Jan Pryor

The development and evaluation of a PDA-based method for public health surveillance data collection in developing countries

BACKGROUND AND PURPOSE EpiData and Epi Info are often used together by public health agencies around the world, particularly in developing countries, to meet their needs of low-cost public health data management; however, the current open source data management technology lacks a mobile component to meet the needs of mobile public health data collectors. The goal of this project is to explore the opportunity of filling this gap through developing and trial of a personal digital assistant (PDA) based data collection/entry system. It evaluated whether such a system could increase efficiency and reduce data transcription errors for public surveillance data collection in developing countries represented by Fiji. METHODS A generic PDA-based data collection software eSTEPS was developed. The software and the data collected using it directly interfaces with EpiData. A field trial was conducted to test the viability of public health surveillance data collection using eSTEPS. The design was a randomised, controlled trial with cross-over design. 120 participants recruited from the Fiji School of Medicine were randomly assigned to be interviewed by one of six interviewers in one of the two ways: (1) paper-based survey followed by PDA survey and (2) PDA survey followed by paper-based survey. Data quality was measured by error rates (logical range errors/inconsistencies, skip errors, missing values, date or time field errors and incorrect data type). Work flow and cost were evaluated in three stages of the survey process: (1) preparation of data collection instrument, (2) data collection and (3) data entry, validation and cleaning. User acceptance was also evaluated in the two groups of participants: (1) data collectors and (2) survey participants. RESULTS None of the errors presented in 20.8% of the paper questionnaires was found in the data set collected using PDA. Sixty-two percent of the participants perceived that the PDA-based questionnaire took less time to complete. Data entry, validation and cleaning for the PDA-based data collection from 120 participants took a total of 1.5h, a 93.26% reduction of time from 20.5h required using paper and pen. The cost is also significantly reduced with PDA-based protocol. Both data collectors and participants prefer to use PDA instead of paper for data collection. The trial results prove that eSTEPS is a feasible solution for public health surveillance data collection in the field. Several deficiencies of the software were also identified and would be addressed in the next version. CONCLUSION eSTEPS offers the potential to meet the need for an effective mobile public health data collection tool for use in the field. The eSTEPS field trial proves that PDA was more efficient than paper for public health survey data collection. It also significantly reduced errors in data entry. The later benefit was derived from the software providing its users with the flexibility of building their own constraints to control the data type, range and logic of data entry.

Hyporesponsiveness to re-challenge dose following pneumococcal polysaccharide vaccine at 12 months of age, a randomized controlled trial.

BACKGROUND To evaluate the immunological impact of the 23-valent pneumococcal polysaccharide vaccine (23vPPS) at 12 months, for children who have received zero to three infant doses of seven-valent pneumococcal conjugate vaccine (PCV), on responses to a subsequent exposure to a small dose of 23vPPS (mPPS). METHODS Five hundred and fifty-two Fijian infants were stratified by ethnicity and randomized into eight groups to receive zero, one, two, or three PCV doses at 14 weeks, six and 14 weeks, or six, ten, and 14 weeks. Within each group, half received 23vPPS at 12 months and all received mPPS at 17 months. Sera were taken prior and one month post-mPPS. FINDINGS By 17 months, geometric mean antibody concentrations (GMC) to all 23 serotypes in 23vPPS were significantly higher in children who had received 23vPPS at 12 months compared to those who had not. Post-mPPS, children who had not received the 12 month 23vPPS had a significantly higher GMC for all PCV serotypes compared with those who had (each p<0.02). For the non-PCV serotypes, children who had not received the 12 month 23vPPS had significantly higher GMC for six of 16 non-PCV serotypes (7F, 9N, 12F, 19A, 22F, 33F) than those who did (each p<0.02). After adjusting for the pre-mPPS level, exposure to 23vPPS was associated with a lower response to mPPS for all serotypes (each p<0.001). INTERPRETATION Despite higher antibody concentrations at 17 months in children who had received 23vPPS at 12 months, the response to a re-challenge was poor for all 23 serotypes compared to children who had not received the 12 month 23vPPS.

Immunogenicity following one, two, or three doses of the 7-valent pneumococcal conjugate vaccine.

The aim was to identify an appropriate infant pneumococcal vaccination strategy for resource poor countries. Fijian infants received zero, one, two, or three doses of 7-valent pneumococcal conjugate vaccine (PCV) in early infancy. Following three PCV doses, geometric mean concentration (GMC) to all seven serotypes were > or = 1.0 microg/mL, and >85% of children achieved antibody levels > or = 0.35 microg/mL at 18 weeks. Following two doses, GMC were lower for 6B, 14, and 23F, but higher for 19F compared with three doses. Following a single dose, significant responses were seen for all serotypes post-primary series compared with the unvaccinated. By 12 months, differences between two and three doses persisted for serotype 14 only. Although GMC following three doses are higher than after two doses, the differences were small. A single dose may offer some protection for most serotypes.

Chest X-ray-confirmed pneumonia in children in Fiji

OBJECTIVE To calculate the incidence and document the clinical features of chest X-ray- (CXR-) confirmed pneumonia in children aged between 1 month and 5 years living in Greater Suva, Fiji. METHODS A retrospective review was undertaken of children aged between 1 month and 5 years with a discharge diagnosis suggesting a lower respiratory tract infection (LRTI) admitted to the Colonial War Memorial Hospital in Suva, Fiji, in the first 10 days of each month from 1 January 2001 to 31 December 2002. Clinical data were collected and CXRs were reread and classified according to WHO standardized criteria for CXR-confirmed pneumonia. FINDINGS Two hundred and forty-eight children with LRTI met the inclusion criteria. CXRs were obtained for 174 (70%) of these cases, of which 59 (34%) had CXR-confirmed pneumonia. The annual incidence of CXR-confirmed pneumonia was 428 cases per 100,000 children aged between 1 month and 5 years living in Greater Suva. If a similar proportion of the children for whom CXRs were unavailable were assumed to have CXR-confirmed pneumonia, the incidence was 607 per 100,000. The incidence appeared to be higher in Melanesian Fijian than Indo-Fijian children. The case-fatality rate was 2.8% in all children with LRTI, and 6.8% in those with CXR-confirmed pneumonia. CONCLUSION This is the first study to document the incidence of CXR-confirmed pneumonia in a Pacific Island country, and demonstrates a high incidence. A significant proportion of hospital admissions of children with LRTI are likely to be preventable by the introduction of pneumococcal conjugate vaccine.

Genomic analysis of hepatitis B virus reveals antigen state and genotype as sources of evolutionary rate variation.

Hepatitis B virus (HBV) genomes are small, semi-double-stranded DNA circular genomes that contain alternating overlapping reading frames and replicate through an RNA intermediary phase. This complex biology has presented a challenge to estimating an evolutionary rate for HBV, leading to difficulties resolving the evolutionary and epidemiological history of the virus. Here, we re-examine rates of HBV evolution using a novel data set of 112 within-host, transmission history (pedigree) and among-host genomes isolated over 20 years from the indigenous peoples of the South Pacific, combined with 313 previously published HBV genomes. We employ Bayesian phylogenetic approaches to examine several potential causes and consequences of evolutionary rate variation in HBV. Our results reveal rate variation both between genotypes and across the genome, as well as strikingly slower rates when genomes are sampled in the Hepatitis B e antigen positive state, compared to the e antigen negative state. This Hepatitis B e antigen rate variation was found to be largely attributable to changes during the course of infection in the preCore and Core genes and their regulatory elements.

Infection frequency of hepatitis C virus and IL28B haplotypes in Papua New Guinea, Fiji, and Kiribati.

It has been estimated that there are more than 60 million Hepatitis C virus (HCV) carriers in the World Health Organisations Western Pacific region (WHO-WPR), where liver cancer is among the top three causes of cancer death. WHO and the US Centres for Disease Control and Prevention report the prevalence of HCV in the South Pacific islands (countries within the WHO-WPR) to be high (5–10% and >2% respectively). However, since HCV is not tested for in many of these countries, there is sparse data available to support this assertion. We screened ∼2000 apparently healthy individuals from Papua New Guinea, Fiji and Kiribati and found a sero-prevalence of 2.0%, 0.1% and 0%, respectively. All sero-positive samples tested negative for HCV RNA. Curious as to why all the sero-positive individuals were negative for HCV-RNA, we also screened them for the HCV protective IL28B SNP markers rs12979860 and rs8099917. All antibody-positive participants bar one had HCV protective haplotypes. Our results suggest that HCV is present in these Pacific island countries, albeit at a prevalence lower than previous estimates. As none of our participants had undergone antiviral treatment, and therefore must have cleared infection naturally, we hypothesise that genotypes 1 and/or 4 are circulating in South Pacific Island people and that these peoples are genetically predisposed to be more likely to spontaneous resolve HCV infection than to become chronic carriers.

Epidemics and Coups: A dynamic undergraduate curriculum in Fiji

A t the end of a three year programme designed to prepare them to vaccinate against and cope with the effects of smallpox and other infectious diseases, three young men, the first products of the predecessor of the Fiji School of Medicine (FSM) graduated in 1888 (Fig 1). In the previous five years around 40,000 Fijians, out of an estimated population of 150,000 people, had died as a result of a measles epidemic imported from Australia. Early graduates were educated and trained to deal with primary care, immunization and the promotion of a healthy physical environment. In response to the demand from Fiji and its Pacific Island neighbouring countries for better trained doctors who would also provide hospital-based care a series of curricular developments led to lengthening of the undergraduate medical programme to 4 and then 5 years in 1931 and 1952 respectively. Class sizes were small and there was close and personal tutelage from lecturers. The qualification from these programmes was a diploma. For the first time, in 1983, a 6-year MBBS degree programme was instituted. THE FIRST COUP