Personal reflections on malaria after 40 years of the Malaria Research Program at the Papua New Guinea Institute of Medical Research

@#These reflections on malaria are mostly from the mirror of the past, which have their own intrinsic interest but also, through accounts of success and failure, shine some light on different paths into the future. The rich history of malaria research in New Guinea is briefly alluded to before turning to the work of the Papua New Guinea Institute of Medical Research. The Malaria Research Program of the Institute began in 1976 and celebrated its 40-year anniversary in 2016. Stories about its beginnings and the personalities involved are recounted. Some of the early studies are described, including prophylaxis with antimalarial drugs in children. The many ways used to try and control malaria are outlined as well as the difficulties that were encountered in the face of dogmatic beliefs and colonial attitudes. New ideas included insecticidal mosquito nets used as bed-nets and a blood stage malaria vaccine, the travails with which are described in some detail. Further final reflections discount the idea of the eradication of malaria and look to the continued use in places where malaria is hard to control of a creative combination of partially successful measures. Playing with ideas is the basis of good science and, though it is more effective when done with sympathetic colleagues, these personal reflections are offered in the hope that they will not prove entirely narcissistic.

The Medical Society and the Medical Journal, with comments on pigbel, swollen belly syndrome, kuru and other Papua New Guinean medical icons

@#The Fiftieth Annual Medical Symposium of the Medical Society of Papua New Guinea held in Goroka from 31 August to 3 September 2014 celebrated the success of the Medical Society and the Papua New Guinea Medical Journal. This paper was presented as an address at the meeting and praised the work of medical doctors, allied health staff, medical scientists and research staff engaged in the field and laboratory for their many achievements over these 50 years. It describes the major Papua New Guinean medical icons of kuru, pigbel and swollen belly syndrome and draws out lessons learned from them and the research that elucidated them. Other medical icons that are briefly described include neonatal tetanus, Burkitt lymphoma, standard treatment books, respiratory bacteriology, insecticide-treated bednets, pneumococcal polysaccharide vaccine, a blood-stage malaria vaccine, snakebite, conservative management of ruptured spleen, radial paralysis in leprosy, the response to BCG and the BCG leprosy trial, bottle-feeding legislation, betelnut chewing and oral cancer, hyperreactive malarious splenomegaly, genetic polymorphisms associated with malaria, subacute sclerosing panencephalitis, donovanosis, endemic goitre and endemic cretinism, lymphatic filariasis, adult asthma and sago haemolytic disease. Attention is also drawn to likely future challenges – from infectious diseases and their unpredictability, outbreaks of disease on a global scale, climate change, the difficulty of establishing effective community engagement in the pursuit of greater equity in health and well-being, and the need to ensure that the mineral wealth of the nation is used for everybody’s benefit. A Health Think-Tank is proposed as a means of developing innovative and efficient ways of improving the health of all Papua New Guineans.

A history of kuru

Kuru is placed in its geographic and linguistic setting in the Eastern Highlands of Papua New Guinea. The epidemic of kuru has declined over the period 1957 to 2005 from more than 200 deaths a year to 1 or none. Since transmission of the kuru prion agent through the mortuary practice of transumption ceased by the early 1960s, the continuation of the epidemic into the present century demonstrates the long incubation periods that are possible in human prion diseases. Several histories of kuru are portrayed, from the different perspectives of the Fore people, of the scientists striving to elucidate the disease, of those engaged in research on prions, and of humans confronting the implications of kuru-like epidemics in the remote past. Kuru has connections to bovine spongiform encephalopathy through intraspecies recycling. The influence of host genetics on the incubation period in kuru may help to predict the shape of the still ongoing epidemic of variant Creutzfeldt-Jakob disease.

Chlamydia trachomatis infection and distribution of serovars in the Eastern Highlands Province, Papua New Guinea

We have used nested polymerase chain reaction (PCR) and the PCR-based endonuclease digestion method to genotype Chlamydia trachomatis serovars in 460 infected individuals from the Eastern Highlands Province of Papua New Guinea. Our study groups comprised women who presented in labour to the Goroka Base Hospital, their newborn infants, symptomatic children who presented to the hospital's Outpatients Department and men and women from 15 randomly selected villages in the Asaro Valley. In this analysis, the major outer membrane protein (MOMP) gene, omp1, of C. trachomatis was amplified using DNA obtained from the endocervix of women, urine from men, and both the eye and nasopharynx of children. Amplified DNAs were digested concurrently using Alul and a combination of EcoRI, Hinl and Hpall restriction enzymes. The mixtures were separated on electrophoretic gels and the respective serovars designated on the basis of resolved digested DNA patterns. Our results, which were confirmed also by omp1 sequence data, show serovars D, E, F, G, H and L3 to be present in the studied communities. The overall relative frequencies of these serovars were 30%, 21%, 25%, 1%, 20% and 2% respectively, with serovars D, E, F and H accounting for 97% of these infections. Double infections among these principal serovars were also detected in all our study groups but at a low overall frequency of 3%. Serovar D was the major agent involved in the aetiology of chlamydial infection in both children and adults though serovar F was the most frequent in newborn infants. Serovar H was relatively less frequent in symptomatic children. No trachoma-related serovars were detected, confirming the rarity of this disease in Papua New Guinea. In contrast, although clinical cases of lymphogranuloma venereum have not been described in the country, the detection of serovar L3 in this study suggests that it may occur. However, the association of L3 also with childhood infection indicates that it may be causing the same pathology as the serovars D-K that are associated with non-ulcerative sexually transmitted infections.

Parasitological and clinical efficacy of standard treatment regimens against Plasmodium falciparum, P. vivax and P. malariae in Papua New Guinea

Resistance of Plasmodium falciparum (Pf) and P. vivax (Pv) to standard antimalarials is widespread in Papua New Guinea (PNG). The objective of the study was to assess the rate of clinical treatment failure (TF) and parasite resistance to amodiaquine (AQ), chloroquine (CQ) and quinine+sulfadoxine/pyrimethamine (Q+SP) for malaria in a rural health centre of the East Sepik Province. 179 patients presenting with symptoms and signs of malaria and with Pf (144 patients), Pv (18 patients), P. malariae (Pm) (7 patients) or mixed infection (10 patients) were included. 86 were treated with AQ, 88 with CQ and 5 with Q+SP. 21/179 patients (12%) were not cured or had a recrudescence of symptoms associated with parasitaemia in the 28 days following treatment, 14% after AQ, 10% after CQ and 0% after Q+SP. The proportion of TF was higher (17%) when the analysis population included only the 108 subjects who had a complete follow-up, especially for failure with Pf following AQ treatment (26%). During the 28 days of follow-up, RII or RIII level of resistance in Pf was detected in 55% of the subjects treated with amodiaquine, 30% of those treated with chloroquine and 0% of those treated with quinine+SP. Of the Pv or Pm parasites only one Pv was found to be RII resistant to CQ in the 28-day test. In vitro resistance of Pf to CQ was higher than to AQ (50% versus 27% of 36 parasite samples that grew successfully). The level of TF and parasitological resistance to standard antimalarial drugs was lower in this area than in urban settings, where drugs are more easily available. AQ performed less well than CQ but the difference is likely to be due to the age of the users, ie, their level of immunity, AQ being the first-line drug for young children. These results provided support for the recent change in the policy for the standard treatment of uncomplicated malaria in PNG from AQ or CQ to the combination of AQ+SP or CQ+SP, a recommendation aimed at slowing down the spread of multidrug resistance.

Ribotyping of Salmonella enterica serovar Typhi isolates from Papua New Guinea over the period 1977 to 1996

The prevalence of typhoid in the Papua New Guinea (PNG) highlands region increased rapidly in the mid-1980s, and now remains endemic. In this study ribotyping has been used to examine the number and types of Salmonella enterica serovar Typhi strains present during the 1977-1996 period. The ribotyping banding pattern results were based on Cla I and Eco RV digests. The 57 PNG isolates were divided into 11 different ribotypes. Comparison of ribotypes using coefficient of similarity values revealed a diverse group of ribotypes. Several strains appear to be endemic in PNG For instance, ribotypes 1, 2 and 3 were most commonly found among PNG isolates and isolates with these ribotypes have been cultured over a period of at least 11 years (1985-1996). Ribotype 3 was also observed in isolates from Malaysia and Thailand. Also found in PNG were ribotypes 4, 5, 6, 7, 8, 9, 16 and 17. The ribotyping suggests that serovar Typhi strains present in PNG include unique strains of serovar Typhi and also strains that are common to other countries.

Antenatal care in Goroka: issues and perceptions

The high maternal mortality rate in Papua New Guinea indicates an urgent need for action. One area for examination is antenatal care. From April 2002 to August 2002 a qualitative study was undertaken in order to identify perceptions, beliefs, barriers and strengths relevant to the utilization of antenatal care by women in the urban, periurban and rural communities of Goroka, Papua New Guinea. Interview data about antenatal care utilization were collected from 20 pregnant or parous women and 4 antenatal health care workers and relevant statistics were reviewed. This information was analyzed in order to identify the constraints faced by the users of antenatal care and health care workers providing such services and to make recommendations aimed to improve the utilization and delivery of antenatal care in Goroka. Multiple encouragers and barriers to using antenatal care were identified within the three categories of physical barriers/encouragers, cultural issues and health care system characteristics. The attitude of health care workers and their perceived ill-mannered treatment of women was one of the most significant concerns raised by the women. Nevertheless, all of the women expressed overall satisfaction with the care given. All of the health care workers stated that antenatal care is very important for the health of both the baby and the mother and expressed a desire to improve the level of care. The major constraints faced were staff shortages, limited supplies and broken equipment. There were four key areas of strength: the broad level of coverage, the high regularity of attendance, the women's commitment to antenatal care and the willingness of health care workers to overcome resource difficulties in the provision of care. Recommendations to improve the delivery of antenatal care services and their utilization by women addressed the situation of women and the interactions between women and health care providers, and proposed innovations in the health care system.

Hospital twinning between Australia and Papua New Guinea

This brief paper presents an argument for the establishment of permanent twinning relationships between hospitals in Australia and Papua New Guinea as one way of expressing the advantages of expanding globalization while countering its disadvantages for human health, especially in poorer countries. This particular suggestion is based on the general argument that widespread and sustainable improvement in people's health will be more likely to occur if health professionals take action themselves and work directly with each other. Disease does not respect national borders. Therefore, professional solidarity must be international, and strengthening the global health sector will amplify its benefits to human health, now and in the future. The particular suggestion that is made here is but one small step in this direction, but should have immediate benefit to those involved.