Glen Mola

Human Papillomavirus and Cervical Cancer in Australasia and Oceania: Risk-factors, Epidemiology and Prevention

The region encompassing Australasia and Oceania, including Australia, New Zealand, Fiji and Papua New Guinea, is a diverse one with respect to ethnicities, cultures and behaviours. It includes countries with comprehensive cervical cytology screening programmes which can be credited with significant reductions in cervical cancer incidence and mortality, and countries with no prevention programmes and significantly higher incidence and mortality. As elsewhere in the world, human papillomavirus (HPV)-16 and 18 are the commonest high-risk types, with the highest rates in women under 25 years of age. These two high-risk HPV types are found most frequently in cervical cancers and high-grade dysplasias, although there are minimal data for many countries in Oceania. In April 2007, Australia became the first country worldwide to commence a government funded universal HPV vaccine programme. The school-based programme targets 12-year old females in an ongoing schedule, with a catch-up programme up to 26 years of age, to be completed in mid-2009. Vaccine introduction has been comprehensively rolled out, with around 75% uptake of the complete vaccine schedule among school-girls in the first year of this initiative. This represents a successful model for other countries. We present data on cervical cancer, risk factors and prevention strategies, including epidemiology of HPV and HPV vaccine strategies.

Factors associated with success or failure in trials of vacuum extraction

Failure rates for vacuum extraction of between one in 16 and one in 600 have been reported. Most studies report that unexpected failure carries a greater risk to both mother and fetus. The aim of this study was to determine factors that were likely to predict success or failure in trials of vacuum extraction.

A review of maternal deaths at Goroka General Hospital, Papua New Guinea 2005-2008

Background:  Papua New Guinea is a developing country with a population of six million, facing significant geographical, cultural and economic barriers to the provision of antenatal and intrapartum care. The maternal mortality ratio (MMR) is an internationally regarded index of the quality of a country’s maternity services; the most recently reported MMR for Papua New Guinea of 773 deaths per 100 000 births is one of the highest in the world.

Field Evaluation of Xpert HPV Point-of-Care Test for Detection of Human Papillomavirus Infection by Use of Self-Collected Vaginal and Clinician-Collected Cervical Specimens

ABSTRACT The World Health Organization has recommended that testing for high-risk human papillomavirus (HPV) (hrHPV) infection be incorporated into cervical screening programs in all settings worldwide. In many high-burden, low-income countries, it will not be feasible to achieve high cervical screening coverage using hrHPV assays that require clinician-collected samples. We conducted the first evaluation of self-collected vaginal specimens compared with clinician-collected cervical specimens for the detection of hrHPV infection using the Xpert HPV test. Women aged 30 to 54 years attending two well-woman clinics in Papua New Guinea were invited to participate and provided self-collected vaginal and clinician-collected cervical cytobrush specimens. Both specimen types were tested at the point of care by using the Xpert HPV test. Women were given their cervical test result the same day. Those with a positive hrHPV test and positive examination upon visual inspection of the cervix with acetic acid were offered same-day cervical cryotherapy. A total of 1,005 women were enrolled, with 124 (12.3%; 95% confidence interval [CI], 10.3%, 14.4%) being positive for any hrHPV infection. There was a 99.4% overall percent agreement (OPA) between vaginal and cervical tests for HPV-16 (95% CI, 98.9%, 99.9%), a 98.5% OPA for HPV-18/45 (95% CI, 97.7%, 99.3%), a 94.4% OPA for other hrHPV infections (95% CI, 92.9%, 95.9%), and a 93.4% OPA for all hrHPV types combined (95% CI, 91.8%, 95.0%). Self-collected vaginal specimens had excellent agreement with clinician-collected cervical specimens for the detection of hrHPV infection using the Xpert HPV test. This approach provides for the first time an opportunity to incorporate point-of-care hrHPV testing into clinical cervical screening algorithms in high-burden, low-income settings.

Mobile phone-based syndromic surveillance system, Papua New Guinea

The health care system in Papua New Guinea is fragile, and surveillance systems infrequently meet international standards. To strengthen outbreak identification, health authorities piloted a mobile phone–based syndromic surveillance system and used established frameworks to evaluate whether the system was meeting objectives. Stakeholder experience was investigated by using standardized questionnaires and focus groups. Nine sites reported data that included 7 outbreaks and 92 cases of acute watery diarrhea. The new system was more timely (2.4 vs. 84 days), complete (70% vs. 40%), and sensitive (95% vs. 26%) than existing systems. The system was simple, stable, useful, and acceptable; however, feedback and subnational involvement were weak. A simple syndromic surveillance system implemented in a fragile state enabled more timely, complete, and sensitive data reporting for disease risk assessment. Feedback and provincial involvement require improvement. Use of mobile phone technology might improve the timeliness and efficiency of public health surveillance.

Vibrio cholerae O1 in 2 Coastal Villages, Papua New Guinea

To the Editor: Cholera outbreak reports are of international public health interest, especially in areas that were previously cholera free (1). Although many recent cholera outbreaks have originated in coastal areas (2), identifying the source of cholera introduction has been challenging (1). The detection of Vibrio cholerae in coastal, brackish and riverine waters in cholera-endemic and cholera-free areas supports the view that autochtonous V. cholerae is involved in the introduction of cholera (3,4). To our knowledge, cholera has not been reported in Papua New Guinea, despite social and environmental conditions likely to facilitate transmission and the nations close proximity to cholera-endemic countries (5,6). On August 6, 2009, a physician who visited the coastal village of Lambutina reported an outbreak of acute watery diarrhea that was associated with the death of his father and 4 other persons from this and a neighboring village. The outbreak began in the village of Nambariwa and spread to neighboring Lambutina, Morobe Province. From August 13, multidisciplinary teams worked with the community to reduce the number of deaths through early identification and treatment of case-patients. The teams also worked to limit transmission through improvements to the water and sanitation infrastructure and by encouraging better hygiene practices among the villagers. A suspected case of cholera was defined as acute watery diarrhea or vomiting in a resident of Lambutina or Nambariwa villages since July 22, 2009. In the 2 villages, 77 cases were identified; attack rates were 14% in Lambutina (48/343) and 5.5% in Nambariwa (29/532). The overall case-fatality ratio was 6.5% (5/77); 2 patients died after they were discharged from the referral hospital. A retrospective frequency-matched case–control study was conducted in Lambutina to identify the risk factors associated with suspected cholera. Neighborhood controls (± 5 years of age) were selected from unaffected households. Univariate and multivariate analyses were conducted with STATA version 10 (StataCorp., College Station, TX, USA). Of the 48 case-patients in Lambutina, 43 participated in the study with 43 age-matched controls. In addition to having close contact with patients who had cholera, univariate analysis showed that case-patients were more likely to have had several exposures related to the death of other patients (Table). However, having close contact with a patient was the only independent risk factor (adjusted odds ratio 4.8, 95% confidence interval 1.7–13.4) (Table). Close contact included providing nursing care for patients or carrying patients onto boats for transport to health care facilities. From the 10 collected samples, 4 isolates were confirmed as V. cholerae O1, biotype El Tor, serotype Ogawa, by PCR detection of an O1-specific region of the rfb gene using established methods and PCR amplification of the tcpA gene polymorphism specific for the El Tor biotype (7). The ctxAB, vct genes (present in toxigenic strains) and the hemolysin gene hlyA (present in all V. cholerae strains) were detected by PCR in all 4 isolates. Although health authorities promptly identified and responded to the outbreak, they could not determine its origin. The El Nino weather phenomenon generates increased rainfall and elevated sea surface temperatures and is a predictor of cholera outbreaks (8), which puts more coastal areas at risk for such outbreaks (9). During this outbreak, Papua New Guinea reported above-average rainfall (10) and warmer sea surface temperatures. Although cholera may have been introduced to Papua New Guinea through an infectious traveler or by other means, climatic factors may have initiated plankton blooms, the abundance of which have also been associated with increased presence of V. cholerae O1. Sea and estuarine waters of these villages are plausible sources of introduction. In Lambutina, the age-specific attack rates were lowest among young children and increased among persons of middle age and among the elderly. Those providing patient care and lifting during transportation as well as those washing the bodies of the deceased may have been more represented in the >40 years age group; however, this situation may not explain the high attack rates among the elderly. Generally, after a cholera outbreak is detected, interventions aim to reduce the proportion of deaths to <1%. The overall case-fatality ratio in the outbreak discussed here was 6.5%, which reflects the challenges to accessing adequate health care in remote settings. This difficulty is exacerbated when the disease occurs for the first time because cholera awareness and preparedness will be weak, as can be seen in the early management of cases during this outbreak. Villagers who have close contact with cholera patients are at greater risk for disease and should be a focus of interventions to limit transmission (e.g., eliminating ingestion of contaminated water, improving hygiene and sanitation). Education to increase awareness of the disease and enhanced access to low-osmolarity oral rehydration solution, Hartmann solution, and zinc supplements are essential. Cholera-endemic and cholera–nonendemic countries with coastal populations are at an increasing risk for cholera outbreaks. Adequate preparation by the health care system is vital to avoid excess deaths. Table Univariate and multivariate analysis of risk factors associated with suspected cholera in Lambutina village, Papua New Guinea, 2009*

Preterm or not--an evaluation of estimates of gestational age in a cohort of women from Rural Papua New Guinea.

Background Knowledge of accurate gestational age is required for comprehensive pregnancy care and is an essential component of research evaluating causes of preterm birth. In industrialised countries gestational age is determined with the help of fetal biometry in early pregnancy. Lack of ultrasound and late presentation to antenatal clinic limits this practice in low-resource settings. Instead, clinical estimators of gestational age are used, but their accuracy remains a matter of debate. Methods In a cohort of 688 singleton pregnancies from rural Papua New Guinea, delivery gestational age was calculated from Ballard score, last menstrual period, symphysis-pubis fundal height at first visit and quickening as well as mid- and late pregnancy fetal biometry. Published models using sequential fundal height measurements and corrected last menstrual period to estimate gestational age were also tested. Novel linear models that combined clinical measurements for gestational age estimation were developed. Predictions were compared with the reference early pregnancy ultrasound (<25 gestational weeks) using correlation, regression and Bland-Altman analyses and ranked for their capability to predict preterm birth using the harmonic mean of recall and precision (F-measure). Results Average bias between reference ultrasound and clinical methods ranged from 0–11 days (95% confidence levels: 14–42 days). Preterm birth was best predicted by mid-pregnancy ultrasound (F-measure: 0.72), and neuromuscular Ballard score provided the least reliable preterm birth prediction (F-measure: 0.17). The best clinical methods to predict gestational age and preterm birth were last menstrual period and fundal height (F-measures 0.35). A linear model combining both measures improved prediction of preterm birth (F-measure: 0.58). Conclusions Estimation of gestational age without ultrasound is prone to significant error. In the absence of ultrasound facilities, last menstrual period and fundal height are among the more reliable clinical measures. This study underlines the importance of strengthening ultrasound facilities and developing novel ways to estimate gestational age.

Cholera risk factors, Papua New Guinea, 2010

BackgroundCholera is newly emergent in Papua New Guinea but may soon become endemic. Identifying the risk factors for cholera provides evidence for targeted prevention and control measures.MethodsWe conducted a hospital-based case–control study to identify cholera risk factors. Using stool culture as the standard, we evaluated a cholera point of care test in the field.Results176 participants were recruited: 54 cases and 122 controls. Independent risk factors for cholera were: being over 20 years of age (aOR 2.5; 95%CI 1.1, 5.4), defecating in the open air (or river) (aOR 4.5; 95% CI 1.4, 14.4) and knowing someone who travelled to a cholera affected area (aOR 4.1; 95%CI 1.6, 10.7); while the availability of soap for handwashing at home was protective (aOR 0.41; 95%CI 0.19, 0.87). Those reporting access to a piped water distribution system in the home were twice as likely to report the availability of soap for handwashing. The sensitivity and specificity of the rapid test were 72% (95% CI 47–90) and 71% (95%CI 44–90%).ConclusionsImproving population access to the piped water distribution system and sanitation will likely reduce transmission by enabling enhanced hygiene and limiting the contamination of water sources. The One step V. cholerae O1/O139 Antigen Test is of limited utility for clinical decision making in a hospital setting with access to traditional laboratory methods. Settlement dwellers and mobile populations of all age groups should be targeted for interventions in Papua New Guinea.

Unintended pregnancy amongst women attending antenatal clinics at the Port Moresby General Hospital

National survey data from Papua New Guinea (PNG) suggest that women are having almost 1.5 times the number of children they desire. Womens ability to space and limit the number of children could have a significant impact on the countrys high infant and maternal mortality rates.

Shigella spp. Antimicrobial Drug Resistance, Papua New Guinea, 2000–2009

To the Editor: Approximately half the Shigella spp. infections in developing countries are caused by endemic shigellae (1), which in these countries are responsible for ≈10% of all episodes of diarrhea among children <5 years of age and up to 75% of deaths from diarrhea (2). Deaths from epidemic Shigella spp. in the community are estimated to outnumber deaths within the healthcare setting. In Papua New Guinea, diarrhea is a major cause of hospital admission and death (3); Shigella spp. are among the most common causes of enteric bacterial infection (4,5), and S. flexneri is the most common serotype (3,6). Outbreaks of bloody diarrhea are frequently reported; however, diagnosis in remote settings is challenging, partly because the storage requirements for the organism are difficult to meet. Multidrug resistance of shigellae is not new (1); many countries have reported resistance to amoxicillin, co-trimoxazole, and chloramphenicol. For this reason, the World Health Organization recommends that all patients with bloody diarrhea be treated with either ciprofloxacin or 1 of the 3 second-line drugs: pivmecillinam, azithromycin, and ceftriaxone (7). The antimicrobial drug currently recommended for patients with bloody diarrhea in primary healthcare settings in Papua New Guinea is co-trimoxazole (8); ciprofloxacin is available only in hospitals. In August 2009, an epidemic of multidrug-resistant S. flexneri infection associated with widespread illness and death across 4 provinces of Papua New Guinea was reported to health authorities. To understand the trends and to inform antimicrobial drug policy makers, we reviewed retrospective microbiological data for 2000–2009. With the exception of 3 isolates collected during an outbreak in the border regions of the 4 provinces during 2009 (excluded from analysis), all isolates in our study were obtained as part of routine surveillance. Fecal samples were collected by clinicians from any patient seeking care for severe diarrhea at Port Moresby General Hospital. Before serologic testing was conducted, samples were spread directly on desoxycholate citrate agar and MacConkey agar plates for culture. Antimicrobial drug resistance testing was performed by using the Kirby-Bauer method. From a total of 3,419 fecal samples cultured, 136 (4.0%) were positive for Shigella spp. The most commonly isolated species was S. flexneri (90.4%); less frequently isolated were S. boydii (3.7 %), S. dysenteriae (2.9%), and S. sonnei (1.5%). Of the 123 S. flexneri isolates, 20 (16%) were further characterized; the most frequent serovars were serovar 2 (40%) and serovar 3 (30%). Many (48%) Shigella spp.–positive isolates were from children <5 years of age. The highest rates of antimicrobial drug resistance of all Shigella spp. were to amoxicillin (96%), co-trimoxazole (86%), and chloramphenicol (60%); no resistance to ciprofloxacin and cephalexin was found (Table). Table Antimicrobial drug resistance of Shigella spp., Papua New Guinea, 2000–2009* Current evidence supports the use of ciprofloxacin, ceftriaxone, and pivmecillinam for treatment of bloody diarrhea (9). It also suggests that dysentery rarely relapses if an infected child has received a full course of treatment with 1 of these drugs and the causative pathogen is sensitive to the drug. Reducing the risk for relapse of bacterial infections among children is beneficial because it reduces the likelihood of subsequent episodes of dysentery occurring in that child and of transmission to others (9). In our study, most isolates were resistant to co-trimoxazole and the other available antimicrobial drugs, indicating that their use would not have reduced illness and subsequent transmission in this setting. The lack of resistance to ciprofloxacin and cephalexin indicates that these drugs may be more effective; however, they are neither available at the primary healthcare level nor recommended in Papua New Guinea, which is cause for concern. Surveillance for antimicrobial drug resistance is essential for the containment of antimicrobial drug resistance globally. However, international surveillance depends on strong national surveillance systems. Despite the existence of a network of subnational laboratories where fecal sample cultures had been performed, these laboratories no longer perform these cultures. In 1964, the laboratory in 1 provincial hospital analyzed and subtyped 1,000 stool samples over a 15-month period (6). In our study, conducted at the national referral hospital (which limits the representativeness), we analyzed 3,419 fecal samples over a 10-year period. Outbreaks of bloody diarrhea are common in remote settings in Papua New Guinea, yet with the exception of the 3 isolates from 2009 that were excluded from analysis, no Shigella spp.–positive samples have been identified during outbreaks. Molecular methods may serve as an adjunct to traditional laboratory methods by improving sensitivity and also enabling diagnosis of Shigella spp. outbreaks among remote populations where specimen storage and transport requirements may be challenging (10). We describe extremely high rates of resistance of Shigella spp. to co-trimoxazole, the recommended treatment for bloody diarrhea in Papua New Guinea. Strengthening national surveillance for antimicrobial drug resistance would provide the evidence to better inform policy decision makers. A review of the national antimicrobial drug policy for management of bloody diarrhea is urgently needed.