Evaluation of the Global Fund-supported National Malaria Control Program in Papua New Guinea, 2009-2014

@#The Global Fund to Fight AIDS, Tuberculosis and Malaria is the major funaer of the National Malaria Control Program in Papua New Guinea (PNG). One of the requirements of a Global Fund grant is the regular and accurate reporting of program outcomes and impact. Under-performance as well as failure to report can result in reduction or discontinuation of program funding. While national information systems should be in a position to provide accurate and comprehensive information for program evaluation, systems in developing countries are often insufficient. This paper describes the five-year plan for the evaluation of the Global Fund Round 8 malaria grant to PNG (2009-2014) developed by the Papua New Guinea Institute of Medical Research (PNGIMR). It builds on a complementary set of studies including national surveys and sentinel site surveillance for the assessment of program outcomes and impact. The PNGIMR evaluation plan is an integral part of the Global Fund grant. The evaluation program assesses intervention coverage (at individual, household and health facility levels), antimalarial drug efficacy, indicators of malaria transmission and morbidity (prevalence, incidence), and all-cause mortality. Operational research studies generate complementary information for improving the control program. Through the evaluation, PNGIMR provides scientific expertise to the PNG National Malaria Control Program and contributes to building local capacity in monitoring and evaluation. While a better integration of evaluation activities into routine systems would be desirable, it is unlikely that sufficient capacity for data analysis and reporting could be established at the National Department of Health (NDoH) within a short period of time. Long-term approaches should aim at strengthening the national health information system and building sufficient capacity at NDoH for routine analysis and reporting, while more complex scientific tasks can be supported by the PNGIMR as the de facto research arm of NDoH.

The proportion of fevers attributable to malaria varies significantly between sites in Papua New Guinea

@#Malaria is endemic across lowland Papua New Guinea (PNG) and case management has been based on symptomatic diagnosis and presumptive treatment of fever cases with an antimalarial. This study aimed to investigate the prevalence of malaria infection among fever cases presenting to 5 purposely selected sentinel health facilities in order to estimate the proportion of patients requiring antimalarial drugs. A total of 1807 fever patients were screened. Overall, 45% of fever patients had a positive malaria blood slide; 35% were infected with Plasmodium falciparum, 9% with P. vivax and 2% with P. malariae. Slide positivity was highest in Dreikikir (75%) and lowest in Wipim (2%). Among patients aged 1-4 years, 22% had moderate to severe anaemia (Hb < 8 g/dI) and 21% of children 2-9 years of age showed signs of splenomegaly (Hackett score 1-5). Comorbidity differed significantly between study sites and was not closely correlated with malaria infection. Clinical diagnosis by health facility staff was malaria for 67% of all fever cases, including 89% of slide-positive and 48% of slide-negative patients. 70% of rapid diagnostic test-negative cases were treated with an antimalarial. It is estimated that due to the lack of parasitological diagnosis the selected health facilities reported an excess of 18% (Dreikikir) to 98% (Wipim) malaria patients on average each month. In consideration of the significant differences in malaria-attributable fevers between study sites, the implementation of parasitological diagnosis in health facilities and administration of antimalarials only to test-positive patients has the potential to significantly improve the management of fever cases and reporting of malaria. A better tailoring to different settings may increase the effectiveness of malaria control interventions.

Isolation of Vibrio cholerae and other enteric microbiota from patients

When cholera was first detected in Papua New Guinea (PNG) in mid-2009, national diagnostic capacity faced many challenges. This was in part due to the non-endemic status of the outbreak, resulting in few local staff experienced in Vibrio cholerae detection and poor access to the required consumables. The PNG Institute of Medical Research conducted culture on specimens from suspected cholera patients in Madang Province, with presumptive V. cholerae isolates sent to Goroka for confirmation. Of 98 samples analysed 15 were culture positive, with V. cholerae detected by polymerase chain reaction (PCR) in an additional 3 samples. Further analyses were conducted to identify other pathogenic bacteria from thiosulphate citrate bile salt sucrose (TCBS) agar. Molecular-based assays detected enteropathogenic (n = 1) and enterotoxigenic (n = 1) strains of Escherichia coli. No other major enteric pathogens were detected. The low detection rate of V. cholerae at the provincial level reflects challenges in the laboratory diagnosis of cholera and in-country challenges in responding to an outbreak of a non-endemic disease, such as lack of in-country diagnostic expertise and available consumables in the early stages. It also suggests that full aetiological investigations are warranted in future outbreaks of acute watery diarrhoea in PNG to fully elucidate the potentially complex aetiology, which could in turn guide diagnostic, treatment and prevention measures.

Evaluation of a WASH intervention demonstrates the potential for improved hygiene practices in Hiri District, Central Province

Water, sanitation and hygiene (WASH) interventions aim to improve health outcomes through provision of safe water supplies and improved sanitation facilities, while also promoting better hygiene practices in communities. Population Services International introduced a WASH intervention project in the Hiri District, Central Province in May 2012. Shortly after its introduction we conducted a survey to determine the uptake of the intervention and gauge its impact. We invited 400 households to participate in the study, which consisted of a questionnaire for the head of the household. A total of 395 questionnaires were completed: 314 from households that had participated in the WASH intervention and 81 that had not (controls). Results demonstrated that improved water sources were not routinely used, with a high dependence on well and surface water. While self-reported handwashing was common, use of soap was not common. Treatment of water inside the house was common in the intervention group (95%), compared to 49% in the non-WASH group. The study indicates that people in the Hiri District are supportive of a WASH intervention, with good uptake of some aspects of the intervention. The sustainability of the intervention remains unknown. Targetted interventions focusing on community priorities might be beneficial in the future.

Evaluation of a rapid immunochromatographic assay for the detection of rotavirus, norovirus and adenovirus from children hospitalized with acute watery diarrhoea

We evaluated the IP-Triple I immunochromatographic rapid test for the detection of rotavirus, norovirus and adenovirus using stool samples from children with diarrhoea. The detection of norovirus and adenovirus was poor compared to polymerase chain reaction assays. However, high sensitivity (92%) and specificity (99%) were obtained for the detection of rotavirus.

Moresby food isn’t good: food security, nutritional information and adherence to antiretroviral therapy in Papua New Guinea

The relationship between HIV (human immunodeficiency virus), food security and nutrition has become increasingly important to practitioners, policy makers and people living with HIV. In this paper we describe for the first time the connection between HIV and antiretroviral therapies, the extent of nutritional counselling for HIV-positive people and food security in Papua New Guinea (PNG). A total of 374 HIV-positive people who were over the age of 16 and who had been on antiretroviral therapy (ART) for more than two weeks were recruited from six provinces, using a non-probability, convenience sampling methodology. A subsample of 36 participants also completed an in-depth qualitative interview. Participants received nutritional advice when beginning ART which focused on three main domains, of which the first two were the most frequently mentioned: what foods to avoid; what foods to eat; and how frequently to eat. 72% of the sample reported that they had experienced an increase in their appetite. Of those who reported that their appetite had increased on ART 33% reported that they did not have enough food to satisfy hunger. People who lived in the capital city, Port Moresby, within the Southern Region of PNG, had significantly more difficulty with food security than those who lived in other regions of the country. Not having enough food was the third most commonly recorded reason for non-adherence to ART. Responses to the HIV epidemic in Papua New Guinea must also begin to address the phenomenon of food insecurity for people with HIV, in particular those who are receiving antiretroviral therapies and who live in the urban areas.

A neonatal pneumococcal conjugate vaccine trial in Papua New guinea: study population, methods and operational challenges

Infants in Papua New Guinea (PNG) are at a high risk of invasive pneumococcal disease, and a substantial burden of this falls on children less than six months old. PNG is planning to introduce a pneumococcal conjugate vaccine for infants in the near future, but to make the maximum impact neonatal immunization will have to be considered. To provide evidence on safety and immunogenicity for neonatal and early infant immunization, we undertook an open randomized controlled trial of 7-valent pneumococcal conjugate vaccine (7vPCV). 318 children received 7vPCV at ages 0, 1 and 2 months or at 1, 2 and 3 months or not at all. All children received 23-valent pneumococcal polysaccharide vaccine at age 9 months. This was a large and complex trial: village reporters visited participants weekly during the first year and fortnightly for a further 6 months and nurses monitored self-reported morbidity and collected many thousands of biological samples. The study team was remarkably successful in achieving the study aims, with 18-month follow-up completed on 77% of enrolled children and over 80% of scheduled samples collected. While the results of the trial will be reported elsewhere, this paper discusses the design of the study and dissects out some of the main reasons for its successful completion. Strong community engagement was an essential factor in success and the principles of equitable partnership and service provision led to a strong research partnership. A two-stage consent process, comprising primary assent followed by later informed consent, led to a high drop-out before initial enrolment, but an outstanding retention of those enrolled in the study. We conclude that factors such as strong community participation, reciprocity and a good relationship between the study team and participants are just as important as the technical elements of laboratory testing and data handling in ensuring the success of a vaccine trial in PNG.