Evaluation of the ARI program: a health facility survey in Simbu, Papua, New Guinea.

The purpose of this health facility survey was to evaluate how the ARI (Acute Respiratory Infection) Program actually works in an everyday, non-research setting. We surveyed 33 clinics and aid posts, including 223 children with ARI and 104 health workers. In this primary health care setting, health workers diagnosed 37% of ARI cases as pneumonia, compared to 69% in the same children assessed independently by trained ARI surveyors using Papua New Guinea case management, which defines fast breathing as > or = 40 per minute for children 1 month to 5 years of age. Agreement between health workers and surveyors was reasonably good (kappa > or = 0.6) for the history of symptoms, but was poor (kappa < 0.3) for diagnoses, treatments and signs such as respiratory rate (RR) and chest indrawing. Health workers counted the RR in only 14% of cases in the survey. In essence, we found that health workers in Simbu are not practising ARI case management. We conclude that case management guidelines which define fast breathing as a rate of > or = 40 per minute classify too many obviously well children as pneumonia. Furthermore, we encountered difficulties in measuring RR accurately, and documented marked inter-observer variation in this setting. Consequently, we are concerned about the ARI Program's excessive reliance on RR and rigid protocols at the expense of clinical sense. Case management guidelines developed for aid post orderlies or village health workers may need to be modified, or used differently by experienced nurses at health centres, who recognize sick children better than by following a standardized protocol. Despite better overall ARI knowledge and practice by nurses, we could demonstrate an impact of the ARI Training Program only on community health workers (CHWs). In order to improve ARI clinical practice, we recommend that the ARI Program in PNG initiates regular on-site clinical supervision of nurses and CHWs at health centres.

The malaria control program in Papua New Guinea: epidemiological surveillance and a look into the future.

The four major phases of the malaria control program in Papua New Guinea are briefly described. Routine indicators utilized during Phases II and III (the periods when residual indoor spraying was used) are presented and their limitations outlined. The new epidemiological indicators developed during Phase IV and now included in the National Health Plan (1991-1995) are presented. Their future use and implications for the malaria control program are analyzed and discussed.

HIV serosurveillance in Papua New Guinea.

To determine human immunodeficiency virus-1 (HIV-1) prevalence in low- and high-risk populations in Papua New Guinea (PNG), anonymous unlinked serosurveillance was conducted in government-administered antenatal and sexually transmitted disease (STD) clinics at six sites beginning in June 1989. Although 3 of 1233 samples were HIV positive in a pilot study, none of 7948 samples was HIV positive during the first full year of serosurveillance (June 1989--May 1990). HIV-infected people are also identified in PNG through clinical diagnostic testing. Although underreporting is probably substantial, 45 HIV-infected people had been identified in PNG (population 3.6 million) through diagnostic testing between 1987 and the end of the first serosurveillance year (May 1990). In view of the steadily emerging clinical problem of acquired immune deficiency syndrome (AIDS) in PNG, the negative results of serosurveillance required explanation. Three possibilities are proposed: 1) the sample size chosen could fail to detect a case 5% (or more) of the time under the likely conditions of this survey; 2) the populations chosen for surveillance may not, yet, be those in which HIV is circulating at this early stage of the epidemic in PNG; and 3) laboratory error could account for some false negative results. The first two of these, alone or in combination, are most likely. Limited surveillance continued in PNG in 1991 and 1992. By June of 1992, 5 of an additional 6035 serosurveillance samples had tested positive. All 5 were among 2000 samples from a single site, the Port Moresby STD Clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: To determine human immunodeficiency virus-1 (HIV-1) prevalence in low- and high-risk populations in Papua New Guinea (PNG), anonymous unlinked serosurveillance was conducted in government-administered antenatal and sexually transmitted disease (STD) clinics at 6 sites beginning in June 1989. Samples were tested in each local hospital laboratory for syphilis reactivity (VDRL) and for antibodies to HIV-1 (Serodia-HIV, Fujirebio). Positive Serodia specimens were forwarded for enzyme immunoassay (EIA) testing. If positive or indeterminate on EIA testing, Western blot confirmatory testing was conducted. Although 3 of 1233 samples were HIV positive in a pilot study, none of 7948 samples were HIV positive during the first full year of serosurveillance (June 1989-May 1990). HIV-infected people are also identified in Papua New Guinea through clinical diagnostic testing. Although underreporting is probably substantial, 45 HIV-infected people had been identified in Papua New Guinea (population 3.6 million) through diagnostic testing between 1987 and the end of the first serosurveillance year (May 1990). Limited surveillance continued in Papua New Guinea in 1991 and 1992. By June of 1992, 5 of an additional 6035 serosurveillance samples had tested positive. All 5 were among 2000 samples from a single site, the Port Moresby STD Clinic. In addition to surveillance, further clinical diagnostic testing had identified a total of 118 HIV-infected people by June of 1992. In STD clinics, genital sores were found to be common at all sites and in both sexes, occurring in 21% of males and 19% of females. Overall, 7.5% of STD patients had a reactive VDRL, as did 3.5% of antenatal women. Explanations for negative results of serosurveillance may be: 1) the sample size chosen faces a 5% (or higher) chance of failing to detect a case under the likely conditions of this survey; 2) the populations chosen for surveillance may not be those in which HIV is circulating at this early stage of the epidemic; and 3) laboratory error. The first two of these, alone or in combination, are most likely.

A survey of sexually transmitted diseases in five STD clinics in Papua New Guinea.

The first multicentre survey of sexually transmitted diseases (STDs) performed in Papua New Guinea was conducted in STD clinics in five towns, Port Moresby, Goroka, Rabaul, Lae and Daru, from September 1989 to May 1990. Infections with Neisseria gonorrhoeae and Chlamydia trachomatis (alone or in combination) were common. Penicillinase-producing N. gonorrhoeae (PPNG) represented 44% of all gonococcal isolates but significant intrinsic resistance to penicillin was not found. Of the other antibiotics tested, significant elevation of minimum inhibitory concentration (MIC) was common only for tetracycline, although no high-level tetracycline resistance was detected. C. trachomatis was detected by direct immunofluorescence (DIF) in 26% of 210 males and 27% of 64 females. 10% (21/210) of males and 11% (7/64) of females were both DIF positive for C. trachomatis and culture positive for N. gonorrhoeae. Of 203 males and 78 females tested, 5% and 12%, respectively, had serological evidence of current syphilis infection. Clinically, genital ulcer disease was most commonly due to syphilis, donovanosis or genital herpes, while specific vaginal infections were commonly seen in female patients attending Port Moresby and Lae STD clinics.