65 research outputs found
Factors associated with ultrasound-aided detection of suboptimal fetal growth in a malaria-endemic area in Papua New Guinea
BACKGROUND: Fetal growth restriction (FGR) is associated with
increased infant mortality rates and ill-health in adulthood.
Evaluation of fetal growth requires ultrasound. As a result,
ultrasound-assisted evaluations of causes of FGR in
malaria-endemic developing countries are rare. We aimed to
determine factors associated with indicators of abnormal fetal
growth in rural lowland Papua New Guinea (PNG). METHODS: Weights
and growth of 671 ultrasound-dated singleton pregnancies (<25
gestational weeks) were prospectively monitored using estimated
fetal weights and birthweights. Maternal nutritional status and
haemoglobin levels were assessed at enrolment, and participants
were screened for malaria on several occasions. FGR was
suspected upon detection of an estimated fetal weight or
birthweight <10(th) centile (small-for-gestational age)
and/or low fetal weight gain, defined as a change in weight
z-score in the first quartile. Factors associated with fetal
weight and fetal weight gain were additionally assessed by
evaluating differences in weight z-scores and change in weight
z-scores. Log-binomial and linear mixed effect models were used
to determine factors associated with indicators of FGR. RESULTS:
SGA and low weight gain were detected in 48.3% and 37.0% of
pregnancies, respectively. Of participants, 13.8%, 21.2%, and
22.8% had a low mid-upper arm circumference (MUAC, <22 cms),
short stature (<150 cms) and anaemia (haemoglobin <90 g/L)
at first antenatal visit. 24.0% (161/671) of women had at least
one malaria infection detected in peripheral blood. A low MUAC
(adjusted risk ratio [aRR] 1.51, 95% CI 1.29, 1.76, P <
0.001), short stature (aRR 1.27, 95% CI 1.04, 1.55, P = 0.009),
and anaemia (aRR 1.27, 95% CI 1.06, 1.51, P = 0.009) were
associated with SGA, and a low body mass index was associated
with low fetal weight gain (aRR 2.10, 95% CI 1.62, 2.71, P <
0.001). Additionally, recent receipt of intermittent preventive
treatment in pregnancy was associated with increased weight
z-scores, and anaemia with reduced change in weight z-scores.
Malaria infection was associated with SGA on crude but not
adjusted analyses (aRR 1.13, 95% CI 0.95, 1.34, P = 0.172).
CONCLUSION: Macronutrient undernutrition and anaemia increased
the risk of FGR. Antenatal nutritional interventions and malaria
prevention could improve fetal growth in PNG
Determining effects of areca (betel) nut chewing in a prospective cohort of pregnant women in Madang Province, Papua New Guinea
BACKGROUND: Chewing areca nut (AN), also known as betel nut, is
common in Asia and the South Pacific and the habit has been
linked to a number of serious health problems including oral
cancer. Use of AN in pregnancy has been associated with a
reduction in mean birthweight in some studies, but this
association and the relationship between AN chewing and other
adverse pregnancy outcomes remain poorly understood. METHODS: We
assessed the impact of AN chewing on adverse outcomes including
stillbirth, low birthweight (LBW, <2,500 g) and anaemia at
delivery (haemoglobin <11.0 g/dL) in a longitudinal cohort of
2,700 pregnant women residing in rural lowland Papua New Guinea
(PNG) from November 2009 until February 2013. Chewing habits and
participant characteristics were evaluated at first antenatal
visit and women were followed until delivery. RESULTS: 83.3%
[2249/2700] of pregnant women used AN, and most chewed on a
daily basis (86.2% [1939/2249]. Smoking and alcohol use was
reported by 18.9% (511/2700) and 5.0% (135/2688) of women,
respectively. AN use was not associated with pregnancy loss or
congenital abnormalities amongst women with a known pregnancy
outcome (n = 2215). Analysis of 1769 birthweights did not
demonstrate an association between AN and LBW (chewers: 13.7%
[200/1459] vs. non-chewers: 14.5% [45/310], P = 0.87) or reduced
mean birthweight (2957 g vs. 2966 g; P = 0.76). Women using AN
were more likely to be anaemic (haemoglobin <11 g/dL) at
delivery (75.2% [998/1314] vs. 63.9% [182/285], adjusted odds
ratio [95% CI]: 1.67 [1.27, 2.20], P < 0.001). Chewers more
commonly had male babies than non-chewers (46.1% [670/1455] vs.
39.8% [123/309], P = 0.045). CONCLUSIONS: AN chewing may
contribute to anaemia. Although not associated with other
adverse pregnancy outcome in this cohort gestational AN use
should be discouraged, given the potential adverse effects on
haemoglobin and well-established long-term health risk including
oral cancer. Future research evaluating the potential
association of AN use and anaemia may be warranted. TRIAL
REGISTRATION: ClinicalTrials.gov NCT01136850 (06 April 2010)
Risk factors and pregnancy outcomes associated with placental malaria in a prospective cohort of Papua New Guinean women
BACKGROUND: Plasmodium falciparum in pregnancy results in
substantial poor health outcomes for both mother and child,
particularly in young, primigravid mothers who are at greatest
risk of placental malaria (PM) infection. Complications of PM
include maternal anaemia, low birth weight and preterm delivery,
which contribute to maternal and infant morbidity and mortality
in coastal Papua New Guinea (PNG). METHODS: Placental biopsies
were examined from 1451 pregnant women who were enrolled in a
malaria prevention study at 14-26 weeks gestation. Clinical and
demographic information were collected at first antenatal clinic
visits and women were followed until delivery. Placental
biopsies were collected and examined for PM using histology. The
presence of infected erythrocytes and/or the malaria pigment in
monocytes or fibrin was used to determine the type of placental
infection. RESULTS: Of 1451 placentas examined, PM infection was
detected in 269 (18.5%), of which 54 (3.7%) were acute, 55
(3.8%) chronic, and 160 (11.0%) were past infections. Risk
factors for PM included residing in rural areas (adjusted odds
ratio (AOR) 3.65, 95% CI 1.76-7.51; p </= 0.001), being
primigravid (AOR 2.45, 95% CI 1.26-4.77; p = 0.008) and having
symptomatic malaria during pregnancy (AOR 2.05, 95% CI
1.16-3.62; p = 0.013). After adjustment for covariates, compared
to uninfected women, acute infections (AOR 1.97, 95% CI
0.98-3.95; p = 0.056) were associated with low birth weight
babies, whereas chronic infections were associated with preterm
delivery (AOR 3.92, 95% CI 1.64-9.38; p = 0.002) and anaemia
(AOR 2.22, 95% CI 1.02-4.84; p = 0.045). CONCLUSIONS: Among
pregnant PNG women receiving at least one dose of intermittent
preventive treatment in pregnancy and using insecticide-treated
bed nets, active PM infections were associated with adverse
outcomes. Improved malaria prevention is required to optimize
pregnancy outcomes
Metaanalysis of the Performance of a Combined Treponemal and Nontreponemal Rapid Diagnostic Test for Syphilis and Yaws
BACKGROUND: The human treponematoses are important causes of
disease. Mother-to-child transmission of syphilis remains a
major cause of stillbirth and neonatal death. There are also
almost 100 000 cases of endemic treponemal disease reported
annually, predominantly yaws. Rapid diagnostic tests (RDTs)
would improve access to screening for these diseases. Most RDTs
cannot distinguish current and previous infection. The Dual Path
Platform (DPP) Syphilis Screen & Confirm test includes both
a treponemal (T1) and nontreponemal (T2) component and may
improve the accuracy of diagnosis. METHODS: We conducted a
metaanalysis of published and unpublished evaluations of the
DPP-RDT for the diagnosis of syphilis and yaws. We calculated
the sensitivity, specificity, and overall agreement of the test
compared with reference laboratory tests. RESULTS: Nine
evaluations, including 7267 tests, were included. Sensitivity
was higher in patients with higher titer rapid plasma reagin
(>/=1:16) for both the T1 (98.2% vs 90.1%, P < .0001) and
the T2 component (98.2% vs 80.6%, P < .0001). Overall
agreement between the DPP test and reference serology was 85.2%
(84.4%-86.1%). Agreement was highest for high-titer active
infection and lowest for past infection. CONCLUSIONS: The RDT
has good sensitivity and specificity of the treponemal and
nontreponemal components both in cases of suspected syphilis and
yaws, although the sensitivity is decreased at lower antibody
titers
Comparative efficacy of low-dose versus standard-dose azithromycin for patients with yaws: a randomised non-inferiority trial in Ghana and Papua New Guinea
Background: A dose of 30 mg/kg of azithromycin is recommended for treatment of yaws, a disease targeted for global eradication. Treatment with 20 mg/kg of azithromycin is recommended for the elimination of trachoma as a public health problem. In some settings, these diseases are co-endemic. We aimed to determine the efficacy of 20 mg/kg of azithromycin compared with 30 mg/kg azithromycin for the treatment of active and latent yaws. Methods: We did a non-inferiority, open-label, randomised controlled trial in children aged 6–15 years who were recruited from schools in Ghana and schools and the community in Papua New Guinea. Participants were enrolled based on the presence of a clinical lesion that was consistent with infectious primary or secondary yaws and a positive rapid diagnostic test for treponemal and non-treponemal antibodies. Participants were randomly assigned (1:1) to receive either standard-dose (30 mg/kg) or low-dose (20 mg/kg) azithromycin by a computer-generated random number sequence. Health-care workers assessing clinical outcomes in the field were not blinded to the patient's treatment, but investigators involved in statistical or laboratory analyses and the participants were blinded to treatment group. We followed up participants at 4 weeks and 6 months. The primary outcome was cure at 6 months, defined as lesion healing at 4 weeks in patients with active yaws and at least a four-fold decrease in rapid plasma reagin titre from baseline to 6 months in patients with active and latent yaws. Active yaws was defined as a skin lesion that was positive for Treponema pallidum ssp pertenue in PCR testing. We used a non-inferiority margin of 10%. This trial was registered with ClinicalTrials.gov, number NCT02344628.
Findings: Between June 12, 2015, and July 2, 2016, 583 (65·1%) of 895 children screened were enrolled; 292 patients were assigned a low dose of azithromycin and 291 patients were assigned a standard dose of azithromycin. 191 participants had active yaws and 392 had presumed latent yaws. Complete follow-up to 6 months was available for 157 (82·2%) of 191 patients with active yaws. In cases of active yaws, cure was achieved in 61 (80·3%) of 76 patients in the low-dose group and in 68 (84·0%) of 81 patients in the standard-dose group (difference 3·7%; 95% CI −8·4 to 15·7%; this result did not meet the non-inferiority criterion). There were no serious adverse events reported in response to treatment in either group. The most commonly reported adverse event at 4 weeks was gastrointestinal upset, with eight (2·7%) participants in each group reporting this symptom.
Interpretation:
In this study, low-dose azithromycin did not meet the prespecified non-inferiority margin compared with standard-dose azithromycin in achieving clinical and serological cure in PCR-confirmed active yaws. Only a single participant (with presumed latent yaws) had definitive serological failure. This work suggests that 20 mg/kg of azithromycin is probably effective against yaws, but further data are needed
The impact of tubal ectopic pregnancy in Papua New Guinea - a retrospective case review
BACKGROUND: Ectopic pregnancy (EP) is an important cause of morbidity and mortality amongst women of reproductive age. Tubal EP is well described in industrialised countries, but less is known about its impact in low-resource countries, in particular in the South Pacific Region. METHODS: We undertook a retrospective review of women with tubal EP treated at a provincial referral hospital in coastal Papua New Guinea over a period of 56 months. Demographic and clinical variables were obtained from patients’ medical records and analysed. The institutional rate of tubal EP was calculated, and diagnosis and management reviewed. Potential risk factors for tubal EP were identified, and delays contributing to increased morbidity described. RESULTS: A total of 73 women had tubal EP. The institutional rate of tubal EP over the study period was 6.3 per 1,000 deliveries. There were no maternal deaths due to EP. The mean age of women was 31.5+/−5.7 years, 85% were parous, 67% were rural dwellers and 62% had a history of sub-fertility. The most commonly used diagnostic aid was culdocentesis. One third of women had clinical evidence of shock on arrival. All women with tubal EP were managed by open salpingectomy. Tubal rupture was confirmed for 48% of patients and was more common amongst rural dwellers. Forty-three percent of women had macroscopic evidence of pelvic infection. Two-thirds of patients received blood transfusions, and post-operative recovery lasted six days on average. Late presentation, lack of clinical suspicion, and delays with receiving appropriate treatments were observed. CONCLUSIONS: Tubal EP is a common gynaecological emergency in a referral hospital in coastal PNG, and causes significant morbidity, in particular amongst women residing in rural areas. Sexually transmitted infections are likely to represent the most important risk factor for tubal EP in PNG. Interventions to reduce the morbidity due to tubal EP include the prevention, detection and treatment of sexually transmitted infections, identification and reduction of barriers to prompt presentation, increasing health workers’ awareness of ectopic pregnancy, providing pregnancy test kits to rural health centres, and strengthening hospital blood transfusion services, including facilities for autotransfusion
Azithromycin-containing intermittent preventive treatment in pregnancy affects gestational weight gain, an important predictor of birthweight in Papua New Guinea - an exploratory analysis
In Papua New Guinea, intermittent preventive treatment with sulphadoxine-pyrimethamine and azithromycin (SPAZ-IPTp) increased birthweight despite limited impact on malaria and sexually transmitted infections. To explore possible nutrition-related mechanisms, we evaluated associations between gestational weight gain (GWG), enrolment body mass index (BMI) and mid-upper arm circumference (MUAC), and birthweight. We investigated whether the increase in birthweight associated with SPAZ-IPTp may partly be driven by a treatment effect on GWG. The mean GWG rate was 393 g/week (SD 250; n = 948). A 100 g/week increase in GWG was associated with a 14 g (95% CI 2.6, 25.4) increase in birthweight (P = 0.016). Enrolment BMI and MUAC also positively correlated with birthweight. SPAZ-IPTp was associated with increased GWG [58 g/week (26, 900), P < 0.001, n = 948] and with increased birthweight [48 g, 95% CI (8, 880), P = 0.019] when all eligible women were considered (n = 1947). Inclusion of GWG reduced the birthweight coefficient associated with SPAZ-IPTp by 18% from 44 to 36 g (n = 948), although SPAZ-IPTp was not significantly associated with birthweight among women for whom GWG data were available (P = 0.13, n = 948). One month post-partum, fewer women who had received SPAZ-IPTp had a low post-partum BMI (<18.5 kg m(-2) ) [adjusted risk ratio: 0.55 (95% CI 0.36, 0.82), P = 0.004] and their babies had a reduced risk of wasting [risk ratio 0.39 (95% CI 0.21, 0.72), P = 0.003]. SPAZ-IPTp increased GWG, which could explain its impact on birthweight and maternal post-partum BMI. Future trials of SPAZ-IPTp must incorporate detailed anthropometric evaluations to investigate mechanisms of effects on maternal and child health
Sensitivity and specificity of a rapid point-of-care test for active yaws: a comparative study.
BACKGROUND: To eradicate yaws, national control programmes use the Morges strategy (initial mass treatment and biannual resurveys). The resurvey component is designed to actively detect and treat remaining yaws cases and is initiated on the basis of laboratory-supported reactive non-treponemal serology (using the rapid plasma reagin [RPR] test). Unfortunately, the RPR test is available rarely in yaws-endemic areas. We sought to assess a new point-of-care assay-the Dual Path Platform (DPP) syphilis assay, which is based on simultaneous detection of antibodies to treponemal and non-treponemal antigens-for guiding use of antibiotics for yaws eradication. A secondary goal was to ascertain at what timepoint the DPP assay line reverted to negative after treatment. METHODS: 703 children (aged 1-18 years) with suspected clinical yaws living in two remote, yaws-endemic villages in Papua New Guinea were enrolled. Clinical suspicion of yaws was established according to a WHO pictorial guide. We obtained blood samples from all patients. We calculated the sensitivity and specificity of the DPP assay for detection of antibodies to treponemal (T1) and non-treponemal (T2) antigens and compared values against those obtained with standard laboratory tests (the Treponema pallidum haemagglutination assay [TPHA] and the RPR test). We followed up a subsample of children with dually positive serology (T1 and T2) to monitor changes in DPP optical density (using an automatic reader) at 3 and 6 months. This trial is registered with ClinicalTrials.gov, number NCT01841203. FINDINGS: Of 703 participants, 389 (55%) were reactive for TPHA, 305 (43%) for the RPR test, and 287 (41%) for both TPHA and the RPR test. The DPP T1 (treponemal) assay had a sensitivity of 88·4% (95% CI 84·8-91·4) and specificity of 95·2% (92·2-97·3). The DPP T2 (non-treponemal) assay had a sensitivity of 87·9% (83·7-91·3) and specificity of 92·5% (89·4-94·9). In subgroup analyses, sensitivities and specificities did not differ according to type of specimen (plasma vs whole blood). For specimens with an RPR titre of 1:8 or greater, the sensitivity of the DPP T2 assay was 94·1% (95% CI 89·9-96·9). Serological cure (including seroreversion or a fourfold reduction in optical density value) was attained at 6 months in 173 (95%) of 182 children with dual-positive serology. INTERPRETATION: The DPP assay is accurate for identification of antibodies to treponemal and non-treponemal antigens in patients with yaws and avoids the need for laboratory support. A change of diagnostic procedure from the currently implemented RPR test to the simpler DPP assay could ease the implementation of yaws eradication activities. FUNDING: Chembio Diagnostic Systems, Newcrest Mining, and the Papua New Guinea National Department of Health
A case of ultrasound-guided prenatal diagnosis of prune belly syndrome in Papua New Guinea - implications for management
BACKGROUND: Prune belly syndrome is a rare congenital malformation of unknown aetiology and is characterised by abnormalities of the urinary tract, a deficiency of abdominal musculature and bilateral cryptorchidism in males. We report a case of prune belly syndrome from Papua New Guinea, which was suspected on pregnancy ultrasound scan and confirmed upon delivery. CASE PRESENTATION: A 26-year-old married woman, Gravida 3 Para 2, presented to antenatal clinic in Madang, Papua New Guinea, at 21(+5) weeks' gestation by dates. She was well with no past medical or family history of note. She gave consent to participate in a clinical trial on prevention of malaria in pregnancy and underwent repeated ultrasound examinations which revealed a live fetus with persistent megacystis and anhydramnios. Both mother and clinicians agreed on conservative management of the congenital abnormality. The mother spontaneously delivered a male fetus weighing 2010 grams at 34 weeks' gestation with grossly abnormal genitalia including cryptorchidism, penile aplasia and an absent urethral meatus, absent abdominal muscles and hypoplastic lungs. The infant passed away two hours after delivery. This report discusses the implications of prenatal detection of severe congenital abnormalities in PNG. CONCLUSION: This first, formally reported, case of prune belly syndrome from a resource-limited setting in the Oceania region highlights the importance of identifying and documenting congenital abnormalities. Women undergoing antenatal ultrasound examinations must be carefully counseled on the purpose and the limitations of the scan. The increasing use of obstetric ultrasound in PNG will inevitably result in a rise in prenatal detection of congenital abnormalities. This will need to be met with adequate training, referral mechanisms and better knowledge of women's attitudes and beliefs on birth defects and ultrasound. National medicolegal guidance regarding induced abortion and resuscitation of a fetus with severe congenital abnormalities may be required
Preterm or not – an evaluation of estimates of gestational age in a cohort of women from rural Papua New Guinea
Abstract Background Knowledge of accurate gestational age is required for comprehensive pregnancy care and is an essential component of research evaluating causes of preterm birth. In industrialised countries gestational age is determined with the help of fetal biometry in early pregnancy. Lack of ultrasound and late presentation to antenatal clinic limits this practice in low-resource settings. Instead, clinical estimators of gestational age are used, but their accuracy remains a matter of debate. Methods In a cohort of 688 singleton pregnancies from rural Papua New Guinea, delivery gestational age was calculated from Ballard score, last menstrual period, symphysis-pubis fundal height at first visit and quickening as well as mid- and late pregnancy fetal biometry. Published models using sequential fundal height measurements and corrected last menstrual period to estimate gestational age were also tested. Novel linear models that combined clinical measurements for gestational age estimation were developed. Predictions were compared with the reference early pregnancy ultrasound (25 gestational weeks) using correlation, regression and Bland-Altman analyses and ranked for their capability to predict preterm birth using the harmonic mean of recall and precision (F-measure). Results Average bias between reference ultrasound and clinical methods ranged from 0–11 days (95% confidence levels: 14–42 days). Preterm birth was best predicted by mid-pregnancy ultrasound (F-measure: 0.72), and neuromuscular Ballard score provided the least reliable preterm birth prediction (F-measure: 0.17). The best clinical methods to predict gestational age and preterm birth were last menstrual period and fundal height (F-measures 0.35). A linear model combining both measures improved prediction of preterm birth (F-measure: 0.58). Conclusions Estimation of gestational age without ultrasound is prone to significant error. In the absence of ultrasound facilities, last menstrual period and fundal height are among the more reliable clinical measures. This study underlines the importance of strengthening ultrasound facilities and developing novel ways to estimate gestational ag
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