Clinical and laboratory features associated with mortality in children with severe malnutrition in Papua New Guinea.

Background: The World Health Organization has a clinical and syndromic approach to the management of severe acute malnutrition which recognises that laboratory investigations are often not possible where children with severe malnutrition present. In low- and middle-income countries including Papua New Guinea, rates of death from severe malnutrition in many hospitals remain 10% or more.Aim: To evaluate the clinical predictors of death and the association between disturbances of electrolytes and haematological investigations in children with severe malnutrition and the risk of mortality.Methods: The clinical and laboratory predictors of death in a prospective cohort of 150 children with severe malnutrition admitted to a provincial hospital in Papua New Guinea were analysed. The clinical signs and electrolytes, complete blood count and liver function tests at presentation and on Days 3 and 5 were recorded.Results: The strongest independent predictors of mortality at assessment on admission were a low child Glasgow coma scale (≤12), hypoxaemia (SpO2 <90%), prolonged capillary refill (>3 seconds) and dysnatraemia (<130 or >150 mmol/L). The area under the receiver operating characteristics curve for these four variables was 0.93.Conclusions: That three of these four criteria correspond closely to the WHO Emergency Clinical Signs reinforces the value of a system of triage and risk assessment in children with severe malnutrition. If a child has emergency signs they should be managed in an area on the ward where close monitoring and supportive care can be provided, the WHO guidelines for severe malnutrition followed, and other specific care provided. Measurements of serum sodium, particularly in children with diarrhoea and dehydration, is also important in risk assessment and management.

Immune response to measles vaccine in 6 month old infants in Papua New Guinea.

OBJECTIVE: To assess the efficacy of the current measles immunization schedule in Papua New Guinea, which is to give the first dose at 6 months of age and the second at 9 months. METHODS: Humoral immune response study of 140 Papua New Guinean infants at 6 months of age, measuring measles IgG antibodies by enzyme immunoassay before and 85 days after the 6-month dose of measles vaccine. RESULTS: After vaccination at 6 months, 35.7% of infants developed a level of measles antibodies consistent with protection (IgG >330 IU/ml); 17.7% had an antibody response (150-330 IU/ml) that is likely to afford some protection; 46.8% had no detectable antibody response (IgG <150 IU/ml). Among 53 infants with no antibody response, 37 (69.5%) developed an antibody response, while 42.4% (37/87) of those with maternal antibodies sero-converted (P = 0.002). CONCLUSIONS: Antibody response to measles vaccine was lower than expected at 6 months. While the presence of maternally derived antibodies accounted for some of the limited seroconversion in young infants, other factors are involved. Issues to be considered in determining the value of the first dose of measles vaccination in mid infancy in poor countries are complex and antibody responses are only one factor. Others, such as cell mediated immune responses, the non-specific protective effect of measles vaccine in preventing illness and death and the practicalities of uptake of vaccines at different ages, are also important.

Rubella control in Papua New Guinea: age-specific immunity informs strategies for introduction of rubella vaccine.

AIM: To determine the age specific immunity profile for rubella from three discrete study populations in Papua New Guinea, and to inform policy regarding the possible introduction of rubella vaccine. BACKGROUND: In 2005, the Western Pacific Region (WPR), of which Papua New Guinea (PNG) is a member state, declared the goal of regional measles elimination by 2012. Recently, WPR has incorporated an accelerated control goal for rubella and congenital rubella syndrome (CRS). PNG currently recommends two doses of measles vaccination at 6 and 9 months of age with a monovalent measles vaccine, which does not include rubella vaccine. METHODS: Convenience samples were collected from 1326 eligible participants in PNG and assessed for rubella immunity using the Dade Behring Enzygnost™ Anti-Rubella-Virus enzyme immunoassay. Nearly 34% were collected during an age stratified prospective survey of febrile patients in Madang Province; approximately 49% were collected from women of childbearing age in East Sepik and Milne Bay Provinces. Remaining specimens were collected from 6 to 7-month-old infants in Port Moresby prior to receiving the first dose of measles vaccine. FINDINGS: Of all samples tested, 65.2% (95% confidence interval (CI): 62.6-67.8) had evidence of immunity to rubella infection. Of women more than 15 years of age, 91.6% (95% CI: 89.4-93.5) were immune. The force of infection was highest between 5 and 19 years of age. CONCLUSIONS: Although a population-based sample was not used, our multi-centre study of the population immunity profile suggests that immunity against rubella is extremely high in most women of childbearing age, but women who become pregnant at an early age may be at high risk of rubella infection during pregnancy and potential delivery of an infant with CRS. Routine measles vaccine coverage, a proxy for measles-rubella vaccine coverage, as measured in recently published studies, is well below the WHO target of 80% coverage. Introduction of a child or infant dose of rubella vaccine requires caution and further study.

Management of meningitis in children with oral fluid restriction or intravenous fluid at maintenance volumes: a randomised trial.

A multi-centre randomised open trial was done to determine whether moderate oral fluid restriction or intravenous fluid at full maintenance volumes would result in a better outcome for children with bacterial meningitis in Papua New Guinea, and what clinical signs could guide fluid management. Children with clinical signs and cerebrospinal fluid suggestive of bacterial meningitis received either breast milk by nasogastric tube at 60% of normal maintenance volumes (n = 172) or intravenous half-normal saline and 5% dextrose at 100% of normal maintenance volumes (n = 174) for the 1st 48 hrs of treatment. An adverse outcome was death or severe neurological sequelae, and a good outcome was defined as intact survival or survival with at worst mild-to-moderate neurological sequelae. The probability of an adverse outcome was 24.7% in the intravenous group and 33.1% in the oral-restricted group, but the difference was not statistically significant (RR 0.75, 0.53-1.04, p = 0.08). Sunken eyes or reduced skin turgor at presentation were risk factors for an adverse outcome (OR 5.70, 95% CI 2.87-11.29) and were most strongly associated with adverse outcome in the fluid-restricted group. Eyelid oedema during treatment was also a risk factor for an adverse outcome (OR 2.54, 95% CI 1.36-4.75) and eyelid oedema was much more common in the intravenous group (26%) than in the restricted group (5%). For many children with bacterial meningitis in less developed countries, moderate fluid restriction is unnecessary and will be harmful; a normal state of hydration should be achieved but over-hydration should be avoided. Giving 100% of normal maintenance fluids, especially with intravenous hypotonic fluid, will lead to oedema in up to one quarter of children with bacterial meningitis. If additional intravenous fluids are required for children with meningitis, an isotonic solution should be used.