Safety and immunogenicity of the two-dose heterologous Ad26.ZEBOV and MVA-BN-Filo Ebola vaccine regimen in infants: a phase 2, randomised, double-blind, active-controlled trial in Guinea and Sierra Leone

BACKGROUND

This study assessed the safety and immunogenicity of the Ad26.ZEBOV and MVA-BN-Filo Ebola virus (EBOV) vaccine regimen in infants aged 4-11 months in Guinea and Sierra Leone.

METHODS

In this phase 2, randomised, double-blind, active-controlled trial, we randomly assigned healthy infants (1:1 in a sentinel cohort, 5:2 for the remaining infants via an interactive web response system) to receive Ad26.ZEBOV followed by MVA-BN-Filo (Ebola vaccine group) or two doses of meningococcal quadrivalent conjugate vaccine (control group) administered 56 days apart. Infants were recruited at two sites in west Africa: Conakry, Guinea, and Kambia, Sierra Leone. All infants received the meningococcal vaccine 8 months after being randomly assigned. The primary objective was safety. The secondary objective was immunogenicity, measured as EBOV glycoprotein-binding antibody concentration 21 days post-dose 2, using the Filovirus Animal Non-Clinical Group ELISA. This study is registered with ClinicalTrials.gov (NCT03929757) and the Pan African Clinical Trials Registry (PACTR201905827924069).

FINDINGS

From Aug 20 to Nov 29, 2019, 142 infants were screened and 108 were randomly assigned (Ebola vaccine n=75; control n=33). The most common solicited local adverse event was injection-site pain (Ebola vaccine 15 [20%] of 75; control four [12%] of 33). The most common solicited systemic adverse events with the Ebola vaccine were irritability (26 [35%] of 75), decreased appetite (18 [24%] of 75), pyrexia (16 [21%] of 75), and decreased activity (15 [20%] of 75). In the control group, ten (30%) of 33 had irritability, seven (21%) of 33 had decreased appetite, three (9%) of 33 had pyrexia, and five (15%) of 33 had decreased activity. The frequency of unsolicited adverse events was 83% (62 of 75 infants) in the Ebola vaccine group and 85% (28 of 33 infants) in the control group. No serious adverse events were vaccine-related. In the Ebola vaccine group, EBOV glycoprotein-binding antibody geometric mean concentrations (GMCs) at 21 days post-dose 2 were 27 700 ELISA units (EU)/mL (95% CI 20 477-37 470) in infants aged 4-8 months and 20 481 EU/mL (15 325-27 372) in infants aged 9-11 months. The responder rate was 100% (74 of 74 responded). In the control group, GMCs for both age groups were less than the lower limit of quantification and the responder rate was 3% (one of 33 responded).

INTERPRETATION

Ad26.ZEBOV and MVA-BN-Filo was well tolerated and induced strong humoral responses in infants younger than 1 year. There were no safety concerns related to vaccination.

FUNDING

Janssen Vaccines & Prevention and Innovative Medicines Initiative 2 Joint Undertaking.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

The Effect of Previous Exposure to Malaria Infection and Clinical Malaria Episodes on the Immune Response to the Two-Dose Ad26.ZEBOV, MVA-BN-Filo Ebola Vaccine Regimen

We assessed whether the immunogenicity of the two-dose Ad26.ZEBOV, MVA-BN-Filo Ebola vaccine regimen with a 56-day interval between doses was affected by exposure to malaria before dose 1 vaccination and by clinical episodes of malaria in the period immediately after dose 1 and after dose 2 vaccinations. Previous malaria exposure in participants in an Ebola vaccine trial in Sierra Leone (ClinicalTrials.gov: NCT02509494) was classified as low, intermediate, and high according to their antibody responses to a panel of Plasmodium falciparum antigens detected using a Luminex MAGPIX platform. Clinical malaria episodes after vaccinations were recorded as part of the trial safety monitoring. Binding antibody responses against the Ebola virus (EBOV) glycoprotein (GP) were measured 57 days post dose 1 and 21 days post dose 2 by ELISA and summarized as Geometric Mean Concentrations (GMCs). Geometric Mean Ratios (GMRs) were used to compare groups with different levels of exposure to malaria. Overall, 587 participants, comprising 188 (32%) adults (aged ≥ 18 years) and 399 (68%) children (aged 1-3, 4-11, and 12-17 years), were included in the analysis. There was no evidence that the anti-EBOV-GP antibody GMCs post dose 1 and post dose 2 differed between categories of previous malaria exposure. There was weak evidence that the GMC at 57 days post dose 1 was lower in participants who had had at least one episode of clinical malaria post dose 1 compared to participants with no diagnosed clinical malaria in the same period (GMR = 0.82, 95% CI: 0.69-0.98, p-value = 0.02). However, GMC post dose 2 was not reduced in participants who experienced clinical malaria post-dose 1 and/or post-dose 2 vaccinations. In conclusion, the Ad26.ZEBOV, MVA-BN-Filo Ebola vaccine regimen is immunogenic in individuals with previous exposure to malaria and in those who experience clinical malaria after vaccination. This vaccine regimen is suitable for prophylaxis against Ebola virus disease in malaria-endemic regions.

Safety and immunogenicity of an Ad26.ZEBOV booster dose in children previously vaccinated with the two-dose heterologous Ad26.ZEBOV and MVA-BN-Filo Ebola vaccine regimen: an open-label, non-randomised, phase 2 trial

BACKGROUND

Children account for a substantial proportion of cases and deaths during Ebola virus disease outbreaks. We aimed to evaluate the safety and immunogenicity of a booster dose of the Ad26.ZEBOV vaccine in children who had been vaccinated with a two-dose regimen comprising Ad26.ZEBOV as dose one and MVA-BN-Filo as dose two.

METHODS

We conducted an open-label, non-randomised, phase 2 trial at one clinic in Kambia Town, Sierra Leone. Healthy children, excluding pregnant or breastfeeding girls, who had received the Ad26.ZEBOV and MVA-BN-Filo vaccine regimen in a previous study, and were aged 1-11 years at the time of their first vaccine dose, received an intramuscular injection of Ad26.ZEBOV (5 × 10¹⁰ viral particles) and were followed up for 28 days. Primary outcomes were safety (measured by adverse events) and immunogenicity (measured by Ebola virus glycoprotein-specific IgG binding antibody geometric mean concentration) of the booster vaccine dose. Safety was assessed in all participants who received the booster vaccination; immunogenicity was assessed in all participants who received the booster vaccination, had at least one evaluable sample after the booster, and had no major protocol deviations that could have influenced the immune response. This trial is registered with ClinicalTrials.gov, NCT04711356.

FINDINGS

Between July 8 and Aug 18, 2021, 58 children were assessed for eligibility and 50 (27 aged 4-7 years and 23 aged 9-15 years) were enrolled and received an Ad26.ZEBOV booster vaccination, more than 3 years after receiving dose one of the Ad26.ZEBOV and MVA-BN-Filo vaccine regimen. The booster was well tolerated. The most common solicited local adverse event during the 7 days after vaccination was injection site pain, reported in 18 (36%, 95% CI 23-51) of 50 participants. The most common solicited systemic adverse event during the 7 days after vaccination was headache, reported in 11 (22%, 12-36) of 50 participants. Malaria was the most common unsolicited adverse event during the 28 days after vaccination, reported in 25 (50%, 36-64) of 50 participants. No serious adverse events were observed during the study period. 7 days after vaccination, the Ebola virus glycoprotein-specific IgG binding antibody geometric mean concentration was 28 561 ELISA units per mL (95% CI 20 255-40 272), which was 44 times higher than the geometric mean concentration before the booster dose. 21 days after vaccination, the geometric mean concentration reached 64 690 ELISA units per mL (95% CI 48 356-86 541), which was 101 times higher than the geometric mean concentration before the booster dose.

INTERPRETATION

A booster dose of Ad26.ZEBOV in children who had received the two-dose Ad26.ZEBOV and MVA-BN-Filo vaccine regimen more than 3 years earlier was well tolerated and induced a rapid and robust increase in binding antibodies against Ebola virus. These findings could inform Ebola vaccination strategies in paediatric populations.

FUNDING

Innovative Medicines Initiative 2 Joint Undertaking.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Prevalence of malaria and helminth infections in rural communities in northern Sierra Leone, a baseline study to inform Ebola vaccine study protocols

Introduction

Recurrent parasitic infections may influence the immune response to vaccines. In the Partnership for Research on Ebola VACcinations extended follow-UP and clinical research capacity build-UP (PREVAC-UP) study being undertaken in Mambolo, northern Sierra Leone, participants are being followed up to assess the potential impact of exposure to malaria and/or helminth infections on long-term immune response to two Ebola vaccines. To support the development of the assays that will be used in this evaluation, a parasitological survey was conducted in Mambolo between November 2019 and February 2020.

Methods

Healthy individuals aged ≥1 year who were resident in Mambolo Chiefdom were selected using a stratified sampling approach and questionnaires were administered to explore their sociodemographic characteristics. Microscopy was used to detect malaria parasites, intestinal helminths and urinary schistosome infections. Rapid blood tests were used to detect infections with Onchocerca volvulus and Wuchereria bancrofti. We estimated the overall prevalence of these infections and used adjusted logistic regression models to explore risk factors for malaria and hookworm infection.

Results

Eight hundred and fifteen (815) residents, 50.9% of whom were female were surveyed. Overall, 309 (39.1%) of 791 persons tested for malaria had a positive blood slide; Plasmodium falciparum was the dominant species. Helminth infection was detected in 122 (15.0%) of 815 stool samples including three mixed infections. The helminth infections comprised 102 (12.5%) cases of hookworm, 11 (1.3%) cases of Trichuris trichiura, 10 (1.2%) cases of Schistosoma mansoni and two (0.2%) cases of Ascaris lumbricoides. Being male (OR = 2.01, 95% CI 1.15–3.50) and residing in a non-riverine community (OR = 4.02, 95%CI 2.32–6.98) were the factors associated with hookworm infection. Onchocerca volvulus and Wuchereria bancrofti infections were found in 3.3% and 0.4% of participants respectively.

Conclusion

Malaria and hookworm are the most prevalent parasite infections and those most likely to influence long-term immune response to Ebola vaccines among the trial participants.

Head Injury Prevalence in a Population of Injured Patients Seeking Care in Ghana, West Africa

Background/Significance:

Much of the literature on head injury (HI) prevalence comes from high-income countries (HICs), despite the disproportionate burden of injuries in low to middle-income countries (LMICs). This study evaluated the HI prevalence in the Kintampo Injury Registry, a collaborative effort between Kintampo Health Research Centre (KHRC) in Ghana and the sidHARTe Program at Columbia University Mailman School of Public Health. In our first aim, we characterize the HI prevalence in the registry. In aim 2, we examine if there are any sex (male/female) differences in head injury outcomes in these populations for points of potential intervention.

Methods

Secondary analysis of data from the Kintampo Injury Registry which had 7,148 registered patients collected during January 2013 to January 2015. The definition of a case was adopted to ensure consistency with the International Statistical Classification of Diseases and Related Health Problems, revision 10 (ICD-10). A 3-page questionnaire was used to collect data from injured patients to include in the registry. The questions were designed to be consistent with the World Health Organization (WHO) guidelines on injury surveillance and were adapted from the questionnaire used in a pilot, multi-country injury study undertaken in other parts of Africa. The questionnaire collected information on the anatomic site of injury (e.g., head), mechanism of injury (e.g., road traffic injuries, interpersonal injuries (including domestic violence), falls, drowning, etc.), severity and circumstances of the injury, as well as precipitating factors, such as alcohol and drug use. The questionnaire consisted mainly of close-ended questions and was designed for efficient data entry. For the secondary data analyses for this manuscript, we only included those with “1st visit following injury” and excluded all transfers and follow-up visits (n = 834). We then dichotomized the remaining 6,314 patients to head injured and non-head injured patients based on responses to the variable “Nature of injury =Head Injury”. We used chi-square and Fisher's exact tests with p < 0.05 as cut-off for statistical significance. Logistic regression estimates were used for effect estimates.

Results

Of the 6,314 patients, there were 208 (3.3%) head-injured patients and 6,106 (96.7%) patients without head injury. Head-injured patients tended to be older (Mean age: 28.9 +/-13.7; vs. 26.1 +/- 15.8; p = 0.004). Seven in 10 head injured patients sustained their injuries via transport/road traffic accidents, and head-injured patients had 13 times the odds of mortality compared with those without head injuries (OR: 13.3; 95% CI: 8.05, 22.0; p < 0.0001) even though over half of them had mild or moderate injury severity scores (p < 0.001). Evaluation of sex differences amongst the head-injured showed that in age-adjusted logistic regression models, males had 1.4 times greater odds of being head injured (OR: 1.4; 95% CI: 1.04, 2.00; p = 0.03) and over twice the risk of mortality (OR: 2.7; 95% CI: 0.74, 10.00; p = 0.13) compared to females.

Conclusion

In these analyses, HI was associated with a higher risk of mortality, particularly amongst injured males; most of whom were injured in transport/road-traffic-related accidents. This study provides an impetus for shaping policy around head injury prevention in LMICs like Ghana.

Ebola Virus Glycoprotein IgG Seroprevalence in Community Previously Affected by Ebola, Sierra Leone

We explored the association of Ebola virus antibody seropositivity and concentration with potential risk factors for infection. Among 1,282 adults and children from a community affected by the 2014-2016 Ebola outbreak in Sierra Leone, 8% were seropositive for virus antibodies but never experienced disease symptoms. Antibody concentration increased with age.

Safety and long-term immunogenicity of the two-dose heterologous Ad26.ZEBOV and MVA-BN-Filo Ebola vaccine regimen in adults in Sierra Leone: a combined open-label, non-randomised stage 1, and a randomised, double-blind, controlled stage 2 trial

BACKGROUND

The Ebola epidemics in west Africa and the Democratic Republic of the Congo highlight an urgent need for safe and effective vaccines to prevent Ebola virus disease. We aimed to assess the safety and long-term immunogenicity of a two-dose heterologous vaccine regimen, comprising the adenovirus type 26 vector-based vaccine encoding the Ebola virus glycoprotein (Ad26.ZEBOV) and the modified vaccinia Ankara vector-based vaccine, encoding glycoproteins from Ebola virus, Sudan virus, and Marburg virus, and the nucleoprotein from the Tai Forest virus (MVA-BN-Filo), in Sierra Leone, a country previously affected by Ebola.

METHODS

The trial comprised two stages: an open-label, non-randomised stage 1, and a randomised, double-blind, controlled stage 2. The study was done at three clinics in Kambia district, Sierra Leone. In stage 1, healthy adults (aged ≥18 years) residing in or near Kambia district, received an intramuscular injection of Ad26.ZEBOV (5 × 1010 viral particles) on day 1 (first dose) followed by an intramuscular injection of MVA-BN-Filo (1 × 108 infectious units) on day 57 (second dose). An Ad26.ZEBOV booster vaccination was offered at 2 years after the first dose to stage 1 participants. The eligibility criteria for adult participants in stage 2 were consistent with stage 1 eligibility criteria. Stage 2 participants were randomly assigned (3:1), by computer-generated block randomisation (block size of eight) via an interactive web-response system, to receive either the Ebola vaccine regimen (Ad26.ZEBOV followed by MVA-BN-Filo) or an intramuscular injection of a single dose of meningococcal quadrivalent (serogroups A, C, W135, and Y) conjugate vaccine (MenACWY; first dose) followed by placebo on day 57 (second dose; control group). Study team personnel, except those with primary responsibility for study vaccine preparation, and participants were masked to study vaccine allocation. The primary outcome was the safety of the Ad26.ZEBOV and MVA-BN-Filo vaccine regimen, which was assessed in all participants who had received at least one dose of study vaccine. Safety was assessed as solicited local and systemic adverse events occurring in the first 7 days after each vaccination, unsolicited adverse events occurring in the first 28 days after each vaccination, and serious adverse events or immediate reportable events occurring up to each participant's last study visit. Secondary outcomes were to assess Ebola virus glycoprotein-specific binding antibody responses at 21 days after the second vaccine in a per-protocol set of participants (ie, those who had received both vaccinations within the protocol-defined time window, had at least one evaluable post-vaccination sample, and had no major protocol deviations that could have influenced the immune response) and to assess the safety and tolerability of the Ad26.ZEBOV booster vaccination in stage 1 participants who had received the booster dose. This study is registered at ClinicalTrials.gov, NCT02509494.

FINDINGS

Between Sept 30, 2015, and Oct 19, 2016, 443 participants (43 in stage 1 and 400 in stage 2) were enrolled; 341 participants assigned to receive the Ad26.ZEBOV and MVA-BN-Filo regimen and 102 participants assigned to receive the MenACWY and placebo regimen received at least one dose of study vaccine. Both regimens were well tolerated with no safety concerns. In stage 1, solicited local adverse events (mostly mild or moderate injection-site pain) were reported in 12 (28%) of 43 participants after Ad26.ZEBOV vaccination and in six (14%) participants after MVA-BN-Filo vaccination. In stage 2, solicited local adverse events were reported in 51 (17%) of 298 participants after Ad26.ZEBOV vaccination, in 58 (24%) of 246 after MVA-BN-Filo vaccination, in 17 (17%) of 102 after MenACWY vaccination, and in eight (9%) of 86 after placebo injection. In stage 1, solicited systemic adverse events were reported in 18 (42%) of 43 participants after Ad26.ZEBOV vaccination and in 17 (40%) after MVA-BN-Filo vaccination. In stage 2, solicited systemic adverse events were reported in 161 (54%) of 298 participants after Ad26.ZEBOV vaccination, in 107 (43%) of 246 after MVA-BN-Filo vaccination, in 51 (50%) of 102 after MenACWY vaccination, and in 39 (45%) of 86 after placebo injection. Solicited systemic adverse events in both stage 1 and 2 participants included mostly mild or moderate headache, myalgia, fatigue, and arthralgia. The most frequent unsolicited adverse event after the first dose was headache in stage 1 and malaria in stage 2. Malaria was the most frequent unsolicited adverse event after the second dose in both stage 1 and 2. No serious adverse event was considered related to the study vaccine, and no immediate reportable events were observed. In stage 1, the safety profile after the booster vaccination was not notably different to that observed after the first dose. Vaccine-induced humoral immune responses were observed in 41 (98%) of 42 stage 1 participants (geometric mean binding antibody concentration 4784 ELISA units [EU]/mL [95% CI 3736-6125]) and in 176 (98%) of 179 stage 2 participants (3810 EU/mL [3312-4383]) at 21 days after the second vaccination.

INTERPRETATION

The Ad26.ZEBOV and MVA-BN-Filo vaccine regimen was well tolerated and immunogenic, with persistent humoral immune responses. These data support the use of this vaccine regimen for Ebola virus disease prophylaxis in adults.

FUNDING

Innovative Medicines Initiative 2 Joint Undertaking and Janssen Vaccines & Prevention BV.

Estimating causes of death where there is no medical certification: evolution and state of the art of verbal autopsy

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

Continuous positive airway pressure in managing acute respiratory distress in children in district hospitals: evidence for scale-up

In children, acute respiratory distress (ARD) is a clinical presentation requiring emergency management, including mechanical ventilation. Mechanical ventilators are lacking in sub-Saharan Africa. Continuous Positive Airway Pressure (CPAP) is an alternative form of non-invasive respiratory support that has been used in high-income countries for over four decades. Its use in sub-Saharan Africa is, however, limited and often restricted to neonates. Controlled trials in Ghana have shown that the use of CPAP in children younger aged 1–12 months reduces 2-week all-cause mortality from ARD by 60% (RR 0·40, 0·19–0·82; p=0·01). The absolute reduction in mortality of 4% implies one infant life saved for every 25 children treated with CPAP. This paper reviews the findings of the trials in Ghana and contrasts the findings with those of trials in Bangladesh and Malawi. It makes the case that implementation research (rather than more controlled trials) is now needed to support the routine, safe and effective use of CPAP in managing ARD in older infants in district hospitals in Ghana.

Making primary healthcare responsive to non-communicable diseases in sub-Saharan Africa

Primary healthcare (PHC) meets the needs of people's health throughout their lives and empowers individuals and communities to oversee their own health. Most of the community-based activities currently undertaken in PHC in sub-Saharan Africa (SSA) address child and maternal health. Non-communicable diseases are now major causes of morbidity and premature mortality in SSA. In this paper, I propose the formal integration of community-based, non-communicable disease prevention and early detection into PHC activities. I offer practical suggestions on how this can be achieved to ensure a continuum of care.

Referral of sick children and levels of adherence by carers: implications on quality health care in the middle belt of Ghana

Introduction

Severely sick-children presenting at primary healthcare facilities need referral to higher level facilities for better care. Adherence to referrals and quality of care received by those referred could serve as critical steps towards their survival.

Objective

To describe experiences with severely sick children referred to higher-level health facilities for care and reasons for non-adherence to referral; to explore healthcare provider's perspectives to referral.

Methods

Referrals among 3046 young children were followed for adherence. Assessment of children referred from a PHC facility adhering to referral advice and reasons for non-adherence to referral was determined. Agreement on reported diagnoses at PHC centres and health-facilities receiving patients was assessed. Perspectives of healthcare providers were assessed.

Results

212 children were referred from PHC centres to various hospitals with 14.2% non-adherence. Reasons given: 48.3% of carers adhering felt child's condition was severe; 43.3% complied with healthcare provider directive. The main reasons for non-adherence to referral were no money for transport (50%) and child condition not serious (30.0%). 69.0% of anaemia cases diagnosed at PHC facilities and hospitals. 65.7% fever diagnosed at a PHC centres were confirmed as malaria at the hospitals. Healthcare providers referred patients for severity, perceivedcomplication and non-response to treatment.

Conclusion

Adherence was generally good. The level of agreement in diagnosis of common diseases such as malaria and anaemia at PHC centres and district hospitals was high and low for rarer diseases. Capacity should be provided at PHC levels for adequate management of cases presented to reduce referrals carers have to make.

Funding

This study did not receive funding from any external sources.

Exploring factors affecting quality implementation of lymphatic filariasis mass drug administration in Bole and Central Gonja Districts in Northern Ghana

Ghana has been implementing Mass Drug Administration (MDA) since the year 2001, and Lymphatic Filariasis transmission has been interrupted in 76 out of the 98 targeted districts. The remaining districts have a microfilaria prevalence above the 1% threshold needed for the interruption of transmission. This study assesses the level of lymphatic filariasis MDA coverage and explored factors affecting the quality of implementation of the MDA in the Bole and Central Gonja Districts of Northern Ghana. A concurrent mixed methods study design approach was used to provide both a quantitative and qualitative insight. A descriptive analysis was carried out, and the results are presented in tables and charts. The transcripts of the qualitative interviews were imported into Nvivo and framework methods of analysis were used. The results were summarized based on the themes and buttressed with narratives with key quotes presented within the texts. The overall MDA coverage in Central Gonja is 89.3% while that of Bole district is 82.9%. Refusal to ingest the drug and adverse drug reactions were higher in Bole district than the Central Gonja District. The persistent transmission of lymphatic filariasis in Bole District was characterized by poor community mobilization and sensitization, nonadherence to the directly observed treatment strategy, refusal to ingest the drug due to the fear of adverse drug reactions, inadequate knowledge and misconceptions about the disease. Reported mass drug administration coverage will not necessarily result into interruption of transmission of the disease without strict compliance to the directly observed treatment strategy, strong stakeholder engagement coupled with evidence-based context-specific multi-channel community education strategies with key educational messages on the cause of the disease and adverse drug reactions. While the clock for the elimination of lymphatic filariasis by the year 2020 and meeting of the Sustainable Development Goal 3 target 3.3 by 2030 is ticking, there is an urgent need for a concerted effort to improve the fidelity of the ongoing lymphatic filariasis MDA campaigns in the Bole District of Northern Ghana.

After 18 years of implementing the global strategy to eliminate lymphatic filariasis in Ghana, the prevalence of the transmission of the disease is still above the threshold needed to interrupt transmission of the disease as a public health problem in some districts. This study showed that, the persistent transmission of the lymphatic filariasis in the Bole District is characterized with a refusal to ingest the drug; reported adverse drug reactions; poor knowledge and misconceptions of the disease, and poor adherence to the mass drug administration protocol. High reported mass drug administration coverage will not lead to interruption of transmission of lymphatic filariasis without strict adherence to the direct observe treatment strategy, strong stakeholder engagement coupled with evidence-based context-specific multi-channel community education strategies with key educational messages on adverse drug reactions and the cause of the disease.

Towards effective participation of the private health sector in Ghana's COVID-19 response

The private health sector is a major service provider group within the health systems of most sub-Saharan African countries. Currently, 90% of COVID-19 cases in Ghana are in urban areas where private health facilities play a major role in service delivery. Yet, there is limited understanding of the issues mediating private health sector participation in public health emergency responses. Challenges related to its involvement in Ghana´s COVID-19 response include lack of clarity on its role, sub-optimal communication channels, inadequate personal protective equipment and fragmentation of the sector. Hence, operational and regulatory actions addressing these challenges will ensure the private sector is fully prepared to contribute to the COVID-19 response and future public health emergencies, thereby strengthening Ghana’s health system.

pfhrp2 and pfhrp3 Gene Deletions That Affect Malaria Rapid Diagnostic Tests for Plasmodium falciparum: Analysis of Archived Blood Samples From 3 African Countries

BACKGROUND

Malaria rapid diagnostic tests (mRDTs) that target histidine-rich protein 2 (HRP2) are important tools for Plasmodium falciparum diagnosis. Parasites with pfhrp2/3 gene deletions threaten the use of these mRDTs and have been reported in Africa, Asia, and South America. We studied blood samples from 3 African countries to determine if these gene deletions were present.

METHODS

We analyzed 911 dried blood spots from Ghana (n = 165), Tanzania (n = 176), and Uganda (n = 570). Plasmodium falciparum infection was confirmed by 18S rDNA polymerase chain reaction (PCR), and pfhrp2/3 genes were genotyped. True pfhrp2/3 gene deletions were confirmed if samples were (1) microscopy positive; (2) 18S rDNA PCR positive; (3) positive for merozoite surface protein genes by PCR or positive by loop-mediated isothermal amplification; or (4) quantitative PCR positive with >5 parasites/µL.

RESULTS

No pfhrp2/3 deletions were detected in samples from Ghana, but deletions were identified in Tanzania (3 pfhrp2; 2 pfhrp3) and Uganda (7 pfhrp2; 2 pfhrp3). Of the 10 samples with pfhrp2 deletions, 9 tested negative by HRP2-based mRDT.

CONCLUSIONS

The presence of pfhrp2/3 deletions in Tanzania and Uganda, along with reports of pfhrp2/3-deleted parasites in neighboring countries, reinforces the need for systematic surveillance to monitor the reliability of mRDTs in malaria-endemic countries.

Sexual and reproductive health of adolescents in schools for people with disabilities

Introduction

Persons with disabilities have the same sexual and reproductive health (SRH) needs as the abled people but they often face barriers to SRH information and services which are necessary for healthy and safe relationships, protection from HIV and other sexually transmitted infections (STIs). This study sought to access the SRH services among adolescents with disabilities in four Special Needs Schools in Ghana.

Methods

The study adopted a cross-sectional study design with a quantitative approach to data collection between the months of January to March, 2018. A structured and pretested questionnaire was used to collect data from adolescents with disabilities from selected schools in Ghana. Both descriptive and inferential statistics were performed using chi-square test and multivariate logistic regression.

Results

Majority of participants had hearing disability (52.1%). The average age at menarche among females was 13 years whiles the age at which puberty was attained among boys was 14 years. School teachers were the major source of information on SRH for the respondents (63.7%) followed by parents (12.2%). A majority (67.1%) of respondents had good knowledge of SRH. Factors which were significantly associated with knowledge level were age (p=0.026), religion (p=0.034), sources of information (p<0.001), guardians (p=0.049).

Conclusion

The majority of participants had good knowledge of SRH, although their knowledge of contraceptive and access were poor. Only condoms were mostly known. There is the need for increased awareness on the availability of other contraceptives methods and the removal of barriers to contraceptive methods.

Parasitic contamination of commonly consumed vegetables in two markets in Ghana

Introduction

Fresh vegetables are an important source of vital nutrients. Poor farming practices and improper washing put consumers at risk of parasitic infections. This study explored the presence of parasitic contamination of commonly-consumed vegetables procured from two markets in Ghana. It also explored the decontamination effects of washing vegetables with different concentrations of saline solution.

Method

Vegetables were procured from two major open markets in Koforidua, Ghana. Vegetables were thoroughly washed twice using 0.0%, 0.45%, 0.9%, 1.5% concentrations of saline solutions. The deposits were examined under the light microscope for the presence of parasites. Smears were made from sediments, stained and observed with Fluorescence microscope to detect any spores or oocysts of Microsporidium sp., and Cryptosporidium sp.

Result

Three hundred and sixty of five types of vegetables were procured. Two hundred and seven (57.5%, 95% Confidence Interval 52.2% - 62.7%) were found to be contaminated with at least one type of parasite. The extent of vegetable contamination was 97.2% (90.3-99.7) of spring onions, 70.8% (58.9-81.0) of lettuce and 50.0% (38.0-62.0) of tomatoes. The commonest parasites were Strongyloides stercoralis (36.4%, 31.4-41.6), Balantidium coli (13.6%, 10.2-17.6) and Cryptosporidium oocyst (11.1%, 8.1-14.8). Parasite recovering rates were 57.5% (52.2-62.7) and 42.2% (37.1-47.5) after first and second washings respectively.

Conclusion

The level of parasite contamination is high and consumption of raw vegetables procured from these markets carry a high risk of parasite infection. Washing vegetables twice with saline was not effective for parasite removal. Improved approaches for washing vegetables before consumption are needed.

Funding

Ensign College-Students Research Award Program of Bob and Lynette Gay.

Using intervention mapping to design and implement quality improvement strategies towards elimination of lymphatic filariasis in Northern Ghana

Introduction

The Global Strategy to Eliminate Lymphatic Filiariasis (GFELF) through Mass Drug Administration (MDA) has been implemented in Ghana since the year 2000 and transmission has been interrupted in 76 of 98 endemic districts. To improve the MDA in the remaining districts with microfilaria (MF) prevalence above the 1% threshold for the interruption of transmission, there is a need to identify and implement appropriate quality improvement (QI) strategies. This paper describes the use of intervention mapping to select QI strategies to improve an existing evidence-based MDA program in Northern Ghana.

Methods

Due to the complexities associated with implementing evidence-based programs (EBP) such as the lymphatic filariasis MDA and variability in the context, an initial assessment to identify implementation bottlenecks associated with the quality of implementation of lymphatic filariasis MDA in the Bole District of Ghana was conducted using a mixed methods approach. Based on the findings of the initial assessment, a context specific QI strategy was designed and operationalized using intervention mapping strategy in terms of seven domains: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification.

Results

The initial needs assessment shows that the persistent transmission of lymphatic filariasis in the Bole District is characterized by high levels of refusal to ingest the drug, high levels of reported adverse drug reactions, low MDA coverage at community level, poor adherence to the MDA protocol and non-participants’ responsiveness.

Conclusion

This study has shown that it is feasible to develop a context specific QI strategy for an existing evidence-based intervention based on an initial needs assessment through stakeholder participation using the IM approach. However, working (towards) QI requires more time than is usually available in public health service. Sufficient theoretical knowledge of implementation research and experience with technical IM experts must be available.

Lymphatic Filariasis is a significant health problem threatening 1.1 billion people in 55 countries globally. After 18 years of implementing MDA in Ghana, LF transmission still persist in some districts with microfilaria prevalence level high above the threshold needed for the interruption of transmission of the disease. For Ghana to meet the 2020 NTDs deadline, it is important to identify context specific need-based QI strategies to make the drug accessible to all eligible individuals in the endemic communities. Hence, this study has demonstrated the feasibility of using IM to develop and implement a context specific QI strategy for an existing evidence-based intervention (LF MDA) towards elimination of lymphatic filariasis as a public health challenge in Bole District of Northern Ghana.

Safety Culture and Perioperative Quality at the Volta River Authority Hospital in Akosombo, Ghana

BACKGROUND

The Volta River Authority Hospital (VRAH) is a district hospital associated with a large public works project in Akosombo, Ghana, that has developed a reputation for high-quality care. We hypothesized that this stems from a culture of safety and standardized processes typical of high-risk engineering environments. To investigate this, we evaluated staff and patient perceptions of safety and quality, as well as perioperative process variability.

MATERIALS AND METHODS

The Safety Attitudes Questionnaire (SAQ) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to evaluate staff and patient perceptions of safety. Perioperative general surgery and obstetrical procedure observations generated process maps, which were analyzed for variability and waste.

RESULTS

Thirty-one SAQs were administered. 83% of workers held a positive perception of teamwork, and 77.4% held a positive perception of safety culture. Fifteen HCAHPS surveys of surgical inpatients showed a median hospital rating of 10 [IQR 8.5-10] on a ten-point scale. 90% gave maximal scores for pain management and 84.4% for nurse communication. Ten general surgery and obstetrical procedures were observed for which process map analysis was notable for no consistent waste steps and 100% adherence to the World Health Organization Safe Surgery Checklist.

CONCLUSIONS

Surveys suggest an institutional commitment to safety with strong teamwork culture and patient communication. Perioperative process mapping supports this culture, with low levels of variability and waste, and is useful for evaluating standardization of care. VRAH demonstrates the feasibility of delivering high standards of perioperative care in a low-resource setting.

Causes of death at the University of Ghana Hospital in Accra-a 37-year review (1979-2015)

Background

An analysis of the causes of death in developing countries is needed to improve healthcare delivery. The aim of this study was to conduct a descriptive analysis of the causes of death at the University of Ghana Hospital from 1979 to 2015.

Methods

Data were extracted from the electronic database of the University of Ghana Hospital. Diseases were grouped into three broad groups of causes of death as per the Global Burden of Disease cause list, with some diseases of epidemiological importance outlined and analysed by age, gender and time in years.

Results

Of 3263 deaths, almost 60% were caused by non-communicable diseases (NCDs) that consisted of cancers, diabetes mellitus, cardiovascular diseases and other systemic conditions. Deaths by malaria, tuberculosis, diarrhoeal diseases and immunizable childhood diseases declined over the years while deaths from NCDs increased. The majority of cases of NCDs were due to cardiovascular disorders.

Conclusions

The study suggests that Ghana has a double burden of disease with predominantly NCDs from cardiovascular diseases, metabolic disorders and cancers. Although malaria and other childhood-related illnesses have declined significantly, human immunodeficiency virus is fuelling the communicable disease mortalities. There is an urgent need to scale up NCD control interventions while strengthening communicable disease control.

Respiratory Pathogens in Children 1 Month to 5 Years of Age Presenting With Undifferentiated Acute Respiratory Distress in 2 District-Level Hospitals in Ghana

Ghanaian children (2176) aged <5 years who presented with undifferentiated acute respiratory distress were tested for respiratory pathogens using a BioFire FilmArray polymerase chain reaction assay. Rhinovirus and/or enterovirus was detected in 36% of the assays, respiratory syncytial virus in 11%, and parainfluenza in 7%. Respiratory syncytial virus and metapneumovirus were detected more frequently in the rainy season than in the dry season.

Using community pharmacies to expand access to screening for noncommunicable diseases in suburban Ghana-A facility-based survey on client needs and acceptability

BACKGROUND

Many of the 28 million deaths from noncommunicable diseases (NCDs) in low- and middle-income countries each year could be prevented through early detection and intervention. The introduction of screening for NCDs in community pharmacies (CPs) in Ghana could enhance access to early detection.

METHODS

We surveyed clients in three districts in suburban Ghana to assess perceived need for screening, willingness to be screened in CPs, and willingness to receive NCD health promotion information through text messages (NCD m-Health). We performed regression analysis to identify predictors of NCD m-Health acceptability.

RESULTS

We interviewed 330 clients in six CPs, 134 (42.3%) of whom were females. The median age was 34 years (interquartile range, 27-43). Fifty-four (16.4%) had no formal education. Although most respondents knew obesity (74.9%), smoking (81.9%), and excessive dietary salt (91.7%) were risk factors for NCDs, only 27.0% knew family history carried similar risk. Most respondents, 61.6% and 70.6%, respectively, had not had their weight and blood pressure (BP) checked for more than 12 months. These included about a third of respondents who were known hypertensives. Similarly, 71.3% of 80 participants with a family history of hypertension had not had their BPs checked. Screening for NCDs in CPs and the sending of NCD m-Health messages was deemed acceptable to 98.5% and 83.1% of the participants, respectively. Formal education beyond junior high school (Grade 9) was the strongest independent predictor of NCD m-Health acceptance (OR = 4.77; 95% CI, 1.72-13.18; P value < 0.01). One hundred and twenty-five (39.4%) participants indicated they would consider unsolicited NCD m-Health messages an invasion of their privacy.

CONCLUSION

An urgent need exists to promote access to NCD screening in these communities. Its introduction into CPs is acceptable to nearly all the clients surveyed. The introduction of NCD m-Health as an accompaniment requires consideration for the privacy of clients.

Dog Bites and Rabies in the Eastern Region of Ghana in 2013-2015: A Call for a One-Health Approach

BACKGROUND

A One-Health approach is advocated to ensure effective rabies surveillance in sub-Saharan Africa. Information is needed to assess the current state of dog bites and rabies in Ghana. We analyzed data on reported events in the Eastern Region of Ghana from 2013 to 2015 to generate information that can be used for rabies elimination in Ghana through the One-Health approach.

METHOD

We extracted data on dog bites and rabies from the database of the regional health service and performed descriptive analysis using Epi Info version 7™. We followed up with interviews with three key informants from the health and veterinary services on issues related to surveillance and data quality.

RESULTS

Overall, 4821 dog bites were reported over the three-year period. This translated into an annual incidence of 172 cases per a population of 100,000. Most of cases were in children aged less than 10 yrs. Fifteen (53.3% males) cases of rabies were recorded in seven out of the 26 municipalities and districts, translating into a rabies to dog bite ratio of 3: 1000. The median age of victims was 9 years (range: 3-72 years). A parallel and uncoordinated system of rabies surveillance is maintained by the health and veterinary services, with gross disparities in the number of reported events and overall impression of underreporting.

CONCLUSION

Rabies remains an important cause of preventable deaths in this region. An integrated approach to surveillance based on the One-Health concept needs to be adopted.

Skin-lightening practices among female high school students in Ghana

OBJECTIVE

The practice of skin lightening (SL) persist despite warnings about its harmful health effects. Adolescents are particularly vulnerable and at risk of prolonged use of SL products. We explored SL practices among high school students in Ghana, West Africa.

STUDY DESIGN

Cross-sectional survey.

METHODS

We used a self-administered questionnaire in a survey on SL practices among randomly selected female students in five Senior High Schools in the Brong Ahafo Region of Ghana. We determined prevalence and used bivariate and multivariate analysis to identify factors associated with the practice.

RESULTS

A total of 410 students with a mean age of 17.6 years (±1.6) participated in the study. While 71.5% of students indicated that they had been approached by relatives and friends to use SL creams, 65.6% admitted to actually using it. Most (85.5%) students identified at least five friends who were using SL products at the time of the survey. Between 22.0% and 44.0% of students knew female teachers who practiced SL. Students in first year were twice as likely to practice SL compared with students in third year (odds ratio [OR] = 1.90, 95% confidence interval [CI] 1.15-3.13). Compared with those who had never been approached, students who had been approached by relatives and friends to use SL products were likely to be using it (OR = 2.24, 95% CI 1.43-3.53). Students who had sisters who used SL products were twice as likely to be users themselves (OR = 1.82, 95% CI 1.12-2.95).

CONCLUSION

The practice of SL among female students in this study is high, and about the same as reported among adults in Ghana and other parts of sub-Saharan Africa. This suggests that the practice is well entrenched. A ban on the sale of SL products to adolescents in Ghana should be considered.

The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.

Associated Factors and Quality of Care Received among Maternal Deaths at a Regional Hospital in Ghana: Maternal Death Audit Review

Maternal death audits are crucial to the reduction of maternal deaths. The aim of this study was to identity factors contributing to maternal deaths at Eastern Regional Hospital of Ghana. Quantitative and qualitative methods were used. Quantitative data on all the maternal deaths from January to December 2012 was extracted from completed audit forms and patients records using a standardized questionnaire. The data were analyzed in Epi-info. Qualitative data was collected through in-depth interviews and focus group discussions with health staff to assess care received and factors leading to death. A total of 43 maternal deaths occurred out of which 37 (86%) were audited. Major causes of deaths were pregnancy induced hypertension (27%) and abortion (21%). Late referrals, poor supervision of junior staff, inadequate numbers of senior clinicians, lack of intensive care facility as well as unavailability and insufficient blood and blood products were the main contributory factors to the deaths. Tertiary health institutions should be adequately equipped, staffed, and funded to address these causes of maternal death.

Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings

Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.

Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence

OBJECTIVES

The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts.

DESIGN

A comparative case study approach, analysing variation in outcomes across different settings.

SETTING

Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case.

PARTICIPANTS

28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria.

INTERVENTIONS

The interventions included different mRDT training packages, supervision, supplies and community sensitisation.

OUTCOME MEASURES

Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial).

RESULTS

Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs.

CONCLUSIONS

Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.

Low level of Hepatitis B knowledge and awareness among pregnant women in the Kintampo North Municipality: Implications for effective disease control

Background: Over 2 billion people are infected with Hepatitis B virus (HBV) and about 240 million are chronic carriers of the virus. Chronic HBV infection is an important cause of liver cancer. The infectivity of HBV is hundred times higher than the HIV virus yet it receives comparatively little attention in public health. The study assessed knowledge and awareness of HBV among pregnant women in the Kintampo Municipality of Ghana.Methods: A cross-sectional survey was conducted among pregnant women attending antenatal clinic in two facilities between September 2010 and November 2010. We performed analysis to determine factors associated with hepatitis B awareness.Results: Forty-one percent of the 504 women were aware of hepatitis B viral infection, 33.5% of the women were able to correctly mention the transmission routes of Hepatitis B. The radio was the most (42%) mentioned source of information on HBV and the least source of information were places of worship (2.7%).After adjusting for other factors, level of education; SSS/SHS and above OR=4.2, P<00.1, 95% CI (2.5, 7.0) and occupation (Civil servant/Student); OR= 3.8, P00.1, 95% CI (1.7, 8.5) were the important predictors of Hepatitis B awareness.Conclusion: There is a low level of knowledge and awareness of HBV among pregnant women in this municipality. This could potentially hamper effective HBV prevention and control in Ghana. Education on hepatitis B need to be included in health promotion activities.Funding: The study was funded by KHRC Director’s small grant Initiative.Keywords: Hepatitis B, knowledge, awareness, women, Ghana

Cost-Effectiveness Analysis of Test-Based versus Presumptive Treatment of Uncomplicated Malaria in Children under Five Years in an Area of High Transmission in Central Ghana

Background

The presumptive approach of confirming malaria in health facilities leads to over-diagnosis of malaria, over use of anti-malaria drugs and the risk of drug resistance development. WHO recommends parasitological confirmation before treatment with artemisinin-based combination therapy (ACT) in all suspected malaria patients. The use of malaria rapid diagnostic tests (mRDTs) would make it possible for prescribers to diagnose malaria at point-of-care and better target the use of antimalarials. Therefore, a cost-effectiveness analysis was performed on the introduction of mRDTs for management of malaria in under-five children in a high transmission area in Ghana where presumptive diagnosis was the norm in public health centres.

Methods

A cluster-randomised controlled trial where thirty-two health centres were randomised into test-based diagnosis of malaria using mRDTs (intervention) or clinical judgement (control) was used to measure the effect of mRDTs on appropriate treatment: ‘a child with a positive reference diagnosis prescribed a course of ACT or a child with a negative reference diagnosis not given an ACT’. Cost data was collected from five purposively selected health centres and used to estimate the health sector costs of performing an mRDT and treat children for malaria and other common febrile illnesses. Costs of training healthcare personnel and supervision in the study period were also collected. A sample of caregivers to children participating in the trial was interviewed about household cost incurred on transport, drugs, fees, and special food during a period of one week after the health centre visit as well as days unable to work. A decision model approach was used to calculate the incremental cost-effectiveness ratios (ICERs). Univariate and multivariate sensitivity analyses were applied to assess the robustness of ICERs.

Results

The availability of mRDTs for malaria diagnosis resulted in fewer ACT treatments compared to the clinical judgement approach (73% versus 81%) and more children appropriately treated (70% versus 57%). The introduction of mRDT-based diagnosis would cost the Ministry of Health US$18.6 per extra appropriately treated child under five compared to clinical judgement while the ICER from a societal perspective was lower at US$11.0 per appropriately treated child. ICERs were sensitive to a decrease in adherence to negative mRDTs, malaria positivity rate and specificity of the mRDT.

Conclusion

The introduction of mRDTs is likely to be considered cost-effective in this high transmission setting as this intervention increased the number of appropriately treated children at low cost.

Trial Registration

ClinicalTrials.gov NCT00832754

Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies

Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.

Low level of Hepatitis B knowledge and awareness among pregnant women in the Kintampo North Municipality: implications for effective disease control

BACKGROUND

Over 2 billion people are infected with Hepatitis B virus (HBV) and about 240 million are chronic carriers of the virus. Chronic HBV infection is an important cause of liver cancer. The infectivity of HBV is hundred times higher than the HIV virus yet it receives comparatively little attention in public health. The study assessed knowledge and awareness of HBV among pregnant women in the Kintampo Municipality of Ghana.

METHODS

A cross-sectional survey was conducted among pregnant women attending antenatal clinic in two facilities between September 2010 and November 2010. We performed analysis to determine factors associated with hepatitis B awareness.

RESULTS

Forty-one percent of the 504 women were aware of hepatitis B viral infection, 33.5% of the women were able to correctly mention the transmission routes of Hepatitis B. The radio was the most (42%) mentioned source of information on HBV and the least source of information were places of worship (2.7%).After adjusting for other factors, level of education; SSS/SHS and above OR=4.2, P<00.1, 95% CI (2.5, 7.0) and occupation (Civil servant/Student); OR= 3.8, P00.1, 95% CI (1.7, 8.5) were the important predictors of Hepatitis B awareness.

CONCLUSION

There is a low level of knowledge and awareness of HBV among pregnant women in this municipality. This could potentially hamper effective HBV prevention and control in Ghana. Education on hepatitis B need to be included in health promotion activities.

FUNDING

The study was funded by KHRC Director's small grant Initiative.

Can we measure cognitive constructs consistently within and across cultures? Evidence from a test battery in Bangladesh, Ghana, and Tanzania

We developed a test battery for use among children in Bangladesh, Ghana, and Tanzania, assessing general intelligence, executive functioning, and school achievement. The instruments were drawn from previously published materials and tests. The instruments were adapted and translated in a systematic way to meet the needs of the three assessment contexts. The instruments were administered by a total of 43 trained assessors to 786 children in Bangladesh, Ghana, and Tanzania with a mean age of about 13 years (range: 7-18 years). The battery provides a psychometrically solid basis for evaluating intervention studies in multiple settings. Within-group variation was adequate in each group. The expected positive correlations between test performance and age were found and reliability indices yielded adequate values. A confirmatory factor analysis (not including the literacy and numeracy tests) showed a good fit for a model, merging the intelligence and executive tests in a single factor labeled general intelligence. Measurement weights invariance was found, supporting conceptual equivalence across the three country groups, but not supporting full score comparability across the three countries.

Covert contraceptive use among women attending a reproductive health clinic in a municipality in Ghana

Background

Covert contraceptive use (CCU) in sub-Saharan Africa is an indication of women’s inability to exercise autonomy in their reproductive choices. The aim of this study was to assess the prevalence and determinants of CCU among a sample of FP clients in a municipality of Ghana.

Methods

We conducted a mixed method study among women attending a public reproductive health clinic in Sunyani, a city of over 250,000 inhabitants in Ghana. An initial survey inquired into sociodemographic characteristics, use of family planning (FP) methods and partner awareness of contraceptive use. The predictors of CCU were explored using logistic regressions. We used the findings to develop a guide which we applied in-depth interviews and focus group discussions with attendants at the same facility. Qualitative data analysis was conducted using a framework approach.

Results

We interviewed 300 women, 48 % of whom were aged between 26–33 years. The injectable was the most widely used method (56 %). The prevalence of CCU was 34 %. In multivariate analysis, single women were more likely to practice CCU than married or co-habiting women (Adjusted OR = 12.12, 95 % C.I. 4.73–31.1). Muslim and traditionalist women were similarly more likely to practice CCU than non-Muslim, non-traditionalist (Adjusted OR = 4.56, 2.29–9.06). Women who preferred to have their first or next child in 4 or more years from the time of the interview were more likely to be in CCU than women who intended to have children within 4 years of the interview (2.57; 1.37–4.83). Single women saw in covert use a statement of their social autonomy. To succeed in CCU, women wished that clinic attendance cards would not be given to them to keep at home. Though many participants saw in CCU a source of anxiety, they expected health workers to consider it and uphold confidentiality in the provision of services.

Conclusions

Covert contraceptive use was high in this municipality and being single was the strongest predictor of the practice. Providers of FP services should reflect on how to adequately address the challenges faced by women who practice CCU.

Monitoring malaria using health facility based surveys: challenges and limitations

Background

Health facility data are more readily accessible for operational planning and evaluation of disease control programmes. The importance, potential challenges and limitations of using facility based survey as an alternative tool for monitoring changes in local malaria epidemiology were examined.

Methods

The study involved six areas within the administrative divisions of The Gambia. The areas were selected to reflect socioeconomic and malaria transmission intensities across the country. The study design involved an age stratified cross sectional surveys that were conducted during the wet season in 2008 and in the 2009 during the dry season. Participants were patients attending clinics in six health centres and the representative populations from the catchment communities of the health centres.

Results

Overall participants’ characteristics were mostly not comparable in the two methodological approaches in the different seasons and settings. More females than males were enrolled (55.8 vs. 44.2 %) in all the surveys. Malaria infection was higher in the surveys in health centres than in the communities (p < 0.0001) and also in males than in females (OR = 1.3; p < 0.001). Males were less likely than females to sleep under an insecticide treated net in the communities (OR = 1.6; 95 % CI 1.3, 1.9) and in the health centres (OR = 1.3; 95 % CI 1.1, 1.5). Representativeness of the ethnic groups was better in the health centre surveys than in the community surveys when compared to the 2003 national population census in The Gambia.

Conclusion

Health facility based survey though a potential tool for monitoring changes in the local epidemiology of malaria will require continuous validation of the facility and participants sociodemograhic characteristics as these may change over time. The effects of health seeking practices on service utilization and health facility surveys as an approach will also need continuous review.

Effect of Test-Based versus Presumptive Treatment of Malaria in Under-Five Children in Rural Ghana--A Cluster-Randomised Trial

BACKGROUND

Malaria-endemic countries in sub-Saharan Africa are shifting from the presumptive approach that is based on clinical judgement (CJ) to the test-based approach that is based on confirmation through test with rapid diagnostic tests (RDT). It has been suggested that the loss of the prophylactic effect of presumptive-administered ACT in children who do not have malaria will result in increase in their risk of malaria and anaemia.

METHODS AND FINDINGS

We undertook a cluster-randomized controlled trial to compare the effects of the presumptive approach using clinical judgment (CJ-arm) and the test-based approach using RDTs (RDT-arm in a high-transmission setting in Ghana. A total of 3046 eligible children (1527 in the RDT arm and 1519 in the CJ- arm) living around 32 health centres were enrolled. Nearly half were female (48.7%) and 47.8% were below the age of 12 months as at enrolment. Over 24-months, the incidence of all episodes of malaria following the first febrile illness was 0.64 (95% CI 0.49-0.82) and 0.76 (0.63-0.93) per child per year in the RDT and CJ arms respectively (adjusted rate ratio 1.13 (0.82-1.55). After the first episode of febrile illness, the incidence of severe anaemia was the same in both arms (0.11 per child per year) and that of moderate anaemia was 0.16 (0.13-0.21) vs. 0.17 (0.14-0.21) per child year respectively. The incidence of severe febrile illness was 0.15 (0.09, 0.24) in the RDT arm compared to 0.17 (0.11, 0.28) per child per year respectively. The proportion of fever cases receiving ACT was lower in the RDT arm (72% vs 81%; p = 0.02).

CONCLUSION

The test-based approach to the management of malaria did not increase the incidence of malaria or anaemia among under-five children in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00832754.

Factors influencing willingness to participate in new drug trial studies: a study among parents whose children were recruited into these trials in northern Ghana

BACKGROUND

During the last decade, the number of clinical trials conducted in sub-Saharan Africa has increased significantly which has helped to address priority health problems in the region. Navrongo health research centre since it was established in 1989, has conducted several trial studies including rectal artesunate trial in the Kassena-Nankana districts. However, there is little evidence-based for assessing the impact of new drug trials. This study explored factors that motivate parents to allow their children to participate in new drug trials in northern Ghana.

METHOD

The study used both quantitative and qualitative methods. The participants were randomly selected from among parents whose children were enrolled in a new drug trial conducted in the Kassena-Nankana districts between 2000 and 2003. QSR Nvivo 9 software was used to code the qualitative data into themes before analysis while STATA software Version 11.2© was used to analyze the quantitative data.

RESULTS

The results showed that majority (95.9%) of the parents were willing to allow their children to be enrolled in future new drug trials. The main factors motivating their willingness to allow their children to be enrolled in these trials were quality of health care services offered to trial participants (92.9%), detail medical examination (90.8%), promptness of care provided (94.4%) and quality of drugs (91.9%). Other factors mentioned included disease prevention (99.5%) and improved living standard (96.1%). Parents reported that the conduct of these trials had reduced the frequency of disease occurrences in the communities because of the quality of health care services provided to the children recruited into these trial studies.

CONCLUSION

Though the implementation of clinical trials in the study area is believed to have positive impact on health status of people particularly trial participants, measures should however be taken to address safety and likely side effects of new drugs given to trial participants during these trial studies.

Shifting from presumptive to test-based management of malaria - technical basis and implications for malaria control in Ghana

The presumptive approach was the World Health Organisation (WHO) recommended to the management of malaria for many years and this was incorporated into syndromic guidelines such as the Integrated Management of Childhood Illnesses (IMCI). In early 2010 however, WHO issued revised treatment guidelines that call for a shift from the presumptive to the test-based approach. Practically, this implies that in all suspected cases, the diagnosis of uncomplicated malaria should be confirmed using rapid test before treatment is initiated. This revision effectively brings to an end an era of clinical practice that span several years. Its implementation has important implications for the health systems in malaria-endemic countries. On the basis of research in Ghana and other countries, and evidence from program work, the Ghana National Malaria Control Program has issued revised national treatment guidelines that call for implementation of test-based management of malaria in all cases, and across all age groups. This article reviews the evidence and the technical basis for the shift to test-based management and examines the implications for malaria control in Ghana.

Should consent forms used in clinical trials be translated into the local dialects? A survey among past participants in rural Ghana

BACKGROUND

Obtaining informed consent is part of the expression of the principle of participant autonomy during clinical trials. It is critical that participants understand the content of informed consent forms and remain in a position to seek independent advice on its content. We conducted a survey among past participants of a clinical trial in the Kassena-Nankana Districts of rural northern Ghana about the usefulness of informed consent forms that are written in the local dialects. The written forms of local dialects are largely undeveloped.

METHOD

We contacted a randomly selected sample of caregivers whose children were enrolled in a completed clinical trial and interviewed them using a structured questionnaire. Analysis sought to determine participants' preference and whether or not they were likely to find confidants who will be able to read, understand and give advice on the content of the informed consent form to them when they take the informed consent forms home.

RESULTS

We interviewed 394 caregivers, 88.6% of whom were women. About half (54%) of the respondents wanted the informed consent forms to be in the English language. Caregivers with higher than primary level education were more likely to prefer the informed consent form to be in English than those with no formal education (74% versus 26%, p = 0.04). The majority (85%) indicated that they would be able to find close confidants who would be able to read and explain it to them if it is in English. In contrast, only 8% thought they would be able to do the same if the informed consent form was written in the local language. Respondents were more likely to find close confidants to read and explain the informed consent form if it were written in English than if it were written in the local language (94% versus 19%, p value < 0.01).

CONCLUSION

The practice of translating informed consent forms into undeveloped local dialects and giving such copies to trial participants to send home needs to be re-evaluated. In populations where the written forms of local dialects are undeveloped and literacy is low, the use of local dialect versions of informed consent forms could ironically enhance the vulnerability of trial participants.

Willingness to undergo HIV testing in the Kintampo districts of Ghana

BACKGROUND

HIV testing is currently a major prevention intervention and remains an entry point to early treatment, care and support. Uptake is however low and alternative approaches are currently being adopted.

OBJECTIVE

An HIV module was incorporated into the routine survey of the Kintampo Health and Demographic Surveillance System (KHDSS) to assess the willingness of adults living in the Kintampo North and South districts to undergo HIV testing.

DESIGN

The study was a descriptive cross-sectional household survey. Univariate and multivariate analysis were used to identify predictors of the willingness to undergo HIV testing.

PARTICIPANTS

Respondents were community members aged 15 to 49 years and selected from randomly generated household listings from the KHDSS.

RESULTS

A total of 11,604 respondents were interviewed, 10,982 (94.6%) of respondents had good general knowledge on HIV/AIDS. Among those with knowledge about HIV/AIDS, 10,819 (98.5%) indicated their willingness to get tested for HIV. Rural residents were more willing to undergo HIV testing than urban dwellers Odds ratio=1.42 (95% Confidence interval: 1.03, 1.96; P-value=0.031). Respondents with primary education were more likely to go for testing relative to those without any education OR=2.02 (95% CI: 0.87, 4.70; P-value=0.046).

CONCLUSION

Expressed willingness to test for HIV is high in this population. Exploring community and population-based interventions to HIV testing and counseling could increase uptake of HIV testing services and should be considered. The underlying motivations need to be explored in order to translate willingness into actual testing.

Predictors of abortions in Rural Ghana: a cross-sectional study

Background

Abortion continues to be used as a method of family planning by many women. The complications of unsafe abortions are a major contributor to maternal mortality in sub-Saharan Africa, including Ghana. This study explored the influence of socio-demographic characteristics on abortions in 156 communities within the Kintampo Health and Demographic Surveillance System (KHDSS) area located in the middle part of Ghana.

Methods

A survey on Sexual and Reproductive Health among a representative sample of females aged 15–49 years was conducted in 2011. They were asked about the outcome of pregnancies that occurred between January 2008 and December 2011. Data on their socio-demographic characteristics including household assets were accessed from the database of the KHDSS. Univariate and multivariate random effects logistic regression models were used to explore the predictors of all reported cases of abortion (induced or spontaneous) and cases of induced abortion respectively.

Results

A total of 3554 women were interviewed. Of this total, 2197 women reported on the outcomes of 2723 pregnancies that occurred over the period. The number of all reported cases of abortions (induced and spontaneous) and induced abortions were 370 (13.6%) and 101 (3.7%) respectively.

Unmarried women were more likely to have abortion as compared to married women (aOR = 1.77, 95% CI [1.21-2.58], p = 0.003). Women aged 20–29 years were 43% less likely to have abortion in comparison with those within the ages 13–19 years (aOR = 0.57, 95% CI [0.34-0.95], p = 0.030). Women with primary, middle/junior high school (JHS) and at least secondary education had higher odds of having abortion as compared to women without education. Compared with the most poor women, wealthiest women were three-fold likely to have abortion.

Unmarried women had higher odds of having induced abortion as compared to married women (aOR = 7.73, 95% CI [2.79-21.44], p < 0.001). Women aged 20–29 years, 30–39 years and 40–49 years were less likely to have induced abortion as compared to those 13–19 years of age.

Conclusion

Extra efforts are needed to ensure that family planning services, educational programs on abortion and abortion care reach the target groups identified in this study.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1572-1) contains supplementary material, which is available to authorized users.

Determinants of unintended pregnancies in rural Ghana

Background

Unintended pregnancies may carry serious consequences for women and their families, including the possibility of unsafe abortion, delayed prenatal care, poor maternal mental health and poor child health outcomes. Although between 1993 and 2008, unintended births decreased from 42% to 37% in Ghana, the rate of decline is low, whilst levels are still very high. This raises the need to understand factors associated with unintended pregnancies, especially among women in rural settings where the rates and risks are highest to help improve maternal health.

Method

We collected data from 1,914 pregnant women attending antenatal clinic between January 2012 and April 2012 in four health facilities in the Mfantseman Municipal of the Central Region of Ghana. We used bivariate and multivariate logistic regression analyses to explore how socio-demographic characteristics, past reproductive health experiences, partner characteristics and relations, awareness and past experience with contraceptives, influenced the status of women’s current pregnancy (whether intended or unintended).

Results

The mean age of the 1,914 respondents in this study was 25.6 ± 6.5 years. Seventy percent (70%) said the pregnancies they were carrying were unintended. The odds of carrying unintended pregnancy among women with five or more children were higher than those with one to two children [AOR 6.06, 95% CI (3.24-11.38) versus AOR 1.48, 95% CI (1.14-1.93)]. Women with other marital arrangements showed significantly higher odds of carrying unintended pregnancy compared to those married by ordinance (Muslim or Christian wedding). Women not living with their partners exhibited increased odds of having unintended pregnancies compared to women who lived with their partners (AOR 1.72, 95% CI: 1.28 - 2.30). Awareness of traditional methods of family planning (withdrawal and rhythm) was associated with lower odds of having unintended pregnancy compared to non-awareness (AOR 0.66, 95% CI (0.49-0.89).

Conclusions

In this study, important risk factors associated with unintended pregnancies were: parity, living arrangements with partner, marriage by ordinance and awareness of traditional, non-pharmacological contraceptive methods. Family planning interventions targeting different groups of women, especially during the postpartum period, would be essential to reduce rates of unintended pregnancies and promote positive health outcomes.

Management of febrile children under five years in hospitals and health centres of rural Ghana

BACKGROUND

The case management of febrile children in hospitals' and health centres' pre-roll out of the new WHO policy on parasitological diagnosis was assessed. The delivery of artemisinin combination therapy (ACT) at these two levels of the health system was compared.

METHODS

Structured observations and exit interviews of 1,222 febrile children attending five hospitals and 861 attending ten health centres were conducted in six districts of the Brong Ahafo Region of Ghana. Effectiveness of delivery of case management of malaria was assessed. Proportions of children receiving ACT, anti-malarial monotherapy and antibiotics were described. Predictors of: a febrile child being given an ACT, a febrile child being given an antibiotic and of carers knowing how to correctly administer the ACT were assessed using logistic regression models stratified by hospitals and health centres.

RESULTS

The system's effectiveness of delivering an ACT to febrile children diagnosed with malaria (parasitologically or clinically) was 31.4 and 42.4% in hospitals and health centres, respectively. The most ineffective process was that of ensuring that carers knew how to correctly administer the ACT. Overall 278 children who were not given an ACT were treated with anti-malarial monotherapy other than quinine. The majority of these children, 232/278 were given amodiaquine, 139 of these were children attending hospitals and 93 attending health centres. The cadre of health staff conducting consultation was a common predictor of the outcomes of interest. Presenting symptoms and examinations conducted were predictive of being given an ACT in hospitals and antibiotic in hospitals and health centres but not of being given an ACT in health centres. Treatment-seeking factors were predictive of being given an ACT if it was more than seven days since the fever began and an antibiotic in hospitals but not in health centres.

CONCLUSION

Interventions to improve adherence to negative parasitological tests are needed, together with guidance on dispensing of antibiotics, but improving the education of carers on how to administer ACT will lead to the greatest immediate increase in the effectiveness of case management. Guidance is needed on implementation of the new test-based treatment for malaria policy in health facilities.

Factors influencing the intention of women in rural Ghana to adopt postpartum family planning

BACKGROUND

Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa and very little is known about how pregnant women arrive at their decisions to adopt PPFP. This information is needed to guide the development of interventions to promote PPFP.

METHODS

We conducted a survey among pregnant women attending antenatal clinics in a rural district in Ghana. We used univariate and multivariate logistic regression analysis to explore how knowledge of various family planning (FP) methods, past experience with their use and the acceptability of PPFP to male partners and close relations influenced the intention of pregnant women to adopt PPFP.

RESULTS

We interviewed 1914 pregnant women in four health facilities. About 84% considered PPFP acceptable, and 70% intended to adopt a method. The most preferred methods were injectables (31.5%), exclusive breastfeeding (16.7%), and oral contraceptive pills (14.8%). Women whose first choice of PPFP method were injectables were more likely to be women who had had past experience with its use (O.R = 2.07, 95% C.I. 1.50-2.87). Acceptability of PPFP by the pregnant woman (O.R. = 3.21, 1.64-6.26), perception of partner acceptability (O.R. = 3.20, 1.94-5.48), having had prior experience with the use of injectables (O.R. = 3.72, 2.61-5.30) were the strongest predictors of the intention to adopt PPFP. Conversely women who knew about the diaphragm (O.R. = 0.59, 0.38-0.93) and those who had past experience with IUD use (O.R. = 0.13, 0.05-0.38) were less likely to want to adopt PPFP.

CONCLUSIONS

Acceptability of PPFP to the pregnant woman, male partner approval, and past experience with the use of injectables are important factors in the PPFP decisions of women in this population. Antenatal and early postnatal care need to be adapted to take these factors into consideration.

An assessment of the likely acceptability of vaginal microbicides for HIV prevention among women in rural Ghana

BACKGROUND

The findings of the CAPRISA tenofovir studies have raised expectations that soon an approved microbicide would be available. However it is in only a limited number of countries in sub-Saharan Africa that the acceptability of microbicides has been evaluated. We conducted a study to assess the acceptability of vaginal microbicides among women in rural Ghana.

METHODS

The study employs a mixed method design, using cross-sectional survey and focus group discussions to further understand issues related to awareness and attitudes towards microbicide development, acceptability and perceived partner attitudes among pregnant women attending antenatal clinic in two health facilities in the Kintampo North municipality of Ghana. We used logistic regression to identify possible predictors of microbicide acceptability among the women surveyed.

RESULTS

Although only 2% of the 504 women were aware of the development of microbicides, 95% were willing to use one when it became available. The cost of a microbicide that will be considered affordable to 50% of women was US$0.75. Although there were concerns about possible wetting effect, gel or creams were the most preferred (68% of women) formulation. Although 71% thought their partners will find microbicide acceptable, apprehensions about the feasibility of and consequences of failed discreet use were evident. 49% of women were concerned about possible negative effect of microbicide on sexual pleasure. Perceived partner acceptability (O.R. =17.7; 95%C.I. 5.03-62.5) and possibility of discreet use (O.R. =8.9 95%C.I. 2.63-30.13) were the important predictors of microbicide acceptability.

CONCLUSION

Achieving microbicide acceptability among male partners should be made a part of the promotive interventions for ensuring effective use among women in rural Ghana.

Acceptability of rapid diagnostic test-based management of Malaria among caregivers of under-five children in rural Ghana

Introduction

WHO now recommends test-based management of malaria (TBMM) across all age-groups. This implies artemisinin-based combination treatment (ACT) should be restricted to rapid diagnostic test (RDT)-positive cases. This is a departure from what caregivers in rural communities have been used to for many years.

Methods

We conducted a survey among caregivers living close to 32 health centres in six districts in rural Ghana and used logistic regression to explore factors likely to influence caregiver acceptability of RDT based case management and concern about the denial of ACT on account of negative RDT results. Focus group discussions were conducted to explain the quantitative findings and to elicit further factors.

Results

A total of 3047 caregivers were interviewed. Nearly all (98%) reported a preference for TBMM over presumptive treatment. Caregivers who preferred TBMM were less likely to be concerned about the denial of ACT to their test-negative children (O.R. 0.57, 95%C.I. 0.33–0.98). Compared with caregivers who had never secured national health insurance cover, caregivers who had valid (adjusted O.R. 1.30, 95% CI 1.07–1.61) or expired (adjusted O.R. 1.38, 95% CI 1.12–1.73) insurance cover were more likely to be concerned about the denial of ACT to their RDT-negative children. Major factors that promote TBMM acceptability include the perception that a blood test at health centre level represents improvement in the quality of care, leads to improvement in treatment outcomes, and offers opportunity for better communication between health workers and caregivers. Acceptability is also enhanced by engaging caregivers in the procedures of the test. Apprehensions about negative health worker attitude could however undermine acceptance.

Conclusion

Test (RDT)-based management of malaria in under-five children is likely to be acceptable to caregivers in rural Ghana. The quality of caregiver-health worker interaction needs to be improved if acceptability is to be sustained.

Estimating malaria parasite density: assumed white blood cell count of 10,000/μl of blood is appropriate measure in Central Ghana

Background

White blood cells count (WBCc) is a bedrock in the estimation of malaria parasite density in malaria field trials, interventions and patient management. White blood cells are indirectly and relatively used in microscopy to estimate the density of malaria parasite infections. Due to frequent lack of facilities in some malaria-endemic countries, in order to quantify WBCc of patients, an assumed WBCc of 8.0 X 10(9)/L has been set by the World Health Organization to help in estimating malaria parasite densities.

Methods

This comparative analysis study, in Central Ghana, compiled laboratory data of 5,902 Plasmodium falciparum malaria parasite positive samples. Samples were obtained from consented participants of age groups less than five years. Full blood counts (FBC) of participants’ samples were analysed using the ABX Micros 60 Haematology Analyzer. Blood slides were read by two competent microscopists to produce concordant results. All internal and external quality control measures were carried out appropriately. Parasite densities were calculated using participants’ absolute WBCc and assumed WBCc of 5,000 to 10,000 per microlitre of blood.

Results

From the 5,902 Pf malaria positive samples, the mean (SD) WBCc and geometric mean parasite density were 10.4 (4.6) × 10(9)/L and 7,557/μL (95 % CI 7,144/μL to 7,994/μL) respectively. The difference in the geometric mean parasite densities calculated using absolute WBCs and compared to densities with assumed WBCs counts were significantly lower for 5.0 × 10(9)/L; 3,937/μL, 6.0 × 10(9)/L; 4,725/μL and 8.0 × 10(9)/L; 6,300/μL. However, the difference in geometric mean parasite density, 7,874/μL (95 % CI, 7,445/μL to 8,328/μL), with assumed WBCc of 10.0 × 10(9)/L was not significant.

Conclusion

Using the assumed WBCc of 8.0 X 10(9)/L or lower to estimate malaria parasite densities in Pf infected children less than five years old could result in significant underestimation of parasite burden. Assumed WBCc of 10.0 × 10(9)/L at 95 % CI of geometric mean of parasite density statistically agreed with the parasite densities produce by the absolute WBCc of participants. The study suggests where resources are limited, use of assumed WBCc of 10.0 × 10(9)/L of blood to estimate malaria parasite density in central Ghana. Preferably, absolute WBCc should be used in drug efficacy and vaccine trials.

Duodenal perforation in a 12-month old child with severe malaria

Peptic ulcer disease (PUD) in children remains rare and difficult to diagnose before the onset of complications. We report on a case of a 12-month child with perforated duodenal ulcer, association with malaria. The severity of the febrile presentation and the positive laboratory confirmation of malaria delayed the diagnosis of PUD. Surgical intervention was successful and without significant sequelae. An awareness of the possibility, and a lower threshold for considering PUD in children may help prevent complications.