ISSN 0031-1480 VOL. 53, NO 3-4, SEPTEMBER-DECEMBER 2010 Medical Society of Papua New Guinea Executive 2010 President: Nakapi Tefuarani Vice-President: Nicholas Mann Secretary: Sylvester Lahe Treasurer: Glen Mola Executive Member: Evelyn Lavu ACKNOWLEDGEMENT We are grateful to the Government of Australia through AusAID for providing funding for the publication of this issue of the Journal. The Editors Published quarterly by the Medical Society of Papua New Guinea Papua New Guinea Medical Journal ISSN 0031-1480 September-December 2010, Volume 53, Number 3-4 EDITORS: PETER M. SIBA, NAKAPI TEFUARANI, FRANCIS HOMBHANJE GUEST EDITORS: DEBORAH LEHMANN AND WILLIAM POMAT Editorial Committee B. Amoa V. Golpak G. Hiawalyer J. Millan G. Mola A. Saweri J. Vince Assistant Editor: Cynthea Leahy Emeritus Editor: Michael Alpers Email: [email protected] Web page: http://www.pngimr.org.pg Registered at GPO, Port Moresby for transmission by Post as a Qualified Publication. Printed by Moore Printing for the Medical Society of Papua New Guinea. Authors preparing manuscripts for publication in the Journal should consult ‘Information for Authors’ inside back cover. Papua New Guinea Medical Journal Volume 53, Number 3-4, September-December 2010 CONTENTS FOCUS ISSUE ON PNEUMONIA RESEARCH EDITORIAL Pneumonia in Papua New Guinea: lessons learnt for the way forward W.S. Pomat, A.R. Greenhill and D. Lehmann 89 Some general factors to be considered when implementing a program to control pneumonia M.P. Alpers 94 ORIGINAL ARTICLES Pneumonia in Papua New Guinea, from the past to the future R.M. Douglas 99 Pneumonia research in Papua New Guinea: 1967-1986 I.D. Riley 106 Pneumonia in Goilala I.H. Kevau and A. Saweri 119 Collaborative studies in mucosal immunology in Goroka R. Clancy 122 Oxygen supplies for hospitals in Papua New Guinea: a comparison of the feasibility and cost-effectiveness of methods for different settings T. Duke, D. Peel, F. Wandi, R. Subhi, M. Sa’avu and S. Matai 126 Improving the aetiological diagnosis of bacterial pneumonia and meningitis in Papua New Guinea L-A.S. Kirkham, H.C. Smith-Vaughan and A.R. Greenhill 139 Nontypeable Haemophilus influenzae and childhood pneumonia A.W. Cripps 147 The bacteriology of lower respiratory infections in Papua New Guinean and Australian Indigenous children K.M. Hare, H.C. Smith-Vaughan and A.J. Leach 151 Streptococcus pneumoniae serogroups and colony morphology: a look back. E.M. Dunne, J. Montgomery, T. Lupiwa, A. Michael and D. Lehmann 166 Human immunodeficiency virus and respiratory disorders: clinical and diagnostic considerations W.J. McBride and A.R. Greenhill 169 Melioidosis – an uncommon but also under-recognized cause of pneumonia in Papua New Guinea J.M. Warner, D.B. Pelowa and B.J. Currie 176 Influenza in the Pacific A. Kelso and P.C. Reading 180 A neonatal pneumococcal conjugate vaccine trial in Papua New Guinea: study population, methods and operational challenges S. Phuanukoonnon, J.C. Reeder, W.S. Pomat, A.H.J. van den Biggelaar, P.G. Holt, G. Saleu, C. Opa, A. Michael, C. Aho, M. Yoannes, J. Francis, T. Orami, P. Namuigi, P.M. Siba, P.C. Richmond and D. Lehmann for the Neonatal Pneumococcal Conjugate Vaccine Trial Study Team 191 MEDICAL RESEARCH PROJECTS IN PAPUA NEW GUINEA 207 MEDLARS BIBLIOGRAPHY 210 AUTHOR INDEX 2006-2009 (Vol. 49-52) 231 SUBJECT AND PLACE-NAME INDEX 2006-2009 (Vol. 49-52) 233 REFEREES 2006-2009 235 PNG Med J 2010 Sep-Dec;53(3-4): 89-93 EDITORIAL Pneumonia in Papua New Guinea: lessons learnt for the way forward In August 2010, the National Department Nevertheless, people are pragmatic and will of Health (NDoH), World Health Organization use health services if available. The (WHO) and the Papua New Guinea Institute government’s intention to deliver life-saving of Medical Research (PNGIMR) convened a treatment and immunizations as near colloquium entitled ‘Action against people’s homes as possible would have a pneumonia: a celebration of 40 years of significant impact on mortality due to pneumonia research and finding the best way pneumonia. According to Alpers, a change forward’. The colloquium was opened by the in attitudes and practices, as well as Minister for Health and HIV/AIDS, community participation in planning, Honourable Sasa Zibe, and closed by the operating and maintaining community health Minister for Education, Honourable James care facilities, is required to lower the burden Marape. More than 300 people attended the of pneumonia in PNG. colloquium, including more than 20 overseas guests from Australia, Switzerland, England Decreasing the burden of pneumonia and the United States. Despite pneumonia requires an understanding of the aetiology being treatable and preventable, it continues of the disease, a fact that was not lost on two to be the main cause of hospitalization and of the pioneers of research on acute death in children in PNG; and indeed respiratory infections (ARIs) in PNG, Bob throughout the world. In addition, research Douglas and Ian Riley. Soon after his arrival on pneumonia, both locally and globally, is in the then Territory of Papua and New hampered by the relative difficulty in attracting Guinea in 1967, Douglas noted that severe funds compared to research into diseases pneumonia was the main cause of with lower burden in children, such as human hospitalization in young men in Lae. In immunodeficiency virus (HIV) infection, addition to describing the clinical features of malaria and tuberculosis. pneumonia in adults, Douglas and Riley set about determining the aetiology of the To commemorate 40 years of pneumonia disease, and found that the most commonly research and to advocate for the importance isolated pathogens were Streptococcus of pneumonia, this focus issue of the Journal pneumoniae (the pneumococcus) and comprises a series of articles on research Haemophilus influenzae (2,3). In this focus related to respiratory infections conducted issue both Douglas and Riley provide over the past 4 decades, while also historical accounts of the early ARI research highlighting future research and policy needs conducted in PNG (4,5). in PNG. A few years later two astute doctors The editorial by Michael Alpers (1) working in Port Moresby, Isi Kevau and Adolf provides an overview of the complexity of Saweri, noted that young men from Goilala factors that contribute to the high burden of in Central Province were commonly pneumonia in PNG and outlines the need for presenting with severe pneumonia. In this an integrated and holistic approach by issue Kevau and Saweri describe their early communities and government agencies to observations and discuss possible improve health systems. In particular, communities can play a major role in mechanisms for the change in clinical improving health care delivery through a presentation of lobar pneumonia from a variety of mechanisms. Two issues severe to a more moderate presentation in highlighted by Alpers that contribute to the the past 40 years (6). In the 1980s high mortality due to pneumonia are firstly researchers found S. pneumoniae and H. that parents and carers may not recognize influenzae to be the most important causes signs of severe disease and secondly that of moderate and severe pneumonia in there is an acceptance, particularly in areas children in the highlands of PNG (7,8), similar where there is poor access to health care, to the findings of studies conducted in adults that people commonly die of pneumonia. some 20 years earlier in lowland PNG. 89 Papua New Guinea Medical Journal Volume 53, No 3-4, Sep-Dec 2010 In this issue Kim Hare and colleagues of pneumonia. In this issue Lea-Ann Kirkham review the bacteriology of acute and chronic and colleagues (13) summarize the findings lower respiratory infections in Indigenous of aetiological studies conducted over the Australian and Papua New Guinean children, past 40 years in PNG, and discuss molecular who suffer similar high rates of respiratory methodology that could be adopted in PNG infections and early onset of dense upper to supplement bacterial culture. Although respiratory tract carriage (9). The authors blood culture remains the gold standard for suggest that, as in Indigenous Australians, diagnosis of bacterial pneumonia in young Papua New Guinean children who suffer children, it lacks sensitivity (at best 30%), severe or recurrent pneumonia are likely to which is further reduced when children have be at increased risk of developing chronic already been administered antibiotics prior suppurative lung disease or bronchiectasis. to presentation to hospital outpatients. Allan Hare et al. also highlight the importance of Cripps notes that a combination of blood nontypeable H. influenzae (NTHi) in chronic culture, trans-thoracic fine-needle aspiration lung disease (CLD) (9). While the and screened sputum can assist in prevalence of CLD in Papua New Guinean determining aetiology, though needle children is unknown Robert Clancy points out aspiration cannot be used routinely as it is that CLD is a major cause of death in adults an invasive procedure and furthermore it can aged >30 years in the highlands of PNG (10). only be done in the presence of consolidation Trials in PNG and overseas suggest that oral (14). Molecular-based diagnostic methods immunotherapy with inactivated NTHi are being used more and more frequently in reduces acute on chronic exacerbations of industrialized countries and the technology CLD in adults and the density of bacteria in is gradually becoming cheaper and more sputum. Oral immunotherapy may reduce robust. As such, the application of robust household transmission and hence disease molecular detection methods for bacteraemic in children. However, a formula for use in pneumonia should be considered at sentinel children should also be considered (10). sites in PNG in the future. Upper respiratory tract colonization is a In addition to H. influenzae and the necessary precursor to pneumonia and otitis pneumococcus, other pathogens, both media.