Mortality rates and the utilization of health services during terminal illness in the Asaro Valley, Eastern Highlands Province, Papua New Guinea.

Between 1980 and 1989 we carried out fortnightly demographic surveillance in a random sample of people living in Goroka town, periurban areas and rural areas in the Lowa and Asaro Census Divisions, all within 1 1/2 hours' drive of the town in the Asaro Valley, Eastern Highlands Province. Cause of death was determined by verbal autopsy supplemented by any available health service information. Crude death and birth rates were 10 and 32 per 1000 person-years, respectively, in 59,906 person-years at risk. The standardized mortality ratio increased with increasing distance from town. Life expectancy at birth was 57 years for males and 55 years for females. The stillbirth rate was 19 per 1000 births, neonatal and infant mortality 21 and 60 per 1000 livebirths, respectively, and 1-4-year mortality 9 per 1000 person-years. Maternal mortality was 3 per 1000 births. Neonatal and infant mortality were respectively 7 and 3 times as high in Asaro Census Division as in Goroka town. Acute lower respiratory tract infections accounted for 22% of all deaths, chronic obstructive lung disease 10%, trauma 8% and gastroenteritis/dysentery 7%. 76% of deaths occurred at home and 44% of people who died had no treatment during their terminal illness. Health services were used most frequently by urban dwellers and by the young. To reduce mortality, a political commitment to provide functioning health services in rural areas is needed; regular supervision of health staff, ensuring the safety of staff and their families, availability of antibiotics as near people's homes as possible and regular mobile maternal and child health clinics are essential. Health education should include recognition of signs of severe disease and the importance of seeking treatment early. In view of high maternal and neonatal mortality, user fees should be waived for pregnant women.

Randomized trial of intake of fat, fiber, and beta carotene to prevent colorectal adenomas.

BACKGROUND: Epidemiologic evidence of associations between the high intake of fat and low intake of dietary fiber, beta carotene, and other dietary constituents and the risk of colorectal neoplasia has been inconsistent and has not provided a sufficient basis for recommendations concerning the dietary prevention of large-bowel cancer in humans. PURPOSE: We conducted a clinical trial to assess the effects on the incidence of adenomas of reducing dietary fat to 25% of total calories and supplementing the diet with 25 g of wheat bran daily and a capsule of beta carotene (20 mg daily). METHODS: We performed a randomized, partially double-blinded, placebo-controlled factorial trial in which half the patients were assigned to each intervention, resulting in seven intervention groups and one control group. Eligibility criteria included histologic confirmation of at least one colorectal adenoma and confidence expressed by the colonoscopist that all polyps had been removed. Dietary changes were individually initiated and monitored by dietitians and research nurses. At surveillance colonoscopy, the size and location of all polyps were recorded, and their histology was later centrally reviewed. Among 424 patients who were randomly assigned in the trial, 13 were found to be ineligible upon histologic review. Among the remaining 411, complete outcome data were collected from 390 at 24 months and from 306 at 48 months. All P values are from two-sided tests of statistical significance. RESULTS: There was no statistically significant prevention of total new adenomas with any of the interventions. We found a statistically non-significant reduced risk of large adenomas (> or = 10 mm) with the low-fat intervention: At 24 months, the odds ratio (OR) adjusted for potential confounders = 0.4 and 95% confidence interval (CI) = 0.1-1.1; at 48 months, OR = 0.3 and 95% CI = 0.1-1.0. Less and statistically nonsignificant reductions in the risk of large adenomas were found with wheat bran: At 24 months, OR = 0.8 and 95% CI = 0.3-2.2; at 48 months, OR = 0.8 and 95% CI = 0.3-2.5. Patients on the combined intervention of low fat and added wheat bran had zero large adenomas at both 24 and 48 months, a statistically significant finding (P = .03). CONCLUSIONS: Because only small numbers of patients were studied, our finding that the combination of fat reduction and a supplement of wheat bran reduced the incidence of large adenomas in this randomized, controlled trial must be treated with caution. The results do suggest, however, that these interventions may reduce the transition from smaller to larger adenomas, a step that may critically define those adenomas most likely to progress to malignancy.

Multiple colonization of the upper respiratory tract of Papua New Guinea children with Haemophilus influenzae and Streptococcus pneumoniae.

Nasal secretions from Papua New Guinea children were cultured using selective agents, to determine the prevalence of multiple colonization for both S. pneumoniae and H. influenzae. 29.5% of 156 and 53% of 93 carriage positive subjects harbored more than one type of S. pneumoniae and H. influenzae respectively. Of 95 strains of pneumococci isolated from multiply colonized children, 40% were relatively resistant to benzylpenicillin. In more than one half of the children in this group both penicillin sensitive and resistant serotypes coexisted. Significantly more penicillin resistant pneumococci were isolated from children with ready access to primary and regional health care services. Among H. influenzae the prevalence of multiple isolations due to nonencapsulated variants only, and encapsulated plus nonencapsulated organisms was similar. The commonest biotypes were types I, II, III and V, and each was similarly associated with multiple carriage.

Pneumococcal vaccine prevents death from acute lower-respiratory-tract infections in Papua New Guinean children.

In three double-blind placebo-controlled trials of pneumococcal capsular polysaccharide vaccines against death from acute lower-respiratory-tract infections (ALRI), children were vaccinated at 6 months to 5 years of age. The efficacy of the vaccines against ALRI as the sole cause of death was estimated at 59% in children vaccinated when younger than 5 years (p = 0.008) and 50% in children vaccinated when younger than 2 years (p = 0.043). Mortality from all causes was 19% less in the vaccinated group.

Colonisation of Haemophilus influenzae and Streptococcus pneumoniae in the upper respiratory tract of neonates in Papua New Guinea: primary acquisition, duration of carriage, and relationship to carriage in mothers.

In order to determine the age of acquisition and duration of carriage of the first strains of Haemophilus influenzae and Streptococcus pneumoniae in the upper respiratory tract of Papua New Guinea children, 25 babies were recruited at, or shortly after birth. Nasal secretions from mothers and children were cultured at 1- to 2-weekly intervals. H. influenzae and S. pneumoniae were acquired within the neonatal period by 60% of the infants, and all were colonised by both organisms within the first 3 months of life. Carriage periods for H. influenzae ranged from 6 to 221 days (mean, 74 days), and for S. pneumoniae from 5 to 290 days (mean, 96 days). Penicillin resistance was detected in 36% of the first acquired strains of pneumococci. Mothers, generally either did not carry H. influenzae or S. pneumoniae, or harboured types different to those first acquired by their infants. However, one-third of mothers subsequently became colonised with H. influenzae and S. pneumoniae types similar to those carried by their babies.