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Objective: To measure immunization coverage among children aged 12-23 months in Papua New Guinea (PNG) and to assess if and why there are differences between hard-to-reach and more accessible communities. Methods: WHO cluster sampling methodology was employed to measure immunization coverage in PNGs four regions. Survey data were re-analyzed according to a local assessment of geographical accessibility indicated by census unit type: urban rural and hard-to-reach. Census units were designated as hard-to-reach if they were five or more kilometres from a health centre. Findings: Nationwide coverage for most antigens falls below the national target of 80% although there are regional differences with Islands performing the best. Late doses are a major concern: just 4% were fully immunized with valid ("on time") doses by 1 year of age. Coverage was lower in both rural and remote communities: at 6 months 48% of children from urban units had received three valid doses of DTP-3 but only 16% in rural areas and 13% in hard-to-reach communities. Reasons for failure to immunize varied: 21% of mothers said their child was not immunized because distance travel conditions or cost of transportation prevented access to local health centres; 27% cited a lack of knowledge or misconceptions about immunization; while 29% believed it was because of an issue with the health system. Conclusions: Throughout PNG there is an urgent need to increase immunization coverage and to ensure that children are immunized on time according to the schedule. Both coverage and timeliness of doses are worse for children living in hard-to-reach and rural areas. Achieving national immunization targets requires improvements in health service delivery including outreach especially for remote and rural communities as well as greater community education and social mobilisation in support of immunization services.

To the Editor: A high case-fatality ratio has often been associated with outbreaks of a new influenza virus but is less commonly reported in association with seasonal influenza. Nevertheless, in developing countries, seasonal influenza has been associated with a high proportion of deaths, especially among remote populations. In Madagascar, seasonal influenza mortality rates of 2.5% have been reported (1), with even higher rates (15%) reported in Indonesia (2) and in the highlands of Papua New Guinea (9.5%) (3). High mortality rates during influenza outbreaks in the developing setting have been ascribed to a lack of access to antimicrobial drugs to treat cases of secondary pneumonia and lack of access to health care in general (1). Diarrheal disease is a major cause of illness and death throughout the world, with diarrheal outbreaks causing a substantial proportion of deaths (4). Endemic shigellosis is responsible for ≈10% of all cases of diarrhea among children

To the Editor: Cholera outbreak reports are of international public health interest, especially in areas that were previously cholera free (1). Although many recent cholera outbreaks have originated in coastal areas (2), identifying the source of cholera introduction has been challenging (1). The detection of Vibrio cholerae in coastal, brackish and riverine waters in cholera-endemic and cholera-free areas supports the view that autochtonous V. cholerae is involved in the introduction of cholera (3,4). To our knowledge, cholera has not been reported in Papua New Guinea, despite social and environmental conditions likely to facilitate transmission and the nation's close proximity to cholera-endemic countries (5,6). On August 6, 2009, a physician who visited the coastal village of Lambutina reported an outbreak of acute watery diarrhea that was associated with the death of his father and 4 other persons from this and a neighboring village. The outbreak began in the village of Nambariwa and spread to neighboring Lambutina, Morobe Province. From August 13, multidisciplinary teams worked with the community to reduce the number of deaths through early identification and treatment of case-patients. The teams also worked to limit transmission through improvements to the water and sanitation infrastructure and by encouraging better hygiene practices among the villagers. A suspected case of cholera was defined as acute watery diarrhea or vomiting in a resident of Lambutina or Nambariwa villages since July 22, 2009. In the 2 villages, 77 cases were identified; attack rates were 14% in Lambutina (48/343) and 5.5% in Nambariwa (29/532). The overall case-fatality ratio was 6.5% (5/77); 2 patients died after they were discharged from the referral hospital. A retrospective frequency-matched case–control study was conducted in Lambutina to identify the risk factors associated with suspected cholera. Neighborhood controls (± 5 years of age) were selected from unaffected households. Univariate and multivariate analyses were conducted with STATA version 10 (StataCorp., College Station, TX, USA). Of the 48 case-patients in Lambutina, 43 participated in the study with 43 age-matched controls. In addition to having close contact with patients who had cholera, univariate analysis showed that case-patients were more likely to have had several exposures related to the death of other patients (Table). However, having close contact with a patient was the only independent risk factor (adjusted odds ratio 4.8, 95% confidence interval 1.7–13.4) (Table). Close contact included providing nursing care for patients or carrying patients onto boats for transport to health care facilities. From the 10 collected samples, 4 isolates were confirmed as V. cholerae O1, biotype El Tor, serotype Ogawa, by PCR detection of an O1-specific region of the rfb gene using established methods and PCR amplification of the tcpA gene polymorphism specific for the El Tor biotype (7). The ctxAB, vct genes (present in toxigenic strains) and the hemolysin gene hlyA (present in all V. cholerae strains) were detected by PCR in all 4 isolates. Although health authorities promptly identified and responded to the outbreak, they could not determine its origin. The El Nino weather phenomenon generates increased rainfall and elevated sea surface temperatures and is a predictor of cholera outbreaks (8), which puts more coastal areas at risk for such outbreaks (9). During this outbreak, Papua New Guinea reported above-average rainfall (10) and warmer sea surface temperatures. Although cholera may have been introduced to Papua New Guinea through an infectious traveler or by other means, climatic factors may have initiated plankton blooms, the abundance of which have also been associated with increased presence of V. cholerae O1. Sea and estuarine waters of these villages are plausible sources of introduction. In Lambutina, the age-specific attack rates were lowest among young children and increased among persons of middle age and among the elderly. Those providing patient care and lifting during transportation as well as those washing the bodies of the deceased may have been more represented in the >40 years age group; however, this situation may not explain the high attack rates among the elderly. Generally, after a cholera outbreak is detected, interventions aim to reduce the proportion of deaths to

Issue: Papua New Guinea is striving to achieve the minimum core requirements under the International Health Regulations in surveillance and outbreak response, and has experienced challenges in the availability and distribution of health professionals. Context: Since mid-2009, a large cholera outbreak spread across lowland regions of the country and has been associated with more than 15 500 notifications at a case fatality ratio of 3.2%. The outbreak placed significant pressure on clinical and public health services. Action: We describe some of the challenges to cholera preparedness and response in this human resource-limited setting, the strategies used to ensure effective cholera management and lessons learnt. Outcome: Cholera task forces were useful to establish a clear system of leadership and accountability for cholera outbreak response and ensure efficiencies in each technical area. Cholera outbreak preparedness and response was strongest when human resource and health systems functioned well before the outbreak. Communication relied on coordination of existing networks and methods for empowering local leaders and villagers to modify behaviours of the population. Discussion: In line with the national health emergencies plan, the successes of human resource strategies during the cholera outbreak should be built upon through emergency exercises, especially in non-affected provinces. Population needs for all public health professionals involved in health emergency preparedness and response should be mapped, and planning should be implemented to increase the numbers in relevant areas. Human resource planning should be integrated with health emergency planning. It is essential to maintain and strengthen the human resource capacities and experiences gained during the cholera outbreak to ensure a more effective response to the next health emergency.

Papua New Guinea (PNG) faces formidable health equity challenges. Technology and information is a key part of an effective health system and a determinant of community health equity. Innovative uses of mHealth technologies are proliferating in PNG and can facilitate improvements in the flow of data and information in the PNG health system. However in isolation these are unlikely to lead to positive change in health equity. This paper considers the implications of mHealth interventions within the broader PNG health system, and discusses the importance of evaluation to ensure mHealth contributes to improved community health outcomes and health equity.

To the Editor: Approximately half the Shigella spp. infections in developing countries are caused by endemic shigellae (1), which in these countries are responsible for ≈10% of all episodes of diarrhea among children

An in-depth evaluation of rural immunization services in Papua New Guinea was conducted to determine the reasons for poor immunization coverage, as well as to document the impact of recent efforts to strengthen the national immunization program.A qualitative process was used to complement quantitative monitoring data. An interview process, based on open-ended questions, active listening and observation, was designed whereby a team of program supervisors collected information from rural health staff. The teams interviewed health staff in 30 health centres that were selected to provide examples of contrasting field situations.This qualitative review provided valuable detail about why immunization services were failing, encompassing locally specific weaknesses, such as logistic reasons for not conducting outreach, and generic systemic problems such as lack of access to funding. In addition, the information gathered provided details on local solutions developed by better-performing facilities. Both these aspects added significant value to quantitative measures of program performance (derived from national health information system data and analysis of supervision checklists). The review also captured a number of behavioural reasons that will need to be overcome before an improvement in the services can be expected.This in-depth evaluation provided valuable information about problems in peripheral immunization clinics and identified local solutions. The high level of detail collected will be important for planning future strengthening of the health system. The study modelled a supportive form of supervision with the potential to improve outcomes from future supervisory visits. Some of the major barriers to improved immunization were locally specific organizational issues, as well as complex human problems. While some issues can be remedied through further strengthening of immunization systems, others lack easy, rapid solutions.

Background: In October 2004, Manam Island volcano in Papua New Guinea erupted, causing over 10 000 villagers to flee to internally displaced person (IDP) camps, including 550 from Dugulaba village. Following violence over land access in March 2010, the IDPs fled the camps, and four months later concurrent outbreaks of acute watery diarrhea and unusual neurological complaints were reported in this population. Materials and Methods: A retrospective case-control study was conducted to identify the risk factors for peripheral neuropathy. Rectal swabs were collected from cases of acute watery diarrhea. Hair and serum metals and metalloids were analyzed by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS). Results: There were 17 deaths among the 550 village inhabitants during the outbreak period at a crude mortality rate 21-fold that of a humanitarian crisis. Vibrio cholerae O1 El Tor Ogawa was confirmed among the population. Access tocommunity-level rehydration was crucial to mortality. Peripheral neuropathy was diagnosed among cases with neurological symptoms. A balanced diet was significantly protective against neuropathy. A dose-response relationship was seen between peripheral neuropathy and a decreasing number of micronutrient- rich foods in the diet. Deficiencies in copper, iron, selenium and zinc were identified among the cases of peripheral neuropathy. Conclusions: Cholera likely caused the mostly preventable excess mortality. Peripheral neuropathy was not caused by cholera, but cholera may worsen existing nutritional deficiencies. The peripheral neuropathy was likely caused by complex micronutrient deficiencies linked to non-diversified diets that potentially increased the vulnerability of this population, however a new zinc-associated neuropathy could not be ruled out. Reoccurrence can be prevented by addressing the root cause of displacement and ensuring access to arable land and timely resettlement.