Nakapi Tefuarani

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.

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.

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.

Papua New Guinea: real progress towards MDG 4 and real challenges

With a mortality rate in the under-5 s of 93 per 1000 live births reported in the 1996 Demographic and Health Survey (DHS), Papua New Guinea (PNG) was at the time one of only four countries with stalled progress in child survival, and seemed destined to fail its national Millennium Development Goal (MDG) 4 target. However, accurate estimates have shown reductions in under-5 and infant mortality rates of 19% and 17% respectively, over 10 years from 1996 to 2006. In that period PNG adopted an integrated and coordinated approach to child health that includes all the essential interventions outlined in the Lancets child survival series, under a framework consistent with the Western Pacific Regional Child Survival Strategy, associated with significant improvements in leadership and coordination of child health services by paediatricians at the provincial and national level. The reduction in child mortality since the mid-1990s is strong encouragement that such an approach can translate to real improvements. This paper outlines the recent advances in child health in PNG, identifying successful areas, and the challenges that lie ahead. There has been increased immunization coverage, introduction of vitamin A supplementation, bed-nets to prevent malaria, interventions to reduce mortality from acute respiratory infection, and improvements in the education of girls. These and improved leadership and coordination help to explain the recent significant gains in child survival.

The medium-to-long-term outcome of Papua New Guinean children after cardiac surgery

Abstract This study reports the medium-to-long-term outcome in Papua New Guinean (PNG) children selected to undergo cardiac surgery at the Royal Alexandra Hospital for Children in Sydney, Australia between 1978 and 1994. Follow-up ranged from 4 to 20 (median 11) years. The cohort comprised 125 children who had surgery and 31 who were initially selected in PNG for surgery but who on further investigation were found to be unsuitable. Through strenuous attempts, local health workers, the media and village and church leaders traced 122 (98%) of the operated and 29 (94%) of the non-operated children. One of the operated children and six of the non-operated children had died, giving respective survival rates among those traced of 99% and 79%. Altogether, 106 (88%) of the 121 operated and 20 (87%) of the 23 non-operated survivors were reviewed. Ninety-nine (93%) of the surgical patients were asymptomatic and all fulfilled the New York Heart Association criteria (NYHAC) class I or II. Mild pulmonary hypertension or residual defects of no haemodynamic significance were present in 47 (44%). In contrast, all 11 survivors from the 18 children originally classified as having inoperable lesions were symptomatic, all in NYHAC classes III or IV, six were on cardiac medication and four had been admitted at least once in the previous year. Ninety-two of 96 (96%) of the surgical group had a normal exercise test and 75 of 96 (78%) had normal chest X-rays. Thirty-nine of 99 had a normal electrocardiogram whilst the remainder had changes related to the underlying lesion and the surgery performed. This study shows that the PNG children who had cardiac surgery at RAHC between 1978 and 1994 had good medium-to-long-term survival.

Evaluation of an interferon-gamma release assay in children with suspected tuberculosis in Papua New Guinea.

There are few data from tuberculosis (TB) endemic settings of the performance and outcome predictors of the QuantiFERON-TB Gold in Tube assay (QFT) in children with suspected TB. A prospective cross-sectional study was conducted in Papua New Guinea children with suspected TB evaluated at Port Moresby General Hospital (Port Moresby, Papua New Guinea). Two hundred sixteen children were enrolled including 106 probable TB, 87 possible TB and 23 without TB. Concordance between QFT and tuberculin skin test results was 86% (P < 0.001, &kgr; = 0.70). QFT was significantly more likely to be positive than tuberculin skin test, overall and within the probable or possible TB categories, with no difference in prevalence of positivity between these 2 categories. The role of QFT in supporting the clinical diagnosis of TB in endemic settings, where resources are limited, remains uncertain especially as cost and technical requirements remain considerable.

Leukaemia in children in Papua New Guinea: an unusual pattern

Abstract We report data on 110 children aged <15 years diagnosed with leukaemia during two periods covering 13.25 years. The data sets were consistent. The reported incidence of leukaemia was low. Only 34 (31%) of the children were diagnosed with acute lymphoblastic leukaemia (ALL) compared with 54 (49%) children with acute myeloid leukaemia (AML). The overall mean (SD) age was 6.6 (3.5) years, 6.1 (3.5) for ALL and 6.9 (3.5) for AML. There was no evidence of an early childhood peak of ALL. The male : female ratio was 1.2 : 1 for all leukaemias, 1.3 for ALL and 1.25 for AML. Only eight (22%) of those diagnosed with ALL were classified as type L1. Our figures reflect a relative absence of the common (cALL) cell type in early childhood leukaemia and support the role of infection and its effect on the immune system in the aetiology of childhood leukaemia. Our data also revealed an unusually high proportion of chronic myeloid leukaemia (CML).

Evaluation of Xpert MTB/RIF assay in children with presumed pulmonary tuberculosis in Papua New Guinea.

Abstract Background: The Gene Xpert MTB/ RIF assay (Xpert) is used for rapid, simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin resistance. This study examined the accuracy of Xpert in children with suspected pulmonary tuberculosis (PTB). Methods: Children admitted to Port Moresby General Hospital with suspected PTB were prospectively enrolled between September 2014 and March 2015. They were classified into probable, possible and TB-unlikely groups. Sputum or gastric aspirates were tested by Xpert and smear microscopy; mycobacterial culture was undertaken on a subset. Children were diagnosed with TB on the basis of standard criteria which were used as the primary reference standard. Xpert, smear for acid-fast bacilli (AFB) and the Edwards TB score were compared with the primary reference standard. Results: A total of 93 children ≤14 years with suspected PTB were enrolled; 67 (72%) were classified as probable, 21 (22%) possible and 5 (5.4%) TB-unlikely. Eighty were treated for TB based on the primary reference standard. Xpert was positive in 26/93 (28%) MTB cases overall, including 22/67 (33%) with probable TB and 4/21 (19%) with possible TB. Three (13%) samples identified rifampicin resistance. Xpert confirmed more cases of TB than AFB smear (26 vs 13, p = 0.019). The sensitivity of Xpert, AFB smear and an Edwards TB score of ≥7 was 31% (25/80), 16% (13/80) and 90% (72/80), respectively, and the specificity was 92% (12/13), 100% (13/13) and 31% (4/13), respectively, when compared with the primary reference standard. Conclusion: Xpert sensitivity is sub-optimal and cannot be relied upon for diagnosing TB, although a positive result is confirmatory. A detailed history and examination, standardised clinical criteria, radiographs and available tests remain the most appropriate way of diagnosing TB in children in resource-limited countries. Xpert helps confirm PTB better than AFB smear, and identifies rifampicin resistance. Practical guidelines should be used to identify children who will benefit from an Xpert assay.