The proportion of fevers attributable to malaria varies significantly between sites in Papua New Guinea

@#Malaria is endemic across lowland Papua New Guinea (PNG) and case management has been based on symptomatic diagnosis and presumptive treatment of fever cases with an antimalarial. This study aimed to investigate the prevalence of malaria infection among fever cases presenting to 5 purposely selected sentinel health facilities in order to estimate the proportion of patients requiring antimalarial drugs. A total of 1807 fever patients were screened. Overall, 45% of fever patients had a positive malaria blood slide; 35% were infected with Plasmodium falciparum, 9% with P. vivax and 2% with P. malariae. Slide positivity was highest in Dreikikir (75%) and lowest in Wipim (2%). Among patients aged 1-4 years, 22% had moderate to severe anaemia (Hb < 8 g/dI) and 21% of children 2-9 years of age showed signs of splenomegaly (Hackett score 1-5). Comorbidity differed significantly between study sites and was not closely correlated with malaria infection. Clinical diagnosis by health facility staff was malaria for 67% of all fever cases, including 89% of slide-positive and 48% of slide-negative patients. 70% of rapid diagnostic test-negative cases were treated with an antimalarial. It is estimated that due to the lack of parasitological diagnosis the selected health facilities reported an excess of 18% (Dreikikir) to 98% (Wipim) malaria patients on average each month. In consideration of the significant differences in malaria-attributable fevers between study sites, the implementation of parasitological diagnosis in health facilities and administration of antimalarials only to test-positive patients has the potential to significantly improve the management of fever cases and reporting of malaria. A better tailoring to different settings may increase the effectiveness of malaria control interventions.

Evaluation of the Global Fund-supported National Malaria Control Program in Papua New Guinea, 2009-2014

@#The Global Fund to Fight AIDS, Tuberculosis and Malaria is the major funaer of the National Malaria Control Program in Papua New Guinea (PNG). One of the requirements of a Global Fund grant is the regular and accurate reporting of program outcomes and impact. Under-performance as well as failure to report can result in reduction or discontinuation of program funding. While national information systems should be in a position to provide accurate and comprehensive information for program evaluation, systems in developing countries are often insufficient. This paper describes the five-year plan for the evaluation of the Global Fund Round 8 malaria grant to PNG (2009-2014) developed by the Papua New Guinea Institute of Medical Research (PNGIMR). It builds on a complementary set of studies including national surveys and sentinel site surveillance for the assessment of program outcomes and impact. The PNGIMR evaluation plan is an integral part of the Global Fund grant. The evaluation program assesses intervention coverage (at individual, household and health facility levels), antimalarial drug efficacy, indicators of malaria transmission and morbidity (prevalence, incidence), and all-cause mortality. Operational research studies generate complementary information for improving the control program. Through the evaluation, PNGIMR provides scientific expertise to the PNG National Malaria Control Program and contributes to building local capacity in monitoring and evaluation. While a better integration of evaluation activities into routine systems would be desirable, it is unlikely that sufficient capacity for data analysis and reporting could be established at the National Department of Health (NDoH) within a short period of time. Long-term approaches should aim at strengthening the national health information system and building sufficient capacity at NDoH for routine analysis and reporting, while more complex scientific tasks can be supported by the PNGIMR as the de facto research arm of NDoH.

Sago haemolytic disease: towards understanding a novel food-borne toxicosis

Sago haemolytic disease is a rare but sometimes fatal disease found primarily in the coastal regions of Papua New Guinea and among groups in which sago is a primary source of carbohydrate. It has been known since 1961 and fungi consistently have been suspected of being involved. Investigations carried out on stored sago and samples recovered from poisoning episodes have failed to indicate the consistent presence of mycotoxins. However, fungi (especially Aspergillus, Fusarium, Penicillium, Trichoderma) with strong haemolytic activity have been associated with sago, particularly when stored in open-weave baskets and sago-leaf-wrapped bundles. The haemolytic activity has been attributed to fatty acids (principally oleic, palmitic, linoleic) contained primarily in the fungal hyphae. It is hypothesized that when these acids are released through hyphal breakdown during digestion and are present in individuals with a low serum albumin level, free fatty acid excess occurs resulting in red cell membrane destruction and intravascular haemolysis. In extreme cases, blood transfusion is required. Methods of storage providing high levels of access to oxygen favour the development of fungi: eg, leaf-encased bundles and open-weave storage favour growth over that seen in starch stored under water, such as in earthen vessels. Ensuring storage does not exceed 3-4 weeks, encouraging anaerobic conditions of the starch and maintaining protein nutrition in communities where sago is relied upon should alleviate outbreak episodes.

Cholera in Papua New Guinea: observations to date and future considerations

Cholera is a severe diarrhoeal illness caused by infection with the bacterium Vibrio cholerae. From July 2009 to late 2011 Papua New Guinea (PNG) experienced thefirst outbreak of cholera ever reported in this country. During this time > 15,000 cases of cholera were reported, resulting in approximately 500 deaths. The origin of this outbreak is unknown, but considering the remote location of the initial outbreak an infected international traveller is unlikely to be the source. In this paper we review the characteristics of the PNG cholera outbreak and discuss the ongoing threat of cholera to the country and the region.

A review of diarrhoea aetiology in Papua New Guinea, 1995-2012

The large contribution of diarrhoea to morbidity and mortality rates in Papua New Guinea (PNG) warrants a significant response to diagnosing aetiology, determining appropriate management and reducing risk factors that facilitate transmission of enteric pathogens. We conducted a review of literature to assess the extent of research published on the aetiology of diarrhoea in PNG between 1995 and 2012. Of 54 peer-reviewed articles that were selected for review, 25 pertained to aetiology. While the majority of articles described typhoid fever and non-typhoid salmonellosis, shigellosis, rotavirus, pigbel and cholera were also represented in the literature reviewed.

Pigbel in the 21st century: still here, and still in need of an effective surveillance system

Pigbel remains a likely significant cause of morbidity and mortality in the highlands of Papua New Guinea (PNG), two decades after the administration of pigbel vaccination ceased. There is a need for an effective surveillance program for pigbel to better understand the disease burden and to target communities for preventive strategies. This paper reviews the epidemiology, pathogenesis, recent history and current data on the burden of pigbel in PNG. We propose a surveillance program based on clinical recognition of likely cases and laboratory confirmation using an ELISA assay for Clostridium perfringens type C beta-toxin. Research aimed at validating this approach in the clinical setting is outlined.

Intestinal parasitic infections and anaemia among pregnant women in the highlands of Papua New Guinea

This study determined the prevalence of intestinal parasitic infections and associations with risk factors among pregnant women in their second or third trimester in Goroka, Eastern Highlands Province, Papua New Guinea. Among the 201 pregnant women enrolled in this study, 163 (81%) were infected with one or more intestinal parasites. Infections with protozoan parasites (65%) were more prevalent than infections with nematodes (31%); protozoan infections included Entamoeba histolytica (43%), Giardia lamblia (39%) and Pentatrichomonas hominis (14%), and nematode infections included hookworm (18%), Ascaris lumbricoides (14%), Strongyloides stercoralis (3%) and Trichuris trichiura (2%). Factors associated with higher risk of intestinal parasitic infections in pregnancy included being a primigravida for protozoan-only infections and education limited to primary school for nematode infections. Altitude-adjusted haemoglobin levels were assessed at the beginning of labour for 110 women, with 69 (63%) found to be anaemic (haemoglobin < 11 g/dl). There were no associations found between being infected in pregnancy and anaemia.

Isolation of Vibrio cholerae and other enteric microbiota from patients

When cholera was first detected in Papua New Guinea (PNG) in mid-2009, national diagnostic capacity faced many challenges. This was in part due to the non-endemic status of the outbreak, resulting in few local staff experienced in Vibrio cholerae detection and poor access to the required consumables. The PNG Institute of Medical Research conducted culture on specimens from suspected cholera patients in Madang Province, with presumptive V. cholerae isolates sent to Goroka for confirmation. Of 98 samples analysed 15 were culture positive, with V. cholerae detected by polymerase chain reaction (PCR) in an additional 3 samples. Further analyses were conducted to identify other pathogenic bacteria from thiosulphate citrate bile salt sucrose (TCBS) agar. Molecular-based assays detected enteropathogenic (n = 1) and enterotoxigenic (n = 1) strains of Escherichia coli. No other major enteric pathogens were detected. The low detection rate of V. cholerae at the provincial level reflects challenges in the laboratory diagnosis of cholera and in-country challenges in responding to an outbreak of a non-endemic disease, such as lack of in-country diagnostic expertise and available consumables in the early stages. It also suggests that full aetiological investigations are warranted in future outbreaks of acute watery diarrhoea in PNG to fully elucidate the potentially complex aetiology, which could in turn guide diagnostic, treatment and prevention measures.

The epidemiology of malaria in the Papua New Guinea highlands: 7. Southern Highlands Province

As the last part of a program to survey the extent of malaria transmission in the Papua New Guinea highlands, a series of rapid malaria surveys were conducted in 2003-2004 and 2005 in different parts of Southern Highlands Province. Malaria was found to be highly endemic in Lake Kutubu (prevalence rate (PR): 17-33%), moderate to highly endemic in Erave (PR: 10-31%) and moderately endemic in low-lying parts (< 1500 m) of Poroma and Kagua (PR: 12-17%), but was rare or absent elsewhere. A reported malaria epidemic prior to the 2004 surveys could be confirmed for the Poroma (PR: 26%) but not for the lower Kagua area. In Kutubu/Erave Plasmodium falciparum was the most common cause of infection (42%), followed by P. vivax (39%) and P. malariae (16%). In other areas most infections were due to P. vivax (63%). Most infections were of low density (72% < 500/ microl) and not associated with febrile illness. Overall, malaria was only a significant source of febrile illness when prevalence rates rose above 10%, or in epidemics. However, concurrent parasitaemia led to a significant reduction in haemoglobin (Hb) level (1.2 g/dl, CI95: [1.1-1.4.], p < 0.001) and population mean Hb levels were strongly correlated with overall prevalence of malarial infections (r = -0.79, p < 0.001). Based on the survey results, areas of different malaria epidemiology are delineated and options for control in each area are discussed.

Vitamin A status of pre-school-age children aged 6 to 59 months in the National Capital District, Papua New Guinea

Assessing the vitamin A status among pre-school-age children is essential for evaluating the magnitude and public health status of vitamin A deficiency in a population. This cross-sectional study assessed the vitamin A status of children aged 6 to 59 months resident in the National Capital District (NCD), Papua New Guinea. Children attending the Children's Outpatient Clinic at Port Moresby General Hospital participated in this study. Informed consent was obtained from parents before using blood samples from their children. Assay of plasma retinol was carried out using the 'Clin-Rep' complete kit for assay of vitamins A and E in plasma by high performance liquid chromatography (HPLC). A commercial enzyme immunoassay kit was used to assay C-reactive protein (CRP) in plasma. Of the 132 children in the study 108 (82%) had received vitamin A capsules. The median plasma retinol concentration of the 132 children was 0.98 micromol/l and the interquartile range 0.65-1.38 micromol/l. Of the 132 children, 35 (27%) had a plasma retinol concentration below 0.70 micromol/l. 75 children (57%) had normal plasma CRP levels and in 57 (43%) the CRP levels were elevated. The median plasma retinol concentration of the children with normal plasma CRP was 1.19 micromol/l and the interquartile range 0.93-1.50 micromol/l. The prevalence of vitamin A deficiency (VAD) in the children with normal plasma CRP was 11%, indicating a moderate public health problem. 74 (56%) males and 58 (44%) females were included in the study. The prevalence of VAD in the male and female children with normal plasma CRP was 14% and 8%, respectively, indicating a moderate public health problem among the male children and a mild public health problem among the female children. The prevalence of subclinical (mild to moderate) and marginal VAD among the children with and without elevated CRP strongly suggests the need for continuous monitoring of the vitamin A status of the vulnerable groups in NCD.

Pneumonia in Goilala

The clinical syndrome of pneumonia in adults in Port Moresby, the capital city of Papua New Guinea, has changed from the 1970s to the present. The severe lobar pneumonia commonly diagnosed in young adult men, characteristically from Goilala and living in settlements in Port Moresby, is no longer seen. Today pneumonia in adults is likely to be milder and bronchopneumonic in type. Possible explanations for the change include changes in immunity and in the bacteria found in the environment and carried in the nasopharynx of recent immigrants to the city. A change in treatment-seeking behaviour together with the wide availability of oral antibiotics is considered to be the most likely cause of the altered clinical syndrome that we have observed.

AIDS in Papua New Guinea: situation in the Pacific.

There has long been reason to anticipate a major heterosexual epidemic of acquired immunodeficiency syndrome (AIDS) in Papua New Guinea (PNG) and probably in the rest of Melanesia. From the social and behavioural perspectives, Melanesia is strikingly similar to other areas of the world with serious epidemics of AIDS. High levels of other sexually transmitted infections indicate behaviour patterns that would also facilitate transmission of human immunodeficiency virus (HIV) and presence of cofactors for HIV infection. Low levels of male circumcision parallel the situation in other epidemic areas. Near-parity by sex in cases reported so far in PNG is evidence that primary infection is largely heterosexual. The late start of a major epidemic in PNG can probably be attributed to: (a) the relatively small aggregation of people in urban centres (even Port Moresby has only one-quarter of a million people); (b) a highway system that does not network across the whole country; (c) limited size of the organized commercial sex sector; and (d) possibly low level of chancroid to act as a cofactor. The situation is now changing. Over the last seven years, HIV infection, probably the highest in Port Moresby and mostly measured there, has been rising by about 60% per annum. This rise is genuine and, if sustained, would infect 10% of the adult population of PNG in little more than 12 years. Some countries of sub-Saharan Africa have witnessed such exponential rises.

Kuru and "new variant" CJD.

Acquired transmissible spongiform encephalopathies in humans include Kuru (a disease which was associated with ritualistic cannibalism in Papua New Guinea), iatrogenic Creutzfeldt-Jakob disease and a newly recognized variant form of Creutzfeldt-Jakob disease (nvCJD). Clinical and neuropathological features of nvCJD are reminiscent of Kuru: early and progressive cerebellar ataxia and numerous characteristic Kuru-type amyloid plaques surrounded by spongiform change. In contrast to typical cases of sporadic CJD, Kuru and nvCJD affect young patients. The newly recognized form of CJD has been identified in ten young people in the UK in 1996, approximately 10 years after the beginning of the bovine spongiform encephalopathy (BSE) epidemic in the UK. Molecular analysis has shown that nvCJD has strain characteristics that are distinct from other types of CJD but similar to those of BSE. In the UK an estimated half a million BSE-infected cows entered the human food chain before the bovine offal ban of 1989. To be effective the oral route probably requires high-infectivity titers which are encountered only in the brain, spinal cord and eyes of naturally infected cows. In patients with Kuru, titers of more than 10(8) infectious doses per gram were reported in the brain tissues. As a result of the estimated very long incubation period of nvCJD (10 to 30 years or more) the predicted nvCJD epidemic will have the shape of a normal distribution curve with a peak expected in 2009. The epidemic may extend until 2030. There is already an example to illustrate such a curve in its descending line: the decline of Kuru deaths following the interruption of ritual cannibalism.

Declining impact of oral rehydration therapy in a Papua New Guinea Highlands Province: a case study with implications for Papua New Guinea's National Diarrheal Disease Control Program.

A provincial diarrheal disease control program that was based on the delivery of oral rehydration solution (ORS) from health facilities now places greater emphasis on the management of diarrhea with fluids at home. The change in strategy has been associated with decreasing utilization of health facilities and increasing mortality from diarrheal disease. The declining impact is attributed to the promotion of home-based management with little preparation of the target population for their therapeutic role. National policy recommends home-based management for mild cases of diarrhea and ORS for more severe cases. Our observations in the Southern Highlands Province have important implications for the diarrheal disease control program in Papua New Guinea.

Viruses associated with acute lower respiratory tract infections in children from the eastern highlands of Papua New Guinea (1983-1985).

This study, conducted at Goroka Hospital from January 1983 to June 1985, examined the viruses identified in nasopharyngeal aspirates (NPA) and urines collected from 716 hospitalised children with moderate or severe pneumonia, in NPA from 170 children with mild pneumonia treated as outpatients and in NPA from a control group of 428 children attending the outpatient department of Goroka Hospital suffering from minor ailments other than upper or lower respiratory tract infections. One or more viruses were identified from 68%, 51% and 43% of children with moderate or severe pneumonia, mild pneumonia and the control group, respectively. One-third of viruses were identified in conjunction with another virus in both control and sick children. Viral identification rates were highest in children under 1 year of age. Cytomegalovirus, adenoviruses, respiratory syncytial virus (RSV), measles and rhinoviruses were the most frequently identified viruses. RSV was associated with mild as well as moderate and severe disease. No virus was associated with an increased risk of death. Annual epidemics of RSV occurred during the wet season. An epidemic of influenza A virus and also influenza B virus and 3 epidemics of parainfluenza 3 virus occurred during the study period. The high viral identification rates in this study suggest a high frequency of transmission associated with the social structure and environment of Papua New Guinean highland villages and high population mobility.