An algorithm for the clinical differentiation of malaria and typhoid: a preliminary communication.

The objective of this study was to determine which clinical features of typhoid and malaria are most helpful in distinguishing the two diseases among Papua New Guinean highlanders. In a study of 35 patients with culture-positive typhoid and 49 with blood-slide-positive malaria (Group 1), the odds of typhoid were increased most in patients with altered bowel habit, an illness of more than 2 week's duration, tremor or the presence of typhoid facies. The odds of typhoid were lowest in patients with pallor or jaundice. These findings were used to derive a clinical diagnostic algorithm, which was then evaluated in a further group of 34 typhoid patients and 41 malaria patients (Group 2). The sensitivity of the algorithm in diagnosing malaria was 91% in Group 1 and 71% in Group 2, with specificities of 85% and 79% respectively. For typhoid, the sensitivity of the algorithm was 85% and 79% for Groups 1 and 2, respectively, and the specificities were 91% and 71%. We conclude that the algorithm merits further evaluation in a primary health care setting and may prove useful in making an earlier diagnosis of typhoid.

Clinical signs of pneumonia in children.

Clinical and chest radiographic findings were recorded prospectively in 185 children with cough who attended an outpatient clinic in Papua New Guinea. Children were studied if they were between 8 weeks and 6 years of age; patients with wheeze, stridor, measles, or pertussis were excluded. 56 children (30%) had radiological evidence of pneumonia. The presence of either a respiratory rate greater than or equal to 50/min or chest indrawing, or of both signs, was a good indication of pneumonia, with a predictive power of 46% for a positive test and 83% for a negative test. A more complex definition of tachypnoea, as a respiratory rate greater than or equal to 40/min in children over 12 months old and greater than or equal to 50/min in infants, showed little additional diagnostic benefit.

Reduction in the incidence of acute bronchitis by an oral Haemophilus influenzae vaccine in patients with chronic bronchitis in the highlands of Papua New Guinea.

Following the administration of a standardized questionnaire, 62 adult patients with chronic bronchitis were enrolled into a double-blind controlled trial of an oral killed Haemophilus influenzae vaccine in the highlands of Papua New Guinea. A 3-day course of vaccine or placebo was given monthly for 3 consecutive months. Participants were monitored weekly over 12 months for acute exacerbations; early morning sputum specimens were collected monthly and during acute exacerbations. Density of colonization by H. influenzae and H. parainfluenzae was determined by standard quantitative and semiquantitative techniques, and the latter method (quadrant score) was used to determine the density of growth of pneumococci. A total of 30 patients received vaccine and 32 placebo. The incidence rate of acute bronchitis in the vaccine group (0.011 episodes/person-weeks) was significantly lower than that in the placebo group (0.021 episodes/person-weeks), but there was no difference between the two groups in the incidence rates of more severe disease. Vaccine efficacy was maximal at times of peak incidence of disease. There was no evidence of a decline in vaccine efficacy for acute bronchitis over the 12-month follow-up period. The number of viable H. influenzae in the sputum declined in both vaccine and placebo groups over the 12-month follow-up period. The average concentration of H. influenzae in the vaccine group fell below that in the placebo group within 1 to 2 months after first immunization and remained so for 12 months, although the difference between the two groups narrowed during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships between growth and acute lower-respiratory infections in children aged less than 5 y in a highland population of Papua New Guinea.

One hundred fifty-six children in the highlands of Papua New Guinea aged less than 5 y, studied for a total of 7019 child-weeks, had an incidence of 1.3 episodes per child-year of acute lower-respiratory-tract infections (ALRIs). There was a marked age trend with an incidence of almost three times this average for children aged less than 6 mo. Those with low weight-for-age or low height-for-age had a higher ALRI incidence rate, with no evidence of cutoffs above which nutritional status had no effect; there was no association between low weight-for-height and increased risk of ALRI. A slow weight gain was not a significant risk factor in the short term but weight gain was reduced during episodes of ALRI.

A review of measles admissions and deaths in the paediatric ward of Goroka Base Hospital during 1989.

We reviewed all measles cases admitted to the paediatric ward of Goroka Base Hospital in 1989, and also interviewed a sample of measles patients attending the paediatric outpatient department. Measles accounted for 11% of all paediatric admissions and 32% of deaths. The case fatality rate for measles was 17%. Children with nosocomial infections and children with low birthweight were more likely to die. The most common complications of measles were pneumonia and diarrhoea, pneumonia being the most common cause of death. Twelve cases of subacute sclerosing panencephalitis were admitted during the year (0.5% of paediatric admissions). Measles was underreported because it was frequently omitted from the discharge diagnosis, the emphasis being placed on the complications. The majority of children with measles admitted to the ward and seen in outpatients had not been vaccinated. Nosocomial infections could have been reduced if all paediatric admissions aged 6-35 months had been vaccinated on admission. We strongly endorse the policy of vaccinating children in Papua New Guinea against measles from the age of 6 months.

PIP: The authors reviewed all measles cases admitted to the pediatric ward of Goroka Base Hospital in 1989, and also interviewed a sample of measles patients attending the pediatric outpatient department. Measles accounted for 11% of all pediatric admissions and 32% of deaths. The case fatality rate for measles was 17%. Children with nosocomial infections and those of low birthweight were more likely to die. The most common complications of measles were pneumonia and diarrhea, pneumonia being the most common cause of death. 12 cases of subacute sclerosing panencephalitis were admitted during the year (0.5% of pediatric admissions). Measles was underreported because it was frequently omitted from the discharge diagnosis, the emphasis being placed on complications. The majority of children with measles admitted to the ward and seen as outpatients had not been vaccinated. Nosocomial infections could have been reduced if all pediatric admissions ages 6-35 months had been vaccinated on admission. The authors strongly endorse the policy of vaccinating children in Papua New Guinea against measles from the age of 6 months.

Hydrocortisone in chloramphenicol-treated severe typhoid fever in Papua New Guinea.

We investigated the effect of hydrocortisone on mortality and complications in chloramphenicol-treated severe typhoid fever (STF) in Goroka, Papua New Guinea. Of 374 culture-positive patients, 146 formed a retrospective comparison group, of whom 41 had STF. Of 228 patients in the intervention group, 58 had STF. Patients without STF had low mortality (2.5%) with standard treatment. In the intervention group, hydrocortisone was used in two dosage schedules, 100 mg for 12 doses (23 patients) and 400 mg for 12 doses (23 patients). There was no difference in mortality between steroid-treated and comparison STF patients (44.8% versus 43.9%) or in complications, and we conclude that moderate doses of steroids are not beneficial in severe typhoid fever.

Bacterial colonization of the upper respiratory tract and its association with acute lower respiratory tract infections in Highland children of Papua New Guinea.

Acute lower respiratory tract infection (ALRI) is the major cause of death among children in Papua New Guinea. This longitudinal study reports the bacteriologic findings for children observed in their hamlets. A total of 1,449 nasal swab specimens from 158 children less than 5 years of age who were studied intensively for 18 months were examined. Non-serotypable strains of Haemophilus influenzae were isolated from 91% of specimens, and serotypable strains were isolated from 35% (8% H. influenzae type b) of specimens. All children had acquired Streptococcus pneumoniae by the age of 3 months. The most frequently occurring serotypes of S. pneumoniae were 6, 19, and 23. Children more frequently carried invasive pneumococci during an episode of ALRI than when they were healthy. Also, children more frequently carried serotypable strains of H. influenzae during the 2 weeks preceding an episode of ALRI than when they were healthy. Between-children analyses showed that children who were susceptible to attacks of ALRI and those who were not susceptible had similar rates of carriage of bacteria.

Viruses associated with acute lower respiratory tract infections in children from the eastern highlands of Papua New Guinea (1983-1985).

This study, conducted at Goroka Hospital from January 1983 to June 1985, examined the viruses identified in nasopharyngeal aspirates (NPA) and urines collected from 716 hospitalised children with moderate or severe pneumonia, in NPA from 170 children with mild pneumonia treated as outpatients and in NPA from a control group of 428 children attending the outpatient department of Goroka Hospital suffering from minor ailments other than upper or lower respiratory tract infections. One or more viruses were identified from 68%, 51% and 43% of children with moderate or severe pneumonia, mild pneumonia and the control group, respectively. One-third of viruses were identified in conjunction with another virus in both control and sick children. Viral identification rates were highest in children under 1 year of age. Cytomegalovirus, adenoviruses, respiratory syncytial virus (RSV), measles and rhinoviruses were the most frequently identified viruses. RSV was associated with mild as well as moderate and severe disease. No virus was associated with an increased risk of death. Annual epidemics of RSV occurred during the wet season. An epidemic of influenza A virus and also influenza B virus and 3 epidemics of parainfluenza 3 virus occurred during the study period. The high viral identification rates in this study suggest a high frequency of transmission associated with the social structure and environment of Papua New Guinean highland villages and high population mobility.

Hepatitis B surface antigen, e antigen and HBV DNA in healthy antenatal patients attending Goroka Hospital and their relationship to tattooing practices.

The prevalence of hepatitis B surface antigen (HBsAg) in women attending the antenatal clinic at Goroka Hospital was 14%. 32% of those positive for HBsAg also had hepatitis B e antigen (HBeAg), indicative of an infectious state. The mean HBV DNA level in HBeAg-positive women was 1800 pg/ml. These results suggest that vertical transmission of hepatitis B virus may be of importance in Papua New Guinea. Tattooing is common in this population: 91% of women in the study had tattoos. Methods employed in tattooing are a potential health risk but in a community which is now exposed to hepatitis B virus early in life tattooing practices are not important in the transmission of hepatitis B infection.

Clinical signs and risk factors associated with pneumonia in children admitted to Goroka Hospital, Papua New Guinea.

This study examined the clinical signs and symptoms in 897 children aged under 5 years presenting with pneumonia to Goroka Hospital in the highlands of Papua New Guinea between June 1982 and July 1985. The usefulness of the signs in predicting severity of disease was determined and risk factors for severe disease were identified. While cyanosis and poor feeding were the strongest predictors of death, bronchial breathing, grunting, and nasal flaring also significantly increased the risk of dying. First-born children, children under 1 year of age, females, malnourished children, and children with symptoms for more than 7 days were at increased risk of severe disease and of dying. Fever alone did not increase the risk of dying unless it was present for more than 7 days. These clinical signs of severity and risk factors may be used to improve the efficiency of health education programmes, for both health workers and mothers, aimed at reducing childhood mortality from pneumonia.

Blood pressure in four remote populations in the INTERSALT Study.

Four remote population samples (Yanomamo and Xingu Indians of Brazil and rural populations in Kenya and Papua New Guinea) had the lowest average blood pressures among all 52 populations studied in INTERSALT, an international cooperative investigation of electrolytes and blood pressure. Average systolic blood pressure was 103 versus 120 mm Hg in the remaining INTERSALT centers; diastolic blood pressure in these four population samples averaged 63 versus 74 mm Hg in the 48 other centers. There was little or no upward slope of blood pressure with age; hypertension was present in only 5% of the rural Kenyan sample and virtually absent in the other three centers. Also in marked contrast with the rest of the centers was level of daily salt intake, as estimated by 24-hour urinary sodium excretion. Median salt intake ranged from under 1 g to 3 g daily versus more than 9 g in the rest of INTERSALT populations. Average body weight was also low in these four centers, with no or low average alcohol intake, again unlike the other centers. The association within these four centers between the above variables and blood pressure was low, possibly reflecting their limited variability. While several other INTERSALT centers also had low average body weight or low prevalence of alcohol drinking, when this was accompanied by much higher salt intake (7-12 g salt or 120-210 mmol sodium daily), hypertension prevalence ranged from 8% to 19%. These findings confirm previous reports that in populations with a low salt intake, there is little or no hypertension or rise of blood pressure with age.(ABSTRACT TRUNCATED AT 250 WORDS)