Associations of maternal iron deficiency with malaria infection in a cohort of pregnant Papua New Guinean women.

BACKGROUND: Iron deficiency (ID) is common in malaria-endemic settings. Intermittent preventative treatment of malaria in pregnancy (IPTp) and iron supplementation are core components of antenatal care in endemic regions to prevent adverse pregnancy outcomes. ID has been associated with reduced risk of malaria infection, and correspondingly, iron supplementation with increased risk of malaria infection, in some studies. METHODS: A secondary analysis was conducted amongst 1888 pregnant women enrolled in a malaria prevention trial in Papua New Guinea. Maternal ID was defined as inflammation-corrected plasma ferritin levels < 15 µg/L at antenatal enrolment. Malaria burden (Plasmodium falciparum, Plasmodium vivax) was determined by light microscopy, polymerase chain reaction, and placental histology. Multiple logistic and linear regression analyses explored the relationship of ID or ferritin levels with indicators of malaria infection. Models were fitted with interaction terms to assess for modification of iron-malaria relationships by gravidity or treatment arm. RESULTS: Two-thirds (n = 1226) and 13.7% (n = 258) of women had ID and peripheral parasitaemia, respectively, at antenatal enrolment (median gestational age: 22 weeks), and 18.7% (120/1,356) had evidence of malaria infection on placental histology. Overall, ID was associated with reduced odds of peripheral parasitaemia at enrolment (adjusted odds ratio [aOR] 0.50; 95% confidence interval [95% CI] 0.38, 0.66, P < 0.001); peripheral parasitaemia at delivery (aOR 0.68, 95% CI 0.46, 1.00; P = 0.050); and past placental infection (aOR 0.35, 95% CI 0.24, 0.50; P < 0.001). Corresponding increases in the odds of infection were observed with two-fold increases in ferritin levels. There was effect modification of iron-malaria relationships by gravidity. At delivery, ID was associated with reduced odds of peripheral parasitaemia amongst primigravid (AOR 0.44, 95% CI 0.25, 0.76; P = 0.003), but not multigravid women (AOR 1.12, 95% CI 0.61, 2.05; P = 0.720). A two-fold increase in ferritin associated with increased odds of placental blood infection (1.44, 95% CI 1.06, 1.96; P = 0.019) and active placental infection on histology amongst primigravid women only (1.24, 95% CI 1.00, 1.54; P = 0.052). CONCLUSIONS: Low maternal ferritin at first antenatal visit was associated with a lower risk of malaria infection during pregnancy, most notably in primigravid women. The mechanisms by which maternal iron stores influence susceptibility to infection with Plasmodium species require further investigation.

Living with thalassaemia in Papua New Guinea, the experience of children, adolescents and their families.

AIM: Thalassaemia, the commonest genetic blood disorder in Papua New Guinea (PNG) presents daunting challenges for the affected children, their parents and families, and the health system. We aimed to describe the quality of life of affected children and adolescents and the experience of and difficulties faced by their parents in the setting of a tertiary referral hospital in PNG. METHODS: A mixed-methods longitudinal study involving baseline questionnaire, then serial interviews with parents, children and adolescents living with ß-thalassaemia attending Port Moresby General Hospital. RESULTS: Twenty-one patients and their families were interviewed over a 6-month period. Most families originated outside the National Capital District and had migrated to be near the Port Moresby General Hospital and its blood bank services. Thirteen patients had at least one affected sibling and four families had experienced the death of at least one other affected child. No child was receiving chelating agents, and most had clinical evidence of iron overload. There were important impacts of thalassemia on quality of life, including very poor school attendance and some aspects of children's self-perception. Families faced significant burdens and made genuine sacrifices to care for their children. CONCLUSION: Regular blood transfusions increase the life-span of children with thalassaemia but there is a need to achieve a hyper-transfusion regimen coupled with chelation therapy. As for all chronic illness, a focused and holistic approach is needed to improve the quality of life for affected children and their families.

Estimating Child Mortality at the Sub-national Level in Papua New Guinea: Evidence From the Integrated Health and Demographic Surveillance System.

BACKGROUND: Child mortality is an important indication of an effective public health system. Data sources available for the estimation of child mortality in Papua New Guinea (PNG) are limited. OBJECTIVE: The objective of this study was to provide child mortality estimates at the sub-national level in PNG using new data from the integrated Health and Demographic Surveillance System (iHDSS). METHOD: Using direct estimation and indirect estimation methods, household vital statistics and maternal birth history data were analysed to estimate three key child health indicators: Under 5 Mortality Rate (U5MR), Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NMR) for the period 2014-2017. Differentials of estimates were evaluated by comparing the mean relative differences between the two methods. RESULTS: The direct estimations showed U5MR of 93, IMR of 51 and NMR of 34 per 1000 live births for all the sites in the period 2014-2017. The indirect estimations reported an U5MR of 105 and IMR of 67 per 1000 live births for all the sites in 2014. The mean relative differences in U5MR and IMR estimates between the two methods were 3 and 24 percentage points, respectively. U5MR estimates varied across the surveillance sites, with the highest level observed in Hela Province (136), and followed by Eastern Highlands (122), Madang (105), and Central (42). DISCUSSION: The indirect estimations showed higher estimates for U5MR and IMR than the direct estimations. The differentials between IMR estimates were larger than between U5MR estimates, implying the U5MR estimates are more reliable than IMR estimates. The variations in child mortality estimates between provinces highlight the impact of contextual factors on child mortality. The high U5MR estimates were likely associated with inequality in socioeconomic development, limited access to healthcare services, and a result of the measles outbreaks that occurred in the highlands region from 2014-2017. CONCLUSION: The iHDSS has provided reliable data for the direct and indirect estimations of child mortality at the sub-national level. This data source is complementary to the existing national data sources for monitoring and reporting child mortality in PNG.

Measuring unmet need for contraception among women in rural areas of Papua New Guinea.

Located in the South West Pacific region, with a population of 7.5 million, Papua New Guinea (PNG) is among a group of Pacific countries with sub-optimal health status. The maternal mortality ratio is 171 per 100,000 live births. Unmet need for contraception and family planning services, although poorly understood in PNG, may be one of the underlying causes of poor maternal health. This study set out to measure the prevalence and trends in unmet need for contraception and the identified socioeconomic factors associated with contraceptive use among women of reproductive age (15-49 years) in PNG. Data available from the Integrated Health and Demographic Surveillance System (IHDSS) were used in this study. A sub-population data set was extracted of 1434 women who gave birth in the preceding two years and resided in four rural surveillance sites: Asaro, Hides, Hiri and Karkar. Analyses of unmet need for contraception were performed with respect to birth spacing and limiting the number of births. Unmet need for contraception was 34% for the previous birth, 37% for the current pregnancy, and 49% for future family planning. The total unmet need for contraception was 35%, of which 49% was for spacing births and 51% for limiting births. Women's age, education and household wealth are the most significant determinants of unmet need for contraception. The high level of unmet need for contraception may contribute to women's poor health status in PNG. Urgent programming responses from the health sector for supporting effective interventions to increase availability and utilisation of contraceptives are required.

Occupational Health and Safety in the Palm Oil Industry: A Systematic Review.

BACKGROUND: The palm oil industry is the largest contributor to global production of oils and fats. Indonesia and Malaysia are the largest producers of palm oil. More than a million workers are employed in this industry, yet there is a lack of information on their occupational health and safety. OBJECTIVE: To identify and summarize occupational hazards among oil palm plantation workers. METHODS: A search was carried out in June 2018 in PubMed, Web of Science, Scopus, and Ovid. Relevant publications were identified by a systematic search of four databases and relevant journals. Publications were included if they examined occupational hazards in oil palm plantation workers. RESULTS: 941 publications were identified; of these, 25 studies were found eligible to be included in the final review. Of the 25 studies examined, 19 were conducted in Malaysia, 2 in Costa Rica, and one each in Ghana, Indonesia, Myanmar, Papua New Guinea, and Cameroon. Oil palm plantation workers were found to be at risk of musculoskeletal conditions, injuries, psychosocial disorders, and infectious diseases such as malaria and leptospirosis. In addition, they have potential exposure to paraquat and other pesticides. CONCLUSION: In light of the potential of palm oil for use as a biofuel, this is an industry with strong growth potential. The workers are exposed to various occupational hazards. Further research and interventions are necessary to improve the working conditions of this already vast and growing workforce.

Epilepsy in Papua New Guinea: a longitudinal cohort study.

Epilepsy affects up to 1-4% of children living in low income and middle countries, however there are few studies of the problems faced by children with epilepsy in such settings. We aimed to document the situation for children with epilepsy in Port Moresby, an urban area in Papua New Guinea, a low-middle income country in the Western Pacific region. We conducted longitudinal cohort study using mixed methods, with serial data collected over 2 years which assessed seizure control, neurodevelopment, and structured interviews with children and parents. For quantitative data descriptive statistics are reported; for qualitative data common responses, themes, experiences and perceptions were grouped and reported in narrative. Forty-seven children with epilepsy were followed for a median of 18 months. Twenty six (55%) children had some associated neurodevelopmental disability. Children gave detailed and vivid descriptions of their experience of seizures. Most children and parents had a positive view of the future but faced many challenges including financial difficulties, fear of having seizures especially at school, restriction of activity that isolated them from peers, and significant stigma and discrimination. Seizure control improved over time for some children, but inconsistent supply of phenobarbitone hindered better control. Comprehensive care for children with epilepsy requires a good knowledge of the individual patient -including their seizure type and comorbidities, their family, and their strengths and vulnerabilities. Children with epilepsy face many problems that can lead to isolation, discrimination and restricted opportunities.

Hemoglobin Levels and the Risk of Malaria in Papua New Guinean Infants: A Nested Cohort Study.

Studies are available that assess the risk of malaria in accordance to the body's iron store and the systematic iron supplementation of preschool children. However, only a few studies evaluated the temporal association between hemoglobin and malaria and their results are opposing. A total of 1,650 3-month-old Papua New Guinean infants were enrolled in this study and followed-up for 12 months. The risk of malaria was assessed in all children every 3 months and with each episode of fever. The incidence of clinical malaria between 3 and 15 months of age was 249 cases per 1,000 infants per year. After adjustment for potential confounding factors, a decrease of 1 g/dL of hemoglobin was associated with a nonsignificant increase of 11% for risk of malaria infection (hazard ratio, 1.11, 95% confidence interval; CI, 0.99-1.25, P = 0.076). Only children with severe anemia (hemoglobin < 8.0 g/dL) at baseline were at higher risk of malaria infection (hazard ratio, 1.72, 95% CI, 1.08-2.76, P = 0.023) during the follow-up year compared with the control group (Hemoglobin > 10.0 g/dL). This association was not statistically significant if only clinical malaria episodes were taken into account (hazard ratio, 1.42, 95% CI, 0.77-2.61, P = 0.26). Our study suggests that infants with lower hemoglobin levels are not protected against malaria infection. Further research that examines the risk of malaria in relation to both hemoglobin and iron store levels would be important to better understand this complex interaction.

Tropical ulcer plant treatments used by Papua New Guinea's Apsokok nomads.

ETHNOPHARMACOLOGICAL RELEVANCE: The tropical ulcer is a debilitating bacterial infection that is common in Papua New Guinea. Deploying healthcare infrastructure to remote and inaccessible rainforest locations is not practical, therefore local plants may be the best treatment option. Here we present an ethnobotanical survey of the tropical ulcer plant medicines used by the semi-nomadic Apsokok who roam the remote central mountains of Papua New Guinea's West New Britain Province. In vitro biological activity in assays relevant to tropical ulcer wound healing is also presented. MATERIALS AND METHODS: Focus groups and semi-structured interviews were used to acquire information on the uses of plants, vouchers of which were identified by comparison with authentic herbarium specimens. Antibacterial disc diffusion assays with Staphylococcus aureus and Fusobacterium ulcerans, MMP-9 enzyme inhibition and dermal fibroblast stimulation assays were carried out on plant saps and aqueous extracts of plant material. LC-MS was used to identify known plant metabolites. RESULTS: The ethnobotanical survey identified sixteen species that were used to treat tropical ulcers, all of which were applied topically. A subset of twelve species were investigated further in vitro. Four species produced zones of inhibition with S. aureus, all 12 species provided low level inhibition of MMP-9 and 8 species stimulated dermal fibroblast proliferation, although cytotoxicity occurred at higher concentrations. The extract of Homalium foetidum Benth. inhibited S. aureus and MMP-9 while at lower sub-cytotoxic concentrations stimulated fibroblast proliferation. Trans-3-O-p-coumaroylquinic acid cis-3-O-p-coumaroylquinic acid were detected in the aqueous extract of H. foetidum. CONCLUSIONS: Topical application of plant saps to wounds results in very high localised concentrations of plant metabolites which is likely to result in inhibition of MMP proteases. H. foetidum is a candidate plant for tropical ulcer treatment in remote areas.

The Burden of Drug-Resistant Tuberculosis in Papua New Guinea: Results of a Large Population-Based Survey.

BACKGROUND: Reliable estimates of the burden of multidrug-resistant tuberculosis (MDR-TB) are crucial for effective control and prevention of tuberculosis (TB). Papua New Guinea (PNG) is a high TB burden country with limited information on the magnitude of the MDR-TB problem. METHODS: A cross-sectional study was conducted in four PNG provinces: Madang, Morobe, National Capital District and Western Province. Patient sputum samples were tested for rifampicin resistance by the Xpert MTB/RIF assay and those showing the presence of resistance underwent phenotypic susceptibility testing to first- and second-line anti-TB drugs including streptomycin, isoniazid, rifampicin, ethambutol, pyrazinamide, ofloxacin, amikacin, kanamycin and capreomycin. RESULTS: Among 1,182 TB patients enrolled in the study, MDR-TB was detected in 20 new (2.7%; 95% confidence intervals [CI] 1.1-4.3%) and 24 previously treated (19.1%; 95%CI: 8.5-29.8%) TB cases. No case of extensively drug-resistant TB (XDR-TB) was detected. Thirty percent (6/20) of new and 33.3% (8/24) of previously treated cases with MDR-TB were detected in a single cluster in Western Province. CONCLUSION: In PNG the proportion of MDR-TB in new cases is slightly lower than the regional average of 4.4% (95%CI: 2.6-6.3%). A large proportion of MDR-TB cases were identified from a single hospital in Western Province, suggesting that the prevalence of MDR-TB across the country is heterogeneous. Future surveys should further explore this finding. The survey also helped strengthening the use of smear microscopy and Xpert MTB/RIF testing as diagnostic tools for TB in the country.

Improving paediatric and neonatal care in rural district hospitals in the highlands of Papua New Guinea: a quality improvement approach.

BACKGROUND: In developing countries such as Papua New Guinea (PNG), district hospitals play a vital role in clinical care, training health-care workers, implementing immunization and other public health programmes and providing necessary data on disease burdens and outcomes. Pneumonia and neonatal conditions are a major cause of child admission and death in hospitals throughout PNG. Oxygen therapy is an essential component of the management of pneumonia and neonatal conditions, but facilities for oxygen and care of the sick newborn are often inadequate, especially in district hospitals. Improving this area may be a vehicle for improving overall quality of care. METHOD: A qualitative study of five rural district hospitals in the highlands provinces of Papua New Guinea was undertaken. A structured survey instrument was used by a paediatrician and a biomedical technician to assess the quality of paediatric care, the case-mix and outcomes, resources for delivery of good-quality care for children with pneumonia and neonatal illnesses, existing oxygen systems and equipment, drugs and consumables, infection-control facilities and the reliability of the electricity supply to each hospital. A floor plan was drawn up for the installation of the oxygen concentrators and a plan for improving care of sick neonates, and a process of addressing other priorities was begun. RESULTS: In remote parts of PNG, many district hospitals are run by under-resourced non-government organizations. Most hospitals had general wards in which both adults and children were managed together. Paediatric case-loads ranged between 232 and 840 patients per year with overall case-fatality rates (CFR) of 3-6% and up to 15% among sick neonates. Pneumonia accounts for 28-37% of admissions with a CFR of up to 8%. There were no supervisory visits by paediatricians, and little or no continuing professional development of staff. Essential drugs were mostly available, but basic equipment for the care of sick neonates was often absent or incomplete. Infection control measures were inadequate in most hospitals. Cylinders were the major source of oxygen for the district hospitals, and logistical problems and large indirect costs meant that oxygen was under-utilized. There were multiple electricity interruptions, but hospitals had back-up generators to enable the use of oxygen concentrators. After 6 months in each of the five hospitals, high-dependency care areas were planned, oxygen concentrators installed, staff trained in their use, and a plan was set out for improving neonatal care. INTERPRETATION: If MGD-4 targets for child health are to be met, reducing neonatal mortality and deaths from pneumonia will have to include better quality services in district hospitals. Establishing better oxygen supplies with a systems approach can be a vehicle for addressing other areas of quality and safety in district hospitals.

Cross-sectional dietary deficiencies among a prison population in Papua New Guinea.

BACKGROUND: To investigate the dietary adequacy of prisoners of Beon Prison, Madang, Papua New Guinea in response to a report of possible nutritional deficiency. METHODS: We undertook an observational, cross-sectional study. All 254 male inmates (May 2010) were eligible to answer a validated interview-based questionnaire; to have a comprehensive dietary assessment; and to provide blood for biochemical analysis (α-tocopherol, ß-carotene, lutein, thiamin, riboflavin, niacin, folate, homocysteine, zinc, ferritin, and vitamins A, B12 and C). Prison guards were invited to participate as a comparison group. RESULTS: 148 male prisoners (58.3%) and 13 male prison guards participated. Prison rations consisted of white rice fortified with thiamin, niacin, and iron, tinned tuna, tinned corned beef, water crackers, and black tea, with occasional intakes of fruit and vegetables. Some prisoners received supplementary food from weekend visitors. From assessment of the prisoners dietary data, median intakes of calcium (137 mg), potassium (677 mg), magnesium (182 mg), riboflavin (0.308 mg), vitamin A (54.1 µg), vitamin E (1.68 mg), vitamin C (5.7 mg) and folate (76.4 µg) were found to be below estimated average requirements (EAR). CONCLUSIONS: The prisoners diets are likely lacking in several micronutrients and recommendations for dietary change have been made to the prison authorities. Ongoing vigilance is required in prisons to ensure the basic human right of access to a nutritionally adequate diet is being observed.

Optic neuropathy among a prison population in Papua New Guinea.

PURPOSE: To estimate the prevalence of optic neuropathy (ON) among prisoners in a provincial prison in Papua New Guinea, and to explore risk factors for this condition among this population. METHODS: Cross-sectional observation study of 148 male prisoners aged ≥18 years using an interview-based questionnaire, assessment of visual and nervous system function, ocular examination, and blood analysis (α-tocopherol, ß-carotene, lutein, folate, homocysteine, holotranscobalamin II, riboflavin, selenium, thiamin, and vitamins A, B(12) and C). Likelihood of the presence of ON was based on ordered groups determined by weighted combination of optic nerve head appearance and visual dysfunction (acuity, field, color perception). Main outcome measures were prevalence and associations of ON. RESULTS: Sample prevalence of clinical ON was 10.4% (95% confidence interval [CI], 6.2-16.8). No cases were found of unexplained non-visual nervous system dysfunction, including peripheral neuropathy. Increasing age (p = 0.001), length of current (p = 0.002) and lifetime (p = 0.03) incarceration, and duration of smoking by current smokers (p = 0.001) were associated with increased ON likelihood. However, when age-controlled, the smoking duration association was not maintained (p = 0.6). Prisoners were folate deficient. Adjusting for age and duration of current incarceration, whole blood (p = 0.02) and red blood cell (p = 0.04) folate concentrations were inversely associated with ON likelihood. No association was found for any other assessed demographic, lifestyle or biochemical measure. CONCLUSIONS: A cluster of ON associated with folate deficiency has been identified. Recommendations for dietary change and micronutrient supplementation have been made.

Severe anemia in Papua New Guinean children from a malaria-endemic area: a case-control etiologic study.

BACKGROUND: There are few detailed etiologic studies of severe anemia in children from malaria-endemic areas and none in those countries with holoendemic transmission of multiple Plasmodium species. METHODOLOGY/PRINCIPAL FINDINGS: We examined associates of severe anemia in 143 well-characterized Papua New Guinean (PNG) children aged 0.5-10 years with hemoglobin concentration <50 g/L (median [inter-quartile range] 39 [33]-[44] g/L) and 120 matched healthy children (113 [107-119] g/L) in a case-control cross-sectional study. A range of socio-demographic, behavioural, anthropometric, clinical and laboratory (including genetic) variables were incorporated in multivariate models with severe anemia as dependent variable. Consistent with a likely trophic effect of chloroquine or amodiaquine on parvovirus B19 (B19V) replication, B19V PCR/IgM positivity had the highest odds ratio (95% confidence interval) of 75.8 (15.4-526), followed by P. falciparum infection (19.4 (6.7-62.6)), vitamin A deficiency (13.5 (5.4-37.7)), body mass index-for-age z-score <2.0 (8.4 (2.7-27.0)) and incomplete vaccination (2.94 (1.3-7.2)). P. vivax infection was inversely associated (0.12 (0.02-0.47), reflecting early acquisition of immunity and/or a lack of reticulocytes for parasite invasion. After imputation of missing data, iron deficiency was a weak positive predictor (6.4% of population attributable risk). CONCLUSIONS/SIGNIFICANCE: These data show that severe anemia is multifactorial in PNG children, strongly associated with under-nutrition and certain common infections, and potentially preventable through vitamin A supplementation and improved nutrition, completion of vaccination schedules, and intermittent preventive antimalarial treatment using non-chloroquine/amodiaquine-based regimens.

Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting.

BACKGROUND: The acceptability of female-controlled biomedical prevention technologies has not been established in Papua New Guinea, the only country in the Pacific region experiencing a generalised, moderate-prevalence HIV epidemic. Socio-cultural factors likely to impact on future product uptake and effectiveness, such as women's ability to negotiate safer sexual choices, and intravaginal hygiene and menstrual practices (IVP), remain unclear in this setting. METHODS: A mixed-method qualitative study was conducted among women and men attending a sexual health clinic in Port Moresby. During in-depth interviews, participants used copies of a hand-drawn template to indicate how they wash/clean the vulva and/or vagina. Interviewers pre-filled commercially available vaginal applicators with 2-3mL KY Jelly® to create a surrogate vaginal microbicide product, which was demonstrated to study participants. RESULTS: A total of 28 IDIs were conducted (women=16; men=12). A diverse range of IVP were reported. The majority of women described washing the vulva only with soap and water as part of their daily routine; in preparation for sex; and following sexual intercourse. Several women described cleaning inside the vagina using fingers and soap at these same times. Others reported cleaning inside the vagina using a hose connected to a tap; using vaginal inserts, such as crushed garlic; customary menstrual 'steaming' practices; and the use of material fragments, cloth and newspaper to absorb menstrual blood. Unprotected sex during menstruation was common. The majority of both women and men said that they would use a vaginal microbicide gel for HIV/STI protection, should a safe and effective product become available. Microbicide use was considered most appropriate in 'high-risk' situations, such as sex with non-regular, transactional or commercial partners. Most women felt confident that they would be able to negotiate vaginal microbicide use with male sexual partners but if necessary would be prepared to use product covertly. CONCLUSIONS: Notional acceptability of a vaginal microbicide gel for HIV/STI prevention was high among both women and men. IVP were diverse in nature, socio-cultural dimensions and motivators. These factors are likely to impact on the future acceptability and uptake of vaginal microbicides and other biomedical HIV prevention technologies in this setting.

Experience in piloting HIV drug resistance early warning indicators to improve the antiretroviral program in Papua New Guinea.

In 2009, World Health Organization human immunodeficiency virus drug resistance early warning indicator monitoring was piloted at 2 large antiretroviral therapy (ART) clinics in Papua New Guinea: Heduru Clinic in Port Moresby and Tininga Clinic in Mount Hagen. Results demonstrated that both Heduru and Tininga clinics met internationally suggested targets for prescribing appropriate first-line ART regimens in accordance with national ART guidelines, retention on first-line ART at 12 months, and drug supply continuity. However, both clinics failed to achieve suggested targets for rates of loss to follow-up and on-time pill pickup. Reasons for poor clinic performance on loss to follow-up and on-time pill pickup were explored, and appropriate corrective actions were implemented.

Iron and infection: narrative review of a major iron supplementation study in Papua New Guinea undertaken by the Department of Tropical Paediatrics, Liverpool School of Tropical Medicine, 1979-1983, its aftermath and the continuing relevance of its results.

In 1978, I returned from a 2-year government posting as provincial paediatrician to East and West Sepik provinces of Papua New Guinea (PNG), having already enrolled on the Diploma of Tropical Medicine and Hygiene (DTM&H) course at the Liverpool School of Tropical Medicine. I had been too late to enrol for the more relevant Diploma in Tropical Paediatrics course, but, whilst on the DTM&H course, made up for lost time by presenting myself to Professor Ralph Hendrickse in his office. I outlined my proposal for a double-blind, controlled, randomised trial of iron intervention with the aim of improving iron nutrition and decreasing susceptibility to and morbidity from infections in a cohort of infants in PNG. My reason for suggesting such a study was the high rate of anaemia in infants there and my perception from the literature of the time that the balance of studies favoured a beneficial effect of iron supplementation on infectious susceptibility, and that iron deficiency was associated with reversible abnormalities of immune function (although it had and has since been difficult to demonstrate the severity and relevance of these in observational in-vivo studies in humans).1,2 Ralph made an on-the-spot decision, immediately offering me the opportunity to join his department on 1 January 1979 on temporary funding while I applied for (and secured) a major grant from the Wellcome Trust for this work.

Treatment with coartem (artemether-lumefantrine) in Papua New Guinea.

A recent drug efficacy trial reported Coartem (artemether-lumefantrine) to be highly effective against Plasmodium falciparum in children less than 5 years of age in Papua New Guinea (PNG). In contrast, we have observed high levels of treatment failures in non-trial conditions in a longitudinal cohort study in the same age group in PNG. Recrudescences were confirmed by genotyping of three different marker genes to provide optimal discrimination power between parasite clones. After excluding genetic host factors by genotyping potentially relevant cytochrome P450 loci, the high number of treatment failures in our study is best explained by poor adherence to complex dosing regimens in combination with insufficient fat supplementation, which are both crucial parameters for the outcome of Coartem treatment. In contrast to the situation in classic drug trials with ideal treatment conditions, our field survey highlights potential problems with unsupervised usage of Coartem in routine clinical practice and under program conditions.

Consumption of guava (Psidium guajava L) and noni (Morinda citrifolia L) may protect betel quid-chewing Papua New Guineans against diabetes.

Rapid increase in the incidence of type 2 diabetes (DM2) in Papua New Guinea, coupled with compelling epidemiological evidence supporting a diabetogenic association with betel quid (BQ) chewing has lead us to investigate dietary strategies that might offer protection from developing DM2. We investigated the dietary habits of Kalo residents from coastal Central Province who are avid BQ chewers yet have a relatively low incidence of DM2 compared to the ethnically similar and adjacent Wanigelans who abstain from BQ yet have an unusually high incidence of DM2. In Kalo, guava bud (Psidium guajava L) and noni (Morinda citrifolia L) were consumed much more frequently than in Wanigela, whereas the inverse was observed for mangrove bean (Bruguiera gymnorrhiza (L) Lam.). These plants, along with BQ and its component ingredients areca nut (Areca catechu L) and Piper betle L inflorescence, were assessed for their ability to mediate insulin-dependent and insulin-independent glucose transport in cultured 3T3-L1 adipocytes. A dose-dependent inhibition of glucose uptake from methanolic extracts of BQ, areca nut and P. betle inflorescence supports previous reports of prodiabetic activity. Conversely, guava bud extract displayed significant insulin-mimetic and potentiating activity. Noni fruit, noni leaf, commercial noni juice and mangrove bean all displayed insulin-like activity but had little or no effect on insulin action. Habitual intake of guava and noni is proposed to offer better protection against DM2 development and/or betel quid diabetogenicity than cooked mangrove bean. These findings provide empirical support that DM2 risk reduction can be accomplished using traditional foods and medicines.