A continuing high incidence of subacute sclerosing panencephalitis (SSPE) in the Eastern Highlands of Papua New Guinea.

The aims of this descriptive study were to confirm the high incidence of subacute sclerosing panencephalitis (SSPE) previously reported from Papua New Guinea (PNG) and to relate SSPE to previous measles vaccination and measles illness. From February 1997 to April 1999 we diagnosed a total of 55 patients with SSPE at Goroka Base General Hospital in Eastern Highlands Province (EHP) of PNG. The diagnosis was based on high cerebrospinal fluid and serum measles virus antibody titres with progressive neurological disorder and myoclonic jerks. Of these 55 patients 42 were from EHP, including 32 whose onset was in the 2-year period 1997-1998. The annual incidence of SSPE in EHP in these 2 years was 98 per million population under 20 years of age, the highest ever reported. This incidence was more than ten times higher than the highest incidence in the prevaccine era reported from elsewhere. The mean age of onset of SSPE was 7.7 years (range 2.8-14.8 years) and the interval between measles and the onset of SSPE, where known, had a mean of 5.9 years and a range of 2.5-11.1 years. Among the SSPE patients 19 had a documented history of measles vaccination. Eight of these 19 also had documentation of previous measles illness; of these, seven were vaccinated after the development of measles and one was vaccinated 20 days before measles illness. Two non-SSPE children received vaccination twice which was documented and subsequently developed measles which was also substantiated by documentation. Two patients with SSPE yielded amplified nucleotide sequences of measles virus that were different from any of the vaccine strains. We found no evidence to implicate measles vaccination in the development of SSPE.

The effect of introduction of minimal standards of neonatal care on in-hospital mortality.

A retrospective study was done to assess the effect on in-hospital neonatal mortality of a series of interventions in neonatal care in the highlands of Papua New Guinea. Between 1995 and 1997, prior to the interventions, the mortality among neonates admitted to the Goroka Hospital Special Care Nursery was 18% and two-thirds of very low birthweight (1-1.5 kg) neonates died. The interventions began in December 1997 and were aimed at reducing mortality among all neonates and particularly among those with very low birthweight. Compared to the 30-month period prior to the interventions, the in-hospital neonatal mortality in the 30-month period after the interventions began was 44% lower (relative risk (RR) 0.56, 95% confidence interval (CI) 0.45-0.69). After adjustment for a higher number of neonates <1500 g in the pre-intervention period, the relative risk was 0.59 (0.48-0.74). The mortality in the intervention phase for very low birthweight babies was 56% lower (RR 0.44, 95% CI 0.30-0.65) and for moderate low birthweight (1.5-2 kg) 50% lower (RR 0.50, 95% CI 0.28-0.90). Mortality was also significantly lower in the intervention phase in neonates with a diagnosis of septicaemia or pneumonia (RR 0.36, 95% CI 0.19-0.67), but there were no differences in mortality from birth asphyxia, meconium aspiration or extremely low birthweight (<1 kg). We estimate that in the 30 months after beginning the interventions 82 neonatal deaths that would previously have occurred were avoided. The costs of the improvements in technology described are estimated at US$445 (K1000) per life saved, but substantial training and improved supervision of staff and other human factors may have been more important than equipment. Apnoea monitors were the single most important technology introduced. A similar evaluation of the effect of minimal standards should be done without the use of incubators and overhead heaters, as these are costly and may be dangerous when used by less experienced operators. The 33 neonatal deaths that we estimate were avoided each year because of the interventions represent less than 10% of all neonatal deaths in the province. Although this study provides justification for increasing the technology for supportive neonatal care and training in medium-sized hospitals in rural areas in developing countries, estimates of cost-effectiveness must be compared with other interventions that will effectively lower neonatal mortality, both in and out of hospitals.

Control measures and the outcome of the measles epidemic of 1999 in the Eastern Highlands Province.

In the Eastern Highlands Province (EHP) of Papua New Guinea (PNG) measles outbreaks have occurred regularly every 3 to 4 years since 1980. The latest was between September 1998 and March 2000. Between July 1999 and March 2000 314 children with measles were reviewed at Goroka Base Hospital. The majority of these children were very young: 55% were under 1 year and 27% under 6 months. The median age of the measles cases was 11 months (range 10 days to 13 years). 40% of the children had a verifiable history of having received at least one dose of measles vaccine. The majority were vaccinated during the epidemic and included many children who either were below 6 months of age or who developed measles within 2 weeks of vaccination. Measles complications occurred in 82% of the children, the most common being pneumonia. Serious complications, particularly severe pneumonia, were more common among the unvaccinated children than in those who had received at least a single dose of the measles vaccine. No deaths occurred among 82 children who had received measles vaccine more than 2 weeks before the onset of clinical measles, compared with 10 deaths in 206 children who had never been vaccinated against measles or were vaccinated in the 2 weeks before presentation (p=0.067). The overall case fatality was 4%: 14% among the hospital-acquired and 2.5% in community-acquired measles. Improvement in the measles vaccination coverage and supplementary vaccination campaigns are required to prevent measles outbreaks in PNG. Intensified measles vaccination campaigns, such as the one conducted in EHP in 1999, are recommended during epidemics to minimize deaths due to measles and to rapidly control outbreaks. The efficacy of measles vaccination can only be measured in total mortality, not in the prevention of clinical measles.

Birthweight and neonatal outcome at the Muhimbili Medical Centre, Dar es Salaam, Tanzania.

A prospective study of neonatal morbidity and mortality was made over four months in 1990 at the neonatal unit in Muhimbili Medical Centre. The incidence of low birthweight (LBW) was 16%. Seven hundred and eighty four LBW infants and 612 heavier infants admitted for care in the unit were followed up for six weeks. The mean birth weight was 2854 grams. LBW carried a seven-fold increased risk of mortality (291/784;37%); this was 64% (291/341) of the total. The risk of morbidity in LBW infants was increased three-fold (436/784;56%) being 73% (436/598) of the total. Factors significantly associated with increased morbidity and mortality were prematurity, birth asphyxia, sepsis, respiratory distress syndrome, hypothermia and hypoglycaemia. The majority of the deaths (83%) occurred within the first week of life.