Child health nursing in the Solomon Islands: A qualitative evaluation of the impact of the 'Bachelor of nursing - Child health'.

AIM: To explore graduates' perceptions of the impact on nursing practice of a new postgraduate course in child health, developed and implemented in the Solomon Islands in 2016. BACKGROUND: The Bachelor of Nursing - Child Health was implemented in 2016 to develop nurses' knowledge and skills in child health and paediatric care with the intent to improve national child health outcomes. DESIGN: A qualitative exploratory, descriptive design was used to evaluate the impact of the Bachelor of Nursing - Child Health on graduates' nursing practice. METHODS: Fourteen nurses who graduated from the first cohort of students enrolled in the child health course were purposively selected to participate. Participants engaged in individual semi-structured interviews, conducted between August and December 2018. A thematic analysis was undertaken following Braun and Clarke's six-phase process. RESULTS: Findings from the study demonstrate positive impacts of the course on graduates' nursing practice. These include a perceived enhanced quality of care through their commitment to evidence-based practice, the ability to contribute to capacity building of colleagues, the reinforcement of provincial public health programmes and expanded participation in managerial activities. Following graduation, most alumni took on senior roles and greater responsibilities, felt more confident in managing unwell children, felt there was better access to and quality of child health care at the community and broader country levels and felt recognised by colleagues and communities. Some graduates faced resistance from colleagues to change practice and felt that despite being given greater responsibilities, nursing levels and salaries remained unchanged. This reflected a potential lack of recognition from hospital or provincial managers, the Nursing Council as the regulatory body for the nursing profession, and the Ministry of Health and Medical Services. A lack of human and material resources also impacted quality of care. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Findings from this study underline the need for the Solomon Islands National University, the Nursing Council, the Public Service and the Ministry of Health and Medical Services to concord and delineate formal accreditation standards for child health nurses. Overall, collaborative efforts and commitments at local, regional and global levels are required to support child health nurses in their ability and ambition to improve national child health outcomes. CONCLUSIONS: Findings from this study demonstrate positive impacts of the course on graduates' nursing practice. The impact of increasing nurses' knowledge and skills on national child health outcomes could be significant. Ongoing implementation and recognition of this course in the Solomon Islands, as well as more broadly across the Pacific region, are recommended.

The utility of procalcitonin in the prediction of serious bacterial infection in a tertiary paediatric intensive care unit.

To determine utility of procalcitonin (PCT) for the prediction of bacterial infection in critically ill children, we analysed the relationship between serum PCT, cultures and other laboratory markers of bacterial sepsis or viral infection in a tertiary paediatric intensive care unit (PICU). The outcome measures were levels of PCT in proven bacteraemia, pneumonia and viral respiratory infection; and comparison of PCT to immature to total neutrophil ratio (ITR) in prediction of bacteraemia. In 420 children with suspected sepsis, 1,226 serum PCT levels were analysed. Children with bacteraemia had a higher median PCT (2.03 ng/ml, interquartile range [IQR] 0.67-42.4) than those who did not have bacteraemia (0.82 ng/ml, IQR 0.295-2.87) (P=0.033). PCT was a significant but only moderate predictor of bacteraemia (AUC 0.65). In 866 episodes of suspected sepsis where paired PCT and ITR were performed, the median ITR in children with bacteraemia was 0.19 ng/ml (IQR 0.04-0.35), and the median PCT was 6.5 ng/ml (IQR 0.71-61.8). PCT was a marginally better predictor of bacteraemia (AUC 0.69) than the ITR (AUC 0.66). In children with viral respiratory tract infection only, the median PCT was 1.26 ng/ml (0.35-5.5), and in those with likely bacterial pneumonia the median PCT was 0.80 ng/ml (IQR 0.28-1.70). In a heterogeneous population of children in a tertiary PICU, PCT measured at a single timepoint was a moderate predictor of proven bacteraemia. In our population PCT did not reliably identify localised bacterial infection or distinguish bacterial from viral respiratory infection.

A mixed-methods evaluation of adherence to preventive treatment among child tuberculosis contacts in Indonesia.

BACKGROUND: Tuberculosis (TB) can be prevented using isoniazid preventive therapy (IPT) among child contacts. However, the benefits of IPT depend on adherence to at least 6 months of daily treatment. A greater understanding of the barriers to and facilitators of adherence to IPT in resource-poor settings is required to optimise the benefits. METHODS: We prospectively evaluated adherence to IPT and its associated factors among child contacts (age 0-5 years) eligible for IPT. We undertook in-depth interviews with care givers and a focus group discussion with health care workers, which were thematically analysed to explore barriers to and facilitators of adherence from the perspective of both care givers and health workers. RESULTS: Of 99 eligible children, 49 (49.5%) did not complete 6 months of IPT. Children whose care giver collected their IPT medications from primary health centres were more likely to have incomplete adherence than those who collected them from hospitals (aOR 2.9, 95%CI 1.1-7.8). Thematic analyses revealed major barriers to and facilitators of adherence: regimen-related, care giver-related and health care-related factors, social support and access. Many of these factors are readily modifiable. CONCLUSION: Providing information about IPT and improving accessibility for care givers to receive IPT at the primary health care facility should be priorities to facilitate implementation.

Oxygen for children and newborns in non-tertiary hospitals in South-west Nigeria: A needs assessment.

BACKGROUND: Oxygen is important for the treatment of hypoxaemia associated with pneumonia, malaria, and other medical, obstetric, and surgical conditions. Access to oxygen therapy is limited in many of the high mortality settings where it would be of most benefit. METHODS: A needs assessment of 12 non-tertiary hospitals in south-west Nigeria, assessing structural, technical and clinical barriers to the provision of safe and effective oxygen therapy. RESULTS: Oxygen supply was reported to be a major challenge by hospital directors. All hospitals had some access to oxygen cylinders, which were expensive and frequently ran out. Nine (75%) hospitals used oxygen concentrators, which were limited by inadequate power supply and lack of maintenance capacity. Appropriate oxygen delivery and monitoring devices (nasal prongs, catheters, pulse oximeters) were poorly available, and no hospitals had clinical guidelines pertaining to the use of -oxygen for children. Oxygen was expensive to patients (median US$20/day) and to hospitals. Estimated oxygen demand is reported using both a constant mean-based estimate and adjustment for seasonal and other variability. CONCLUSIONS: Making oxygen available to sick children and neonates in Nigerian hospitals will require: improving detection of hypoxaemia through routine use of pulse oximetry; improving access to oxygen through equipment, training, and maintenance structures; and commitment to building hospital and state structures that can sustain and expand oxygen initiatives.

An evaluation of chest X-ray in the context of community-based screening of child tuberculosis contacts.

BACKGROUND: There are no published data on the critical review of chest X-ray (CXR) findings of children in the context of community-based contact screening. OBJECTIVES: To describe the quality, findings and inter-observer agreement of CXRs in child TB contacts in Indonesia. METHODS: We performed antero-posterior (AP) and lateral CXR in children who had had close contact with a pulmonary TB case. The CXRs were interpreted independently by four reviewers. RESULTS: A total of 530 CXRs of 265 children were reviewed. Most (63%) of the children were asymptomatic at the time of CXR. Only 60% of the CXRs were reported as moderate to good quality by all reviewers, and inter-observer agreement on quality was slight to moderate (weighted κ = 0.16-0.35) for AP view. The majority of the CXRs were reported as normal (range 65-77%), with fair to moderate inter-observer agreement (κ = 0.25-0.46). Hilar lymphadenopathy (6-16%) was the most common CXR abnormality reported with poor inter-observer agreement (κ = -0.03 to 0.25). CONCLUSION: The CXRs of child TB contacts investigated in the community were characterised by low quality, low agreement and low yield. Our findings support guidelines that CXR is not routinely indicated in asymptomatic child TB contacts in this setting.

Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature.

BACKGROUND: Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries. METHODS: High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed. RESULTS: 6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified. CONCLUSION: Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.

Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan.

This study explored the perceived value, role and reported use of clinical guidelines by clinicians in urban paediatric and maternity hospital settings, and the effect of current implementation strategies on clinician attitudes, knowledge and behaviour. A total of 63 clinicians from 7 paediatric and maternity hospitals in Kabul, Afghanistan participated in structured focus groups; content analysis methodology was used for identification and analysis of key themes. Seven sets of guidelines, protocols or standards were identified (including 5 WHO-endorsed guidelines). However, most are failing to achieve high levels of use. Factors associated with guideline use included: clinician involvement in guideline development; multidisciplinary training; demonstrable results; and positive clinician perceptions regarding guideline quality and contextual appropriateness. Implementation activities should fulfil 3 major objectives: promote guideline awareness and access; stimulate motivation among clinical guideline users; and actively facilitate adherence to guidelines.

A simple probabilistic model of submicroscopic diatom morphogenesis.

Unicellular algae called diatoms morph biomineral compounds into tough exoskeletons via complex intracellular processes about which there is much to be learned. These exoskeletons feature a rich variety of structures from submicroscale to milliscale, many that have not been reproduced in vitro. In order to help understand this complex miniature morphogenesis, here we introduce and analyse a simple model of biomineral kinetics, focusing on the exoskeleton's submicroscopic patterned planar structures called pore occlusions. The model reproduces most features of these pore occlusions by retuning just one parameter, thereby indicating what physio-biochemical mechanisms could sufficiently explain morphogenesis at the submicroscopic scale: it is sufficient to identify a mechanism of lateral negative feedback on the biomineral reaction kinetics. The model is nonlinear and stochastic; it is an extended version of the threshold voter model. Its mean-field equation provides a simple and, as far as the authors are aware, new way of mapping out the spatial patterns produced by lateral inhibition and variants thereof.

Clinical management of diarrhoea in children

Diarrhoea is one of the commonest reasons children require health care in Papua New Guinea (PNG). Acute watery diarrhoea is the commonest form, and is due to viruses. Oral rehydration solution, zinc and continued breastfeeding are highly effective treatments that can be delivered in homes and health facilities. Antibiotics are not useful in acute watery diarrhoea--they make it worse. Deaths from acute watery diarrhoea should be rare if basic curative services are available. Persistent diarrhoea (lasting longer than 14 days) is commonly associated with other co-morbidities, including malnutrition, anaemia, HIV (human immunodeficiency virus) infection, parasite (such as Giardia) or worm infections and environmental enteropathy. Educating parents on handwashing, food preparation, water purification, improvements in sanitation and the home environment, breastfeeding, nutrition and immunization are essential in preventing diarrhoea. Cholera appeared in PNG in 2009, causing over 500 deaths in all age groups. Cholera emerged because of limited access to safe, clean drinking water and poor sanitation. Addressing these will have beneficial effects not only on cholera but also on all causes of diarrhoea and many other common childhood infections.

Pigbel in the 21st century: still here, and still in need of an effective surveillance system

Pigbel remains a likely significant cause of morbidity and mortality in the highlands of Papua New Guinea (PNG), two decades after the administration of pigbel vaccination ceased. There is a need for an effective surveillance program for pigbel to better understand the disease burden and to target communities for preventive strategies. This paper reviews the epidemiology, pathogenesis, recent history and current data on the burden of pigbel in PNG. We propose a surveillance program based on clinical recognition of likely cases and laboratory confirmation using an ELISA assay for Clostridium perfringens type C beta-toxin. Research aimed at validating this approach in the clinical setting is outlined.

Co-morbidity: exploring the clinical overlap between pneumonia and diarrhoea in a hospital in Dhaka, Bangladesh.

BACKGROUND: There is limited information on risk factors for pneumonia and pneumonia-related deaths in children who also have diarrhoea. AIM: To identify risk factors for the above in order to improve strategies for case management and to develop appropriate public health messages. METHODS: All children under 5 years of age admitted to the Special Care Ward, Dhaka Hospital of the International Centre for Diarrhoeal Disease Research (ICDDR,B) from 1 September to 31 December 2007 were considered for enrollment if they also had diarrhoea. Of the 258 children with diarrhoea enrolled, those with (n=198) or without (n=60) WHO-defined pneumonia constituted the pneumonia and comparison groups, respectively. Among the 198 children with pneumonia, children who survived (n=174) were compared with those who died in hospital (n=24). RESULTS: After adjusting for socio-demographic factors, including low levels of literacy of either parent, low household income, not having a window or exhaust fan in the kitchen, household smoking and over-crowding, children with pneumonia were more likely to sleep on a bare wooden-slatted or bamboo bed (OR 2·7, 95% CI 1·40-5·21, p = 0·003) than on other bedding, and were also more likely to have a parent/care-giver with poor knowledge of pneumonia (OR 1·94, 95% CI 1·02-3·70, p=0·043). Independent risk factors for death include severe underweight (OR 5·2, 95% CI 1·2-22·0, p=0·03), hypoxaemia (OR 17·5, 95% CI I 1·9-160·0, p=0·01), severe sepsis (OR 8·7, 95% CI I 1·8-41·5, p=0·007) and lobar consolidation (OR 11·9, 95% CI 2·3-61·6, p=0·003). CONCLUSIONS: Increased public awareness of signs of pneumonia and severe sepsis in children under 5 is important to mitigate the risks of pneumonia and pneumonia-related deaths, and the importance of appropriate bedding for young children in reducing the risk of pneumonia needs to be addressed.

The functioning of oxygen concentrators in resource-limited settings: a situation assessment in two countries.

SETTING: The paediatric wards of hospitals in Malawi and Mongolia. OBJECTIVE: To describe oxygen concentrator functioning in two countries with widespread, long-term use of concentrators as a primary source of oxygen for treating children. DESIGN: A systematic assessment of concentrators in the paediatric wards of 15 hospitals in Malawi and nine hospitals in Mongolia. RESULTS: Oxygen concentrators had been installed for a median of 48 months (interquartile range [IQR] 6-60) and 36 months (IQR 12-96), respectively, prior to the evaluation in Malawi and Mongolia. Concentrators were the primary source of oxygen. Three quarters of the concentrators assessed in Malawi (28/36) and half those assessed in Mongolia (13/25) were functional. Concentrators were found to remain functional with up to 30 000 h of use. However, several concentrators were functioning very poorly despite limited use. Concentrators from a number of different manufacturers were evaluated, and there was marked variation in performance between brands. Inadequate resources for maintenance were reported in both countries. CONCLUSION: Years after installation of oxygen concentrators, many machines were still functioning, indicating that widespread use can be sustained in resource-limited settings. However, concentrator performance varied substantially. Procurement of high-quality and appropriate equipment is critical, and resources should be made available for ongoing maintenance.

Maternal antibodies to rotavirus: could they interfere with live rotavirus vaccines in developing countries?

INTRODUCTION: Past experience with live oral vaccines including licensed rotavirus vaccines demonstrates a trend towards reduced vaccine efficacy in developing countries compared with developed countries. The reasons behind this disparity are not well understood. Transplacental transfer of maternal antibodies and breast milk ingestion may attenuate vaccine responses in infants in developing countries where rotavirus infections are endemic, and maternal antibody levels are high. We examined the prevalence and level of rotavirus antibody in maternal and cord serum, colostrum and breast milk in a developing country setting. METHODS: 100 mother-infant pairs were prospectively recruited from December 2008 to February 2009 at Dr. Sardjito Hospital, Yogyakarta, Indonesia. Maternal and cord sera were collected during delivery. Colostrum and transitional breast milk were collected between day 0-3 and day 7-10 postpartum respectively. Rotavirus-specific IgA and IgG were estimated for all specimens and virus neutralization assays were conducted on a subset of milk specimens. RESULTS: All maternal and cord serum samples were positive for rotavirus-specific IgG antibodies with a strong correlation between levels of rotavirus-specific IgG in mothers and levels transferred to infants in cord blood (r=0.86; p=0.001). 78% of colostrum and 67% of transitional breast milk specimens were positive for rotavirus-specific IgA. There was a median 4-fold decrease in rotavirus-specific IgA from colostrum to transitional breast milk. Neutralizing antibodies were present in 56% of colostrum specimens assayed (19/34) and in 41% of transitional milk specimens assayed (14/34). CONCLUSIONS: Maternal serum and breast milk antibodies to rotavirus are highly prevalent in a developing country setting. Evaluation of the impact of maternal anti-rotavirus serum and breast milk antibody upon vaccine immunogenicity would help to inform rotavirus vaccination strategies, especially in developing settings.

Influences of dehydration on clinical features of radiological pneumonia in children attending an urban diarrhoea treatment centre in Bangladesh.

BACKGROUND: As the signs of dehydration often overlap with those of pneumonia, it may be difficult for health workers in resource-poor settings to make a clinical diagnosis of pneumonia in children with dehydration. This issue has received very little attention. AIM: To compare the clinical features of pneumonia in children with and without dehydration caused by diarrhoea. METHODS: All children aged 2-59 months with diarrhoea and radiologically confirmed pneumonia admitted to the Special Care Ward (SCW) of Dhaka Hospital, ICDDR,B between September and December 2007 were enrolled for the study. Children with dehydration (67 cases) and those without (101 controls) were compared. RESULTS: Cases presented less frequently with fast breathing (60% vs 88%, p<0.001) and lower chest-wall indrawing (67% vs 82%, p=0.035) than did controls. In logistic regression analysis, cases more often had severe malnutrition (OR 2.31, CI 1.06-5.02, p=0.035) and cyanosis (OR 19.05, CI 1.94-186.68, p=0.011) and were abnormally sleepy (OR 372, CI 1.71-8.08, p=0.001). CONCLUSIONS: Fast breathing and lower chest-wall indrawing may be less reliable for the diagnosis of pneumonia in children with dehydration, especially when there is severe malnutrition.

Oxygen is an essential medicine: a call for international action.

Hypoxaemia is commonly associated with mortality in developing countries, yet feasible and cost-effective ways to address hypoxaemia receive little or no attention in current global health strategies. Oxygen treatment has been used in medicine for almost 100 years, but in developing countries most seriously ill newborns, children and adults do not have access to oxygen or the simple test that can detect hypoxaemia. Improving access to oxygen and pulse oximetry has demonstrated a reduction in mortality from childhood pneumonia by up to 35% in high-burden child pneumonia settings. The cost-effectiveness of an oxygen systems strategy compares favourably with other higher profile child survival interventions, such as new vaccines. In addition to its use in treating acute respiratory illness, oxygen treatment is required for the optimal management of many other conditions in adults and children, and is essential for safe surgery, anaesthesia and obstetric care. Oxygen concentrators provide the most consistent and least expensive source of oxygen in health facilities where power supplies are reliable. Oxygen concentrators are sustainable in developing country settings if a systematic approach involving nurses, doctors, technicians and administrators is adopted. Improving oxygen systems is an entry point for improving the quality of care. For these broad reasons, and for its vital importance in reducing deaths due to lung disease in 2010: Year of the Lung, oxygen deserves a higher priority on the global health agenda.

Oxygen concentrators: a practical guide for clinicians and technicians in developing countries.

Hypoxaemia is a common problem causing child deaths in developing countries, but the cost-effective ways to address hypoxaemia are ignored by current global strategies. Improving oxygen supplies and the detection of hypoxaemia has been shown to reduce death rates from childhood pneumonia by up to 35%, and to be cheaper per life saved than other effective initiatives such as conjugate pneumococcal vaccines. Oxygen concentrators provide the cheapest and most consistent source of oxygen in health facilities where power supplies are reliable. To implement and sustain oxygen concentrators requires strengthening of health systems, with clinicians, teachers, administrators and technicians working together. Programmes built around the use of pulse oximetry and oxygen concentrators are an entry point for improving quality of care, and are a unique example of successful integration of appropriate technology into clinical care. This paper is a practical and up-to-date guide for all involved in purchasing, using and maintaining oxygen concentrators in developing countries.

The aetiology, clinical presentations and outcome of febrile encephalopathy in children in Papua New Guinea.

BACKGROUND: Febrile encephalopathy, defined as fever, seizures and/or altered consciousness, is a common presentation in children in tropical developing countries. Outcomes range from complete recovery through varying degrees of neurological disability which slowly resolve or remain permanent to death from either the acute illness or complications. Whilst bacterial meningitis accounts for a proportion of children affected, the aetiology in many remains unclear but includes malaria and probably viral encephalitis. AIM: To understand the aetiology, presentation and outcome of febrile encephalopathy in children in Papua New Guinea. METHODS: Children aged between 1 month and 12 years presenting to Port Moresby General Hospital with febrile encephalopathy were studied prospectively. A detailed history and examination and the following laboratory investigations were undertaken as appropriate: cerebrospinal fluid (CSF) microscopy and bacterial culture, gram stain, measurement of protein and glucose and latex agglutination testing for Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitides; Ziehl-Neelsen staining and india ink examination on selected samples; IgM for Japanese encephalitis, dengue, rubella and measles; PCR testing and mycobacterial culture for Mycobacterium tuberculosis. Blood was tested for flavivirus, measles and rubella IgM and IgG. RESULTS: 149 children were enrolled in the study. 129 had a lumbar puncture and CSF examination; 66 had a normal CSF white cell count. A clinical or laboratory-based diagnosis was possible for 140 children, but a definite pathogen was identifiable for only 55 (37%). The diagnoses included bacterial meningitis in 33 (S. pneumonia 16, H. influenza 13 and N. meningitides 4), tuberculous meningitis (5), probable tuberculous meningitis (18), malaria (10), cryptococcal meningitis (1), flavivirus encephalitis (5), rubella encephalitis (1), hepatic encephalopathy (1) and HIV encephalopathy (1). There were 28 cases of meningitis of unspecified aetiology. Of the five children with IgM-confirmed flavivirus encephalitis, one had dengue serotype 1 and two had Japanese encephalitis. Twenty-five children (including three of the five children with CSF flavivirus IgM) had serological IgG evidence of previous flavivirus infection. A history of multiple convulsions, the presence of neck stiffness and use of the Glasgow coma score (GCS) and TB score chart helped to identify children with bacterial meningitis and an adverse outcome and those with febrile convulsions. CONCLUSION: The study confirms the importance of S. pneumonia and H. influenza as major causes of febrile encephalopathy in children in Papua New Guinea. Flaviviruses including Japanese encephalitis are a cause of the febrile encephalopathy syndrome, as is Mycobacterium tuberculosis. All children with febrile encephalopathy should have their GCS and TB scores recorded and should be examined for neck stiffness, and a history of the frequency of convulsions should be recorded. These basic clinical data can help to discriminate aetiology, to guide treatment and monitoring and to identify the children at highest risk of adverse outcome.

Oxygen supplies for hospitals in Papua New Guinea: a comparison of the feasibility and cost-effectiveness of methods for different settings

Oxygen therapy is essential in all wards, emergency departments and operating theatres of hospitals at all levels, and oxygen is life-saving. In Papua New Guinea (PNG), an effective oxygen system that improved the detection and treatment of hypoxaemia in provincial and district hospitals reduced death rates from pneumonia in children by as much as 35%. The methods for providing oxygen in PNG are reviewed. A busy provincial hospital will use on average about 38,000 l of oxygen each day. Over 2 years the cost of this amount of oxygen being provided by cylinders (at least K555,000) or an oxygen generator (about K1 million) is significantly more than the cost of setting up and maintaining a comprehensive system of bedside oxygen concentrators (K223,000). A district hospital will use 17,000 l per day. The full costs of this over 2 years are K33,000 if supplied by bedside concentrators, or K333,000 plus transport costs if the oxygen source is cylinders. In provincial and district hospitals bedside oxygen concentrators will be the most cost-effective, simple and reliable sources of oxygen. In large hospitals where there are existing oxygen pipelines, or in newly designed hospitals, an oxygen generator will be effective but currently much more expensive than bedside concentrators that provide the same volume of oxygen generation. There are options for oxygen concentrator use in hospitals and health centres that do not have reliable power. These include battery storage of power or solar power. While these considerably add to the establishment cost when changing from cylinders to concentrators, a battery-powered system should repay its capital costs in less than one year, though this has not yet been proven in the field. Bedside oxygen concentrators are currently the 'best-buy' in supplying oxygen in most hospitals in PNG, where cylinder oxygen is the largest single item in their drug budget. Oxygen concentrators should not be seen as an expensive intervention that has to rely on donor support, but as a cost-saving intervention for all hospitals.