"Whenever they cry, I cry with them": Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea.

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

Identifying competencies for Australian health professionals working in international health.

A profile of the roles performed by Australian health professionals working in international health was constructed to identify the core competencies they require, and the implications for education and training of international health practitioners. The methods used included: literature review and document analysis of available training and education; an analysis of competencies required in job descriptions for international health positions; and consultations with key informants. The international health roles identified were classified in four main groups: Program Directors, Program Managers, Team Leaders and Health Specialists. Thirteen 'core' competencies were identified from the job analysis and key informant/group interviews. Contributing to international health development in resource poor countries requires high level cultural, interpersonal and teamwork competencies. Technical expertise in health disciplines is required, with flexibility to adapt to new situations. International health professionals need to combine public health competencies with high level personal maturity to respond to emerging challenges.

Mortality rates and the utilization of health services during terminal illness in the Asaro Valley, Eastern Highlands Province, Papua New Guinea.

Between 1980 and 1989 we carried out fortnightly demographic surveillance in a random sample of people living in Goroka town, periurban areas and rural areas in the Lowa and Asaro Census Divisions, all within 1 1/2 hours' drive of the town in the Asaro Valley, Eastern Highlands Province. Cause of death was determined by verbal autopsy supplemented by any available health service information. Crude death and birth rates were 10 and 32 per 1000 person-years, respectively, in 59,906 person-years at risk. The standardized mortality ratio increased with increasing distance from town. Life expectancy at birth was 57 years for males and 55 years for females. The stillbirth rate was 19 per 1000 births, neonatal and infant mortality 21 and 60 per 1000 livebirths, respectively, and 1-4-year mortality 9 per 1000 person-years. Maternal mortality was 3 per 1000 births. Neonatal and infant mortality were respectively 7 and 3 times as high in Asaro Census Division as in Goroka town. Acute lower respiratory tract infections accounted for 22% of all deaths, chronic obstructive lung disease 10%, trauma 8% and gastroenteritis/dysentery 7%. 76% of deaths occurred at home and 44% of people who died had no treatment during their terminal illness. Health services were used most frequently by urban dwellers and by the young. To reduce mortality, a political commitment to provide functioning health services in rural areas is needed; regular supervision of health staff, ensuring the safety of staff and their families, availability of antibiotics as near people's homes as possible and regular mobile maternal and child health clinics are essential. Health education should include recognition of signs of severe disease and the importance of seeking treatment early. In view of high maternal and neonatal mortality, user fees should be waived for pregnant women.

Acquisition and invasiveness of different serotypes of Streptococcus pneumoniae in young children.

Rates of acquisition and mean duration of nasal carriage of different serotypes of Streptococcus pneumoniae have been estimated by fitting a stochastic model to longitudinal carriage data in children from Papua New Guinea. Immunogenicity and two indices of relative invasiveness were determined for each serotype. Immunogenic serotypes were less frequently acquired and were carried for shorter periods, but no relationship between immunogenicity and invasiveness was apparent using either index of invasiveness. Frequent invasion was associated with a high acquisition rate and high frequency and prolonged duration of carriage. Carriage studies can provide a broad indication of which serotypes cause invasive disease but not the proportion of disease due to individual serotypes; some serotypes which cause invasive disease (e.g. serotype 46) are not found even in extensive carriage studies. The antibiotic resistance of carriage organisms, however, does approximate the resistance patterns of invasive organisms and thus may be used to monitor changing patterns of antimicrobial susceptibility in the community.

Reduction in the incidence of acute bronchitis by an oral Haemophilus influenzae vaccine in patients with chronic bronchitis in the highlands of Papua New Guinea.

Following the administration of a standardized questionnaire, 62 adult patients with chronic bronchitis were enrolled into a double-blind controlled trial of an oral killed Haemophilus influenzae vaccine in the highlands of Papua New Guinea. A 3-day course of vaccine or placebo was given monthly for 3 consecutive months. Participants were monitored weekly over 12 months for acute exacerbations; early morning sputum specimens were collected monthly and during acute exacerbations. Density of colonization by H. influenzae and H. parainfluenzae was determined by standard quantitative and semiquantitative techniques, and the latter method (quadrant score) was used to determine the density of growth of pneumococci. A total of 30 patients received vaccine and 32 placebo. The incidence rate of acute bronchitis in the vaccine group (0.011 episodes/person-weeks) was significantly lower than that in the placebo group (0.021 episodes/person-weeks), but there was no difference between the two groups in the incidence rates of more severe disease. Vaccine efficacy was maximal at times of peak incidence of disease. There was no evidence of a decline in vaccine efficacy for acute bronchitis over the 12-month follow-up period. The number of viable H. influenzae in the sputum declined in both vaccine and placebo groups over the 12-month follow-up period. The average concentration of H. influenzae in the vaccine group fell below that in the placebo group within 1 to 2 months after first immunization and remained so for 12 months, although the difference between the two groups narrowed during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumococcal vaccine trials in Papua New Guinea: relationships between epidemiology of pneumococcal infection and efficacy of vaccine.

Field trials in Papua New Guinea have shown that pneumococcal capsular polysaccharide vaccine protects children less than 2 years of age from death due to acute lower respiratory infections (ALRI). The vaccine appears to reduce mortality by preventing bacteremia. Evidence suggests that highly invasive "adult" pneumococcal serotypes are comparatively more important as a cause of ALRI in developing countries where ALRI-related mortality is higher than in North America. Capsular polysaccharide vaccines are more likely to be immunogenic for these serotypes than for the "pediatric" serotypes. The evaluation of pneumococcal vaccines in areas where mortality is high should have the highest priority. For such trials investigators should, at minimum, define epidemiologic circumstances in terms of (1) the invasive serotypes of pneumococci, (2) the protective levels of antibody, (3) the antibody response to vaccination, and (4) the general immune status of the population.

Effect of pneumococcal vaccine on morbidity from acute lower respiratory tract infections in Papua New Guinean children.

The effect of a 14-valent pneumococcal polysaccharide vaccine on morbidity from acute lower respiratory tract infection (ALRI) was determined in a randomized double-blind controlled trial in children under the age of 5 years living in the Paupa New Guinea highlands. The vaccine did not protect against mild ALRI. Vaccine efficacy in the study as a whole was 28% for moderate/severe ALRI, which was not statistically significant though consistent with the significant effect on mortality. Children entered the trial in five separate cohorts 4 months apart. The incidence of disease and vaccine efficacy varied between cohorts and with age. There was no vaccine effect in the first cohort, which had a much higher proportion of older children. The effect was greatest and statistically significant among those groups encountering an epidemic of moderate and severe ALRI at a young age. It was therefore in children at the most vulnerable age in times of greatest incidence of disease that the vaccine had its most potent effect. It is postulated that the efficacy of pneumococcal vaccine is dependent on the predominant invading serotypes in the period after vaccination, the age at which children develop immunocompetence to specific vaccine serotypes, and the levels of naturally acquired specific immunity already present in children at the time of vaccination, and that for all of these conditions there will be a cohort effect.

Bacterial colonization of the upper respiratory tract and its association with acute lower respiratory tract infections in Highland children of Papua New Guinea.

Acute lower respiratory tract infection (ALRI) is the major cause of death among children in Papua New Guinea. This longitudinal study reports the bacteriologic findings for children observed in their hamlets. A total of 1,449 nasal swab specimens from 158 children less than 5 years of age who were studied intensively for 18 months were examined. Non-serotypable strains of Haemophilus influenzae were isolated from 91% of specimens, and serotypable strains were isolated from 35% (8% H. influenzae type b) of specimens. All children had acquired Streptococcus pneumoniae by the age of 3 months. The most frequently occurring serotypes of S. pneumoniae were 6, 19, and 23. Children more frequently carried invasive pneumococci during an episode of ALRI than when they were healthy. Also, children more frequently carried serotypable strains of H. influenzae during the 2 weeks preceding an episode of ALRI than when they were healthy. Between-children analyses showed that children who were susceptible to attacks of ALRI and those who were not susceptible had similar rates of carriage of bacteria.

Pneumococcal vaccine prevents death from acute lower-respiratory-tract infections in Papua New Guinean children.

In three double-blind placebo-controlled trials of pneumococcal capsular polysaccharide vaccines against death from acute lower-respiratory-tract infections (ALRI), children were vaccinated at 6 months to 5 years of age. The efficacy of the vaccines against ALRI as the sole cause of death was estimated at 59% in children vaccinated when younger than 5 years (p = 0.008) and 50% in children vaccinated when younger than 2 years (p = 0.043). Mortality from all causes was 19% less in the vaccinated group.

Immunisation with a polyvalent pneumococcal vaccine. Effect of respiratory mortality in children living in the New Guinea highlands.

In Tari, in the southern highlands of Papua New Guinea, each child experienced, on average, two acute lower respiratory tract infections (ALRTI) between birth and age 5 years. The yearly mortality rate from ALRTI was 30 per 1000 in infants, and 4 per 1000 in children aged between 1 and 4 years. A double-blind trial of a 14-valent pneumococcal polysaccharide vaccine was carried out on 871 children from this community who were aged between 6 months and 5 years. Morbidity from ALRTI was lower (by 37%) in children given the vaccine provided they were at least 17 months of age at the time of immunisation. There were 8 deaths from ALRTI in the placebo group, but only 1 death in the vaccine group.

An epidemiologic approach to pneumococcal disease.

In many countries of the developing world, pneumonia remains a leading cause of morbidity and premature mortality. In their quest for effective control measures not dependent on the socioeconomic changes in Western societies that have paralleled a reduction in mortality from pneumonia, these poorer countries are looking towards modern antibiotic therapy and pneumococcal vaccines as short-term approaches to the problem. This paper summarizes information about the response of human populations to Streptococcus pneumoniae with particular reference to the author's experience in Papua New Guinea, where penicillin resistance is an increasing problem and where pneumococcal vaccines have been shown in field trials to reduce mortality from respiratory disease among both adults and children. In each developing country, basic epidemiologic data are needed to assist in choosing the best available combination of strategies for control of disease due to S. pneumoniae. Our current understanding of the determinants of pneumococcal carriage and pneumococcal disease is still inadequate, however, and there is need for studies of the interaction of the pneumococcus and its host at the mucosal surface to better understand the differences in the behavior observed for the various serotypes.

Pneumococcal disease and its prevention with polyvalent pneumococcal polysaccharide vaccines--a review.

Polyvalent pneumococcal polysaccharide vaccines have been shown to be safe, immunogenic and efficacious and are becoming available for use in patients at high risk of developing pneumococcal infections. Precise estimates of the role of the pneumococcus in human respiratory disease are difficult to obtain, as this organism is also a frequent commensal of the upper respiratory tract; and as the optimal techniques for the identification and proof of its role are not widely used. Nevertheless, the pneumococcus remains the principal cause of adult pneumonia and paediatric otitis media, and is also an important cause of death from bacteremia and meningitis. At present it seems likely that in Australia these vaccines will be most useful amongst people over the age of 50 years, those with chronic systemic disease, alcoholics, splenectomized individuals and disadvantaged groups such as Australian aborigines, all of whom are particularly susceptible to pneumo-coccal bacteremia which has a considerable mortality rate. The possibility of preventing pneumococcal otitis media in childhood is still being evaluated. Studies of the role played by the various pneumococcal serotypes in Australian populations are urgently needed.

Immunisation with a polyvalent pneumococcal vaccine. Reduction of adult respiratory mortality in a New Guinea Highlands community.

A double-blind controlled trial of a 14-valent pneumococcal polysaccharide vaccine was carried out in 11 958 adults at Tari in the Papua New Guinea Highlands. Pneumococcal infection, confirmed by blood-culture and lung aspirate, was less in the vaccinated group by 84%. Mortality from pneumonia was less by 44%.