almost 300 pregnant women. The USVI DOH infectious disease surveillance activities are a crucial component of public health in the USVI, especially as the SARS-CoV-2 pandemic progresses. It is vital that the USVI DOH continue to monitor and release information about pathogens affecting residents with transparency to the public. USVI 2020 CHA | 96 USVI Community Health Assessment 2020 CHAPTER 9 Mortality & Hospital Care MORTALITY TRENDS | LIFE EXPECTANCY | PREMATURE MORTALITY | HOSPITALIZATIONS & EMERGENCY CARE USVI 2020 CHA | 97 Mortality & Hospital Care Five Things You Should Know in 2020  Between 2008 – 2015, the overall USVI mortality rate declined from 729.0 deaths per 100,000 to 531.0 deaths per 100,000. The four leading causes of death in the USVI in 2016 were heart disease, cancer, homicide, and unintentional injuries. The USVI has the highest homicide rate in the United States and the fifth highest in the world. In 2017, the top cause of premature death in the USVI was homicide, with 2,341.3 years of potential life lost before the age of 75 per 100,000 residents. The most common complaints among emergency department visits between 2016 – 2019 were abdominal pain, a “check-up,” or lower extremity pain or injury. USVI By the Numbers 78.6 Life expectancy in 2017 #1 Rank in homicide rate among United States states & territories in 2016 2,341 Years of potential life lost before 75 due to homicide in 2017 45 Number of people who died from homicide in 2016 125 Number of people who died from heart disease in 2016 24 Number of people who died from unintentional injury in 2016 109 Number of people who died from cancer in 2016 2,650 Number of hospital admissions on St. Croix in 2019 USVI 2020 Community Health Assessment USVI Department of Health 3500 Estate Richmond Christiansted, 00820-4323, U.S. Virgin Islands For More Information Visit doh.vi.gov Key Findings | USVI Community Health Assessment 2020 USVI 2020 CHA | 98 Mortality & Hospital Care Examining how we die provides clues into how healthy we are as a community. Some deaths, like those caused by intentional or unintentional injury, are preventable and shorten our lifespan. Trends in mortality also tell us how well our health care system is working. Hospitalizations and emergency care are our safety net when our health declines or when we want to improve our health with surgical intervention. This chapter describes how we die and how we use our health care system. Mortality Trends Overall Mortality Rate The overall mortality rate in the USVI has been decreasing, following the national trend. Between 2008 – 2015, the overall mortality rate declined from 729.0 deaths per 100,000 to 531.0 deaths per 100,000 (Figure 9.1). The USVI mortality rate increased between 2015 – 2016 to 575.1 deaths per 100,000. Figure 9.1 | USVI Age-Adjusted Mortality Rate per 100,000, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System Leading Causes of Death The four leading causes of death in the USVI in 2016 were heart disease, cancer, homicide, and unintentional injuries. The USVI death rates for the top four causes were lower than the national 776.5 US 728.8 648.7 USVI 575.1 - 200.0 400.0 600.0 800.0 1,000.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 99 rate, with the exception of homicide with 44.7 deaths per 100,000 compared to 6.2 deaths per 100,000 nationally (Figure 9.2). Figure 9.2 | USVI Age-Adjusted Deaths per 100,000 for Top Causes of Death, 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System Heart disease is the leading cause of death in the United States and in every state and territory. The death rate due to heart disease has been trending downward nationally, as has the USVI rate. However, the USVI death rate from heart disease increased between 2015 – 2016 (from 97.1 per 100,000 in 2015 to 124.5 per 100,000 in 2016) (Figure 9.3). Figure 9.3 | USVI Age-Adjusted Mortality Rate p\er 100,000 for Heart Disease, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System NOTE | Vital statistics for the USVI are unavailable for 2013-2014. 124.5 109.2 44.7 23.6 165.5 155.8 6.2 47.4 Heart Disease Cancer Assault (Homicide) Unintentional Injuries 200.2 US 165.5 175.7 USVI 124.5 0 50 100 150 200 250 300 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 100 Cancer mortality has also been declining nationally but began increasing in the USVI in 2015. The USVI cancer mortality rate increased from 96.7 per 100,000 in 2015 to 109.2 per 100,000 in 2016 (Figure 9.4). Figure 9.4 | USVI Age-Adjusted Mortality Rate per 100,000 for Cancer, 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System NOTE | Vital statistics for the USVI are unavailable for 2013-2014. While the USVI has a higher rate of homicide than the United States, the overall homicide rate in the USVI has been decreasing steadily since 2010—from 63.3 deaths per 100,000 in 2010 to 44.7 deaths per 100,000 in 2016 (Figure 9.5). Among other countries, the USVI homicide rate is fifth in the world behind Jamaica with 47.0 deaths per 100,000 in 2016 (Figure 9.6). The USVI has the highest homicide rate in the United States and is more than double the rate in Louisiana, which has the second highest homicide rate in the United States at 14.3 deaths per 100,000 (Figure 9.7). Figure 9.5 | USVI Age-Adjusted Mortality Rate per 100,000 for Assault (Homicide), 2006-2016 SOURCE | National Center for Health Statistics, National Vital Statistics System NOTE | Vital statistics for the USVI are unavailable for 2013-2014. 180.7 US 155.8 108.2 USVI 109.2 0.0 50.0 100.0 150.0 200.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 6.2 US 6.2 44.2 USVI 44.7 0.0 25.0 50.0 75.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 101 Figure 9.6 | Homicides per 100,000, by Top 20 Countries with Highest Homicide Rates, 2016 SOURCE | UN Office on Drugs and Crime's International Homicide Statistics database Figure 9.7 | Homicides per 100,000, USVI and Top 5 U.S. States, 2016 SOURCE | NCHS, National Vital Statistics System 83.1 56.5 56.3 47.0 44.7 37.6 36.5 34.0 29.7 28.5 28.4 27.3 25.5 21.8 19.8 19.3 19.2 18.4 16.9 15.2 El Salvador Honduras Venezuela, RB Jamaica US Virgin Islands Belize St. Vincent and the Grenadines South Africa Brazil St. Martin (French part) Bahamas, The Guatemala Colombia Dominica Central African Republic Mexico Puerto Rico Guyana St. Lucia Dominican Republic 44.7 14.3 12.1 11.8 10.1 9.9 USVI Louisiana Mississippi Alabama Maryland Missouri USVI 2020 CHA | 102 The death rate for unintentional injuries has been increasing nationally but has decreased in the USVI from 29.1 deaths per 100,000 in 2006 to 23.6 deaths per 100,000 in 2016 (Figure 9.8). Figure 9.8 | USVI Age-Adjusted Mortality Rate per 100,000 for Unintentional Injuries, 2006- 2016 SOURCE | National Center for Health Statistics, National Vital Statistics System NOTE | Vital statistics for the USVI are unavailable for 2013-2014. Life Expectancy Life expectancy in the U.S. Virgin Islands has remained consistent over the past several years at 78.5 years (Figure 9.9) but increased to 79.8 years in 2019, according to the Central Intelligence Agency World Fact Book. In contrast, life expectancy in the United States has been declining since 2017, from 79.4 years to 78.6 years in 2019. Premature Mortality Premature mortality measures the numbers of years a person could have lived if a preventable event or condition had not caused death. In 2017, the top cause of premature death in the USVI was homicide, with 2,341.3 years of potential life lost before the age of 75 per 100,000 residents (Figure 9.10). The years of potential life lost due to homicide was more than double the second cause of premature death: heart disease. 39.8 US 47.4 29.1 USVI 23.6 0.0 25.0 50.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 USVI 2020 CHA | 103 Figure 9.9 | Number of Years Lived on Average by USVI Residents, 2010-2017 SOURCE | World Bank World Development Indicators Figure 9.10 | Number of USVI Resident Years of Potential Life Lost Before Age 75, 2017 SOURCE | National Center for Health Statistics, National Vital Statistics System Hospitalizations & Emergency Care Both hospitals in the USVI experienced major damage following Hurricanes Irma and Maria in late 2017. During the storm, Schneider Regional Medical Center Hospital evacuated all its patients to St. Croix and other hospitals in the region. Hospital admissions and emergency department visits 78.0 US 79.4 78.5 USVI 78.5 75.0 80.0 85.0 2010 2011 2012 2013 2014 2015 2016 2017 2,341.3 1,080.8 786.1 515.1 445.6 271.9 207.4 177.7 168.7 77.4 Homicide Heart disease Cancer Perinatal Motor vehicle accidents Suicide Cerebrovascular Diabetes Hypertension Chronic lower respiratory disease USVI 2020 CHA | 104 declined over the 2016 – 2019 period at one of USVI’s major hospitals.3 In 2016, the Juan F. Luis Hospital and Medical Center had 3,392 admissions, but this number declined to 2,650 in 2019 (Figure 9.11). Emergency department visits followed the same trend, declining from 18,781 visits in 2016 to 15,802 visits in 2019. The decline may be due to facility destruction caused by Hurricanes Irma and Maria and the challenges associated with providing health services during recovery. Figure 9.11 | Number of Hospital Admissions and Emergency Department Visits at Governor Juan F. Luis Hospital and Medical Center, St. Croix, USVI, 2016-2019 SOURCE | USVI Department of Health The most common complaints among emergency department visits between 2016 – 2019 were abdominal pain, a check-up, or lower extremity pain or injury (Figure 9.12). The number of visits for check-ups in 2019 was 1,279—a decrease from 2,051 visits for check-ups at the emergency department in 2016. The largest source of health insurance among persons admitted to the hospital between 2016 – 2019 was either Medicare or Medicaid (Figure 9.13). 3 Data available for this portion of the assessment is from the Juan F. Luis Hospital and Medical Center on St. Croix unless otherwise specified. More detailed information describing inpatient and emergency department care at Schneider Regional Medical Center in St. Thomas was unavailable for this report. 3,392 Hospital admissions 2,650 18,781 Emergency department visits 15,802 - 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 2016 2017 2018 2019 USVI 2020 CHA | 105 Figure 9.12 | Top Ten Chief Complains at the Emergency Department, Governor Juan F. Luis Hospital and Medical Center, St. Croix, USVI, 2016-2019 SOURCE | USVI Department of Health Figure 9.13 | Number of Hospital Admissions by Insurance Source, Governor Juan F. Luis Hospital and Medical Center, St. Croix, USVI, 2016-2019 SOURCE | USVI Department of Health 1,817 1,553 1,339 1,336 2,051 1,479 1,276 1,279 1,094 1,067 1,069 1,011 886 835 906 808 676 550 534 496 530 505 534 556 807 588 501 512 883 490 497 496 485 514 431 371 235 282 274 220 2016 2017 2018 2019 Abdominal Pain Check-up Lower Extremity Pain/Injury Chest Pain Upper Extremity Pain/Injury Motor Vehicle Accident Cough Fever Laceration Behavioral Health 1014 1012 682 749 940 895 641 824 518 460 277 342 320 263 191 251 16 29 9 10 582 597 534 474 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2016 2017 2018 2019 Medicare Medicaid CIGNA Other Workers Comp VA Self-Pay USVI 2020 CHA | 106 Looking Ahead Mortality is the final marker for health in any community. The number of USVI residents of older age is increasing, which means that diseases like heart disease and cancer are also increasing. While overall mortality rates are decreasing, there is one cause of death that is notable: death by homicide. The USVI has the highest homicide rate in the United States compared to all other states and territories and has the fifth highest homicide rate in the world when compared to other countries. This trend is consistent and urgent. Men, particularly young men, are dying from violence that is preventable and this must be addressed to ensure a healthier USVI. At the same time, the USVI health care system is serving community residents for primary care—a challenge experienced across the United States and beyond. This trend is important, especially because of destruction to key acute care facilities during the 2017 hurricane season and the need to ensure capacity to handle emerging health threats like COVID-19. A key next step for the USVI DOH is to improve availability of health care statistics to assess system capacity across all services provided territory-wide. As mentioned in Chapter 4: Births and Reproductive Health, there is a gap in vital statistics data, including death statistics. There is no data on mortality for both 2013 and 2014. This gap impairs the USVI DOH’s capacity to assess improvements and drivers of trends in mortality. It will be important to address this gap in future assessments to better support planning for community health improvement activities. USVI 2020 CHA | 107 USVI Community Health Assessment 2020 Appendix USVI 2020 CHA | 108 Glossary of Terms Birth rate The number of live births per 1,000 women in a specific population or location. CASPER The Community Assessment for Public Health Emergency Response survey system is a data collection system funded and conducted by the Centers for Disease Control and Prevention. Determinants of health The personal, social, economic, and environmental factors that determine the health status of individuals or populations. Epidemic The occurrence of cases of an illness, health-related behavior, or other health-related event in excess of what one would normally expect in a specific population or location. Fertility rate The number of births per 1,000 women in a specific population or location. Incidence The number of cases of disease that occur during a specified period. Incidence is often expressed as a rate. Infant mortality The number of babies born alive who die before their first birthday per 1,000 live births. Leading Health Indicators A smaller set of measures from the Healthy People 2020 initiative that describe high-priority targets (e.g., diabetes prevalence, current smoking). Life Expectancy A measure of the average time a person can be expected to live in a specific population or location. Morbidity A measure describing the presence of disease or a health condition in a specific population or location. Mortality A measure of deaths in a specific population or location. Pandemic An epidemic that affects or attacks the population of an extensive region, country, or continent. Partners Individuals, leaders, organizations, and agencies that collaborate with the USVI DOH to improve the health and wellness of Virgin Islanders. Pathogen A microorganism such as bacterium, virus, or fungus that causes disease in people or animals. Prevalence The number of cases of a disease, affected people, or people with a characteristic related to health and wellness that is present during a specified time period. Prevalence is often expressed as a rate. USVI 2020 CHA | 109 Screening The use of technology and procedures to differentiate those individuals with signs or symptoms of disease from those less likely to have the disease. Statistical Significance A measure of likelihood that a relationship between two or more things is caused by something other than chance. Years of Potential Life Lost A measure of the effects of disease or injury in a population that calculates years of life lost before a specific age (often ages 64 or 75). USVI 2020 CHA | 110 Abbreviations AIDS Acquired Immunodeficiency Disease Syndrome BRFSS Behavioral Risk Factor Surveillance System CASPER Community Assessment for Public Health Emergency Response CDC Centers for Disease Control and Prevention HIB Haemophilus influenzae type B vaccine HIV Human Immunodeficiency Virus HRSA Human Resources and Services Administration MMR Measles, mumps, rubella vaccine SNAP Supplemental Nutrition Assistance Program TANF Temporary Assistance for Needy Families USPSTF United States Preventive Services Task Force USVI DOH United States Virgin Islands Department of Health WIC Special Supplemental Nutrition Program for Women, Infants, and Children YRBS Youth Risk Behavior Survey