John Vince

Features and Prognosis of Severe Malaria Caused by Plasmodium falciparum, Plasmodium vivax and Mixed Plasmodium Species in Papua New Guinean Children

Background Mortality from severe pediatric falciparum malaria appears low in Oceania but Plasmodium vivax is increasingly recognized as a cause of complications and death. The features and prognosis of mixed Plasmodium species infections are poorly characterized. Detailed prospective studies that include accurate malaria diagnosis and detection of co-morbidities are lacking. Methods and Findings We followed 340 Papua New Guinean (PNG) children with PCR-confirmed severe malaria (77.1% P. falciparum, 7.9% P. vivax, 14.7% P. falciparum/vivax) hospitalized over a 3-year period. Bacterial cultures were performed to identify co-incident sepsis. Clinical management was under national guidelines. Of 262 children with severe falciparum malaria, 30.9%, 24.8% and 23.2% had impaired consciousness, severe anemia, and metabolic acidosis/hyperlactatemia, respectively. Two (0.8%) presented with hypoglycemia, seven (2.7%) were discharged with neurologic impairment, and one child died (0.4%). The 27 severe vivax malaria cases presented with similar phenotypic features to the falciparum malaria cases but respiratory distress was five times more common (P = 0.001); one child died (3.7%). The 50 children with P. falciparum/vivax infections shared phenotypic features of mono-species infections, but were more likely to present in deep coma and had the highest mortality (8.0%; P = 0.003 vs falciparum malaria). Overall, bacterial cultures were positive in only two non-fatal cases. 83.6% of the children had alpha-thalassemia trait and seven with coma/impaired consciousness had South Asian ovalocytosis (SAO). Conclusions The low mortality from severe falciparum malaria in PNG children may reflect protective genetic factors other than alpha-thalassemia trait/SAO, good nutrition, and/or infrequent co-incident sepsis. Severe vivax malaria had similar features but severe P. falciparum/vivax infections were associated with the most severe phenotype and worst prognosis.

Can clinical signs predict hypoxaemia in Papua New Guinean children with moderate and severe pneumonia

Abstract Pulse oximetry was performed on 77 children admitted with acute lower respiratory tract infections (ALRI) to the childrens ward in Port Moresby General Hospital, Papua New Guinea over a 4-month period in 2002. Clinical findings were correlated with different levels of hypoxaemia, <93%, <90% and <85%. Cyanosis, head nodding and drowsiness were good predictors of hypoxia but lacked sensitivity. Decisions to use oxygen based on these signs would therefore result in a significant number of children with hypoxia not receiving oxygen. Pulse oximetry is the best indicator of hypoxaemia in children with ALRI and, although relatively expensive, its use might be cost-effective in controlling oxygen requirements.

The aetiology, clinical presentations and outcome of febrile encephalopathy in children in Papua New Guinea

Abstract Background: Febrile encephalopathy, defined as fever, seizures and/or altered consciousness, is a common presentation in children in tropical developing countries. Outcomes range from complete recovery through varying degrees of neurological disability which slowly resolve or remain permanent to death from either the acute illness or complications. Whilst bacterial meningitis accounts for a proportion of children affected, the aetiology in many remains unclear but includes malaria and probably viral encephalitis. Aim: To understand the aetiology, presentation and outcome of febrile encephalopathy in children in Papua New Guinea. Methods: Children aged between 1 month and 12 years presenting to Port Moresby General Hospital with febrile encephalopathy were studied prospectively. A detailed history and examination and the following laboratory investigations were undertaken as appropriate: cerebrospinal fluid (CSF) microscopy and bacterial culture, gram stain, measurement of protein and glucose and latex agglutination testing for Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitides; Ziehl—Neelsen staining and india ink examination on selected samples; IgM for Japanese encephalitis, dengue, rubella and measles; PCR testing and mycobacterial culture for Mycobacterium tuberculosis. Blood was tested for flavivirus, measles and rubella IgM and IgG. Results: 149 children were enrolled in the study. 129 had a lumbar puncture and CSF examination; 66 had a normal CSF white cell count. A clinical or laboratory-based diagnosis was possible for 140 children, but a definite pathogen was identifiable for only 55 (37%). The diagnoses included bacterial meningitis in 33 (S. pneumonia 16, H. influenza 13 and N. meningitides 4), tuberculous meningitis (5), probable tuberculous meningitis (18), malaria (10), cryptococcal meningitis (1), flavivirus encephalitis (5), rubella encephalitis (1), hepatic encephalopathy (1) and HIV encephalopathy (1). There were 28 cases of meningitis of unspecified aetiology. Of the five children with IgM-confirmed flavivirus encephalitis, one had dengue serotype 1 and two had Japanese encephalitis. Twenty-five children (including three of the five children with CSF flavivirus IgM) had serological IgG evidence of previous flavivirus infection. A history of multiple convulsions, the presence of neck stiffness and use of the Glasgow coma score (GCS) and TB score chart helped to identify children with bacterial meningitis and an adverse outcome and those with febrile convulsions. Conclusion: The study confirms the importance of S. pneumonia and H. influenza as major causes of febrile encephalopathy in children in Papua New Guinea. Flaviviruses including Japanese encephalitis are a cause of the febrile encephalopathy syndrome, as is Mycobacterium tuberculosis. All children with febrile encephalopathy should have their GCS and TB scores recorded and should be examined for neck stiffness, and a history of the frequency of convulsions should be recorded. These basic clinical data can help to discriminate aetiology, to guide treatment and monitoring and to identify the children at highest risk of adverse outcome.

Lumbar Puncture in Children from an Area of Malaria Endemicity Who Present with a Febrile Seizure

BACKGROUND Although routine lumbar puncture (LP) is often recommended as part of the assessment of fever-associated seizures in children, accumulating evidence questions its value and reveals a decrease in its frequency. Our primary hypothesis was that children who present with a single seizure but with no clinical signs of meningism or coma do not require LP as part of initial diagnostic assessment. METHODS We prospectively followed up 377 children aged 2 months through 10 years who presented with at least 1 fever-associated seizure to Modilon Hospital, Madang, Papua New Guinea, from November 2007 through July 2009. Clinical management was performed by hospital staff according to national pediatric guidelines. RESULTS Of 188 children with a single seizure and 189 children with multiple seizures, 139 (73.9%) and 154 (81.5%), respectively, underwent a LP as part of their initial assessment. Of the 130 children with a single seizure but no evidence of meningism (ie, neck stiffness, positive Kernigs or Brudzinskis sign, and bulging fontanelle) or coma (Blantyre Coma Score 2), none (95% confidence interval, 0%-3.6%) had proven or probable acute bacterial meningitis, and only 1 patient had viral encephalitis (subacute sclerosing panencephalitis). Eighty-one of these children (62.3%) had a final diagnosis of a simple febrile seizure. Proven or probable acute bacterial meningitis was more common in children with a single seizure and meningism or coma (10; 17.2%) and in those with multiple seizures without or with meningism or coma (2 [2.0%] and 30 [33.7%], respectively). CONCLUSIONS Initial LP is unnecessary when careful clinical assessment indicates features of a simple febrile seizure.

Male involvement in sexual and reproductive health in the Mendi district, Southern Highlands province of Papua New Guinea: a descriptive study

BackgroundLack of male involvement and support for sexual and reproductive health services is seen by many Papua New Guinean women as a barrier to accessing services. Poor utilization of services by both men and women is reflected in high maternal mortality and high rates of HIV/AIDS and sexually transmitted infections in the Southern Highlands Province. It is therefore important to understand the type of services provided, men’s perceptions of these services and the Health Sector’s capacity to involve men in its programs.MethodsInformation from interviews of married men, officers in charge of health facilities, and information from a focus group discussion with village leaders was collected to assess possible constraints to reproductive and sexual health care delivery.ResultsAlthough many men had heard about antenatal care, supervised births, family planning and sexually transmitted infections including, HIV/AIDS, many were unaware of their importance and of the types of services provided to address these issues. There was a very strong association between men’s literacy and their knowledge of Sexual and Reproductive Health (SRH) issues, their discussion of these issues with their wives and their wives’ utilisation of sexual and reproductive health services. Some men considered SRH services to be important but gave priority to social obligations. Although men made most decisions for sexual and reproductive issues, pregnancy, child birth and rearing of children were regarded as women’s responsibilities. Knowledge of HIV/AIDS appeared to have changed sexual behaviour in some men. Services for men in this rural setting were inadequate and service providers lacked the capacity to involve men in reproductive health issues.ConclusionPoor knowledge, socio-cultural factors and inadequate and inappropriate services for men hampered utilization of services and impaired support for their wives’ service utilization. Programmatic and policy initiatives should focus on improving service delivery to accommodate men in sexual and reproductive health.

Surgical programme at Royal Alexandra Hospital, Sydney, for Papua New Guinea children with congenital heart disease, 1978-1994.

Objective: To report the history of the Royal Alexandra Hospital for Children (RAHC) Papua New Guinea (PNG) cardiac surgical programme and describe the selection, preoperative clinical features and postoperative outcome of children with congenital heart disease managed by the programme.

Childhood malignant tumours in Papua New Guinea

Data from the Papua New Guinea Tumour Registry and the Central Pathology Department were reviewed in order to document the incidence and pattern of malignancies in children in Papua New Guinea. Altogether, 680 cases of histologically defined childhood malignancies were recorded during the 14.5 years from 1971 to 1985. The frequencies of the various tumours were compared with past data and with published data from other countries. The incidence of malignancies in Papua New Guinean children appeared to be low, 36.5/1,000,000/year, with a male:female ratio of 1.6:1. Lymphoma was the most commonly occurring tumour and Burkitts tumour accounted for 53% in this group. The relative frequency of leukaemia compared with lymphoma appeared to have increased since a previous report. A relatively high incidence of retinoblastoma (6.9%) and of other embryonal tumours (4.8%) was recorded, whilst the recorded incidences of tumours of the central nervous system (3.8%) and neuroblastoma (3.7%) were low. Ewings sarcoma accounted for almost half of the bone tumours, whilst Kaposis sarcoma was a relatively frequent soft tissue tumour. Differences and similarities between the Papua New Guinea data and those from other countries are discussed.

Predictors of Acute Bacterial Meningitis in Children from a Malaria-Endemic Area of Papua New Guinea

Predictors of acute bacterial meningitis (ABM) were assessed in 554 children in Papua New Guinea 0.2-10 years of age who were hospitalized with culture-proven meningitis, probable meningitis, or non-meningitic illness investigated by lumbar puncture. Forty-seven (8.5%) had proven meningitis and 36 (6.5%) had probable meningitis. Neck stiffness, Kernigs and Brudzinskis signs and, in children < 18 months of age, a bulging fontanel had positive likelihood ratios (LRs) ≥ 4.3 for proven/probable ABM. Multiple seizures and deep coma were less predictive (LR = 1.5-2.1). Single seizures and malaria parasitemia had low LRs (≤ 0.5). In logistic regression including clinical variables, Kernigs sign and deep coma were positively associated with ABM, and a single seizure was negatively associated (P ≤ 0.01). In models including microscopy, neck stiffness and deep coma were positively associated with ABM and parasitemia was negatively associated with ABM (P ≤ 0.04). In young children, a bulging fontanel added to the model (P < 0.001). Simple clinical features predict ABM in children in Papua New Guinea but malaria microscopy augments diagnostic precision.

Burkitt lymphoma in Papua New Guinea--40 years on.

Abstract Background: Burkitt lymphoma is common in tropical Africa and Papua New Guinea, where it has been reported to account for 16% of all childhood malignancies. Aim: This study aimed to compare the geographical distribution of recent cases and their anatomical site of presentation with findings from previous studies, and to determine survival using the current treatment protocol. Methods: The study included all cases of Burkitt and Burkitt-like lymphoma in children up to 14 years of age diagnosed between January 1998 and December 2003. Results: Thirty-six children were diagnosed with Burkitt lymphoma, accounting for 50% of all lymphomas and 13% of all childhood malignancies. The median age was 6 years (interquartile range 4–8 years) and the male:female ratio was 8:1. Facial structures were the most commonly affected sites, accounting for 21 (58%) cases, followed by spinal involvement in three. The majority (89%) of patients came from malaria-holo-endemic, coastal PNG and three were from the highland region. The national incidence was 1.7/100,000 but provincial rates varied, the highest of 13.4/100,000 being in Gulf province. Only two of the 16 patients who received chemotherapy were known to be in remission at 12 months. Conclusions: Burkitt tumour remains a common childhood malignancy in PNG. There is a need to improve diagnosis and reporting so that treatment can be started early. The most appropriate treatment regimen for use in PNG and other resource-poor countries remains to be determined.

Congenital heart disease in Papua New Guinean children

Summary The aim of the study was to analyse critically the programme for surgical management of children in Papua New Guinea (PNG) with congenital heart disease. A hospital record-based analysis was undertaken to document the pattern, management and short-term outcome of surgery in PNG children referred with a diagnosis of congenital heart disease to the Royal Alexandra Hospital for Children in Sydney, Australia. On admission, physical examination, chest radiogram, electrocardiogram, cross-sectional echocardiogram and, in most cases, cardiac catheterization were performed. Of the 170 children referred over the 17-year period, 1978–1994, 165 were confirmed to have congenital heart disease and were included in the study. Their ages ranged from 2 months to 16 years (median 5.5) and the male to female ratio was 1:1. One-sixth had delayed milestones and one-fifth long-term wasting. A large number were tachypnoeic, in heart failure or had pulmonary hypertension on admission. Ventricular septal defect, 34%, tetralogy of Fallot, 23%, and patent ductus arteriosus, 16.4%, were the predominant defects. Lesions such as aortic stenosis, coarctation of the aorta and transposition of the great arteries are under-represented. Altogether, 133 children (81%) had surgery; 75% were open- and 25% closed-heart operations. The complications were unremarkable and the mortality rate (6%) acceptable for the era. The programme was therefore very successful for a small proportion of children born in PNG with congenital heart disease.