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1585
Disability & Rehabilitation
2012
34
18
1585
1588
©2012 Informa UK, Ltd.
10.3109/09638288.2011.651190
0963-8288
1464-5165
Disability & Rehabilitation, 2012; 34(18): 1585–1588©2012 Informa UK, Ltd.ISSN 0963-8288 print/ISSN 1464-5165 onlineDOI: 10.3109/09638288.2011.651190
14 November 2011
05 December 2011
December 2011
Purpose: This article is intended to focus on the need for the use of rehabilitation services, for children with meningitis in Papua New Guinea, which is one of largest developing country in The Pacific with diverse culture and landscape. Meningitis is the fifth leading disease that results in disability in the country. The first line of treatment is usually antibiotics, administration of vaccination is also recommended. Currently community based rehabilitation workers and Physiotherapist offer the rehabilitation services. There is a need for the other rehabilitation professionals and appropriate education to the CBR workers, caregivers for providing effective Rehabilitation. Method: Articles related to meningitis were recruited through various electronic database such as Ovid SP, MEDLINE, CINHAL, Google Scholar and HINARI and EBSCOhost for full text. The search includes journal articles, editorials, research reports, systematic reviews and books. Results: The neurological sequelae resulting from meningitis are increasing. There is a need for Hib vaccination to reduce the rate of mortality. Physiotherapists are new professionals that emerged since 2006 and are assisting in reducing the motor and neurological disability. Conclusions: A multidisciplinary approach is required to manage the child with meningitis. Adequate knowledge, resources and assistance about the condition among the health professionals, carers and teachers would enable the children to achieve the quality of life.
Keywords: Developing country, meningitis, physiotherapy
Introduction
Papua New Guinea (PNG) is one the largest developing nation in the pacific with a estimated population of 6, 187, 591 in July 2011 [1] among those 87% lives in rural settings. PNG is unique with its geographical location with a collection 600 islands and 850 indigenous languages spoken. World Health Organization (WHO) estimates that 10% of any population
has some of disability. This estimation would mean that approximately 670,000 of population would have some form of disability. The 1990 Census of PNG identified 11,938 per-sons 10-years old and over as being handicapped or disabled. The handicapped or disabled category was listed as one of the economic activity codes in the 1990 census [2].
In rural areas of PNG, meningitis causes high rates of mor-tality and severe long-term disability in a high proportion of survivors [3]. Meningitis is fifth leading causes of mortality among the communicable diseases in PNG where 379 cases reported death in 2008 (Male: 200, Female: 179) with a rate of 5.87 per 100,000 populations [4]. Studies indicate that antibi-otic therapy is the first line of treatment for acute meningitis. There found to be little emphasis on management for neuro-logical sequelae resulting from meningitis and to reduce the rate of disability. Hence this article highlights the need for such resources in the country to support the children with meningitis.
What is meningitis?
Meningitis or leptomeningitis is one of the inflammatory disorders in brain. The infection is spread through the cere-brospinal fluid (CSF), which involves the pia, arachnoid, and subarchnoid spaces and the adjacent superficial structures of brain and spinal cord. A wide variety of organisms, the
PERSPECTIVES IN REHABILITATION
Meningitis: is a major cause of disability amongst Papua New Guinea children?
Priya Karthikeyan & Karthikeyan P. Ramalingam
Department of Physiotherapy, Divine Word University, Madang, Papua New Guinea
Correspondence: Priya Karthikeyan, Lecturer, Department of Physiotherapy, Divine Word University, PO Box 483, Madang, Papua New Guinea. Tel: 675 4241 886; Mobile: 675 71412425. E-mail: [email protected]
• Meningitis is a neurological disorder resulting from mild to severe neurological sequelea.
• The need for availability of cephalosporin is required to reduce the consequence of disease.
• Multidisciplinary approach will reduce the rate of disability resulting from meningitis.
Implications for Rehabilitation
(Accepted December 2011)
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spread through CSF accounts for the variety and the extent of neurological sequelae. Infections caused by gram-negative entero bacilli like Escherichia coli, and group B streptococci occur most frequently. Typical causative in children include Neisseria meningitides and Haemophilus influenza, the most common cause of community-acquired meningitis. Studies have shown that neurological sequelae occur from 25% to 50%, hemiparies from 15% to 30%, speech from 10% to 20% of the cases [5]. Bacterial meningitis is the leading cause of death and responsible for the neurological disabilities in many survivors.
Meningitis in developing nations
Mortality of neonatal meningitis is found to be 40–58% in developing countries [6]. Developing countries like Ethiopia, Gambia, PNG and Philippines have the highest rate of neonatal mortality resulting from meningitis [6–9]. WHO estimates that 5 million children under one month of age die every year in developing countries [10]. Bacterial meningitis is the common cause of fatality of 170,000 and disability globally for each year. WHO, International clas-sification of Functions defines the neurological sequelae comprise a range of findings with implications for child development and functioning and include such deficits as hearing loss, vision loss, cognitive delay, speech/language disorder, behavioural problems, motor delay/impairment, and seizures, studies found that the hearing loss and motor impairment were the most frequently reported problem [11]. As stated in Global Burden of Disease, sequelae is defined as the health status resulting from bacterial meningitis the natural history of disease that has impaired quality of life or activities of daily living [12,13].
Moodely and Bullock have identified the following neuro-logical sequelae among child resulting from bacterial meningi-tis were early inflammatory changes, subpial encephalopathy, vasculitis and infarction of major vessels, raised intracranial pressure, hydrocephalus after meningitis, subdural effu-sions, subdural empyema and brain abscess, cerebral corti-cal and white matter atrophy, multicystic encephalomalacia. Aggressive therapy can be provided with appropriate inves-tigation such as computed tomography. Vaccination is rec-ommended for teens and adults as they are more prone to meningococcal infection [14].
The drug resistance to antibiotics has been the greatest prob-lem in the developing countries. Scarborough and Thwaites highlighted that there is a urgent need to improve the diagnoses and management for meningitis. The vaccinations have sup-ported the developed world and third world countries should try to implement to reduce the rate of fatality and neurological complications resulting from meningitis. Implementation of vaccines were successful in countries such as Kenya and Uganda [15]. Chandran et al., highlighted the importance of long-term sequelae need to be considered for the survivors of meningitis [16]. Wandi et al., have stated that the poor outcome of meningi-tis are due to the availability of resources, the appropriate knowl-edge of the disease, accessibility of the patients, the immune and the nutritional status [3].
Health status of children in PNG
Trevor has observed that in Eastern Highlands which has the 20% population of the entire highlands which rates nearly 770 infant death among 10,000 children each year where the potential cause of death can be avoidable [17]. Until 1980 the health services were satisfactory whereas after 1997 there was a major breakdown in the system where the infrastructure and the availability of resources were limited to cater the need of maternal and child health, hence there needs to be rees-tablishment to develop the resources to prevent the illnesses. Health care system in PNG is through aid posts and provincial hospitals [18]. The treatment for meningitis ranges from acute care using medical interventions to long-term rehabilitation. A multidisciplinary approach is necessary for the patients to improve the quality of life.
Meningitis in PNG
Meningitis is one of the leading causes of mortality among the Papua new Guineans (PNGs), though the studies on meningitis existed since 1968 [19,20], not much have been done to reduce the mortality rate resulting from meningitis. Gartten et al. [19], have studied the major cause for purulent meningitis among highland children, their findings were over the period of 4 years from 1980–1984, nearly 92% of children population was infected either with H. influenzae and strepto-coccus pneumonia or both. About 79% of children died during their 12 months of age. The recommendation of vaccines was insisted for young children. A study on aetiology and clinical signs of bacterial meningitis in children in Goroka general hospital, determined 30% of 697 children found to be clinical diagnosis of meningitis, 12% blood culture-proven bacterial meningitis (case fatality rate 34%) and 10% had probable or possible meningitis. The clinical signs were inability to feed, vomiting, drowsiness, “staring eyes” and bulging fontanelle, convulsions in young children, neck stiffness, fever haemo-globin 9 g/dl in addition to the classical signs of meningitis were associated with increased mortality. The need for admin-istration of conjugate Hib vaccine for the infants to prevent the pneumoccal disease [21].
Wandi et al. [3], has reported that 13% of children death is caused by meningitis. The neurological complication in PNG were Deafness 11% (48), severe speech delay 15% (75), delayed developmental milestones 11% (61), Cerebral palsy 14% (100) Hemiparesis 8% (89), Late death, Ataxia 6% (100), Epilepsy 3% (60), Hydrocepalus 2% (100), Squint 0%(0). There was very limited advancement in the use of diagnostic tools and inadequate drugs in the rural hospitals, where the people have to access in the provincial hospitals. The access of hospitals by the patients due to difficulty in the geographic location was also the possible causes of lack of appropriate treatment for meningitis and resulting in disability. Third generation cephalosporin are required to treat the children in PNG. Though the importance of drug was insisted the late complication cannot be managed with this treatment.
Chinchankar et al. [22], states acute bacterial meningitis in early childhood has a considerable mortality, morbidity and
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© 2012 Informa UK, Ltd.
serious long-term sequelae, neuro-developmental follow-up and therapy should begin early. There is only one study by Edmond et al., which reflected on the disability sequelae and quality of life done among children in urban Senegal, taking consideration of physical, social and emotional status of life. It is found that nearly 65.4% of patients had major sequelae and had a significant lower quality of life [23].
A retrospective study (2005–2008) in Modilon General Hospital in Madang province have documented that 78% of children are admitted with meningitis in a year, nearly 22% were referred for physiotherapy for the neurological com-plications. There were some indications that patients didn’t receive the proper service due to the fact such as children admitted in the hospital were discharged without the referral and also the physician, health extension officer have ignored the referral [24].
Community Based Rehabilitation (CBR) workers are the key people to assess the rural communities in PNG. There are also many village volunteers being trained by the special-ized personnel to assist the people with disability. A survey [25] conducted among the CBR workers in Madang region to understand how do they manage or educate the patients or carers with different physical and mental disabilities revealed that the CBR workers have a limited source of information regarding meningitis and also they have not received a proper training. The study also identified that the CBR workers and caregivers need more education on meningitis and its mani-festations for better rehabilitation.
Measures to reduce the outcome of meningitis
The above stated review describes rehabilitation plays a vital role in the management of meningitis. It includes a multidisci-plinary team where it is necessary to analyse the requirement of the patient needs, communication with the health profes-sionals, care givers and teachers to make sure of adequate care and support (Figure 1). Meningitis requires long-term rehabilitation of various forms of disabilities ranging form intellect deficits to epilepsy, physical disabilities, depression and chronic fatigue [26].
The rehabilitation services in PNG were provided by Non-governmental organisations (NGO) such as Callan services, Volunter Service Overseas (VSO) and National Orthotic and prosthetic service are providing the resources for the children with hearing loss. Physiotherapists are managing neurological and cardio respiratory rehabilitation to reduce the complica-tions. Inclusive education was the recent approach to include the children with disability to acquire their educational rights. As PNG is unique and diverse, there is often lack or even no rehabilitation team available in the country, to provide ade-quate services.
Physiotherapy is a young profession in the country and such training is offered as Bachelor of Physiotherapy in one of well-known private university. This is only university, which train the physiotherapists since 2003. At the moment nearly 20 physiotherapists and few physiotherapy technicians are pro-viding the services. These services help to assist the children with motor impairments. Early intervention on neurological complications and the referrals from the physicians enables to reduce the impact of meningitis. The role of physiotherapy enable to improve the physical ability whereby managing the neuro-developmental problems, reduce spasticity, improve the functional abilities for the activities of daily living and to promote independent living.
Conclusions
The rehabilitation of meningitis depends on three main areas; Awareness, Accessibility and Availability. Community based rehabilitation is an appropriate way of approaching the patients with disability. The health professionals have to ana-lyze the need for the community by evaluating and assisting the patients to prevent the disability. Saito et al. [27], devel-oped a tuberculous meningitis acute neurological scoring system to identify the long-term neurological sequelae and Saha et al. [28], have used the physical and neuro develop-mental assessment to follow-up the meningitis patients; these scales could provide the health professions an awareness. Awareness on meningitis and its manifestation is a crucial area where everyone needs to be educated. Though the acces-sibility is a major constraint the early intervention with the adequate availability of the facilities will facilitate to reduce the rate of disability. In recent years, the residual patients with disability where empowered with the assistance from various non-governmental organizational and other disabled people organization support. Special education training pro-grams were provided by Callan services in the country that will further allow the disabled people to avail education for their livelihood.
Acknowledgements
We would like to extend our special thanks to Dr. Jose Orathinkal for his assistance.
Declaration of Interest: The authors report no conflicts of interest.Figure 1. Measures to reduce the outcomes of meningitis.
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