Peter Poore

Clinical signs that predict death in children with severe pneumonia.

It is important to define clinical signs that can be used to identify children who have a high risk of dying from pneumonia so that these children can be given more intensive therapy. We prospectively studied 748 children in Papua New Guinea who had severe pneumonia, as defined by the World Health Organization. There was a very high mortality in children with a prolonged illness, severe roentgenogram changes, cyanosis, leukocytosis, hepatomegaly or inability to feed, and there was a trend toward a higher mortality in children with grunting or severe chest indrawing. Afebrile malnourished children had a particularly high mortality, but afebrile children had an increased mortality only if they were malnourished, and malnourished children had an increased mortality only if they were afebrile. Mortality was not increased in very young children or in children with tachypnea or tachycardia. The World Health Organization has suggested that most children with pneumonia in developing countries can be treated with penicillin but has recommended that children who are cyanotic or too sick to feed be treated with chloramphenicol because of their high risk of dying; our findings confirm that children who are cyanotic or too sick to feed have a very high risk of dying from pneumonia.

CHLORAMPHENICOL ALONE VERSUS CHLORAMPHENICOL PLUS PENICILLIN FOR SEVERE PNEUMONIA IN CHILDREN

748 children with severe pneumonia in three hospitals in Papua New Guinea were randomised to receive intramuscular injections of either chloramphenicol alone or chloramphenicol plus penicillin. Sequential analysis showed no difference between the two treatments. 48 (13%) of the 377 children in the chloramphenicol alone group died, and 3 (0.8%) were changed to different treatment. 62 (17%) of the 371 children in the chloramphenicol-plus-penicillin group died, and 6 (1.6%) were changed to different treatment. The difference in failure rates (death or withdrawal for change of treatment) was 4.8% +/- 5.2% (+/- 95% confidence limits). In children with severe pneumonia, treatment with chloramphenicol alone is as effective as treatment with chloramphenicol plus penicillin.

CHLORAMPHENICOL ALONE VERSUS CHLORAMPHENICOL PLUS PENICILLIN FOR BACTERIAL MENINGITIS IN CHILDREN

367 children with cerebrospinal-fluid findings suggestive of bacterial meningitis were randomised to receive either chloramphenicol alone by intramuscular injection, or chloramphenicol plus penicillin by intravenous injection. Sequential analysis showed no difference in mortality between the two treatments. 48 (26%) of the 183 children in the chloramphenicol alone group died, and 49 (27%) of the 184 children in the chloramphenicol plus penicillin group died. In children with bacterial meningitis chloramphenicol alone given by intramuscular injection is as effective as chloramphenicol plus penicillin given intravenously.

Vaccination strategies in developing countries

By 1990 it is hoped that all of the worlds infants will have access to immunization services and that these services will then continue indefinitely. The link between people and health services, including immunization, can only be forged and maintained by an effective system of delivery and support to all health workers. A careful choice of strategies for this delivery system and an understanding of local cultural attitudes and behaviour is vital if this link is to be effective. Health workers will have to be trained and then supported in the field by regular contact with their supervisors. They will also need continuous, reliable, predictable and adequate supplies of equipment, drugs, vaccines, fuel and money, including salaries. Immunization is cost effective as a health intervention, but an effective programme of immunization can contribute much more than just vaccines, if it is developed in the context of primary health care (PHC) as originally proposed in 1978 at the conference in Alma Ata.

The policy of the Save the Children Fund UK.

The choices available to people deciding on family size are determined by cultural, economic and social considerations. Before any realistic and acceptable action can be advised, which might influence family size and population growth, it is necessary to understand the balance between resource availability and consumption, access to contraceptive technology, and the social and cultural influences under which people live. Any intervention should seek to increase the range of choices available to people and to create the conditions which enable them to afford those choices. It is in the poorer parts of the world that population growth is greatest and choices are most limited. Inequitable resource distribution globally is at the root of high population growth rates in poorer areas. Excessive consumption patterns in the industrialized countries pose as great a threat to the development of a sustainable global environment as do the high growth rates in the developing countries. There is no technological short cut to limiting population growth. For any service, including family spacing, to have a significant impact over a long period of time, it must be delivered through a secure, reliable and effective system to families who fully understand the benefits and the implications, and whose choice is informed and made freely.

Availability of quality vaccines: policies of a non-government organization

The availability of vaccines, or any other health service, depends upon, first, the existence of a reliable system of delivery, and the effective management of this system to reach the target population and, second, the acceptance by parents or guardians of the value of the vaccine in preventing death and disability in young children and their mothers. This system must be fully funded and resourced for the foreseeable future if the service is to be sustainable. Today the major obstacles to effective immunization of young children in developing countries is the inadequate, insecure and unpredictable availability of funds and their management. Unless these problems are addressed and solved, the immunization targets set by the World Health Assembly (WHA) will not be met.

Distance teaching using self-marking multiple choice questions.

In Papua New Guinea health extension officers receive a 3-year course of training in college, followed by a period of in-service training in hospital. They are then posted to a health center, where they are in charge of all health services within their district. While the health extension officers received an excellent basic training, and were provided with books and appropriate, locally produced texts, they often spent months or even years after graduation in remote rural health centers with little communication from colleagues. This paper describes an attempt to improve communication, and to provide support inexpensively by post. Multiple choice questions, with a system for self-marking, were sent by post to rural health workers. Multiple choice questions are used in the education system in Papua New Guinea, and all health extension officers are familiar with the technique. The most obvious and immediate result was the great enthusiasm shown by the majority of health staff involved. In this way a useful exchange of correspondence was established. With this exchange of information and recognition of each others problems, the quality of patient care must improve.