Snakebite mortality at Port Moresby General Hospital, Papua New Guinea, 1992-2001

OBJECTIVE: Fatal snakebites at Port Moresby General Hospital (PMGH), Papua New Guinea (PNG), were examined to identify interventions that may improve patient survival. DESIGN: Retrospective case series. SUBJECTS AND SETTING: Inpatients at PMGH who presented with snakebite, had evidence of envenomation, and died as inpatients between 1 January 1992 and 31 December 2001. OUTCOME MEASURES: Number and cause of fatalities; ventilation bed-days; antivenom timing, dose and price. RESULTS: 87 deaths occurred among 722 snakebite admissions to the intensive care unit (ICU). Of these 722 patients, 82.5% were ventilated, representing 45% of all ventilated ICU patients and 60% (3430/5717) of all ICU ventilator bed-days. The median duration of ventilation in fatal snakebite cases was significantly less than in non-fatal cases for children (3.0 v. 4.5 days) and adults (3.0 v. 5.0 days). The case-fatality rate for children (14.6%) was significantly greater than that for adults (8.2%). Sixty fatalities were examined in detail: 75% received blood products; 53% received antivenom (mostly a single ampoule of polyvalent), but only 5% received antivenom < or = 4 hours post-bite. Major causes of death included respiratory complications (50%), probable intracerebral haemorrhage (17%), and renal failure (10%). Antivenom unit costs increased significantly over the decade; in 2000 an ampoule of polyvalent antivenom was 40-fold more expensive in PNG than in Australia on a gross domestic product (A dollars) per capita basis. CONCLUSIONS: Management of severe snakebite is a major challenge for PMGH. Improved antivenom procurement and use policies (including increased use of appropriate monovalent antivenoms), combined with targeted snakebite education interventions (community- and hospital-based), are key interventions to reduce the ongoing toll from snakebite.     

A case-control study of stillbirths at the Port Moresby General Hospital

From September 1995 to May 1997, 315 consecutive stillbirths and 315 randomly selected controls were studied at the Port Moresby General Hospital to determine the causes of the deaths, to describe the sociodemographic and reproductive characteristics of the mothers, and to see if there were any avoidable factors in the stillbirths and where the responsibility for them lay. 249 (79%) of the stillbirths were antepartum and 14% were intrapartum; the timing of death could not be determined in the remaining 21 (7%). 36% of the stillbirths were unexplained. The common identified causes were: syphilis (VDRL and TPHA positive) 10%, intrauterine growth restriction/placental insufficiency 9%, antepartum haemorrhage 9%, malaria 6%, major congenital abnormalities 6%, cord accidents 6%, pregnancy-induced hypertension 5% and acute intrapartum asphyxia 4%. Multiple logistic regression analysis showed a significant association between stillbirth and the following variables: husband's occupation unskilled, age over 35 years, poor antenatal attendance, a past history of stillbirth, syphilis and malaria. An avoidable factor was established in 41% of the cases; in 60% the responsibility for the avoidable factor lay with the patient and her relatives.     

Perinatal outcome and associated factors of persistent breech presentation at the Port Moresby General Hospital,Papua New Guinea

A study of 502 singleton persistent breech presentations and 502 controls of cephalic presentations during labour, at the Port Moresby General Hospital, was carried out from January 1988 to July 1993. In 76 (15%) of the cases, at least one attempt was made at external cephalic version. Backward logistic regression analysis showed that Momase or Islands region ethnicity, previous breech delivery, lack of antenatal care, preterm delivery, low birthweight and congenital anomalies were significantly associated with persistent breech delivery. The perinatal outcome of babies with breech presentation was worse than among babies with cephalic presentation.     

A case-control study of singleton low birthweight babies at the Port Moresby General Hospital

A retrospective study of 432 consecutive singleton low birthweight babies and 432 unmatched controls was carried out at the Port Moresby General Hospital from January to December 1988. Of the 432 low birthweight babies 65% were preterm, 27% were light for gestational age, 6% were both preterm and light for gestational age and 2.5% could not be classified. The results of the analysis showed low birthweight to be significantly associated with the past delivery of a low birthweight infant, very young and elderly mothers, lack of antenatal care, poor family planning, hypertensive disease in pregnancy and intrauterine death. This study reveals that maternal education and improved antenatal care and family planning would ultimately reduce the incidence of low birthweight babies and perinatal mortality in Papua New Guinea.     

Blood pressure distribution in children at Port Moresby, Papua New Guinea

A study of blood pressure levels in 626 apparently healthy children aged 8 to 16 years in Port Moresby, Papua New Guinea showed that blood pressure gradually increased with age, was generally higher in females and correlated positively (p less than 0.001) with age, body weight, height and an index of obesity. Body weight and height appear to be the most important predictors of blood pressure. Of the children examined, 32 (5.1%) had elevated blood pressures which were more than two standard deviations above the mean.     

Yaws in the periurban settlements of Port Moresby,Papua New Guinea

Yaws is a re-emerging disease in Papua New Guinea. A resurgence of yaws is documented in the periurban settlements around Port Moresby. A total of 494 cases were identified from April 2000 to September 2001. The age distribution ranged from 2 years to adult (median 9 years). Presenting symptoms were adequately recorded in 286 cases (58%). Of these, 42% presented with raised painless sores, 47% with bone/joint symptoms only and 11% with both sores and bone/joint symptoms. Children in communities with a suspected high prevalence were surveyed and examined for presence of primary yaws sores. 33 out of 227 children examined (15%) had evidence of primary yaws sores. Initial control measures have been case-finding and treatment of contacts, but in areas of known high prevalence mass treatment is planned.     

The management of children with cancer in Papua New Guinea: a review of children with cancer at Port Moresby General Hospital

In the period of three and a half years between January 1998 and June 2001, 64 children with cancer were seen at the Paediatric Unit of Port Moresby General Hospital (PMGH). 62 children presented for the first time, whilst 2 were under review, having started treatment in 1996. The male:female ratio was 1.8:1. The median age was 60 months with an interquartile range of 36-84 months. 50% of the children were from the Port Moresby area, 15% from Central Province and 35% were referred from other provinces. Lymphoma, with Burkitt's lymphoma predominating, was as common as leukaemia. 20 (31%) of the children presented either at an advanced stage of disease or with cancer associated with a poor prognosis with available treatment, and were not offered curative treatment. 2 children transferred overseas for treatment. Of 42 families offered treatment 38 accepted and continued. At review 5 years after the start of the study 19 of the 20 children not offered treatment were known to have died and the outcome for 1 was unknown. Of the 38 children who underwent treatment at PMGH 24 (63%) were known to have died, 2 (5%) were still under treatment, 7 (18%) were in remission and the outcome for 5 (13%) was unknown. Of the 24 known to have died, remission induction failed in 16, relapse followed remission in 3 and 5 died from infection. The mean (SD) survival of those who died was 3.9 (3.4) months. 24 (51%) of the 47 known deceased children died in hospital, including 7 (32%) of the 22 referred patients. Significant problems were encountered in patient treatment. Infections occurred in 74% of treated children and drug shortages were experienced in 26%. The substantial problems faced by the families included marital discord, major financial hardship and, for those referred from other provinces whose children died, major delays and difficulties in repatriation. It is suggested that in Papua New Guinea the most appropriate approach to treatment for most children with cancer is the model in which paediatricians at the child's nearest appropriately staffed hospital take responsibility. Appropriate drug regimens, readily available drugs, ongoing advice and data collection should be coordinated through a central source. Accurate data should facilitate rational decisions.     

A comparison of booked and unbooked mothers delivering at the Port Moresby General Hospital: a case-control study

A case-control study of unbooked mothers delivering at the maternity unit of the Port Moresby General Hospital was undertaken over a period of 7 months. 48 mothers who had no antenatal attendances during pregnancy were recruited with 96 booked controls. Reasons for non-attendance, understanding of the importance of antenatal clinics and socioeconomic and demographic factors were recorded to assess likely risk factors for non-attendance. Almost half the mothers cited financial difficulties as the reason for non-attendance at antenatal clinics despite most of them knowing that it was important to have antenatal care during pregnancy. The two most important risk factors for being unbooked were mothers having no education (p <0.001) and the type of employment of their spouse (p <0.01). Unbooked mothers were more likely to have preterm babies (OR 16.1; 95%CI 3.4-75.7) and all 6 perinatal deaths occurred in babies born to unbooked mothers. Remedial approaches would need to take into account maternal education, education of partners and the fact that despite free antenatal services in urban clinics financial difficulties in terms of other costs involved still remain an obstacle to overcome.     

A retrospective survey of patients with one previous caesarean section delivered at the Port Moresby General Hospital: a comparative study of those delivered vaginally and those delivered by repeat caesarean section

We studied 510 patients in a retrospective, nonrandomized, comparative survey of vaginal births and repeat caesarean section after one primary caesarean section at the Port Moresby General Hospital. 478 (94%) were allowed a trial of scar (TOS). The most common indications for elective caesarean section in the other 32 patients were cephalopelvic disproportion (CPD) 31%, contracted pelvis 19% and preeclampsia 12.5%. In 41% of patients TOS was terminated by emergency caesarean section. Logistic regression analysis showed that the following were significantly associated with repeat caesarean section after TOS: parity of one, no vaginal birth after the primary caesarean section, narrow obstetric conjugate, birthweight of 2500 g or greater, short stature, high level of the head at admission to the labour ward and region of origin.     

Oral health status of teenage schoolchildren in Port Moresby, Papua New Guinea.

In Papua New Guinea the main dental problem has been periodontal disease and related conditions. Dental caries appears to be low in many community groups. The aim of this study was to explore the prevalence of dental caries and the periodontal health status of teenage schoolchildren in Port Moresby. 200 children of mean age 15.4 years were examined from two urban community high schools in Port Moresby. 44% of the children examined were caries-free and the average decayed, missing or filled teeth (DMFT) score was 1.43, while only 2.5% of the children had totally healthy periodontal tissues. 18% of them showed pathological periodontal pockets of 4 or 5mm in depth, the remaining children having either gingival bleeding, calculus or both. The results indicated that this group of children showed a low prevalence of dental caries and a high prevalence of periodontal problems. No cases with deep periodontal pockets of 6mm or more were found.     

Sexual abuse of children presenting to the Children's outpatient Department of Port Moresby General Hospital

Over a one-year period in the Children's Outpatient Department of Port Moresby General Hospital 23 cases of child sexual abuse were diagnosed. 20 (87%) were female. The perpetrator was known to be a male relative or acquaintance in 14 (61%) cases. The patients presented either with a history or overt signs of sexual abuse. With increasing awareness of child sexual abuse as a significant problem in paediatrics there will be an increase in the frequency of diagnosis of this condition in Papua New Guinea.     

Predictors of HIV testing and serostatus amongst children admitted to Port Moresby General Hospital

The aim of this study was to identify factors associated with current HIV (human immunodeficiency virus) testing practice at Port Moresby General Hospital and positive serostatus among children tested, as a basis for contributing to guidelines on HIV testing for children in Papua New Guinea. Data were extracted from hospital records to determine the demographic and presenting clinical characteristics of admitted children tested for HIV serostatus between 1 December 2005 and 30 November 2006. These data were compared with corresponding data from untested control children from the same wards. The same characteristics were compared between seropositive and seronegative cases. Odds ratios were derived for potential predictors of testing and its outcome. During the study period, HIV tests were reported on 215 children, of whom 57 were seropositive. Controls were 264 untested children. Tested children were more likely to be aged 18 months or less, to have been admitted for more than 7 days, and to have diarrhoea, be malnourished or have oral candidiasis. Among children tested, suspected tuberculosis as a presenting illness was significantly predictive of HIV-positive serostatus. This study indicates that certain clinical factors associated with HIV-positive status in children may not yet have been incorporated into testing practice, and underlines the importance of developing a systematic approach to testing children for HIV in Papua New Guinea.     

Knowledge about sexually transmitted diseases shown by people attending the STD Clinic at Port Moresby General Hospital

289 patients at Port Moresby General Hospital's Sexually Transmitted Diseases (STD) Clinic were interviewed over the January-March 1985 period to evaluate the level of knowledge about STDs shown by people attending the clinic. The questionnaire used included open-ended and precoded questions and had been translated into the 2 major languages spoken in this area of Papua New Guinea. The data were processed by the Prime computer using the BMDP statistical package. There were 231 (80%) males and 58 females; their ages ranged from 15-47 years with a mean of 24.8 and a mode of 20 years. The patients came from all provinces except West Sepik and North Solomons. 85% of the patients had heard about gonorrhea, 38% about syphilis, and 11% about donovanosis. Of those who had heard about gonorrhea, only 25 (10%) knew a corresponding local name for gonorrhea. In general, the patients knew the symptoms of gonorrhea but not of syphilis or donovanosis. A large number responded affirmatively that they had ever suffered with, had sex with someone suffering with, or had sex with someone they suspected of having gonorrhea; a few responded affirmatively to these questions in regard to syphilis and donovanosis. There was considerable variation in the replies to the causes of gonorrhea, syphilis, and donovanosis. The older patients with a mean age of 29.7 years tended to believe the cause was sorcery (puripuri); the younger patients did not. Among the 256 patients that responded to the question about what they considered to be the worst consequences of STD, 39% thought it was death. 66% responded that there was no treatment for STD in their local area; 3 identified the use of leaves, bark of trees, and ashes. The plant most commonly mentioned was the "budowai" plant. The study results indicate that even among those individuals who attend a clinic for STDs the knowledge about the major 3 STDs of the country remains limited. Ignorance of causes, symptoms, and complications is common.