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.     

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.     

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.     

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.     

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 case-control study of primary caesarean section at the Port Moresby General Hospital, Papua New Guinea, to identify epidemiological predictors of abdominal delivery

A retrospective study of 274 consecutive primary caesarean sections and 274 unmatched controls was carried out at Port Moresby General Hospital from January to December 1992. The primary caesarean section rate was 3.5%. Stepwise logistic regression analysis showed that primary caesarean section was significantly associated with maternal height of less than 150 cm; nulliparity; symphysis-fundal height of more than 38 cm at admission in labour; cervical dilatation of less than 4 cm at admission in labour; and the level of fetal head at admission in labour of 3/5 or higher.     

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.     

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.     

The aetiology of severe anaemia among antenatal patients of the Port Moresby General Hospital

Between October 1998 and September 2000, 111 consecutive pregnant patients admitted to the Port Moresby General Hospital antenatal ward with a haemoglobin level of 6 g/dl or less were studied. The main causes of the severe anaemia were as follows: iron deficiency on its own or in combination with another factor 66%--iron deficiency on its own 43% and combined folate and iron deficiency 23%--and folate deficiency 18%. Malaria was a contributory factor in 13 patients (12%). A combination of blood film, bone marrow study, serum assays of ferritin, folate and vitamin B12, and mean corpuscular volume (MCV) was used to determine the cause of the anaemia. Ferritin levels on their own poorly correlated with the presence of iron in the bone marrow. A low MCV correlated well with iron deficiency anaemia while a high MCV was associated with folic acid deficiency. It would seem therefore that while a bone marrow study is mandatory to reach a definitive diagnosis of severe anaemia, MCV, in conjunction with the red cell morphology on blood film, would be a good marker for iron and folic acid deficiency anaemia, especially as we do not have serum assays readily available for folate, ferritin and vitamin B12 in Papua New Guinea.     

Acute lower respiratory tract infections in children admitted to Port Moresby General Hospital

The clinical pattern of acute lower respiratory tract infection (ALRTI) in children admitted to Port Moresby General Hospital (PMGH) was studied. Most patients (60%) were less than twelve months of age. Common symptoms were cough, fever and shortness of breath. Common signs were crepitations, chest recession, elevated temperature and tachypnoea. Concurrent illness was common, with evidence of malnutrition in 62% patients. Most patients were anaemic (haemoglobin less than 10g per dl). Blood cultures isolated pathogens in 13% of patients in which it was done, the most common isolate being Haemophilus influenzae. Chest radiograph showed most patients had multisegmental changes, with the lower lobes commonly involved. Of the 129 patients, discharges accounted for 106 (82%), while 15 (12%) absconded and eight (6%) died. Of those 121 discharged or absconding, 15 (12%) were readmitted within three months of departure. Sixty-six (51%) patients stayed in hospital for four days or less. Of the eight patients who died, six (75%) were malnourished, six (75%) were less than eighteen months of age, seven (87.5%) were sick for one week or less before admission, five (62.5%) had received antibiotics before admission and chest radiograph showed more lung zones affected than in those not dying. Of the eight patients who died, six had white cell counts (WCC) performed and none of these was more than 30,000.     

Total lymphocyte counts in adult HIV/AIDS patients in Port Moresby General Hospital

We carried out a prospective study of total lymphocyte counts in 124 adult patients who were diagnosed with HIV (human immunodeficiency virus) infection and/or AIDS (acquired immune deficiency syndrome) and were admitted to Port Moresby General Hospital (PMGH) from January to June 2003. The median and mean values of lymphocyte counts in these patients were found to be 0.7 x 10(9)/l and 0.9 x 10(9)/l, respectively, with a standard deviation of 0.7, both of which counts are significantly lower (p < 0.0001) than those found in members of a control population who were well and HIV-antibody-negative. We found that the lower the total lymphocyte count, the more clinically advanced was the HIV disease state. Haemoglobin values were also significantly lower in these patients. For 35% of these patients, tuberculosis was the principal diagnosis made upon being admitted. An apparent 11% of the patients who had a clinical suspicion of AIDS were HIV-antibody-negative. Total lymphocyte count methods could be used in developing countries that do not have appropriate facilities for CD4 count and viral load assays in order to monitor the patient's disease state and progression towards AIDS.