Low birth weight (LBW, <2.50 kg) and preterm birth (PTB, <37 completed weeks of gestation) are important contributors to neonatal death. Newborn foot length has been reported to identify LBW and PTB babies. The objectives of this study were to determine the diagnostic accuracy of foot length to identify LBW and PTB and to compare foot length measurements of a researcher with those of trained volunteers in Papua New Guinea. Newborn babies were enrolled prospectively with written informed consent from their mothers, who were participating in a clinical trial in Madang Province. The reference standards were birth weight, measured by electronic scales and gestational age at birth, based on ultrasound scan and last menstrual period at the first antenatal visit. Newborn foot length was measured within 72 hours of birth with a firm plastic ruler. Optimal foot length cut-off values for LBW and PTB were derived from receiver operating characteristic curve analysis. Bland-Altman analysis was used to assess inter-observer agreement. From 12 October 2019 to 6 January 2021, we enrolled 342 newborns (80% of those eligible); 21.1% (72/342) were LBW and 7.3% (25/342) were PTB. The area under the curve for LBW was 87.0% (95% confidence intervals 82.8-90.2) and for PTB 85.6% (81.5-89.2). The optimal foot length cut-off was <7.7 cm for both LBW (sensitivity 84.7%, 74.7-91.2, specificity 69.6%, 63.9-74.8) and PTB (sensitivity 88.0% (70.0-95.8), specificity 61.8% (56.4-67.0). In 123 babies with paired measurements, the mean difference between the researcher and volunteer measurements was 0.07 cm (95% limits of agreement -0.55 to +0.70) and 7.3% (9/123) of the pairs were outside the 95% limits of agreement. When birth at a health facility is not possible, foot length measurement can identify LBW and PTB in newborns but needs appropriate training for community volunteers and evaluation of its impact on healthcare outcomes.

We aimed to identify clinical and laboratory predictors of mortality in children from a malaria-endemic area of Papua New Guinea hospitalized for severe illness. Children aged 0.5-10 years presenting with any WHO-defined feature of severe malarial illness were eligible for recruitment. Each child was assessed with a detailed clinical examination, blood film microscopy, malaria rapid diagnostic testing (RDT), a full blood examination, and blood glucose and lactate concentrations. Clinical care was coordinated by local medical staff in accordance with national guidelines. Daily study assessments were conducted until death or discharge. Other biochemical tests and malaria polymerase chain reaction (PCR) tests were performed subsequently. Logistic regression identified independent predictors of death. Of 787 evaluable children with severe illness, 336 had confirmed severe malaria (microscopy and PCR positive) and 58 (6.6%) died during hospitalization. The independent predictors of mortality were hyperlactatemia (adjusted odds ratio [95% CI]: 2.85 [1.24-6.41], P = 0.01), malnutrition (2.92 [1.36-6.23], P = 0.005), renal impairment (3.85 [1.53-9.24], P = 0.002), plasma albumin (0.93 [0.88-0.98] for a 1 g/L increase, P = 0.004), and Blantyre coma score (BCS) ≤ 2 (10.3 [4.77-23.0] versus a normal BCS, P < 0.0001). Confirmed severe malaria (0.11 [0.03-0.30] versus non-malarial severe illness, P < 0.0001) was independently associated with lower mortality. Although established risk factors were evident, malaria was inversely associated with mortality. This highlights the importance of accurate diagnosis through blood film microscopy, RDTs, and, if available, PCR to both guide management and provide valid epidemiological data.

Background:In Papua New Guinea, TB is considered to be a major public health problem, but little is known about the prevalence and prognosis of presumed TB in children. Methods:As part of a prospective hospital-based surveillance on the northern coast of mainland Papua New Guinea, the authors investigated the admission prevalence and case fatality rate associated with presumed TB over a 6-year period (2011-2016). All children admitted who were diagnosed with TB were followed-up until discharge or death. Results:Of 8992 paediatric admissions, 734 patients (8.2%) were diagnosed with presumed TB and there were 825 deaths, with TB accounting for 102 (12.4%). Extrapulmonary TB was the final diagnosis in 384 admissions {prevalence 4.3% [384/8992 (95% CI 3.9-4.7)]} with a case fatality rate of 21.4% [82/384 (95% CI 17.4-25.9)]. TB meningitis, disseminated TB and pericardial TB had high case fatality rates of 29.0% (53/183), 28.9% (11/38) and 25% (4/16), respectively. Severe malnutrition was more common in patients with pulmonary compared with extrapulmonary TB (25.4% vs 15.6%; p<0.01). Conclusions:Improved community-based case detection strategies, routine BCG vaccinations and other effective forms of TB control need revitalization and sustainability to reduce the high case fatality rates associated with childhood TB in Papua New Guinea.

Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL.

Approximately half of all childhood mortality in Papua New Guinea (PNG) occurs in the neonatal period - the first 28 days of life. In this 5-year retrospective study, causes of admissions and in-ho...

Introduction: Child maltreatment is prevalent globally. In Papua New Guinea (PNG), child maltreatment remains an under-reported problem.Methods: As part of a 10 month prospective observational study conducted at Modilon Hospital in PNG, we investigated the burden of child maltreatment in the form of sexual abuse, physical abuse and neglect, leading to hospitalization in children <= 14 years.Results: Of 1061 screened admissions, 107 (10%) fulfilled the definition of child maltreatment. The in-hospital admission prevalence of sexual abuse was 5.7% [60 of 1061; 95% confidence interval (CI): 4.4-7.3]. Neglect accounted for 3.4% (36 of 1061; 95% CI: 2.4-4.7) of admissions, while physical abuse accounted for 1.0% (11 of 1061; 95% CI: 0.6-1.9). Mortality was highest in the neglected group, with severe acute malnutrition accounting for 89% of deaths.Conclusion: Improved awareness, establishment of appropriate channels for addressing child maltreatment and enforcement of child protection laws in PNG and other epidemiologically similar settings are urgently needed.

We thank John Bolnga and colleagues for raising the question of whether we saw an effect of distance to a health facility on perinatal mortality. We are, unfortunately, not able to report on perinatal mortality as we did not record stillbirths. However, our data show some evidence of neonatal mortality rising with distance to a hospital. Neonatal mortality increased from 29·6 (95% CI 25·4–34·6) per 1000 livebirths for those living less than 5 km from a hospital to 39·7 (33·5–47·1) for those living more than 35 km from a hospital (crude odds ratio 1·31 [95% CI 0·98–1·76], p=0·0139 using a test for trend; figure). Others have also reported that distance to care is a determinant of neonatal mortality—although not in all settings.1Lohela T Campbell O Gabrysch S Distance to care, facility delivery and early neonatal mortality in Malawi and Zambia.PLoS One. 2012; 1: e52110Crossref Scopus (89) Google Scholar, 2Okwaraji YB Edmond KM Proximity to health services and child survival in low- and middle-income countries: a systematic review and meta-analysis.BMJ Open. 2012; 2: e001196Crossref Scopus (33) Google Scholar Bolnga and colleagues rightly raise the question of whether maternal and perinatal mortality reduce in parallel. Without doubt, babies suffer severely and mortality rates are high if the mother faces complications during childbirth such as eclampsia or obstructed labour. But neonates could more commonly be affected by complications such as premature birth or asphyxia, whereas the mother might not always be at risk. Consequently, the distance decay of maternal mortality and neonatal mortality could differ. Importantly, it is not sufficient to focus on distance to facilities. We also need to consider the quality of care available, the type of complications, and whether the mother or the baby is affected. The second key message of our Article is that both pregnancy-related and maternal mortality rates are high even within a 5 km radius around the hospitals, despite the fact that 72% of women gave birth in a hospital and 8% had a caesarean section. This finding suggests that the quality of care in hospitals could be a key problem.3Hanson C Cox J Mbaruku G et al.Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households.Lancet Glob Health. 2015; 3: e387-e395Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar Quality of care could also be a key factor contributing to neonatal mortality, which is also unacceptably high for those living within 5 km of a hospital at 29·6 per 1000 livebirths. Policy makers in resource-poor settings might have to make difficult decisions about whether to prioritise accessibility or quality of care. We welcome the recent WHO initiative of prioritising the quality of intrapartum care4Tunçalp Ö Were WM MacLennan C et al.Quality of care for pregnant women and newborns—the WHO vision.BJOG. 2015; 122: 1045-1049Crossref PubMed Scopus (503) Google Scholar and hope that this and other quality improvement initiatives in resource-poor settings will target both the mother and her baby. We declare no competing interests. Maternal and perinatal mortality in resource-limited settingsClaudia Hanson and colleagues (July, 2015)1 report that maternal mortality was four times higher in women who lived more than 35 km from a hospital in rural Tanzania than in women who lived within 5 km of a hospital. We strongly agree with the findings of their study, but are interested to know whether a similar association was noted between distance and perinatal mortality. Full-Text PDF Open Access

Although the WHO recommends all countries use International Classification of Diseases (ICD)-10 coding for reporting health data, accurate health facility data are rarely available in developing or low and middle income countries. Compliance with ICD-10 is extremely resource intensive, and the lack of real data seriously undermines evidence-based approaches to improving quality of care and to clinical and public health programme management. We developed a simple tool for the collection of accurate admission and outcome data and implemented it in 16 provincial hospitals in Papua New Guinea over 6 years. The programme was low cost and easy to use by ward clerks and nurses. Over 6 years, it gathered data on the causes of 96 998 admissions of children and 7128 deaths. National reports on child morbidity and mortality were produced each year summarising the incidence and mortality rates for 21 common conditions of children and newborns, and the lessons learned for policy and practice. These data informed the National Policy and Plan for Child Health, triggered the implementation of a process of clinical quality improvement and other interventions to reduce mortality in the neediest areas, focusing on diseases with the highest burdens. It is possible to collect large-scale data on paediatric morbidity and mortality, to be used locally by health workers who gather it, and nationally for improving policy and practice, even in very resource-limited settings where ICD-10 coding systems such as those that exist in some high-income countries are not feasible or affordable.

BACKGROUND:The diagnosis of acute bacterial meningitis (ABM) is challenging in resource-limited settings where cerebral malaria and viral encephalitis are also common. METHODS:To assess the accuracy of an initial clinical diagnosis of ABM in a malaria-endemic area of Papua New Guinea (PNG), a retrospective chart review of hospitalized children aged 2 months to 10 years was conducted. RESULTS:Of the 481 eligible children, 240 had an initial clinical diagnosis of ABM that was confirmed independently by trained research staff under standardized conditions, with laboratory support in only 84 (17.5%; 84/481). When compared with the final laboratory-confirmed diagnosis, an initial diagnosis of ABM had a sensitivity, specificity, positive predictive value and negative predictive value of 76% (95% CI 66-85%), 56% (95% CI 51-61%), 27% (95% CI 21-33) and 92% (95% CI 87-95%), respectively. There was discordance between initial and final diagnosis of ABM in 196 children; 176 initially considered to have ABM had an alternative diagnosis, while 20 without an initial diagnosis of ABM were confirmed to have ABM. CONCLUSION:These data show that initial misdiagnosis of ABM is common in a malaria-endemic area of PNG. A diagnostic algorithm using standardized assessment for meningeal irritation, coma and malaria parasitological testing needs further evaluation in this setting.

In resource-limited countries, childhood malnutrition is common and intertwined with poverty. Although substantial financial and political commitments have been made globally in an attempt to reduce childhood mortality, in the Pacific region, including Papua New Guinea, malnutrition remains a neglected but significant cause of childhood deaths. The under-5 mortality in Papua New Guinea has been declining.1Wang H Liddell CA Coates MM et al.Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; (published online May 2.)http://dx.doi.org/10.1016/S0140-6736(14)60497-9Google Scholar Significant funding support by the global community in recent years has enabled the revival of the malaria control programme in the Pacific region, resulting in a substantial decline in the incidence of malaria. Additionally, after the introduction of the pentavalent vaccine in 2007 and more recently the pneumococcal vaccine, the high burden of invasive Haemophilus influenzae type b and pneumococcal diseases, particularly presenting as pneumonia and acute bacterial meningitis, the two major causes of childhood death in Papua New Guinea,2Duke T Poka H Dale F Michael A Mgone J Wal T Chloramphenicol versus benzylpenicillin and gentamicin for the treatment of severe pneumonia in children in Papua New Guinea: a randomised trial.Lancet. 2002; 359: 474-480Summary Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 3Laman M Manning L Hwaiwhange I et al.Lumbar puncture in children from an area of malaria endemicity who present with a febrile seizure.Clin Infect Dis. 2010; 51: 534-540Crossref PubMed Scopus (22) Google Scholar is expected to decline provided vaccination coverage is sustained and improved. Despite these gains, however, malnutrition not driven by HIV is emerging as the most important cause of childhood mortality in Papua New Guinea. Of 20 546 childhood hospital admissions throughout Papua New Guinea in 2012, 1660 children died and malnutrition directly caused or contributed to 36% of these deaths.5 Anecdotal data from the north coast of the country suggest that malnutrition is already the leading cause of childhood deaths. Of 3676 children aged 2 months or older admitted to Modilon hospital between 2009 and 2013, 314 (8·5%) died. Malnutrition directly caused or contributed to 45·5% of these deaths. Severe acute malnutrition was the primary diagnosis in 17% of deaths in 2009 (9/53), 15% in 2010 (6/39), 16% in 2011 (12/74), 12% in 2012 (10/80), and 23% in 2013 (16/68). Despite the decline of malaria and the expected decline of vaccine-preventable bacterial infections, malnutrition, which has been neglected for many years, is emerging as the leading cause of childhood deaths in Papua New Guinea. Although multifactorial, childhood malnutrition can be reduced if given a fair share of financial and political commitment, including basic strengthening of child health services, family planning services, and effective public health educational programmes. We declare no competing interests.