An outbreak of dengue fever in children in the National Capital District of Papua New Guinea in 2016

BACKGROUND

The first documented outbreak of dengue which included cases with haemorrhage occurred in Papua New Guinea in 2016.

AIM

To document the presentation and outcome of children with dengue in Port Moresby.

METHODS

This prospective cross-sectional descriptive study was conducted in Port Moresby General Hospital during a 6-month period from 6 January to 6 July 2016. Altogether, 165 children aged 1-14 years who met the WHO criteria for probable dengue were assessed and treated. Clinical features, presence of warning signs and signs of severe dengue, date of onset, management and outcome were recorded. Blood specimens were collected for serological testing and full blood count.

RESULTS

The median age was 6 years (interquartile range 3-8). Eighty-eight (53%) children had no warning signs and were managed as outpatients. Of the 165 patients, 42 (25%) had abdominal pain, 28 (17%) had bleeding and 3 (2%) had clinical evidence of fluid accumulation. The median (IQR) lowest platelet count in those tested was 34 × 10⁹/L (22-54). Two children were transfused with packed red blood cells and one received a platelet transfusion. No child developed dengue shock and none died. Non-structural protein 1 (NS1) and dengue IgM were positive in 122/144 (85%) and 36/111 (32%) of blood samples, respectively. 150/151 blood samples tested for dengue were positive on one or more tests.

CONCLUSION

There is the potential for future outbreaks of increased severity in Papua New Guinea. Surveillance, mosquito reduction initiatives and health education programmes are needed to reduce the impact of future outbreaks.

Medical Students at the School of Medicine and Health Sciences, University of Papua New Guinea: Predictors of Performance and Student Backgrounds

BACKGROUND

Papua New Guinea, a lower middle income country with a population of around 8.5 million, the majority of whom live in rural areas, produces far fewer than the number of medical graduates required to meet the WHO-recommended doctor/population ratio. The School of Medicine and Health Sciences is under pressure to increase its output and ensure the graduates are able to function in rural settings. Through two studies, we aimed to determine the predictors of student performance and their socioeconomic and educational background to assist in determining admission policies and improve completion rates.

METHODS

A retrospective study analysed data relating to student performance from six annual cohorts. A cross-sectional study among currently enrolled students sought information about their socioeconomic and educational background.

RESULTS

Of the 300 students enrolled in the six cohorts, 176 (59%) completed the programme in the scheduled 4 years. There were no differences in completion rates by gender or route of entry to the programme. Grade point average at medical school entry predicted academic performance. Sixty-four per cent of the students who failed to complete in four years attributed their poor academic performance to social issues. Overall attrition was only 8%. Seventy-six per cent (162/214) of the enrolled students completed the cross-sectional survey. Most (79%) of students' fathers and 58% of mothers had postsecondary education. Seventy-three per cent of respondents indicated that they had been to preschool or elementary school. Thirty-six per cent had attended primary school in a village or government/mission station. Just over half (53%) of the students indicated that English had been the language most used in primary school. Males were more likely to have made a specific career choice than females. The majority (141/162, 88%) of the students indicated that they had experienced some academic difficulty during the years.

CONCLUSION

Prior academic performance predicted timely completion of the MBBS programme. Just over a third of students had attended rural village primary schools. Social and domestic issues were common and adversely affected academic performance.

Epilepsy in Papua New Guinea: a longitudinal cohort study

Epilepsy affects up to 1-4% of children living in low income and middle countries, however there are few studies of the problems faced by children with epilepsy in such settings. We aimed to document the situation for children with epilepsy in Port Moresby, an urban area in Papua New Guinea, a low-middle income country in the Western Pacific region. We conducted longitudinal cohort study using mixed methods, with serial data collected over 2 years which assessed seizure control, neurodevelopment, and structured interviews with children and parents. For quantitative data descriptive statistics are reported; for qualitative data common responses, themes, experiences and perceptions were grouped and reported in narrative. Forty-seven children with epilepsy were followed for a median of 18 months. Twenty six (55%) children had some associated neurodevelopmental disability. Children gave detailed and vivid descriptions of their experience of seizures. Most children and parents had a positive view of the future but faced many challenges including financial difficulties, fear of having seizures especially at school, restriction of activity that isolated them from peers, and significant stigma and discrimination. Seizure control improved over time for some children, but inconsistent supply of phenobarbitone hindered better control. Comprehensive care for children with epilepsy requires a good knowledge of the individual patient -including their seizure type and comorbidities, their family, and their strengths and vulnerabilities. Children with epilepsy face many problems that can lead to isolation, discrimination and restricted opportunities.

Drug-resistant tuberculosis diagnosis since Xpert® MTB/RIF introduction in Papua New Guinea, 2012-2017

SETTING

Xpert® MTB/RIF was introduced in Papua New Guinea in 2012 for the diagnosis of tuberculosis (TB) and of rifampicin-resistant TB (RR-TB), a marker of multi-drug-resistant TB (MDR-TB).

OBJECTIVE

To assess the concordance of Xpert with phenotypic drug susceptibility testing (DST) performed at the supranational reference laboratory and to describe the patterns of drug-resistant TB observed.

DESIGN

This was a retrospective descriptive study of laboratory data collected from April 2012 to December 2017.

RESULTS

In 69 months, 1408 specimens with Xpert results were sent for mycobacterial culture and DST; Mycobacterium tuberculosis was cultured from 63% (884/1408) and DST was completed in 99.4%. The concordance between Xpert and culture for M. tuberculosis detection was 98.6%. Of 760 RR-TB cases, 98.7% were detected using Xpert; 98.5% of 620 MDR-TB cases were identified using phenotypic DST. Phenotypic resistance to second-line drugs was detected in 59.4% (522/879) of specimens tested, including 29 with fluoroquinolone resistance; the majority were from the National Capital District and Daru Island.

CONCLUSION

The high concordance between phenotypic DST and Xpert in identifying RR-TB cases supports the scale-up of initial Xpert testing in settings with high rates of drug resistance. However, rapid DST in addition to the detection of RR-TB is required.

Simplified management protocol for term neonates after prolonged rupture of membranes in a setting with high rates of neonatal sepsis and mortality: a quality improvement study

In low-income and middle-income countries, courses of antibiotics are routinely given to term newborns whose mothers had prolonged rupture of membranes (PROM). Rational antibiotic use is vital given rising rates of antimicrobial resistance and potential adverse effects of antibiotic exposure in newborns. However missing cases of sepsis can be life-threatening.This is a quality improvement evaluation of a protocol for minimal or no antibiotics in term babies born after PROM in Papua New Guinea. Asymptomatic, term babies born to women with PROM >12 hours prior to birth were given a stat dose of antibiotics, or no antibiotics if the mother had received intrapartum antibiotics, reviewed and discharged at 48-72 hours with follow-up. Clinical signs of sepsis within the first week and the neonatal period were assessed. Of 170 newborns whose mothers had PROM, 133 were assessed at 7 days: signs of sepsis occurred in 10 babies (7.5%; 95% CI 4.4% to 13.2%) in the first week. Five had isolated fever, four had skin pustules and one had fever with periumbilical erythema. An additional four (3%) had any sign of sepsis between 8 and 28 days. There was one case of bacteraemia and no deaths. 37 were lost to follow-up, but hospital records did not identify any subsequent admissions for infection. A rate of sepsis was documented that was comparable with other studies in low-income countries. This protocol may reduce antimicrobial resistance and consequences of antibiotic exposure in newborns, provided safeguards are in place to monitor for signs of sepsis.

Antibiotic use in the management of children with the common cold at a provincial hospital in Papua New Guinea: a point-prevalence study

BACKGROUND

Antibiotic prescribing for self-limiting viral infections such as the common cold or viral upper respiratory tract infection (URTI) is irrational and increases the risk of antibiotic resistance. However, such a practice is widespread and is likely to be as common in Papua New Guinea as in many other countries.

METHODS

In a cross-sectional descriptive study, children were recruited who had been diagnosed with a common cold or URTI by attending clinical staff-mostly nurses-in a provincial hospital's children's outpatient department using a standard definition. The frequency of antibiotic prescribing was determined and the clinical knowledge and practices of nurses, health extension officers, community health workers and doctors working in the children's outpatients department regarding the common cold and its management was assessed.

RESULTS

One hundred and eight children diagnosed with the common cold were enrolled; 89 (82.4%) were prescribed antibiotics. Children with fever on examination, those older than 12 months and those whose symptoms lasted ≥7 days were more likely to be prescribed antibiotics. Of the health workers surveyed, 95% knew that viruses were the cause of the common cold, but 30% thought that antibiotics were needed for treatment.

CONCLUSIONS

Although among healthcare workers, there was a gap between knowledge of aetiology and knowledge of appropriate management of the common cold, there was a larger apparent gap between that knowledge and practice. Findings from this study could be used to identify interventions promoting rational antibiotic use, targeting both health-care workers and the community.

Evaluation of Xpert MTB/RIF assay in children with presumed pulmonary tuberculosis in Papua New Guinea

BACKGROUND

The Gene Xpert MTB/ RIF assay (Xpert) is used for rapid, simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin resistance. This study examined the accuracy of Xpert in children with suspected pulmonary tuberculosis (PTB).

METHODS

Children admitted to Port Moresby General Hospital with suspected PTB were prospectively enrolled between September 2014 and March 2015. They were classified into probable, possible and TB-unlikely groups. Sputum or gastric aspirates were tested by Xpert and smear microscopy; mycobacterial culture was undertaken on a subset. Children were diagnosed with TB on the basis of standard criteria which were used as the primary reference standard. Xpert, smear for acid-fast bacilli (AFB) and the Edwards TB score were compared with the primary reference standard.

RESULTS

A total of 93 children ≤14 years with suspected PTB were enrolled; 67 (72%) were classified as probable, 21 (22%) possible and 5 (5.4%) TB-unlikely. Eighty were treated for TB based on the primary reference standard. Xpert was positive in 26/93 (28%) MTB cases overall, including 22/67 (33%) with probable TB and 4/21 (19%) with possible TB. Three (13%) samples identified rifampicin resistance. Xpert confirmed more cases of TB than AFB smear (26 vs 13, p = 0.019). The sensitivity of Xpert, AFB smear and an Edwards TB score of ≥7 was 31% (25/80), 16% (13/80) and 90% (72/80), respectively, and the specificity was 92% (12/13), 100% (13/13) and 31% (4/13), respectively, when compared with the primary reference standard.

CONCLUSION

Xpert sensitivity is sub-optimal and cannot be relied upon for diagnosing TB, although a positive result is confirmatory. A detailed history and examination, standardised clinical criteria, radiographs and available tests remain the most appropriate way of diagnosing TB in children in resource-limited countries. Xpert helps confirm PTB better than AFB smear, and identifies rifampicin resistance. Practical guidelines should be used to identify children who will benefit from an Xpert assay.

Training experience in drug and alcohol liaison work

We describe our training experience as members of a drug and alcohol liaison service within a major general teaching hospital. This type of liaison work offers valuable experience in the joint management of patients with well established substance misuse problems and also provides the opportunity for early recognition and preventative interventions.

Risk factors for malnutrition in children at Port Moresby General Hospital, Papua New Guinea: a case-control study

Fifty children admitted for malnutrition were age matched with 50 admitted for other reasons. These children were more likely to be female (p = 0.003), born low birth weight (p = 0.02), after a short birth interval (p = 0.014) and to be incompletely vaccinated (p < 0.001) than control children, and to be living in rural villages or settlement housing (p < 0.001) with inadequate water supply (p < 0.001) and sanitation (p = 0.037), with overcrowding (p = 0.016) and low household income (p = 0.04). Their parents were more likely to have had no or only rudimentary education than parents of control children [Odds ratio (OR) 3.58 for mothers, 4.12 for fathers]. Parental consumption of alcohol as well as smoking in the mother was more common in the malnourished children. Running water in the house was an independent protective factor (OR 0.23) and the fathers' poor employment status (OR 4.12) an independent risk factor. The solution to malnutrition involves improving community understanding of nutrition and in reducing social inequalities.

Male involvement in sexual and reproductive health in the Mendi district, Southern Highlands province of Papua New Guinea: a descriptive study

BACKGROUND

Lack of male involvement and support for sexual and reproductive health services is seen by many Papua New Guinean women as a barrier to accessing services. Poor utilization of services by both men and women is reflected in high maternal mortality and high rates of HIV/AIDS and sexually transmitted infections in the Southern Highlands Province. It is therefore important to understand the type of services provided, men's perceptions of these services and the Health Sector's capacity to involve men in its programs.

METHODS

Information from interviews of married men, officers in charge of health facilities, and information from a focus group discussion with village leaders was collected to assess possible constraints to reproductive and sexual health care delivery.

RESULTS

Although many men had heard about antenatal care, supervised births, family planning and sexually transmitted infections including, HIV/AIDS, many were unaware of their importance and of the types of services provided to address these issues. There was a very strong association between men's literacy and their knowledge of Sexual and Reproductive Health (SRH) issues, their discussion of these issues with their wives and their wives' utilisation of sexual and reproductive health services. Some men considered SRH services to be important but gave priority to social obligations. Although men made most decisions for sexual and reproductive issues, pregnancy, child birth and rearing of children were regarded as women's responsibilities. Knowledge of HIV/AIDS appeared to have changed sexual behaviour in some men. Services for men in this rural setting were inadequate and service providers lacked the capacity to involve men in reproductive health issues.

CONCLUSION

Poor knowledge, socio-cultural factors and inadequate and inappropriate services for men hampered utilization of services and impaired support for their wives' service utilization. Programmatic and policy initiatives should focus on improving service delivery to accommodate men in sexual and reproductive health.

The medium-to-long-term outcome of Papua New Guinean children after cardiac surgery

This study reports the medium-to-long-term outcome in Papua New Guinean (PNG) children selected to undergo cardiac surgery at the Royal Alexandra Hospital for Children in Sydney, Australia between 1978 and 1994. Follow-up ranged from 4 to 20 (median 11) years. The cohort comprised 125 children who had surgery and 31 who were initially selected in PNG for surgery but who on further investigation were found to be unsuitable. Through strenuous attempts, local health workers, the media and village and church leaders traced 122 (98%) of the operated and 29 (94%) of the non-operated children. One of the operated children and six of the non-operated children had died, giving respective survival rates among those traced of 99% and 79%. Altogether, 106 (88%) of the 121 operated and 20 (87%) of the 23 non-operated survivors were reviewed. Ninety-nine (93%) of the surgical patients were asymptomatic and all fulfilled the New York Heart Association criteria (NYHAC) class I or II. Mild pulmonary hypertension or residual defects of no haemodynamic significance were present in 47 (44%). In contrast, all 11 survivors from the 18 children originally classified as having inoperable lesions were symptomatic, all in NYHAC classes III or IV, six were on cardiac medication and four had been admitted at least once in the previous year. Ninety-two of 96 (96%) of the surgical group had a normal exercise test and 75 of 96 (78%) had normal chest X-rays. Thirty-nine of 99 had a normal electrocardiogram whilst the remainder had changes related to the underlying lesion and the surgery performed. This study shows that the PNG children who had cardiac surgery at RAHC between 1978 and 1994 had good medium-to-long-term survival.

Burkitt lymphoma in Papua New Guinea—40 years on

BACKGROUND

Burkitt lymphoma is common in tropical Africa and Papua New Guinea, where it has been reported to account for 16% of all childhood malignancies.

AIM

This study aimed to compare the geographical distribution of recent cases and their anatomical site of presentation with findings from previous studies, and to determine survival using the current treatment protocol.

METHODS

The study included all cases of Burkitt and Burkitt-like lymphoma in children up to 14 years of age diagnosed between January 1998 and December 2003.

RESULTS

Thirty-six children were diagnosed with Burkitt lymphoma, accounting for 50% of all lymphomas and 13% of all childhood malignancies. The median age was 6 years (interquartile range 4-8 years) and the male:female ratio was 8:1. Facial structures were the most commonly affected sites, accounting for 21 (58%) cases, followed by spinal involvement in three. The majority (89%) of patients came from malaria-holo-endemic, coastal PNG and three were from the highland region. The national incidence was 1.7/100,000 but provincial rates varied, the highest of 13.4/100,000 being in Gulf province. Only two of the 16 patients who received chemotherapy were known to be in remission at 12 months.

CONCLUSIONS

Burkitt tumour remains a common childhood malignancy in PNG. There is a need to improve diagnosis and reporting so that treatment can be started early. The most appropriate treatment regimen for use in PNG and other resource-poor countries remains to be determined.

Predictors of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea

Predictors of acute bacterial meningitis (ABM) were assessed in 554 children in Papua New Guinea 0.2-10 years of age who were hospitalized with culture-proven meningitis, probable meningitis, or non-meningitic illness investigated by lumbar puncture. Forty-seven (8.5%) had proven meningitis and 36 (6.5%) had probable meningitis. Neck stiffness, Kernig's and Brudzinski's signs and, in children < 18 months of age, a bulging fontanel had positive likelihood ratios (LRs) ≥ 4.3 for proven/probable ABM. Multiple seizures and deep coma were less predictive (LR = 1.5-2.1). Single seizures and malaria parasitemia had low LRs (≤ 0.5). In logistic regression including clinical variables, Kernig's sign and deep coma were positively associated with ABM, and a single seizure was negatively associated (P ≤ 0.01). In models including microscopy, neck stiffness and deep coma were positively associated with ABM and parasitemia was negatively associated with ABM (P ≤ 0.04). In young children, a bulging fontanel added to the model (P < 0.001). Simple clinical features predict ABM in children in Papua New Guinea but malaria microscopy augments diagnostic precision.

Features and prognosis of severe malaria caused by Plasmodium falciparum, Plasmodium vivax and mixed Plasmodium species in Papua New Guinean children

Background

Mortality from severe pediatric falciparum malaria appears low in Oceania but Plasmodium vivax is increasingly recognized as a cause of complications and death. The features and prognosis of mixed Plasmodium species infections are poorly characterized. Detailed prospective studies that include accurate malaria diagnosis and detection of co-morbidities are lacking.

Methods and Findings

We followed 340 Papua New Guinean (PNG) children with PCR-confirmed severe malaria (77.1% P. falciparum, 7.9% P. vivax, 14.7% P. falciparum/vivax) hospitalized over a 3-year period. Bacterial cultures were performed to identify co-incident sepsis. Clinical management was under national guidelines. Of 262 children with severe falciparum malaria, 30.9%, 24.8% and 23.2% had impaired consciousness, severe anemia, and metabolic acidosis/hyperlactatemia, respectively. Two (0.8%) presented with hypoglycemia, seven (2.7%) were discharged with neurologic impairment, and one child died (0.4%). The 27 severe vivax malaria cases presented with similar phenotypic features to the falciparum malaria cases but respiratory distress was five times more common (P = 0.001); one child died (3.7%). The 50 children with P. falciparum/vivax infections shared phenotypic features of mono-species infections, but were more likely to present in deep coma and had the highest mortality (8.0%; P = 0.003 vs falciparum malaria). Overall, bacterial cultures were positive in only two non-fatal cases. 83.6% of the children had alpha-thalassemia trait and seven with coma/impaired consciousness had South Asian ovalocytosis (SAO).

Conclusions

The low mortality from severe falciparum malaria in PNG children may reflect protective genetic factors other than alpha-thalassemia trait/SAO, good nutrition, and/or infrequent co-incident sepsis. Severe vivax malaria had similar features but severe P. falciparum/vivax infections were associated with the most severe phenotype and worst prognosis.

Development of a clinical algorithm to prioritise HIV testing of hospitalised paediatric patients in a low resource moderate prevalence setting

OBJECTIVE

To develop a clinical algorithm to identify paediatric patients who should be offered HIV testing in a setting of moderate HIV prevalence and limited resources.

METHODS

In a prospective cross-sectional study at Port Moresby General Hospital, Papua New Guinea, carers of inpatients were offered HIV testing and counselling for their children. Recruited children were tested for HIV antibodies and DNA. Standardised clinical information was collected. Multivariate regression analysis was used to ascertain independent predictors of HIV infection and these were used to develop a predictive algorithm.

RESULTS

From September 2007 to October 2008, 487 children were enrolled. Overall, 55 (11%) with a median age of 7 months were found to be HIV-infected. In multivariate analysis, independent predictors of HIV infection were: persistent fever (OR = 2.05 (95% CI 1.11 to 4.68)), lymphadenopathy (OR = 2.29 (1.12 to 4.68)), oral candidiasis (OR = 3.94 (2.17 to 7.14)) and being underweight for age (OR = 2.03 (1.03 to 3.99)). The presence of any one of these conditions had a sensitivity of 96% in detecting a child with HIV infection. Using an algorithm based on the presence of at least one of these conditions would result in around 40% of hospitalised children being offered testing.

CONCLUSIONS

This clinical algorithm may be a useful screening tool for HIV infection in hospitalised children in situations where it is not feasible to offer universal HIV testing, providing guidance for HIV testing practices for increased identification and management of HIV-infected children in Papua New Guinea.

Lumbar puncture in children from an area of malaria endemicity who present with a febrile seizure

BACKGROUND

Although routine lumbar puncture (LP) is often recommended as part of the assessment of fever-associated seizures in children, accumulating evidence questions its value and reveals a decrease in its frequency. Our primary hypothesis was that children who present with a single seizure but with no clinical signs of meningism or coma do not require LP as part of initial diagnostic assessment.

METHODS

We prospectively followed up 377 children aged 2 months through 10 years who presented with at least 1 fever-associated seizure to Modilon Hospital, Madang, Papua New Guinea, from November 2007 through July 2009. Clinical management was performed by hospital staff according to national pediatric guidelines.

RESULTS

Of 188 children with a single seizure and 189 children with multiple seizures, 139 (73.9%) and 154 (81.5%), respectively, underwent a LP as part of their initial assessment. Of the 130 children with a single seizure but no evidence of meningism (ie, neck stiffness, positive Kernig's or Brudzinski's sign, and bulging fontanelle) or coma (Blantyre Coma Score 2), none (95% confidence interval, 0%-3.6%) had proven or probable acute bacterial meningitis, and only 1 patient had viral encephalitis (subacute sclerosing panencephalitis). Eighty-one of these children (62.3%) had a final diagnosis of a simple febrile seizure. Proven or probable acute bacterial meningitis was more common in children with a single seizure and meningism or coma (10; 17.2%) and in those with multiple seizures without or with meningism or coma (2 [2.0%] and 30 [33.7%], respectively).

CONCLUSIONS

Initial LP is unnecessary when careful clinical assessment indicates features of a simple febrile seizure.

Characterization of the Li beam probe with a beam profile monitor on JET

The lithium beam probe (LBP) is widely used for measurements of the electron density in the edge plasma of magnetically confined fusion experiments. The quality of LBP data strongly depends on the stability and profile shape of the beam. The main beam parameters are as follows: beam energy, beam intensity, beam profile, beam divergence, and the neutralization efficiency. For improved monitoring of the beam parameters, a beam profile monitor (BPM) from the National Electrostatics Corporation (NEC) has been installed in the Li beam line at JET. In the NEC BPM, a single grounded wire formed into a 45° segment of a helix is rotated by a motor about the axis of the helix. During each full revolution, the wire sweeps twice across the beam to give X and Y profiles. In this paper, we will describe the properties of the JET Li beam as measured with the BPM and demonstrate that it facilitates rapid optimization of the gun performance.

Upgrade of the lithium beam diagnostic at JET

A 60 kV neutral Li beam is injected into the edge plasma of JET to measure the electron density. The beam observation system has been improved by replacing a Czerny-Turner spectrometer with a high-resolution transmission-grating spectrometer and a fast back-illuminated frame-transfer camera. The larger throughput of the spectrometer, the increased sensitivity, and the faster readout of the new camera allow inter-ELM (edge localized mode) measurements (frame rate of 100 Hz). The calibration of the setup, as well as an improved spectral fitting technique in the presence of carbon background radiation, is discussed in detail. The density calculation is based on a statistical analysis method. Results are presented for different plasma scenarios.

The aetiology, clinical presentations and outcome of febrile encephalopathy in children in Papua New Guinea

BACKGROUND

Febrile encephalopathy, defined as fever, seizures and/or altered consciousness, is a common presentation in children in tropical developing countries. Outcomes range from complete recovery through varying degrees of neurological disability which slowly resolve or remain permanent to death from either the acute illness or complications. Whilst bacterial meningitis accounts for a proportion of children affected, the aetiology in many remains unclear but includes malaria and probably viral encephalitis.

AIM

To understand the aetiology, presentation and outcome of febrile encephalopathy in children in Papua New Guinea.

METHODS

Children aged between 1 month and 12 years presenting to Port Moresby General Hospital with febrile encephalopathy were studied prospectively. A detailed history and examination and the following laboratory investigations were undertaken as appropriate: cerebrospinal fluid (CSF) microscopy and bacterial culture, gram stain, measurement of protein and glucose and latex agglutination testing for Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitides; Ziehl-Neelsen staining and india ink examination on selected samples; IgM for Japanese encephalitis, dengue, rubella and measles; PCR testing and mycobacterial culture for Mycobacterium tuberculosis. Blood was tested for flavivirus, measles and rubella IgM and IgG.

RESULTS

149 children were enrolled in the study. 129 had a lumbar puncture and CSF examination; 66 had a normal CSF white cell count. A clinical or laboratory-based diagnosis was possible for 140 children, but a definite pathogen was identifiable for only 55 (37%). The diagnoses included bacterial meningitis in 33 (S. pneumonia 16, H. influenza 13 and N. meningitides 4), tuberculous meningitis (5), probable tuberculous meningitis (18), malaria (10), cryptococcal meningitis (1), flavivirus encephalitis (5), rubella encephalitis (1), hepatic encephalopathy (1) and HIV encephalopathy (1). There were 28 cases of meningitis of unspecified aetiology. Of the five children with IgM-confirmed flavivirus encephalitis, one had dengue serotype 1 and two had Japanese encephalitis. Twenty-five children (including three of the five children with CSF flavivirus IgM) had serological IgG evidence of previous flavivirus infection. A history of multiple convulsions, the presence of neck stiffness and use of the Glasgow coma score (GCS) and TB score chart helped to identify children with bacterial meningitis and an adverse outcome and those with febrile convulsions.

CONCLUSION

The study confirms the importance of S. pneumonia and H. influenza as major causes of febrile encephalopathy in children in Papua New Guinea. Flaviviruses including Japanese encephalitis are a cause of the febrile encephalopathy syndrome, as is Mycobacterium tuberculosis. All children with febrile encephalopathy should have their GCS and TB scores recorded and should be examined for neck stiffness, and a history of the frequency of convulsions should be recorded. These basic clinical data can help to discriminate aetiology, to guide treatment and monitoring and to identify the children at highest risk of adverse outcome.

Comparison of the use of liquid crystal thermometers with glass mercury thermometers in febrile children in a children's ward at Port Moresby General Hospital, Papua New Guinea

We compared the temperatures recorded, in febrile children admitted to a children's ward at Port Moresby General Hospital, by a doctor and by a group of nurses using glass mercury thermometers (GMT) and liquid crystal thermometers (LCT, Nextemp and Traxit. The mean difference (with 95% confidence intervals) in temperatures between GMT and Nextemp were -0.12 degrees C (-0.16 degrees C to -0.08 degrees C) for the doctor and 0.12 degrees C (0.04-0.20 degrees C) for nurses. The mean difference in temperatures between GMT and Traxit were -0.05 degrees C (-0.09 degrees C to -0.01 degrees C) for the doctor and 0.19 degrees C (0.10-0.28 degrees C) for the nurses. A similar result was obtained when one of the Nextemp thermometers used in the initial study was compared with GMT on a small sample of patients by the doctor 8 months later. Limited evaluation showed nursing staff were in favour of using the LCTs. Nextemp and Traxit thermometers can be used interchangeably with GMT in this setting.

Immune response to measles vaccine in 6 month old infants in Papua New Guinea

OBJECTIVE

To assess the efficacy of the current measles immunization schedule in Papua New Guinea, which is to give the first dose at 6 months of age and the second at 9 months.

METHODS

Humoral immune response study of 140 Papua New Guinean infants at 6 months of age, measuring measles IgG antibodies by enzyme immunoassay before and 85 days after the 6-month dose of measles vaccine.

RESULTS

After vaccination at 6 months, 35.7% of infants developed a level of measles antibodies consistent with protection (IgG >330 IU/ml); 17.7% had an antibody response (150-330 IU/ml) that is likely to afford some protection; 46.8% had no detectable antibody response (IgG <150 IU/ml). Among 53 infants with no antibody response, 37 (69.5%) developed an antibody response, while 42.4% (37/87) of those with maternal antibodies sero-converted (P = 0.002).

CONCLUSIONS

Antibody response to measles vaccine was lower than expected at 6 months. While the presence of maternally derived antibodies accounted for some of the limited seroconversion in young infants, other factors are involved. Issues to be considered in determining the value of the first dose of measles vaccination in mid infancy in poor countries are complex and antibody responses are only one factor. Others, such as cell mediated immune responses, the non-specific protective effect of measles vaccine in preventing illness and death and the practicalities of uptake of vaccines at different ages, are also important.

Attitudes to HIV testing among carers of children admitted to Port Moresby General Hospital, Papua New Guinea

AIM

To assess the acceptability of voluntary counselling and testing among the carers of children admitted to hospital in Papua New Guinea.

METHODS

Forty semistructured interviews were carried out between February and April 2007.

RESULTS

All the carers interviewed were women, mostly from Port Moresby. Virtually all of them attended primary school. About half of them attended secondary school but none completed it. Half of them knew an adult or child with HIV. Three quarters of the women interviewed would consent to having a child in their care tested for HIV, and over half of those who had never been tested would agree to be tested themselves. Correct answers to more than half the HIV knowledge questions posed were significantly related to agreement to an HIV test.

CONCLUSIONS

This study supports the need for further evaluation of knowledge about HIV/AIDS and opportunities for health promotion in this group of women, particularly in view of the implication for voluntary counselling and testing and prevention of mother-to-child HIV transmission programmes in Papua New Guinea.

Operation Open Heart in PNG, 1993-2006

OBJECTIVE

To report on the 'Operation Open Heart' (OOH) cardiac surgical program in Papua New Guinea (PNG). To document the short-term surgical outcome, the experience gained and the skill transfer from the visiting team members to their PNG counterparts.

METHODOLOGY

Analysis of the database compiled from the records of the patients who were operated on by the visiting cardiothoracic surgical team.

RESULTS

Four hundred and seventy patients from all regions of the country received operations. Three hundred and thirty seven (72%) were children less than 12 years of age, 39 (8%) were between 12 and 18 years of age and 263 (56%) were females. One hundred and eighty five (40%) patients had open heart procedures. Complications were unremarkable and the short-term mortality was 1.9%. Clinical skills were transferred to, and experience was gained by national anaesthetists, surgeons, paediatricians, physicians and nurses from intensive and full nursing care units and the operating theatre.

CONCLUSIONS

The program not only achieved a higher annual operation rate than previous programs but also had a lower mortality rate. It achieved its objective of service delivery and, to a considerable extent, its objective of skill transfer. There now is an established and active group of PNG doctors and nurses with the skills, experience and confidence to perform patent ductus repair safely and efficiently. The program is cheaper than its predecessors, and is less disruptive for parents, patients and families.

Can clinical signs predict hypoxaemia in Papua New Guinean children with moderate and severe pneumonia?

Pulse oximetry was performed on 77 children admitted with acute lower respiratory tract infections (ALRI) to the children's ward in Port Moresby General Hospital, Papua New Guinea over a 4-month period in 2002. Clinical findings were correlated with different levels of hypoxaemia, <93%, <90% and <85%. Cyanosis, head nodding and drowsiness were good predictors of hypoxia but lacked sensitivity. Decisions to use oxygen based on these signs would therefore result in a significant number of children with hypoxia not receiving oxygen. Pulse oximetry is the best indicator of hypoxaemia in children with ALRI and, although relatively expensive, its use might be cost-effective in controlling oxygen requirements.

A comparison of booked and unbooked mothers delivering at the Port Moresby General Hospital: a case-control study

A case-control study of unbooked mothers delivering at the maternity unit of the Port Moresby General Hospital was undertaken over a period of 7 months. 48 mothers who had no antenatal attendances during pregnancy were recruited with 96 booked controls. Reasons for non-attendance, understanding of the importance of antenatal clinics and socioeconomic and demographic factors were recorded to assess likely risk factors for non-attendance. Almost half the mothers cited financial difficulties as the reason for non-attendance at antenatal clinics despite most of them knowing that it was important to have antenatal care during pregnancy. The two most important risk factors for being unbooked were mothers having no education (p <0.001) and the type of employment of their spouse (p <0.01). Unbooked mothers were more likely to have preterm babies (OR 16.1; 95%CI 3.4-75.7) and all 6 perinatal deaths occurred in babies born to unbooked mothers. Remedial approaches would need to take into account maternal education, education of partners and the fact that despite free antenatal services in urban clinics financial difficulties in terms of other costs involved still remain an obstacle to overcome.

Adoption and hospital admission in Port Moresby, Papua New Guinea

We report a study of adopted children admitted to the children's wards of Port Moresby General Hospital, Papua New Guinea over a 5-month period in 2000. The proportion of hospitalized children known to be adopted was almost three times that in the children's outpatients department. Gastroenteritis and neonatal sepsis were more common causes of admission in adopted children than in the general paediatric hospital population. Admitted adopted children were lighter and shorter than the controls with no difference in weight-for-height, suggesting that stunting is the predominant nutritional problem among adopted children. These differences were even more marked in children with diagnoses other than gastroenteritis. Thirty-three (82.5 per cent) of the adopted children had ever been bottle fed compared with 11 (13.75 per cent) of the controls (p = 0.029). Twelve (30 per cent) children had been adopted because of neglect or abandonment. The biological mothers of seven of these children had died, and two children had been bought for cash. Biological mothers were more likely than the adoptive or control mothers to be single and less than 20 years of age. Knowledge of formal adoption procedures was very poor. The present study therefore shows that adoption in Papua New Guinea is not without risk and it is important that adoption should be recognized as having the potential for serious adverse effects on the child's well-being, especially since adoption is likely to become even more prevalent as the HIV epidemic continues. Consideration needs to be given to protection of the rights of children at high risk of adoption.

Surgical programme at Royal Alexandra Hospital, Sydney, for Papua New Guinea children with congenital heart disease, 1978-1994

OBJECTIVE

To report the history of the Royal Alexandra Hospital for Children (RAHC) Papua New Guinea (PNG) cardiac surgical programme and describe the selection, preoperative clinical features and postoperative outcome of children with congenital heart disease managed by the programme.

METHODS

Details for each of the PNG cardiac patients admitted to RAHC following selection by visiting cardiologists between 1978 and 1994 were entered into a database, and analysed and interpreted.

RESULTS

A congenital heart defect was confirmed in 165 of the 170 children selected. The male to female ratio was 1:1 and the mean age on admission to RAHC was 5.5 years. Almost all of the children for whom data were available (98%) had a weight for age and 41% had a height for age less than the 3rd centile. One-sixth had delayed milestones. A large number were tachypnoeic, in heart failure, or had pulmonary hypertension on admission. Ventricular septal defect and tetralogy of Fallot were the commonest defects, and lesions such as aortic stenosis, coarctation of the aorta and transposition of the great arteries were absent or rare. Thirty-one (19%) of the children selected initially did not receive surgery because of pulmonary hypertension, or because the lesions did not fall within the programme guidelines for operation. One hundred and twenty-nine children had corrective and four had palliative procedures. Half of the operated children had postoperative complications. Eight children died, all following open-heart procedures, giving a case fatality rate of 6%. Preoperative tachypnoea, hepatomegaly, cardiac failure and pulmonary hypertension were strongly associated with poor outcome.

CONCLUSIONS

The programme was an arduous exercise for all organizations concerned, but achieved comparatively good short-term outcomes. The experience gained should assist in planning for similar programmes.

Congenital heart disease in Papua New Guinean children

The aim of the study was to analyse critically the programme for surgical management of children in Papua New Guinea (PNG) with congenital heart disease. A hospital record-based analysis was undertaken to document the pattern, management and short-term outcome of surgery in PNG children referred with a diagnosis of congenital heart disease to the Royal Alexandra Hospital for Children in Sydney, Australia. On admission, physical examination, chest radiogram, electrocardiogram, cross-sectional echocardiogram and, in most cases, cardiac catheterization were performed. Of the 170 children referred over the 17-year period, 1978-1994, 165 were confirmed to have congenital heart disease and were included in the study. Their ages ranged from 2 months to 16 years (median 5.5) and the male to female ratio was 1:1. One-sixth had delayed milestones and one-fifth long-term wasting. A large number were tachypnoeic, in heart failure or had pulmonary hypertension on admission. Ventricular septal defect, 34%, tetralogy of Fallot, 23%, and patent ductus arteriosus, 16.4%, were the predominant defects. lesions such as aortic stenosis, coarctation of the aorta and transposition of the great arteries are under-represented. Altogether, 133 children (81%) had surgery; 75% were open- and 25% closed-heart operations. The complications were unremarkable and the mortality rate (6%) acceptable for the era. The programme was therefore very successful for a small proportion of children born in PNG with congenital heart disease.

Hyperekplexia: a rare differential of neonatal fits described in a developing country

Hyperekplexia is a rare condition in which there is an exaggerated startle response. We report how a case presented in Papua New Guinea (PNG) and was diagnosed with international support. This is the first reported case in PNG. It is an important diagnosis to make to prevent sudden death and inappropriate treatment. The case illustrates the benefit of having a link with an international specialist and we discuss the importance of communication between developing and industrialized countries.

Protection of breastfeeding in Papua New Guinea

In Papua New Guinea the bottle-feeding of babies has been increasing, predominantly among unemployed women of low educational status. Many women are unaware of their legal right to have breaks at work for the purpose of breastfeeding, and a high proportion of workplaces have no facilities for mothers who wish to breastfeed their children. The laws on the feeding of infants should be updated and implemented, and an effort is needed to explain the benefits of breastfeeding and the rights of working mothers.

Infant feeding practices in Papua New Guinea

Concern about a possibly increasing prevalence of bottle-feeding led in 1995 to an Infant Feeding Survey of 1822 mothers attending urban health facilities. Infant feeding practices including feeding of colostrum, exclusive breastfeeding, weaning practices and bottle-feeding were assessed. This revealed that 28.8% of mothers had not given colostrum to their babies, that 43.5% of 3-month-old babies were exclusively breastfed, and that solids were introduced before 4 months of age in over half of the study population. Bottle-feeding was used by 20% of the study population. Feeding practices differed in women of Highlands and of Coastal origin. The findings emphasize the need to strengthen health education programmes which take into account the mothers' different cultural backgrounds. The issue of breast-feeding by mothers in paid employment needs to be addressed.

Screening contacts of children with tuberculosis: an important and worthwhile part of case management

The outcome of screening the household contacts of 49 newly diagnosed tuberculous children as currently practised in the Paediatric Unit of the Port Moresby General Hospital is described. The screening program generated 182 chest X-rays and 67 Mantoux tests. 32 (39%) of 83 child contacts and 11 (11%) of 99 adults were commenced on antituberculous therapy, and 2 children aged 6 months were started on INAH chemoprophylaxis. Adult contacts were identified in 11 (22%) of the 49 families screened. Such a program is an extremely important part of the case management of children with newly diagnosed tuberculosis and their families.

Assessment of HIV/AIDS knowledge, attitudes and behaviour of high school students in Papua New Guinea

OBJECTIVE

To assess the knowledge, attitudes and behaviour of high school students (grade 10) with regard to HIV infection and AIDS.

METHODS

A self-administered questionnaire survey was carried out in 21 high schools in 6 different provinces. The questionnaire was anonymous and contained questions about HIV transmission, preventive measures, attitudes towards HIV infection and a few questions about personal sexual behaviour.

PRELIMINARY RESULTS

A total of 1811 students completed the questionnaire. 46% were female. The average age was 17 years. Over 98% knew what AIDS and HIV were. 97% knew that HIV was sexually transmitted, but many misconceptions existed: one-third thought that HIV was transmitted by mosquitoes, 7% that HIV-infected persons were a danger in the classroom. 72% knew that using a condom at every sexual encounter was a way of protection from HIV infection. Approximately 25% reported to have had sexual contacts, and of 15-year-old students 14% were sexually active. Although STD/AIDS education is part of the curriculum for grade 8 the principals of the majority of the schools reported that no formal teaching was done.

DISCUSSION

Although the majority of students knew that HIV is sexually transmitted, basic knowledge about STDs is lacking and is not taught as part of the curriculum in most of the schools. Teaching about STDs and HIV needs to be enforced and safe sexual practices need to be discussed with the students.

Persistent diarrhoea in children admitted to Port Moresby General Hospital

A retrospective study of the records of children admitted to Port Moresby General Hospital with diarrhoea during 1992 and 1993 was carried out to determine the morbidity, mortality and risk factors associated with persistent diarrhoea. 858 admissions of children under five years of age who had diarrhoea were identified from the ward admission registers, and case records for 724 were studied. Persistent diarrhoea occurred in 20%, and nearly half of these were in the 12-23 months age group. Children with persistent diarrhoea had a case fatality rate of 4.9%. Seasonality was similar for both persistent and non-persistent diarrhoea. In the crude analysis children of 12 months and older had a greater risk of developing persistent diarrhoea than those less than 12 months (odds ratio for children 12-23 months was 2.0 and for children 24-59 months 1.7; confidence intervals were 1.2-3.1 and 1.0-2.9 respectively); however, this difference was not found after logistic regression analysis. Poor nutritional status was a significant risk factor for persistent diarrhoea and remained so after controlling for confounding variables (odds ratio 2.7; confidence interval 1.8-4.0).

Criteria audit: making use of existing data

The first steps in setting up a criteria audit are presented with the aim of serving as a guide for starting quality assurance activities in Papua New Guinea. These activities need to be based on data, and the systematic and critical analysis of any available data on the process or outcome of health care delivery is a simple, cheap and useful basis for its improvement. Criteria are defined and the completeness and relevance of the data audited are discussed. Recommendations on the use of available recorded data and on the improvement of record-keeping practices are made.