COVID-19

The first COVID-19 community cases in the CNMI were identified on March 26, 2020 with limited further transmission. After eliminating local transmission in 2020, CNMI experienced its next community outbreak, again comprising only a small cluster of cases, in March 2021. A larger, more prolonged outbreak occurred at the end of 2021, extending into 2022. Before this large outbreak, the CNMI had time to obtain adequate resources, train personnel and deliver a community-based vaccination campaign and access to treatments. Thus, by the time of the first significant community spread, CNMI was uniquely protected; the case fatality rate was low and there was sufficient capacity within the health-care system to cope with increased case numbers as a result of the importation of both the Delta and Omicron variants of concern (VOCs).

Between March 2020 and October 2021, the period between the first case notification and the start of the larger community outbreak in October 2021, the CNMI recorded just 291 cases, with a vaccination coverage rate at 73.4% in the overall population and 90.4% of the vaccine-eligible population (individuals aged 12 years and older)[1]. By December 2021, just 2 months after the start of the CNMI’s first surge, the COVID-19 cases reported totaled 3,281 (see Figure 1).

Figure 1. Daily number of laboratory-confirmed COVID-19 cases, Commonwealth of the Northern Mariana Islands, 26 March 2020–31 December 2021 (N = 3281)

The COVID-19 outbreak that occurred at the start of FY2022 resulted in schools transitioning to virtual learning, increased community-based testing, and increased vaccination activity to vaccinate those in the community who have not been vaccinated and young children and infants, when vaccines were made available to those populations. The CHCC worked closely with the CNMI Public School System to provide school-based vaccination services, coordinate communications to increase vaccine confidence, and monitor vaccination data to inform targeted vaccination activities and to assist with decisions on when schools will resume in person learning. Division of Public Health staff members, including MICAH team members were engaged in the overall territory response efforts, including aggressive testing, treatment, and vaccination campaigns, guided by recommendations by the US Centers for Disease Control and Prevention. A second wave, or surge, of COVID-19 infections occurred in the early part of 2022 and then a third smaller surge in the summer months (see Figure 2).

 

 

 

 

 

 

Figure 2. COVID-19 Cases Reported in the CNMI in 2022.

 Source: Commonwealth Healthcare Corporation Weekly Syndromic Surveillance Report

In addition to schools, many community partner agencies transitioned to remote work suspending face to face activities and community events, which significantly impacted the CNMI MCH Title V workplan activities including the implementation of evidence based strategies and the collection of Evidence Based or Informed Strategy Measures (ESMs).

As of July 08, 2023, there were a total of 13,981 reported cases of COVID-19 in the CNMI, 311 hospitalizations and 46 deaths related to COVID-19. The COVID-19 fatality ratio in the CNMI is .33%, lower than the nation’s rate of 1.1%.[2]

In 2020, the COVID-19 pandemic severely impacted the CNMI workforce, especially those in the tourist and service industries, which are major sources of revenue in the Northern Mariana Islands. However, in 2022, with the easing of travel restrictions and the downgrade of covid-19 pandemic, the tourist industry began showing signs of recovery with 95,956 or 656% increase in tourist arrivals from the previous year. Majority of the tourist populations that are traveling to the CNMI are from Korea, representing 78% of visitors, followed by Guam and U.S. at 10% and 7% respectively. Table 1 illustrates the tourist arrivals by quarter in the year 2022[3].

Figure 3. Number of arrivals to the CNMI in 2022

 

On-going Needs Assessment Activities

MCH continues to collaborate with the CHCC hospital, Health and Vital Statistics Office, and key partners such as the CNMI Public School System and WIC for improved data collection, analysis and reporting activities. Participation is highly encouraged in partnership meetings with associates and stakeholders for gathering quality data in promoting programmatic activities. In addition, establishing membership with local groups and committees such as the Disability Network Providers (DNP), Early Intervention Services Program’s Interagency Coordinating Council, and the Head Start Advisory Council (HSAC) provides MCH opportunities to network with agency partners for obtaining updates on annual plans, objectives, needs, and any emerging issues occurring through partner programs.

 

MCH continues to receive data from the health system primary care clinics, Health & Vital Statistics Office (HVSO), hospital admissions and Carevue Electronic Health Records for chart reviews and to help inform ongoing needs assessment processes.

The MCH Jurisdictional survey is a Federally available data (FAD) source used to gather valuable MCH data to inform annual needs assessment activities as well as serving as a data source for National Outcome Measures (NOMs) and National Performance Measures (NPMs). A third round of MCH Jurisdictional survey is critical for attaining data to inform the Title V Maternal and Child Health (MCH) Block Grant annual reports. The 2021 MCH Jurisdictional survey provided data for 19 National Performance Measures and 14 National Outcome Measures for the Title V MCH Block Grant Programs.

 

In May 2021, the CHCC was awarded funding through the Centers for Disease Control and Prevention (CDC) to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). The PRAMS collects jurisdiction-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS surveillance currently covers about 81% of all U.S. births. The CNMI MCH will utilize the PRAMS data to investigate emerging issues and to plan and review programs and policies aimed at improving health outcomes for CNMI mothers and babies. The State Systems Development Initiative (SSDI) supports the PRAMS Integrated Data Collection System (PIDS) by using SAS software to generate monthly samples and summarize information in the dataset. Data collection from the sample birth records began in July 2022 through June 2023. For the Calendar Year 2022, the PRAMS project sampled 373 birth records of the total 473 live births recorded in the CNMI. At the end of the Phase 8 data collection, the CNMI PRAMS project accomplished a 57.91% response rate. Currently, the CDC PRAMS is working with the CNMI to submit all requirements for data weighting. When weighted data becomes available, the CNMI MCH will be able to analyze and use data to support informed decision-making pertaining to public health interventions specific to the MCH population.

Update on Health Status/Needs of MCH Population

Women/Maternal Health

Data gathered from the MCH Jurisdictional Survey (MCH-JS) in 2021 indicates that an estimated 57.1 percent of women ages 18 thru 44 years reported completing a preventive health visit in the past year, which is a slight increase from 2019 data of 55.5 percent. However, review of other indicators of preventive services among women of reproductive age in 2022 illustrate slight decreases in the number of Pap Smears conducted (803 less pap smears conducted), number of family planning visits (17% decrease), and the percentage of early prenatal care among women with live births (5 percentage point decrease).

Perinatal/Infant Health

In 2022, Health and Vital Statistics reported 473 live births in the CNMI, of which 73.57 percent of the births covered by Medicaid. Approximately 94 percent of infants were breastfed, however less than 1 percent of infants were breastfed exclusively through 6 months. Additionally, 10.8 percent of infants were born with low birthweight, an increase of 2.6 percentage points from the previous year; and the percentage of infants born preterm was 12.3 percent, an increase of 3.4 percentage points from 2021. The CNMI infant mortality rate for 2022 was 12.7 per 1,000, a slight increase from 12.2 in 2021.

Child Health

The 2021, MCH-JS indicated 43.5 percent of children ages 6 through 11 years were reported to be physically active at least 60 minutes per day, a decrease from 2019 survey data of 52.7 percent. The percentage of children who were reported with decayed teeth or cavities on the MCH-JS also increased from 13 percent in 2019 to 17 percent in 2021, however there was an increase in the percentage of children reported to have accessed preventive dental care, with 46.4 percent of children ages 1 through 17 years reporting that they had a preventive dental visit in the 2021. This is an increase of 14.9 percentage points from the initial 2019 MCH-JS survey.

The percentage of parents in 2021 that reported their children (ages 0 through 17 years) to be in excellent or very good condition was 72 percent, a decrease from the 2019 percentage of 81.2 percent and significantly lower than the US national percentage of 90.4 percent.

There was a decrease in the vaccination coverage among CNMI children ages 19 through 35 months for the combined 7-vaccine series between 2021 (70%) and 2022 (66.3%).

Adolescent Health

CNMI 2021 Maternal and Child Health Jurisdictional Survey data on the adolescent well-visits indicate that just 39.3 percent of adolescent ages 12 through 17 years had a preventive visit in the past year, a slight decrease compared to the 2020 percentage of 42.4 percent. The State value for teen births among 15 to 19 years olds decreased to 9.9 per 1000 in 2022 compared to a rate of 13.0 per 1,000 in 2021, a decline from 15.1 per 1,000 in 2020 and 21.0 per 1,000 in 2019. Vaccinations among the CNMI adolescent population are also maintaining high coverage with 96.6 percent of teens ages 13 through 17 years with at least one dose of the HPV vaccine, 98.3 percent of the same group receiving at least one dose of the meningococcal conjugate vaccine and 99.5 percent receiving at least one dose of the Tdap vaccine.

Data for the 2021 CNMI Youth Risk Behavior Survey (YRBS) was released in the spring of 2023 providing updates on a variety of youth risk behavior for middle and high school students in the CNMI. Table 1, below, provides trend data for select indicators for the years 2015 thru 2021.

Table 1. CNMI YRBS Trend Data for select indicators, percent among High School Students, 2015 – 2021

Survey Question	2015	2017	2019	2021
Unintentional Injuries and Violence
Were electronically bullied	15.4	17.3	14.2	15.4
Were bullied on school property	22.1	23.2	18.4	9.9
Felt sad or hopeless	36.2	40.7	47.7	54.6
Seriously considered attempting suicide	22.8	25.0	28.5	29.6
Made a plan about how they would attempt suicide	23.3	22.8	27.1	27.6
Actually attempted suicide	13.5	13.6	18.0	17.6
Suicide attempt resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse	2.9	4.3	4.9	5.3
Tobacco Use
Ever tried cigarette smoking	54.9	45.2	44.8	35.6
Currently smoked cigarettes	17.9	12.4	10.8	6.9
Currently smoked cigarettes daily	2.8	2.5	1.9	1.4
Ever used electronic vapor products	53.3	53.6	64.5	56.1
Currently used electronic vapor products	26.3	13.7	24.4	26.4
Currently used electronic vapor products daily	2.0	1.9	4.1	7.8
Sexual Behavior
Were currently sexually active	29.0	24.3	23.6	17.5
Did not use a condom during last sexual intercourse	54.2	47.4	61.0	61.9
Did not use both a condom during last sexual intercourse and birth control pills; an IUD (e.g., Mirena or ParaGard) or implant (e.g., Implanon or Nexplanon); or a shot (e.g., Depo-Provera), patch (e.g., OrthoEvra), or birth control ring (e.g., NuvaRing) before last sexual intercourse	--	--	--	94.7
Physical Activity
Were not physically active at least 60 minutes per day on 5 or more days	56.6	62.8	63.5	71.8
Spent 3 or more hours per day on screen time	--	--	--	77.6
Did not attend physical education (PE) classes on all 5 days	70.2	71.5	73.8	72.8
Obesity, Overweight, and Weight Control
Had obesity	16.0	16.4	21.6	23.4
Were overweight	17.4	18.2	15.9	19.2
Described themselves as slightly or very overweight	32.3	33.8	36.0	41.0
Other Health Topics
Never saw a dentist	7.9	6.2	--	5.2
Reported that their mental health was most of the time or always not good	--	--	--	31.9
Did not get 8 or more hours of sleep	71.9	77.2	76.4	81.7

-- indicates No Data

Data Source: Centers for Disease Control and Prevention, High School YRBS, Northern Mariana Islands

 

According to the 2021 results of Youth Risk Behavioral Survey (YRBS), adolescents in grades 9 through 12 who are obese increased from 21.6 to 23.4 percent in 2019 to 2021 respectively; similarly, adolescents who were not physically active at least 60 minutes per day on 5 or more days increased from 63.5 percent in 2019 to 71.8 percent in 2021. Additionally, an increase is noted in the percentage of high school teens reporting suicidal ideation, with almost 30 percent of high school student in the CNMI reporting seriously considered attempting suicide in 2021. While the CNMI is reporting a decrease in cigarette use among high school students, the number of teens currently using and daily use of electronic vapor products, or e-cigarettes, is on the rise. According to the 2021 CNMI YRBS, more than half (56.1 percent) of high school students have tried electronic vapor products, more than a quarter (26.4 percent) reported current use, and 7.8 percent reported daily use.

 

Children with Special Health Care Needs (CSHCN)

According to the MCH-JS, the CNMI has an estimated 7.3 percent of children ages 0 through 17 years who met the criteria for having a special health care need based on the CSHCN screener. Data gathered from the CNMI MCH Jurisdictional Survey indicated that only 14.1 percent of CSHCN, ages 0 through 17 in 2021 reported having a medical home, significantly lower than the US percentage of 42.0 percent[4]. Additionally, only 32.7 percent of families of CSHCN reported receiving services necessary for transition into adult healthcare.

 

Title V Program Capacity Updates & Changes

In the spring of 2021, the MCHB was restructured to include the Immunization and WIC programs and renamed into the Maternal, Infant, Child and Adolescent Health (MICAH) Programs. The Title V Block Grant is administered through the CHCC MICAH Programs. The MCH Program is one of the seven programs under the MICAH, along with Family Planning, Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, H.O.M.E. Visiting, WIC, Immunization and Vaccines for Children (VFC), Family to Family Health Information Center, PRAMS and State System Development Initiative. In December of 2022, the MICAH Programs Administrator, who serves as the Title V Block Grant Project Director, was promoted to the role of Director of Population Health Services. In January of 2023, the former Fiscal Specialist is now serving as the MICAH Programs Administrator.

 

In April of 2022, the Child Health Coordinator, who also served as the CSHCN Project Director, resigned from the position. After the departure of the Child Health Coordinator/CSHCN Project Director, the MICAH programs unit began the process to realign the unit structure and restructure staff positions to more effectively address the needs of the community based on the priorities and strategies identified through the needs assessment process. The realignment and restructuring was completed on April 2023.  Mrs. Shiella Deray has is now serving as the CSHCN Project Director.

 

During the COVID-19 pandemic response in FY2021 and into FY2022, the MCH Title V Project Director served as the COVID-19 Vaccinations Operations Lead as part of the CHCC emergency response structure. Other staff members, including the MCH Services Manager and CYSHCN Program Manager were also assigned to COVID-19 vaccination operations.

 

Partnerships, Collaboration, and Coordination

Perhaps one of the most significant partnerships the MICAH programs works diligently to maintain and strengthen are the partnerships with the clinical providers who serve the CNMI MCH populations. Chairpersons for the Women’s and Children’s Clinics at the CHCC health department and health system are critical collaborators for advocating and championing many of the priorities and strategies that are intended to improve the health and wellness outcomes of CNMI women, children, and their families. The Medical Director for Public Health and the Family Planning Medical Director also play critical roles in the various activities and strategies identified in the CNMI MCH Title V, providing input and guidance on strategies.

 

The CNMI Public School System continues to be a major partner for strategies and activities targeting children ages zero through 17 years. The PSS Early Intervention Services Program and the Early Head Start program serve children from birth through 3 years. PSS serves children ages 3 through 5 years in Head Start programs and children ages 6 through 17 years are enrolled in PSS K through 12th grade programs. The CHCC has formal MOUs with the PSS to collaborate on programs serving children enrolled throughout the system. CHCC population health programs collaborate with PSS to offer training/capacity building, school based screening services (such as STD/HIV and diabetes or hypertension), as well as other sexual and reproductive health services, such as counseling and access to contraceptives to prevent teen pregnancies and STD transmission. Other initiatives that CHCC has partnered with PSS are: Developmental Screenings, Bullying Prevention, Teen Pregnancy Reduction, Improving Immunization rates, Nutrition, and Physical Activity.

 

The Child Care Development Fund (CCDF), a program serving low-income families through childcare subsidies, is an additional key partner in the MCH program’s work for serving children and families. MCH continues to partner with CCDF in the CNMI wide implementation of standardized developmental screening and in implementing the Quality Rating Improvement System (QRIS), which is focused on refining and improving the standards of quality for early care and education programs in the CNMI.

 

The MCH and WIC Programs have worked collaboratively for many years to improve breastfeeding rates, lower childhood obesity rates, and increase access to prenatal care.

 

The MCH partnership with the Northern Marianas College (NMC) Expanded Food Nutrition and Education Program (EFNEP) is focused nutrition and addressing obesity related activities among the MCH population. Additionally, nursing students through the NMC Nursing Program conduct clinical rotations in the Immunization clinic during the Fall and Spring semesters each year.

 

The Disability Network Partners (DNP) consists of programs that provide services to individuals with special healthcare needs and their families. The Northern Marianas College’s University Centers of Excellence in Developmental Disabilities (UCEDD), CNMI Office of Vocational Rehabilitation, and Developmental Disabilities Council comprise the CNMI Tri-Agency partners who lead the overall DNP. Other partners involved in the DNP include the Northern Marianas Protection and Advocacy Systems Inc. (NMPASI), Public School System Special Education Program (SPED), Center for Living Independently (CLI), and the MICAH Programs. The DNP meets on a quarterly basis and works on projects such as the CNMI Disability Resource Directory, and the Annual Transition Conferences. Additionally, the CNMI MCH Title V Project Director serves as a council member on the Governor appointed CNMI Developmental Disabilities Council.

 

The CNMI Department of Public Safety and the Division of Fire and Emergency Services are also key partners in promoting the health and safety of the MCH population. MCH partners with the Department of Public Safety on child passenger safety initiatives, which include workforce capacity building that enable child passenger safety technician certification for MCH and CHCC nursing staff.

  

Internal partnerships across CHCC population health programs helps to strengthen the MCH system in the CNMI. MCH works closely with the Immunization Program in increasing community awareness on the importance of vaccines and in increasing access to immunizations through collaborations on community outreach events. Collaboration with the Breast and Cervical Cancer Screening Program positively contributes in the MCH program’s efforts for increasing preventive screening rates among women in the CNMI. Other collaborative efforts include Diabetes, Cancer, Tobacco Control and other chronic disease prevention and health promotion.

 

The program coordinates with the Health & Vital Statistics Office, CHCC HIT Dept., and CHCC Medical Records Department on initiatives involving access and improving quality of population-based data.

 

Operationalization of 5-Year Needs Assessment

MICAH Programs staff work to evaluate and revise strategies and activities based on outcomes. Staff work collaboratively across programs and with partners to meet short- and long-term outcomes to support improvements in national and state performance measures that eventually impact the Title V national outcome measures.

5-Year Plan Changes for 2021-2025 (FY 2022)

No changes to Title V priority selections were made in FY2022. However, a change in strategy for the child health domain was made. The strategy of improving well-child visits as a mechanism for improving physical activity and addressing obesity related issues among children 6 through 11 years is replaced with the strategy to increase the number of families enrolling into evidence-based nutrition and physical activity programs or curriculum.

Health Equity & Social Determinants of Health

The MICAH programs worked to integrate activities within the Title V MCH work plan for FY 2023 to address social determinants of health in strategies across population health domains as an approach for addressing health equity in the CNMI. Integrating screening for social determinants of health and implementing referral mechanisms were included as part of strategies to address priorities.

 

Changes in Organizational Structure and Leadership

A major organizational change was the transfer of the CNMI Medical Referral Program to the CHCC. In January of 2022, the CNMI Medical Referral Program was transferred from the Office of the CNMI Governor to the CHCC. The Medical Referral Program is designed to provide residents of the CNMI, inclusive of the MCH populations and CSHCN, access to medical care that is not available in the CNMI. Currently, the CHCC is undergoing a review, revision, and developing policies and procedures to streamline medical referral reviews and processes to more effectively meet the health needs of the CNMI population. With improved program processes, the organization anticipates improvements in financial performance, processes for accessing off-island care, and an opportunity to identify and implement actions to improve sustainability of the program. While there are identified areas of opportunity and potential for improving healthcare access with this transition, it must be noted that the transfer comes with a risk of financial liability. The Medical Referral Program has historically operated underfunded, with an annual appropriation of $2 million a year and annual spending of $15 million to $18 million.

 

Emerging Public Health Issues

 

The end of the US federal COVID-19 Public Health Emergency (PHE) was on May 11, 2023 in addition to the World Health Organization (WHO) declaring the end of the Global Pandemic in the same month. Multiple factors contributed to the end of both the PHE and the Global Pandemic, including population immunity, access to therapeutics and treatment, and a downward trend in infections and deaths. For very many in the CNMI, the end of the PHE also means and end to Medicaid coverage. In FY2022, the CNMI had approximately 24,000 (51%)[5] community members enrolled under the Medicaid Presumptive Eligibility coverage, which ended with the PHE. The loss of Medicaid coverage for thousands in the CNMI is an emerging public health issue with the potential to negatively impact access to primary and preventive care for the CNMI population, including the MCH populations.

 

 

 

 

[1] World Health Organization. (2023). How the Commonwealth of the Northern Mariana Islands stalled COVID-19 for 22 months and managed its first significant community transmission.

[2] John Hopkins Coronavirus Resource Center. (2023). Mortality Analysis. Retrieved on July 19, 2023 from https://coronavirus.jhu.edu/data/mortality

[3] CNMI Department of Commerce (2022) Economic Indicator: Visitor Arrivals. Retrieved on July 5, 2023, from: https://ver1.cnmicommerce.com/ei-visitor-arrivals/

[4] The Child & Adolescent Health Measurement Initiative. (ND). 2020-2021 National Survey of Children's Health. Retrieved on July 14, 2023 from https://www.childhealthdata.org/browse/survey/results?q=8569&r=1

[5] Commonwealth Medicaid Agency. (2022). 2022 Citizen-Centric Report Commonwealth Medicaid Agency (CMA) Office of the Governor. Accessed on July 14, 2023 from https://cnmileg.net/resources/files/2022%20CENTRIC%20REPORT/Medicaid%20CCR22.pdf