Completion of three-dose hepatitis B vaccination cycle and associated factors among health care workers in the Greater Accra Region of Ghana

BACKGROUND

Despite the availability of a safe and effective vaccine coupled with the awareness of the potential risk of Healthcare Workers acquiring Hepatitis B Virus infection, some HCWs never get vaccinated. Generally, hepatitis B vaccination coverage globally is below the expected level as adherence has remained poor in various healthcare settings, especially in developing countries. The objective of this study was to assess the completion of a three-dose Hepatitis B virus vaccination cycle and associated factors among healthcare workers in the Greater Accra Region of Ghana.

METHODS AND MATERIALS

An analytical cross-sectional study was conducted and included 363 healthcare workers selected using probability sampling procedures. The participants were recruited from five facilities within the Greater Accra Region in the first half of 2018. A pretested questionnaire was used to collect data which was analyzed using SPSS version 21. The proportion of healthcare workers receiving the recommended 3 doses of the hepatitis vaccine was computed. The multivariable analysis procedure identified the factors associated with adherence to the receipt of three doses of the hepatitis B vaccine. Odds ratios were estimated with corresponding confidence intervals with the level of significance set at 0.05.

RESULTS

A total of 340 sample units were included in the analysis. Most of the participants (252/340, 74.1%) were females, mainly nurses/midwives (162/340, 47.6%) with a mean age of 34.5 (SD ±7.7). A high proportion of the participants (82.7%) have tertiary/post-tertiary level education and ever participated in at least one training workshop on the prevention of blood-borne infections (80.6%). Overall vaccination uptake was 60.9% (207/340) (95% CI = 55.7%-66.1%). Complete vaccination coverage (three doses) was 46.8% (159/340). High-risk perception (AOR = 4.0; 95% CI = 1.3-12.5), and previous training in infection prevention (AOR = 2.8; 95% CI = 1.1-7.5) were significantly associated with adherence to receipt of three doses of hepatitis B vaccine.

CONCLUSION

Adherence to three-dose hepatitis B vaccination cycles is not universal among the healthcare workers in the Greater Accra Region. Receipt of the three-dose regimen is significantly associated with high-risk perception and attendance of training in infectious disease prevention. Interventions to increase risk perception and training in the prevention of blood-borne infections could improve adherence to complete/full vaccination protocol among healthcare workers who are at constant risk of exposure to the hepatitis B virus.

Smoke exposure, hemoglobin levels and the prevalence of anemia: a cross-sectional study in urban informal settlement in Southern Ghana

BACKGROUND

In sub-Saharan African cities, more than half of the population lives in informal settlements. These settlements are close to smoky dumpsites, industrial plants, and polluted roads. Furthermore, polluting fuels remain their primary sources of energy for cooking and heating. Despite evidence linking smoke and its components to anaemia, none of these studies were conducted on populations living in urban informal settlements. This study investigated the risks of anemia/mean Haemoglobin (HB) levels in an informal settlement in Accra, Ghana. Exposure to smoke was examined across various sources, encompassing residences, neighborhoods, and workplaces.

METHODS

The study was a facility-based cross-sectional design among residents at Chorkor, an informal settlement in the Greater Accra region of Ghana. A questionnaire was administered at a community hospital during an interview to gather data on sources of smoke exposure in the household, in the neighbourhood, and in the workplace. A phlebotomist collected blood samples from the participants after the interview to assess their anaemia status.

RESULTS

The population (n = 320) had a high prevalence of anemia, with 49.1% of people fitting the WHO's definition of anemia, while the average HB level was 12.6 ± 2.1 g/dL. Anemia was associated with the number of different types of waste burnt simultaneously [(1 or 2: prevalence ratio (PR): 95% confidence interval (CI), 1.14, 0.99-1.28: 3+: 1.16, 1.01-1.63, p-for-trend = 0.0082)], fuel stacking [(mixed stacking: 1.27, 1.07-1.20: dirty stacking:1.65, 1.19-2.25, p-for-trend = 0.0062)], and involvement in fish smoking (1.22, 0.99-1.06). However, the lower limit of the CIs for number of different forms of garbage burned simultaneously and engagement in fish smoking included unity. Reduced mean HB levels were associated with the number of different types of waste burnt simultaneously [(1 or 2: regression coefficient (β): 95% confidence interval (CI), -0.01, -0.97- -0.99: 3+: -0.14, -0.77- -0.05)], current smoker [(yes, almost daily: -1.40, -2.01- -0.79: yes, at least once a month: -1.14, -1.79- -0.48)], Second-Hand-Smoking (SHS) (yes, almost daily: -0.77, -1.30- -0.21), fuel stacking [(mixed stacking-0.93, -1.33-0.21: dirty stacking-1.04, -1.60- -0.48)], any smoke exposure indicator in the neighbourhood (-0.84, -1.43- -0.25), living close to a major road (-0.62, -1.09- -0.49), and fish smoking (-0.41,-0.93- -0.12).

CONCLUSION

Although the cross-sectional design precludes causality, smoke exposure was associated with mean HB levels and anaemia among populations living in informal settlements.

Household concentrations and female and child exposures to air pollution in peri-urban sub-Saharan Africa: measurements from the CLEAN-Air(Africa) study

BACKGROUND

Relatively clean cooking fuels such as liquefied petroleum gas (LPG) emit less fine particulate matter (PM2·5) and carbon monoxide (CO) than polluting fuels (eg, wood, charcoal). Yet, some clean cooking interventions have not achieved substantial exposure reductions. This study evaluates determinants of between-community variability in exposures to household air pollution (HAP) across sub-Saharan Africa.

METHODS

In this measurement study, we recruited households cooking primarily with LPG or exclusively with wood or charcoal in peri-urban Cameroon, Ghana, and Kenya from previously surveyed households. In 2019-20, we conducted monitoring of 24 h PM2·5 and CO kitchen concentrations (n=256) and female cook (n=248) and child (n=124) exposures. PM2·5 measurements used gravimetric and light scattering methods. Stove use monitoring and surveys on cooking characteristics and ambient air pollution exposure (eg, walking time to main road) were also administered.

FINDINGS

The mean PM2·5 kitchen concentration was five times higher among households cooking with charcoal than those using LPG in the Kenyan community (297 μg/m3, 95% CI 216-406, vs 61 μg/m3, 49-76), but only 4 μg/m3 higher in the Ghanaian community (56 μg/m3, 45-70, vs 52 μg/m3, 40-68). The mean CO kitchen concentration in charcoal-using households was double the WHO guideline (6·11 parts per million [ppm]) in the Kenyan community (15·81 ppm, 95% CI 8·71-28·72), but below the guideline in the Ghanaian setting (1·77 ppm, 1·04-2·99). In all communities, mean PM2·5 cook exposures only met the WHO interim-1 target (35 μg/m3) among LPG users staying indoors and living more than 10 min walk from a road.

INTERPRETATION

Community-level variation in the relative difference in HAP exposures between LPG and polluting cooking fuel users in peri-urban sub-Saharan Africa might be attributed to differences in ambient air pollution levels. Thus, mitigation of indoor and outdoor PM2·5 sources will probably be critical for obtaining significant exposure reductions in rapidly urbanising settings of sub-Saharan Africa.

FUNDING

UK National Institute for Health and Care Research.

Entomological risk assessment for transmission of arboviral diseases by Aedes mosquitoes in a domestic and forest site in Accra, Ghana

Dengue, Zika and chikungunya are Aedes-borne viral diseases that have become great global health concerns in the past years. Several countries in Africa have reported outbreaks of these diseases and despite Ghana sharing borders with some of these countries, such outbreaks are yet to be detected. Viral RNA and antibodies against dengue serotype-2 have recently been reported among individuals in some localities in the regional capital of Ghana. This is an indication of a possible silent transmission ongoing in the population. This study, therefore, investigated the entomological transmission risk of dengue, Zika and chikungunya viruses in a forest and domestic population in the Greater Accra Region, Ghana. All stages of the Aedes mosquito (egg, larvae, pupae and adults) were collected around homes and in the forest area for estimation of risk indices. All eggs were hatched and reared to larvae or adults for morphological identification together with larvae and adults collected from the field. The forest population had higher species richness with 7 Aedes species. The predominant species of Aedes mosquitoes identified from both sites was Aedes aegypti (98%). Aedes albopictus, an important arbovirus vector, was identified only in the peri-domestic population at a prevalence of 1.5%, significantly higher than previously reported. All risk indices were above the WHO threshold except the House Index for the domestic site which was moderate (19.8). The forest population recorded higher Positive Ovitrap (34.2% vs 26.6%) and Container (67.9% vs 36.8%) Indices than the peri-domestic population. Although none of the mosquito pools showed the presence of dengue, chikungunya or Zika viruses, all entomological risk indicators showed that both sites had a high potential arboviral disease transmission risk should any of these viruses be introduced. Continuous surveillance is recommended in these and other sites in the Metropolis to properly map transmission risk areas to inform outbreak preparedness strategies.

Low-Cost Sensor Performance Intercomparison, Correction Factor Development, and 2+ Years of Ambient PM2.5 Monitoring in Accra, Ghana

Particulate matter air pollution is a leading cause of global mortality, particularly in Asia and Africa. Addressing the high and wide-ranging air pollution levels requires ambient monitoring, but many low- and middle-income countries (LMICs) remain scarcely monitored. To address these data gaps, recent studies have utilized low-cost sensors. These sensors have varied performance, and little literature exists about sensor intercomparison in Africa. By colocating 2 QuantAQ Modulair-PM, 2 PurpleAir PA-II SD, and 16 Clarity Node-S Generation II monitors with a reference-grade Teledyne monitor in Accra, Ghana, we present the first intercomparisons of different brands of low-cost sensors in Africa, demonstrating that each type of low-cost sensor PM2.5 is strongly correlated with reference PM2.5, but biased high for ambient mixture of sources found in Accra. When compared to a reference monitor, the QuantAQ Modulair-PM has the lowest mean absolute error at 3.04 μg/m3, followed by PurpleAir PA-II (4.54 μg/m3) and Clarity Node-S (13.68 μg/m3). We also compare the usage of 4 statistical or machine learning models (Multiple Linear Regression, Random Forest, Gaussian Mixture Regression, and XGBoost) to correct low-cost sensors data, and find that XGBoost performs the best in testing (R2: 0.97, 0.94, 0.96; mean absolute error: 0.56, 0.80, and 0.68 μg/m3 for PurpleAir PA-II, Clarity Node-S, and Modulair-PM, respectively), but tree-based models do not perform well when correcting data outside the range of the colocation training. Therefore, we used Gaussian Mixture Regression to correct data from the network of 17 Clarity Node-S monitors deployed around Accra, Ghana, from 2018 to 2021. We find that the network daily average PM2.5 concentration in Accra is 23.4 μg/m3, which is 1.6 times the World Health Organization Daily PM2.5 guideline of 15 μg/m3. While this level is lower than those seen in some larger African cities (such as Kinshasa, Democratic Republic of the Congo), mitigation strategies should be developed soon to prevent further impairment to air quality as Accra, and Ghana as a whole, rapidly grow.

Malaria and typhoid fever among patients presenting with febrile illnesses in Ga West Municipality, Ghana

BACKGROUND

Clinicians in areas where malaria and typhoid fever are co-endemic often treat infected patients irrationally, which may lead to the emergence of drug resistance and extra cost to patients. This study determined the proportion of febrile conditions attributable to either malaria and/or typhoid fever and the susceptibility patterns of Salmonella spp. isolates to commonly used antimicrobial agents in Ghana.

METHODS

One hundred and fifty-seven (157) febrile patients attending the Ga West Municipal Hospital, Ghana, from February to May 2017 were sampled. Blood samples were collected for cultivation of pathogenic bacteria and the susceptibility of the Salmonella isolates to antimicrobial agents was performed using the Kirby-Bauer disk diffusion method with antibiotic discs on Müller Hinton agar plates. For each sample, conventional Widal test for the detection of Salmonella spp was done as well as blood film preparation for detection of Plasmodium spp. Data on the socio-demographic and clinical characteristics of the study participants were collected using an android technology software kobo-collect by interview.

RESULTS

Of the total number of patients aged 2-37 years (median age = 6 years, IQR 3-11), 82 (52.2%) were females. The proportion of febrile patients with falciparum malaria was 57/157 (36.3%), while Salmonella typhi O and H antigens were detected in 23/157 (14.6%) of the samples. The detection rate of Salmonella spp in febrile patients was 10/157 (6.4%). Malaria and typhoid fever coinfection using Widal test and blood culture was 9 (5.7%) and 3 (1.9%), respectively. The isolates were highly susceptible to cefotaxime, ceftriaxone, ciprofloxacin, and amikacin but resistant to ampicillin, tetracycline, co-trimoxazole, gentamicin, cefuroxime, chloramphenicol, and meropenem.

CONCLUSION

Plasmodium falciparum and Salmonella spp coinfections were only up to 1.9%, while malaria and typhoid fever, individually, were responsible for 36.3% and 6.4%, respectively. Treatment of febrile conditions must be based on laboratory findings in order not to expose patients to unnecessary side effects of antibiotics and reduce the emergence and spread of drug resistance against antibiotics.

Review of 2022 WHO guidelines on the control and elimination of schistosomiasis

Schistosomiasis is a helminthiasis infecting approximately 250 million people worldwide. In 2001, the World Health Assembly (WHA) 54.19 resolution defined a new global strategy for control of schistosomiasis through preventive chemotherapy programmes. This resolution culminated in the 2006 WHO guidelines that recommended empirical treatment by mass drug administration with praziquantel, predominately to school-aged children in endemic settings at regular intervals. Since then, school-based and community-based preventive chemotherapy programmes have been scaled-up, reducing schistosomiasis-associated morbidity. Over the past 15 years, new scientific evidence-combined with a more ambitious goal of eliminating schistosomiasis and an increase in the global donated supply of praziquantel-has highlighted the need to update public health guidance worldwide. In February, 2022, WHO published new guidelines with six recommendations to update the global public health strategy against schistosomiasis, including expansion of preventive chemotherapy eligibility from the predominant group of school-aged children to all age groups (2 years and older), lowering the prevalence threshold for annual preventive chemotherapy, and increasing the frequency of treatment. This Review, written by the 2018-2022 Schistosomiasis Guidelines Development Group and its international partners, presents a summary of the new WHO guideline recommendations for schistosomiasis along with their historical context, supporting evidence, implications for public health implementation, and future research needs.

Preponderance of vaccine-preventable diseases hotspots in northern Ghana: a spatial and space-time clustering analysis from 2010 to 2014

BACKGROUND

Vaccine-preventable diseases (VPDs) persist globally with a disproportionately high burden in Low and Middle-Income Countries (LMICs). Although this might be partly due to the failure to sustain vaccination coverage above 90% in some WHO regions, a more nuanced understanding of VPD transmission beyond vaccination coverage may unveil other important factors in VPD transmission and control. This study identified VPDs hotspots and explored their relationships with ecology, urbanicity and land-use variations (Artisanal and Small-scale Gold Mining (ASGM) activities) in Ghana.

METHODS

District-level disease count data from 2010 to 2014 from the Ghana Health Service (GHS) and population data from the Ghana Population and Housing Census (PHC) were used to determine clustering patterns of six VPDs (Measles, Meningitis, Mumps, Otitis media, Pneumonia and Tetanus). Spatial and space-time cluster analyses were implemented in SaTScan using the discrete Poisson model. P-values were estimated using a combination of sequential Monte Carlo, standard Monte Carlo, and Gumbel approximations.

RESULTS

The study found a preponderance for VPD hotspots in the northern parts of Ghana and northernmost ecological zones (Sudan Savannah and Guinea Savannah). Incidence of meningitis was higher in the Sudan Savannah ecological zone relative to: Tropical Rain Forest (p = 0.001); Semi Deciduous Forest (p < 0.0001); Transitional Zone (p < 0.0001); Coastal Savannah (p < 0.0001) and Guinea Savannah (p = 0.033). Except for mumps, which recorded a higher incidence in urban districts (p = 0.045), incidence of the other five VPDs did not differ across the urban-rural divide. Whereas spatial analysis suggested that some VPD hotspots (tetanus and otitis media) occur more frequently in mining districts in the southern part of the country, a Mann-Whitney U test revealed a higher incidence of meningitis in non-mining districts (p = 0.019). Pneumonia and meningitis recorded the highest (722.8 per 100,000) and least (0.8 per 100,000) incidence rates respectively during the study period.

CONCLUSION

This study shows a preponderance of VPD hotspots in the northern parts of Ghana and in semi-arid ecoclimates. The relationship between ASGM activities and VPD transmission in Ghana remains blurred and requires further studies with better spatial resolution to clarify.

Parenting practices and family relationships during the COVID-19 lockdown in Ghana

The effects of the COVID-19 pandemic have been far reaching across almost every sphere of life. Families, which are the basic units of society, have not been spared the ravages of the pandemic. Changes in family daily routines as a result of COVID-19 can affect spousal relationships, parenting and childcare practices. However, the extent to which the pandemic has affected parenting practices and family relationships in Ghana is not known.

The goal of this study was to assess how parenting practices and family relationships have been influenced during the COVID-19 pandemic in Ghana. Data for this paper was drawn from an online questionnaire response from 463 participants in Ghana as a subset analysis from a multi-country study on personal and family coping system with COVID-19 pandemic in the global south.

The mean score for pre-COVID-19 relationship with partner (36.86) was higher (p<0.0001) than the mean score for during COVID-19 relationship with partner (35.32) indicating that COVID-19 has had negative influence on relationships. The mean score for pre-COVID-19 parenting (32.78) was higher (p<0.0001) compared to the mean score for during COVID-19 parenting (31.40) indicating negative influence on parenting. We have predicted that participants whose coping levels were “Well” on the average, are likely to be doing well in relationship with partners and parenting practices during the COVID-19 period

The challenging public health containment measures of the COVID-19 pandemic have negatively influenced the relationship between partners and parenting practices in Ghana.

Interventions to Reduce Pesticide Exposure from the Agricultural Sector in Africa: A Workshop Report

Despite the fact that several cases of unsafe pesticide use among farmers in different parts of Africa have been documented, there is limited evidence regarding which specific interventions are effective in reducing pesticide exposure and associated risks to human health and ecology. The overall goal of the African Pesticide Intervention Project (APsent) study is to better understand ongoing research and public health activities related to interventions in Africa through the implementation of suitable target-specific situations or use contexts. A systematic review of the scientific literature on pesticide intervention studies with a focus on Africa was conducted. This was followed by a qualitative survey among stakeholders involved in pesticide research or management in the African region to learn about barriers to and promoters of successful interventions. The project was concluded with an international workshop in November 2021, where a broad range of topics relevant to occupational and environmental health risks were discussed such as acute poisoning, street pesticides, switching to alternatives, or disposal of empty pesticide containers. Key areas of improvement identified were training on pesticide usage techniques, research on the effectiveness of interventions targeted at exposure reduction and/or behavioral changes, awareness raising, implementation of adequate policies, and enforcement of regulations and processes.

Urinary Pesticide Residual Levels and Acute Respiratory Infections in Children Under 5 Years of Age: Findings From the Offinso North Farm Health Study

BACKGROUND

Several environmental factors are associated with the risk of acute lower respiratory infections (ALRIs) and upper respiratory infections (URIs) in children under 5 years of age (YOA). Evidence implicating chemical pesticides remains equivocal. There are also no data on this subject in these children in Ghana. This study investigated the association between urinary pesticide residual levels and the risk for ALRIs/URIs in children under 5 YOA.

METHODS

The participants for this study were from the Offinso North Farm Health Study, a population-based cross-sectional study. Two hundred and fifty four parents/guardians who had answered affirmatively to the question "Has your child ever accompanied you to the farm?" were interviewed on household socio-demographic and environmental factors, being breastfed, child education, age, gender, and respiratory infection. One hundred fifty children were randomly selected to provide the first void urine.

RESULTS

The proportion of children with ALRI was 22.1% and those with URI was 35.8%. We observed a statistically significant exposure-response relation of p,p'-DDE (tertile) with ALRI (1.7-3.2 µg/L urine: prevalence ratio [PR] = 1.22 [1.05-1.70], ⩾3.2 µg/L urine: 1.50 [1.07-3.53] [P-for trend = .0297]). This observation was in children older than two YOA (P-for trend = .0404). Delta-HCH and beta-HCH (2-levels) were significantly associated with ALRI but not URI. The risk of ALRI increased with deltamethrin levels in an exposure-response manner (2.5-9.5 µg/L urine: 2.10 [1.37-3.24], ⩾9.5 µg/L urine: 4.38 [1.87-10.32] [P-for trend = .0011]) and this was also observed in children older than two YOA. Similar observation was noted for URI. Bifenthrin (>0.5 µg/L urine) was positively associated with ALRI and URI whereas permethrin (⩾1.2 µg/L urine) was not associated only with URI.

CONCLUSIONS

The present study supports the hypothesis that exposure to chemical pesticides is associated with respiratory infections in children under 5 YOA.

Coping strategies adapted by Ghanaians during the COVID-19 crisis and lockdown: A population-based study

BACKGROUND

The COVID-19 pandemic and control measures adopted by countries globally can lead to stress and anxiety. Investigating the coping strategies to this unprecedented crisis is essential to guide mental health intervention and public health policy. This study examined how people are coping with the COVID-19 crisis in Ghana and identify factors influencing it.

METHODS

This study was part of a multinational online cross-sectional survey on Personal and Family Coping with COVID-19 in the Global South. The study population included adults, ≥18 years and residents in Ghana. Respondents were recruited through different platforms, including social media and phone calls. The questionnaire was composed of different psychometrically validated instruments with coping as the outcome variable measured on the ordinal scale with 3 levels, namely, Not well or worse, Neutral, and Well or better. An ordinal logistic regression model using proportional odds assumption was then applied.

RESULTS

A total of 811 responses were included in the analysis with 45.2% describing their coping level as well/better, 42.4% as neither worse nor better and 12.4% as worse/not well. Many respondents (46.9%) were between 25-34 years, 50.1% were males while 79.2% lived in urban Ghana. Having pre-existing conditions increased the chances of not coping well (aOR = 1.86, 95%CI: 1.15-3.01). Not being concerned about supporting the family financially (aOR = 1.67, 95%CI: 1.06-2.68) or having the feeling that life is better during the pandemic (aOR = 2.37, 95%CI: 1.26-4.62) increased chances of coping well. Praying (aOR: 0.62, 95%CI: 0.43-0.90) or sleeping (aOR: 0.55, 95%CI: 0.34-0.89) more during the pandemic than before reduces coping.

CONCLUSION

In Ghana, during the COVID-19 pandemic, financial security and optimism about the disease increase one's chances of coping well while having pre-existing medical conditions, praying and sleeping more during the pandemic than before reduces one's chances of coping well. These findings should be considered in planning mental health and public health intervention/policy.

Prevalence and changes in boredom, anxiety and well-being among Ghanaians during the COVID-19 pandemic: a population-based study

BACKGROUND

The outbreak of the COVID-19 pandemic has been associated with several adverse health outcomes. However, few studies in sub-Saharan Africa have examined its deleterious consequences on mental health. Therefore, we investigated the prevalence and changes in boredom, anxiety and psychological well-being before and during the COVID-19 pandemic in Ghana.

METHODS

Data for this study were drawn from an online survey of 811 participants that collected retrospective information on mental health measures including symptoms of generalized anxiety disorder, boredom, and well-being. Additional data were collected on COVID-19 related measures, biosocial (e.g. age and sex) and sociocultural factors (e.g., education, occupation, marital status). Following descriptive and psychometric evaluation of measures used, multiple linear regression was used to assess the relationships between predictor variables and boredom, anxiety and psychological well-being scores during the pandemic. Second, we assessed the effect of anxiety on psychological well-being. Next, we assessed predictors of the changes in boredom, anxiety, and well-being.

RESULTS

Before the COVID-19 pandemic, 63.5% reported better well-being, 11.6% symptoms of anxiety, and 29.6% symptoms of boredom. Comparing experiences before and during the pandemic, there was an increase in boredom and anxiety symptomatology, and a decrease in well-being mean scores. The adjusted model shows participants with existing medical conditions had higher scores on boredom (ß = 1.76, p < .001) and anxiety (ß = 1.83, p < .01). In a separate model, anxiety scores before the pandemic (ß = -0.25, p < .01) and having prior medical conditions (ß = -1.53, p < .001) were associated with decreased psychological well-being scores during the pandemic. In the change model, having a prior medical condition was associated with an increasing change in boredom, anxiety, and well-being. Older age was associated with decreasing changes in boredom and well-being scores.

CONCLUSIONS

This study is the first in Ghana to provide evidence of the changes in boredom, anxiety and psychological well-being during the COVID-19 pandemic. The findings underscore the need for the inclusion of mental health interventions as part of the current pandemic control protocol and public health preparedness towards infectious disease outbreaks.

Barriers facing persons with disability in accessing sexual and reproductive health services in sub-Saharan Africa: A systematic review

Background

There is evidence that persons with disabilities often encounter grave barriers when accessing sexual and reproductive health services. To the best of our knowledge, however, no systematic review has been conducted to pull together these pieces of research evidence for us to understand the nature, magnitude and extent of these barriers in different settings in sub-Saharan Africa. We do not yet have a good understanding of the strength/quality of the evidence that exist on the barriers persons with disabilities face when accessing sexual and reproductive health services in sub-Saharan Africa. We therefore conducted a systematic review to examine the barriers persons with disabilities face in accessing sexual and reproductive health services in sub-Saharan Africa.

Methods

A systematic review was conducted using PRISMA guidelines (PROSPEROO protocol registration number: CRD42017074843). An electronic search was conducted in Medline, EMBASE, CINAHL, PsycINFO, and Web of Science from 2001 to 2020. Manual search of reference list was also conducted. Studies were included if they reported on barriers persons with disability face in accessing sexual and reproductive health services. The Critical Appraisal Skills Programme and Centre for Evidence Based Management (CEBMa) appraisal tools were used to assess methodological quality of eligible studies.

Findings

A total of 1061 studies were identified. Only 26 studies covering 12 sub-Saharan African countries were eligible for analysis. A total of 33 specific barriers including inaccessible physical health infrastructure and stigma and discrimination were identified. These barriers were further categorised into five levels: broader national level barriers; healthcare system/institutional barriers; individual level barriers; community level barriers; and economic barriers.

Conclusion

Persons with disabilities face a myriad of demand and supply side barriers to accessing sexual and reproductive healthcare in sub-Saharan Africa. Multilevel interventions are urgently needed to address these barriers.

Disparate on-site access to water, sanitation, and food storage heighten the risk of COVID-19 spread in Sub-Saharan Africa

COVID-19 is an active pandemic that likely poses an existential threat to humanity. Frequent handwashing, social distancing, and partial or total lockdowns are among the suite of measures prescribed by the World Health Organization (WHO) and being implemented across the world to contain the pandemic. However, existing inequalities in access to certain basic necessities of life (water, sanitation facility, and food storage) create layered vulnerabilities to COVID-19 and can render the preventive measures ineffective or simply counterproductive. We hypothesized that individuals in households without any of the named basic necessities of life are more likely to violate the preventive (especially lockdown) measures and thereby increase the risk of infection or aid the spread of COVID-19. Based on nationally-representative data for 25 sub-Saharan African (SSA) countries, multivariate statistical and geospatial analyses were used to investigate whether, and to what extent, household family structure is associated with in-house access to basic needs which, in turn, could reflect on a higher risk of COVID-19 infection. The results indicate that approximately 46% of the sampled households in these countries (except South Africa) did not have in-house access to any of the three basic needs and about 8% had access to all the three basic needs. Five countries had less than 2% of their households with in-house access to all three basic needs. Ten countries had over 50% of their households with no in-house access to all the three basic needs. There is a social gradient in in-house access between the rich and the poor, urban and rural richest, male- and female-headed households, among others. We conclude that SSA governments would need to infuse innovative gender- and age-sensitive support services (such as water supply, portable sanitation) to augment the preventive measures prescribed by the WHO. Short-, medium- and long-term interventions within and across countries should necessarily address the upstream, midstream and downstream determinants of in-house access and the full spectrum of layers of inequalities including individual, interpersonal, institutional, and population levels.

Quantifying risks and interventions that have affected the burden of diarrhoea among children younger than 5 years: an analysis of the Global Burden of Disease Study 2017

BACKGROUND

Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017.

METHODS

This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years.

FINDINGS

Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162-593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1-87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1-74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2-15·5), childhood wasting (9·9% decrease, 9·6-10·2), and low use of oral rehydration solution (6·9% decrease, 4·8-8·4).

INTERPRETATION

Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors-particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution-appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness.

FUNDING

Bill & Melinda Gates Foundation.

Respiratory and non-respiratory symptoms associated with pesticide management practices among farmers in Ghana's most important vegetable hub

The data presented here are from the Offinso North District Farm Health Study (ONFAHS), a population-based cross-sectional study among vegetable farmers in Ghana. The paper addresses knowledge, pesticide handling practices, and protective measures related to pesticide use by self-reported symptoms for 310 adult farmers who completed a comprehensive questionnaire on pesticide management practices and health. In addition, an inventory was prepared using information supplied by pesticide sellers/dealers in this district. We report that cough and wheezing (but not breathlessness) are positively associated with stirring pesticide preparations with bare hands/drinking water while mixing/applying pesticides, and stirring pesticide preparations with bare hands/drinking water/smoking cigarettes while mixing/applying pesticides. There is a significant exposure-response association between the number of precautionary measures practiced while handling pesticides and cough and wheezing but not with breathlessness. We also found unsafe practices to be associated with sexual dysfunction, nervousness, and lack of concentration. The results also suggest a negative association between practice of any precautionary measure when mixing/applying pesticides and sexual dysfunction, nervousness, and lack of concentration. We found that in spite of the fact that farmers have adequate knowledge about the environment and health effects of pesticides, several unhygienic practices are in widespread use, indicating that knowledge is not necessarily always translated in action. Further action is necessary to promote the safe use of pesticides and to replace existing poor management practices among these and other farmers in Ghana.

Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment.

METHODS

We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator.

FINDINGS

The global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

INTERPRETATION

The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Population and fertility by age and sex for 195 countries and territories, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Population estimates underpin demographic and epidemiological research and are used to track progress on numerous international indicators of health and development. To date, internationally available estimates of population and fertility, although useful, have not been produced with transparent and replicable methods and do not use standardised estimates of mortality. We present single-calendar year and single-year of age estimates of fertility and population by sex with standardised and replicable methods.

METHODS

We estimated population in 195 locations by single year of age and single calendar year from 1950 to 2017 with standardised and replicable methods. We based the estimates on the demographic balancing equation, with inputs of fertility, mortality, population, and migration data. Fertility data came from 7817 location-years of vital registration data, 429 surveys reporting complete birth histories, and 977 surveys and censuses reporting summary birth histories. We estimated age-specific fertility rates (ASFRs; the annual number of livebirths to women of a specified age group per 1000 women in that age group) by use of spatiotemporal Gaussian process regression and used the ASFRs to estimate total fertility rates (TFRs; the average number of children a woman would bear if she survived through the end of the reproductive age span [age 10-54 years] and experienced at each age a particular set of ASFRs observed in the year of interest). Because of sparse data, fertility at ages 10-14 years and 50-54 years was estimated from data on fertility in women aged 15-19 years and 45-49 years, through use of linear regression. Age-specific mortality data came from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimates. Data on population came from 1257 censuses and 761 population registry location-years and were adjusted for underenumeration and age misreporting with standard demographic methods. Migration was estimated with the GBD Bayesian demographic balancing model, after incorporating information about refugee migration into the model prior. Final population estimates used the cohort-component method of population projection, with inputs of fertility, mortality, and migration data. Population uncertainty was estimated by use of out-of-sample predictive validity testing. With these data, we estimated the trends in population by age and sex and in fertility by age between 1950 and 2017 in 195 countries and territories.

FINDINGS

From 1950 to 2017, TFRs decreased by 49·4% (95% uncertainty interval [UI] 46·4-52·0). The TFR decreased from 4·7 livebirths (4·5-4·9) to 2·4 livebirths (2·2-2·5), and the ASFR of mothers aged 10-19 years decreased from 37 livebirths (34-40) to 22 livebirths (19-24) per 1000 women. Despite reductions in the TFR, the global population has been increasing by an average of 83·8 million people per year since 1985. The global population increased by 197·2% (193·3-200·8) since 1950, from 2·6 billion (2·5-2·6) to 7·6 billion (7·4-7·9) people in 2017; much of this increase was in the proportion of the global population in south Asia and sub-Saharan Africa. The global annual rate of population growth increased between 1950 and 1964, when it peaked at 2·0%; this rate then remained nearly constant until 1970 and then decreased to 1·1% in 2017. Population growth rates in the southeast Asia, east Asia, and Oceania GBD super-region decreased from 2·5% in 1963 to 0·7% in 2017, whereas in sub-Saharan Africa, population growth rates were almost at the highest reported levels ever in 2017, when they were at 2·7%. The global average age increased from 26·6 years in 1950 to 32·1 years in 2017, and the proportion of the population that is of working age (age 15-64 years) increased from 59·9% to 65·3%. At the national level, the TFR decreased in all countries and territories between 1950 and 2017; in 2017, TFRs ranged from a low of 1·0 livebirths (95% UI 0·9-1·2) in Cyprus to a high of 7·1 livebirths (6·8-7·4) in Niger. The TFR under age 25 years (TFU25; number of livebirths expected by age 25 years for a hypothetical woman who survived the age group and was exposed to current ASFRs) in 2017 ranged from 0·08 livebirths (0·07-0·09) in South Korea to 2·4 livebirths (2·2-2·6) in Niger, and the TFR over age 30 years (TFO30; number of livebirths expected for a hypothetical woman ageing from 30 to 54 years who survived the age group and was exposed to current ASFRs) ranged from a low of 0·3 livebirths (0·3-0·4) in Puerto Rico to a high of 3·1 livebirths (3·0-3·2) in Niger. TFO30 was higher than TFU25 in 145 countries and territories in 2017. 33 countries had a negative population growth rate from 2010 to 2017, most of which were located in central, eastern, and western Europe, whereas population growth rates of more than 2·0% were seen in 33 of 46 countries in sub-Saharan Africa. In 2017, less than 65% of the national population was of working age in 12 of 34 high-income countries, and less than 50% of the national population was of working age in Mali, Chad, and Niger.

INTERPRETATION

Population trends create demographic dividends and headwinds (ie, economic benefits and detriments) that affect national economies and determine national planning needs. Although TFRs are decreasing, the global population continues to grow as mortality declines, with diverse patterns at the national level and across age groups. To our knowledge, this is the first study to provide transparent and replicable estimates of population and fertility, which can be used to inform decision making and to monitor progress.

FUNDING

Bill & Melinda Gates Foundation.

Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Lower respiratory infections are a leading cause of morbidity and mortality around the world. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, provides an up-to-date analysis of the burden of lower respiratory infections in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 26 years and shows how the burden of lower respiratory infection has changed in people of all ages.

METHODS

We used three separate modelling strategies for lower respiratory infections in GBD 2016: a Bayesian hierarchical ensemble modelling platform (Cause of Death Ensemble model), which uses vital registration, verbal autopsy data, and surveillance system data to predict mortality due to lower respiratory infections; a compartmental meta-regression tool (DisMod-MR), which uses scientific literature, population representative surveys, and health-care data to predict incidence, prevalence, and mortality; and modelling of counterfactual estimates of the population attributable fraction of lower respiratory infection episodes due to Streptococcus pneumoniae, Haemophilus influenzae type b, influenza, and respiratory syncytial virus. We calculated each modelled estimate for each age, sex, year, and location. We modelled the exposure level in a population for a given risk factor using DisMod-MR and a spatio-temporal Gaussian process regression, and assessed the effectiveness of targeted interventions for each risk factor in children younger than 5 years. We also did a decomposition analysis of the change in LRI deaths from 2000-16 using the risk factors associated with LRI in GBD 2016.

FINDINGS

In 2016, lower respiratory infections caused 652 572 deaths (95% uncertainty interval [UI] 586 475-720 612) in children younger than 5 years (under-5s), 1 080 958 deaths (943 749-1 170 638) in adults older than 70 years, and 2 377 697 deaths (2 145 584-2 512 809) in people of all ages, worldwide. Streptococcus pneumoniae was the leading cause of lower respiratory infection morbidity and mortality globally, contributing to more deaths than all other aetiologies combined in 2016 (1 189 937 deaths, 95% UI 690 445-1 770 660). Childhood wasting remains the leading risk factor for lower respiratory infection mortality among children younger than 5 years, responsible for 61·4% of lower respiratory infection deaths in 2016 (95% UI 45·7-69·6). Interventions to improve wasting, household air pollution, ambient particulate matter pollution, and expanded antibiotic use could avert one under-5 death due to lower respiratory infection for every 4000 children treated in the countries with the highest lower respiratory infection burden.

INTERPRETATION

Our findings show substantial progress in the reduction of lower respiratory infection burden, but this progress has not been equal across locations, has been driven by decreases in several primary risk factors, and might require more effort among elderly adults. By highlighting regions and populations with the highest burden, and the risk factors that could have the greatest effect, funders, policy makers, and programme implementers can more effectively reduce lower respiratory infections among the world's most susceptible populations.

FUNDING

Bill & Melinda Gates Foundation.

Systematic review of the effects of agricultural interventions on food security in northern Ghana

Background

Food insecurity and poverty rates in Ghana are highest in the districts from latitude 8° N upwards. These have motivated several interventions aimed at addressing the food insecurity via promoting agricultural growth. An assessment of the overall impact of these interventions on food security is necessary to guide policy design and future interventions.

Methods and findings

A systematic review was used to assess the cumulative evidence of the effect of development interventions, implemented from 2006 to 2016 on food security, especially in Northern Ghana. Information were retrieved from over 20 Government and non-Governmental organisations through online search and actual visits. The number of studies included in systematic review was 22. The study showed that a large number of interventions have been implemented in Northern Ghana over the study period. Access to quality extension services, training and capacity building was a major intervention strategy. About 82% of studies considered increasing production but only 14% of the studies reported on changes in yield. About 42% of the included studies used market access as a strategy but about 44% reported increase in incomes of beneficiaries (with only seven studies providing numerical evidence for this claim). The ranking of frequency of intervention strategies was in the order extension and capacity building > production > postharvest value addition > water and irrigation facilities > storage facilities > input supply. A substantial number of the studies had no counterfactuals, weakening confidence in attributing impacts on food security for even the beneficiaries.

Conclusions

It is concluded that evidence for impacts of the interventions on food security was weak, or largely assumed. A logical recommendation is the need for development partners to synchronise their measurement and indicators of food security outcomes. It is also recommended that some food security indicators are explicitly incorporated into intervention design while bearing in mind the potential need for counterfactuals.

Inducible nitric oxide synthase 2 promoter polymorphism and malaria disease severity in children in Southern Ghana

Objective

We assessed the association of mutant allele frequencies of nitric oxide synthase 2 (NOS2) gene at two SNPs (-954 and -1173) with malaria disease severity in children from a malaria endemic area in Southern Ghana.

Method

Using children recruited at the hospital, assigned into clinical subgroups of uncomplicated and severe malaria and matching with their “healthy control” counterparts, we designed a case control study. Genomic DNA was extracted and genotyping using Restriction Fragment Polymorphism was done.

Result

A total of 123 malaria cases (91 uncomplicated, 32 severe) and 100 controls were sampled. Their corresponding mean Hbs were 9.6, 9.3 and 11.2g/dl and geometric mean parasite densities of 32097, 193252 and 0 parasites/ml respectively. Variant allele frequencies varied from 0.09 through 0.03 to 0.12 for G-954C and 0.06 through 0.03 to 0.07 for C-1173T in the uncomplicated, severe and healthy control groups respectively. There was a strong linkage disequilibrium between the two alleles (p<0.001). For the -954 position, the odds of developing severe malaria was found to be 2.5 times lower with the carriage of a C allele compared to those without severe malaria (χ²; p< 0.05) though this isn’t the case with -1173.

Conclusion

The carriage of a mutant allele in the -954 NOS2 gene may have a protective effect on malaria among Southern Ghanaian children.

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.

METHODS

We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8-75·9 million [7·2%, 6·0-8·3]), 45·1 million (29·0-62·8 million [5·6%, 4·0-7·2]), 36·3 million (25·3-50·9 million [4·5%, 3·8-5·3]), 34·7 million (23·0-49·6 million [4·3%, 3·5-5·2]), and 34·1 million (23·5-46·0 million [4·2%, 3·2-5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3-3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0-11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862-11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018-19 228).

INTERPRETATION

The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

FUNDING

Bill & Melinda Gates Foundation, and the National Institute on Aging and the National Institute of Mental Health of the National Institutes of Health.

Effectiveness of interventions to reduce household air pollution and/or improve health in homes using solid fuel in low-and-middle income countries: A systematic review and meta-analysis

BACKGROUND

Cookstove intervention programs have been increasing over the past two (2) decades in Low and Middle Income Countries (LMICs) across the globe. However, there remains uncertainty regarding the effects of these interventions on household air pollution concentrations, personal exposure concentrations and health outcomes.

OBJECTIVES

The primary objective was to determine if household air pollution (HAP) interventions were associated with improved indoor air quality (IAQ) in households in LMICs. Given the potential impact of HAP interventions on health, a secondary objective was to evaluate the effectiveness of HAP interventions to improve health in populations receiving these interventions.

DATA SOURCES

OVID Medline, Ovid Embase, SCOPUS and PubMED were searched from their inception until December 2015 with no restrictions on study design. The WHO Global database of household air pollution measurements and Members' archives were also reviewed together with the reference lists of identified reviews and relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTION

We considered randomized controlled trials, or non-randomized control trials, or before-and-after studies; original studies; studies conducted in a LMIC (based on the United Nations Human Development Report released in March 2013 (World Bank, 2013); interventions that were explicitly aimed at improving IAQ and/or health from solid fuel use; studies published in a peer-reviewed journal or student theses or reports; studies that reported on outcomes which was indicative of IAQ or/and health. There was no restriction on the type of comparator (e.g. household receiving plancha vs. household using traditional cookstove) used in the intervention study.

STUDY APPRAISAL AND SYNTHESIS METHODS

Five review authors independently used pre-designed data collection forms to extract information from the original studies and assessed risk of bias using the Effective Public Health Practice Project (EPHPP). We computed standardized weighted mean difference (SMD) using random-effects models. Heterogeneity was computed using the Q and I2-statistics. We examined the influence of various characteristics on the study-specific effect estimates by stratifying the analysis by population type, study design, intervention type, and duration of exposure monitoring. The trim and fill method was used to assess the potential impact of missing studies.

RESULTS

Fifty-five studies met our a priori inclusion criteria and were included in the systematic review. Fifteen studies provided 43 effect estimates for our meta-analysis. The largest improvement in HAP was observed for average particulate matter (PM) (SMD=1.57) concentrations in household kitchens (1.03), followed by daily personal average concentrations of PM (1.18), and carbon monoxide (CO) concentrations in kitchens. With respect to personal PM, significant improvement was observed in studies of children (1.26) and studies monitoring PM for ≥24h (1.32). This observation was also noted in terms of studies of kitchen concentrations of CO. A significant improvement was also observed for kitchen levels of PM in both adult populations (1.56) and in RCT/cohort designs (1.59) involving replacing cookstoves without chimneys. Our findings on health outcomes were inconclusive.

LIMITATIONS, CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

We observed high statistical between study variability in the study-specific estimate. Thus, care should be taken in concluding that HAP interventions - as currently designed and implemented - support reductions in the average kitchen and personal levels of PM and CO. Further, there is limited evidence that current stand-alone HAP interventions yield any health benefits. Post-intervention levels of pollutants were generally still greatly in excess of the relevant WHO guideline and thus a need to promote cleaner fuels in LMICs to reduce HAP levels below the WHO guidelines.

SYSTEMATIC REVIEW REGISTRATION NUMBER

The review has been registered with PROSPERO (registration number CRD42014009768).

Associations between pesticide use and respiratory symptoms: A cross-sectional study in Southern Ghana

BACKGROUND

Indiscriminate use of pesticides is a common practice amongst farmers in Low and Middle Income Countries (LMIC) across the globe. However, there is little evidence defining whether pesticide use is associated with respiratory symptoms.

OBJECTIVES

This cross-sectional study was conducted with 300 vegetable farmers in southern Ghana (Akumadan). Data on pesticide use was collected with an interviewed-administered questionnaire. The concentration of seven organochlorine pesticides and 3 pyrethroid pesticides was assayed in urine collected from a sub-population of 100 vegetable farmers by a gas chromatograph equipped with an electron capture detector (GC-ECD).

RESULTS

A statistically significant exposure-response relationship of years per day spent mixing/applying fumigant with wheezing [30-60 days/year: prevalence ratio (PR)=1.80 (95% CI 1.30, 2.50); >60days/year: 3.25 (1.70-6.33), p for trend=0.003] and hours per day spent mixing/applying fumigant with wheezing [1-2h/day: 1.20 (1.02-1.41), 3-5h/day: 1.45 (1.05-1.99), >5h/day: 1.74 (1.07-2.81), p for trend=0.0225]; days per year spent mixing/applying fungicide with wheezing [30-60 days/year: 2.04 (1.31-3.17); >60days/year: 4.16 (1.72-10.08), p for trend=0.0017] and h per day spent mixing/applying fungicide with phlegm production [1-2h/day: 1.25 (1.05-1.47), 3-5h/day: 1.55 (1.11-2.17), >5h/day: 1.93 (1.17-3.19), p for trend=0.0028] and with wheezing [1-2h/day: 1.10 (1.00-1.50), 3-5h/day: 1.20 (1.11-1.72), >5h/day: 1.32 (1.09-2.53), p for trend=0.0088]; h per day spent mixing/applying insecticide with phlegm production [1-2h/day: 1.23 (1.09-1.62), 3-5h/day: 1.51 (1.20-2.58), >5h/day: 1.85 (1.31-4.15), p for trend=0.0387] and wheezing [1-2h/day: 1.22 (1.02-1.46), 3-5h/day: 1.49 (1.04-2.12), >5h/day: 1.81 (1.07-3.08), p for trend=0.0185] were observed. Statistically significant exposure-response association was also observed for a combination of activities that exposes farmers to pesticide with all 3 respiratory symptoms. Furthermore, significant exposure-response associations for 3 organochlorine insecticides: beta-HCH, heptachlor and endosulfan sulfate were noted.

CONCLUSIONS

In conclusion, vegetable farmers in Ghana may be at increased risk for respiratory symptoms as a result of exposure to pesticides.

Harmful postures and musculoskeletal symptoms among fish trimmers of a fish processing factory in ghana: a preliminary investigation

This study investigated musculoskeletal symptoms among fish trimmers (skinners and polishers) in a fish processing factory in Ghana. The methods used included administration of questionnaire, walk through observation, interview, task analysis and future workshop. All 50 female participants answered and submitted their questionnaires. Of the 11 operations performed by skinners only 1 was rated as low risk. Also of the 12 operations performed by polishers only 2 were rated as low risk. Neck side bending, neck flexion, prolonged standing, shoulder elevation, abducted arms, repetitious reaching forward and wrist deviation were observed in most operations. This corresponds with questionnaire results in which musculoskeletal symptoms were mostly prevalent in the neck, the shoulder, the low back, the wrist/hand and the knee regions. There was no significant correlation (p < .05) between musculoskeletal symptoms and age, working hours and length of service. Task redesign, workplace changes and worker training were suggested to improve the work.

Human Health Risk Assessment of Artisanal Miners Exposed to Toxic Chemicals in Water and Sediments in the Prestea Huni Valley District of Ghana

A human health risk assessment of artisanal miners exposed to toxic metals in water bodies and sediments in the PresteaHuni Valley District of Ghana was carried out in this study, in line with US EPA risk assessment guidelines. A total of 70 water and 30 sediment samples were collected from surface water bodies in areas impacted by the operations of artisanal small-scale gold mines in the study area and analyzed for physico-chemical parameters such as pH, TDS, conductivity, turbidity as well as metals and metalloids such as As, Cd, Hg and Pb at CSIR-Water Research Institute using standard methods for the examination of wastewater as outlined by American Water Works Association (AWWA). The mean concentrations of As, Cd, Hg and Pb in water samples ranged from 15 μg/L to 325 μg/L (As), 0.17 μg/L to 340 μg/L (Cd), 0.17 μg/L to 122 μg/L (Pb) and 132 μg/L to 866 μg/L (Hg), respectively. These measured concentrations of arsenic (As), mercury (Hg), cadmium (Cd) and lead (Pb) were used as input parameters to calculate the cancer and non-cancer health risks from exposure to these metals in surface water bodies and sediments based on an occupational exposure scenario using central tendency exposure (CTE) and reasonable maximum exposure (RME) parameters. The results of the non-cancer human health risk assessment for small-scale miners working around river Anikoko expressed in terms of hazard quotients based on CTE parameters are as follows: 0.04 (Cd), 1.45 (Pb), 4.60 (Hg) and 1.98 (As); while cancer health risk faced by ASGM miners in Dumase exposed to As in River Mansi via oral ingestion of water is 3.1 × 10(-3). The hazard quotient results obtained from this study in most cases were above the HQ guidance value of 1.0, furthermore the cancer health risk results were found to be higher than the USEPA guidance value of 1 × 10(-4) to 1 × 10(-6). These findings call for case-control epidemiological studies to establish the relationship between exposure to the aforementioned toxic chemicals and diseases associated with them as identified in other studies conducted in different countries as basis for developing policy interventions to address the issue of ASGM mine workers safety in Ghana.

Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries

BACKGROUND

This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified.

METHODS

Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described.

RESULTS

From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage.

CONCLUSION

Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

Comparative Assessment of Heavy Metals in Drinking Water Sources in Two Small-Scale Mining Communities in Northern Ghana

The study assessed levels of heavy metals in drinking water sources in two small-scale mining communities (Nangodi and Tinga) in northern Ghana. Seventy-two (72) water samples were collected from boreholes, hand dug wells, dug-out, and a stream in the two mining communities. The levels of mercury (Hg), arsenic (As), lead (Pb), zinc (Zn), and cadmium (Cd) were determined using an atomic absorption spectrophotometer (AAS). Mean levels (mg/l) of heavy metals in water samples from Nangodi and Tinga communities were 0.038 and 0.064 (Hg), 0.031 and 0.002 (As), 0.250 and 0.031 (Pb), 0.034 and 0.002 (Zn), and 0.534 and 0.023 (Cd), respectively, for each community. Generally, levels of Hg, As, Pb, Zn, and Cd in water from Nangodi exceeded the World Health Organisation (WHO) stipulated limits of 0.010 for Hg, As, and Pb, 3.0 for Zn and 0.003 for Cd for drinking water, and levels of Hg, Pb, and Cd recorded in Tinga, exceeded the stipulated WHO limits. Ingestion of water, containing elevated levels of Hg, As, and Cd by residents in these mining communities may pose significant health risks. Continuous monitoring of the quality of drinking water sources in these two communities is recommended.

Historical Perspective and Risk of Multiple Neglected Tropical Diseases in Coastal Tanzania: Compositional and Contextual Determinants of Disease Risk

Background

In the past decade, research on neglected tropical diseases (NTDs) has intensified in response to the need to enhance community participation in health delivery, establish monitoring and surveillance systems, and integrate existing disease-specific treatment programs to control overlapping NTD burdens and detrimental effects. In this paper, we evaluated the geographical distribution of NTDs in coastal Tanzania.

Methods and Findings

We also assessed the collective (compositional and contextual) factors that currently determine risks to multiple NTDs using a cross sectional survey of 1253 individuals in coastal Tanzania. The results show that the effect size in decreasing order of magnitude for non-binary predictors of NTD risks is as follows: NTD comorbidities > poverty > educational attainment > self-reported household quality of life > ethnicity. The multivariate analysis explained 95% of the variance in the relationship between NTD risks and the theoretically-relevant covariates. Compositional (biosocial and sociocultural) factors explained more variance at the neighbourhood level than at the regional level, whereas contextual factors, such as access to health services and household quality, in districts explained a large proportion of variance at the regional level but individually had modest statistical significance, demonstrating the complex interactions between compositional and contextual factors in generating NTD risks.

Conclusions

NTD risks were inequitably distributed over geographic space, which has several important policy implications. First, it suggests that localities of high burden of NTDs are likely to diminish within statistical averages at higher (regional or national) levels. Second, it indicates that curative or preventive interventions will become more efficient provided they can be focused on the localities, particularly as populations in these localities are likely to be burdened by several NTDs simultaneously, further increasing the imperative of multi-disease interventions.

Neglected Tropical Diseases (NTDs) are characterized by their high incidence in low-income countries, thus maintaining the disastrous poverty-disease-poverty cycle. Apart from poverty, however, little is known of the magnitude of importance of both compositional and contextual factors in creating disease risk at the local level, although this knowledge is critical to disease control and policy action. In this study, we show that the order of importance of both sets of factors is as follows: NTD comorbidities > poverty > educational attainment > self-reported household quality of life > ethnicity.

Integrated assessment of artisanal and small-scale gold mining in Ghana--part 1: human health review

This report is one of three synthesis documents produced via an integrated assessment (IA) that aims to increase understanding of artisanal and small-scale gold mining (ASGM) in Ghana. Given the complexities surrounding ASGM, an IA framework was utilized to analyze economic, social, health, and environmental data, and co-develop evidence-based responses with pertinent stakeholders. The current analysis focuses on the health of ASGM miners and community members, and synthesizes extant data from the literature as well as co-authors' recent findings regarding the causes, status, trends, and consequences of ASGM in Ghana. The results provide evidence from across multiple Ghanaian ASGM sites that document relatively high exposures to mercury and other heavy metals, occupational injuries and noise exposure. The work also reviews limited data on psychosocial health, nutrition, cardiovascular and respiratory health, sexual health, and water and sanitation. Taken together, the findings provide a thorough overview of human health issues in Ghanaian ASGM communities. Though more research is needed to further elucidate the relationships between ASGM and health outcomes, the existing research on plausible health consequences of ASGM should guide policies and actions to better address the unique challenges of ASGM in Ghana and potentially elsewhere.

Association of arsenic with adverse pregnancy outcomes/infant mortality: a systematic review and meta-analysis

BACKGROUND

Exposure to arsenic is one of the major global health problems, affecting > 300 million people worldwide, but arsenic's effects on human reproduction are uncertain.

OBJECTIVES

We conducted a systematic review and meta-analysis to examine the association between arsenic and adverse pregnancy outcomes/infant mortality.

METHODS

We searched PubMed and Ovid MEDLINE (from 1946 through July 2013) and EMBASE (from 1988 through July 2013) databases and the reference lists of reviews and relevant articles. Studies satisfying our a priori eligibility criteria were evaluated independently by two authors.

RESULTS

Our systematic search yielded 888 articles; of these, 23 were included in the systematic review. Sixteen provided sufficient data for our quantitative analysis. Arsenic in groundwater (≥ 50 μg/L) was associated with increased risk of spontaneous abortion (6 studies: OR = 1.98; 95% CI: 1.27, 3.10), stillbirth (9 studies: OR = 1.77; 95% CI: 1.32, 2.36), moderate risk of neonatal mortality (5 studies: OR = 1.51; 95% CI: 1.28, 1.78), and infant mortality (7 studies: OR = 1.35; 95% CI: 1.12, 1.62). Exposure to environmental arsenic was associated with a significant reduction in birth weight (4 studies: β = -53.2 g; 95% CI: -94.9, -11.4). There was paucity of evidence for low-to-moderate arsenic dose.

CONCLUSIONS

Arsenic is associated with adverse pregnancy outcomes and infant mortality. The interpretation of the causal association is hampered by methodological challenges and limited number of studies on dose response. Exposure to arsenic continues to be a major global health issue, and we therefore advocate for high-quality prospective studies that include individual-level data to quantify the impact of arsenic on adverse pregnancy outcomes/infant mortality.

Effectiveness of interventions to reduce indoor air pollution and/or improve health in homes using solid fuel in lower and middle income countries: protocol for a systematic review

BACKGROUND

Indoor air pollution (IAP) interventions are widely promoted as a means of reducing indoor air pollution/health from solid fuel use; and research addressing impact of these interventions has increased substantially in the past two decades. It is timely and important to understand more about effectiveness of these interventions. We describe the protocol of a systematic review to (i) evaluate effectiveness of IAP interventions to improve indoor air quality and/or health in homes using solid fuel for cooking and/or heating in lower- and middle-income countries, (ii) identify the most effective intervention to improve indoor air quality and/or health, and (iii) identify future research needs.

METHODS

This review will be conducted according to the National Institute for Health and Care Excellence (NICE) guidelines and will be reported following the PRISMA statement. Ovid MEDLINE, Ovid Embase, SCOPUS, and PubMed searches were conducted in September 2013 and updated in November 2014 (and include any further search updates in February 2015). Additional references will be located through searching the references cited by identified studies and through the World Health Organization Global database of household air pollution measurements. We will also search our own archives. Data extraction and risk of bias assessment of all included papers will be conducted independently by five reviewers.

DISCUSSION

The study will provide insights into what interventions are most effective in reducing indoor air pollution and/or adverse health outcomes in homes using solid fuel for cooking or heating in lower- or middle-income countries. The findings from this review will be used to inform future IAP interventions and policy on poverty reduction and health improvement in poor communities who rely on biomass and solid fuels for cooking and heating.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (registration number CRD42014009768 ).

Household air pollution from solid fuel use and risk of adverse pregnancy outcomes: a systematic review and meta-analysis of the empirical evidence

Background

About 41% of households globally, mainly in developing countries rely on solid fuels for cooking with consequences for fetal growth and development. Previous reviews were limited in scope, assessing only two outcomes (birth weight, stillbirth). With important evidence accumulating, there is a need to improve the previous estimates and assess additional outcomes. We conducted a systematic review and meta-analysis to evaluate the quality and strength of available evidence on household air pollution (HAP) and the whole range of adverse pregnancy outcomes.

Methods

PubMed, Ovid Medline, Scopus and CINAHL were searched from their inception to the end of April 2013. All epidemiological study designs were eligible for inclusion in the review. The random-effects model was applied in computing the summary-effect estimates (EE) and their corresponding 95% confidence interval (CI).

Results

Of 1505 studies screened, 19 studies satisfied the inclusion criteria. Household combustion of solid fuels resulted in an 86.43 g (95% CI: 55.49, 117.37) reduction in birth weight, and a 35% (EE = 1.35, 95% CI: 1.23, 1.48) and 29% (EE = 1.29, 95% CI: 1.18, 1.41) increased risk of LBW and stillbirth respectively.

Conclusion

Combustion of solid fuels at home increases the risk of a wide range of adverse pregnancy outcomes. Access to clean household energy solutions is the surest way to combat HAP and mitigate their adverse effects.

Association of indoor dampness and molds with rhinitis risk: a systematic review and meta-analysis

BACKGROUND

A substantial proportion of the world's population is exposed to indoor dampness-related exposures. Since the 1990s, studies have assessed the relation between indoor dampness and mold and rhinitis, but the evidence has been inconclusive. No previous meta-analysis has been reported on this topic.

OBJECTIVE

We conducted a systematic review and meta-analysis of studies on the relations between indoor dampness and mold and the risk of different types of rhinitis and investigated whether these relations differ according to the type of exposure.

METHODS

A systematic search of the Ovid MEDLINE and EMBASE databases was conducted (1950 through August 2012), and reference lists of relevant articles were reviewed. Cross-sectional, case-control, and cohort studies in children or adults were selected according to a priori criteria and evaluated by 3 authors independently.

RESULTS

Thirty-one studies on rhinitis, allergic rhinitis (AR), or rhinoconjunctivitis were included. In meta-analyses the largest risk was observed in relation to mold odor (rhinitis: 2.18 [95% CI, 1.76-2.71]; AR: 1.87 [95% CI, 0.95-3.68]). The risk related to visible mold was also consistently increased (rhinitis: 1.82 [95% CI, 1.56-2.12]; AR: 1.51 [95% CI, 1.39-1.64]; rhinoconjunctivitis: 1.66 [95% CI, 1.27-2.18]). In addition, exposure to dampness was related to increased risk of all types of rhinitis.

CONCLUSION

This meta-analysis provides new evidence that dampness and molds at home are determinants of rhinitis and its subcategories. The associations were strongest with mold odor, suggesting the importance of microbial causal agents. Our results provide evidence that justifies prevention and remediation of indoor dampness and mold problems, and such actions are likely to reduce rhinitis.

Occupational exposures and adverse pregnancy outcomes among nurses: a systematic review and meta-analysis

BACKGROUND

The nursing profession has been associated with several adverse pregnancy outcomes. However, the associations between occupational exposures and adverse pregnancy outcomes among this group have not been systematically examined. This review collates all epidemiological evidence to examine the strength of associations and consistency among eligible studies.

METHODS

A computer search of EMBASE and PubMed from 1966 through August 2009 was performed, followed by a search of reference lists of relevant studies and narrative reviews

RESULTS

Fourteen studies explored the relation between anesthetic gases and spontaneous abortion, 8 the relation between anesthetic gases and congenital malformations, 7 the relation between chemotherapy agents and congenital malformations, and 4 the relation between shift work and spontaneous abortion. In the random-effects models the summary odds ratio (OR) was moderately elevated for all the relations: OR = 1.27, 95% confidence interval (CI) 0.99-1.63 for anesthetic gases and spontaneous abortion. The summary OR was between 1.05 and 1.09 in high-quality studies, registry-based studies, and cohort studies: OR = 1.33, 95% CI 1.09-1.68 for anesthetic gases and congenital malformation. The summary OR was between 0.97 and 1.22 for high-quality studies, registry-based studies, and cohort studies: OR = 1.35; 95% CI 0.91-2.01 for chemotherapy agent and spontaneous abortion. The summary OR was between 1.34 and 1.69 for high-quality studies, registry-based studies, and cohort studies: OR = 1.44, 95% CI 1.06-1.95 for shift work and spontaneous abortion.

CONCLUSIONS

Nurses were found to be at increased risk of adverse pregnancy outcomes, but the strength of association was weaker in the well-designed studies. The significance of the findings is limited by the number and heterogeneity of the studies.

Residential dampness and molds and the risk of developing asthma: a systematic review and meta-analysis

CONTEXT

Studies from different geographical regions have assessed the relations between indoor dampness and mold problems and the risk of asthma, but the evidence has been inconclusive.

OBJECTIVE

To assess the relations between indicators of indoor dampness and mold problems and the risk of developing new asthma, and to investigate whether such relations differ according to the type of exposure.

DATA SOURCES

A systematic literature search of PubMed database from 1990 through March 2012 and the reference lists of recent reviews and of relevant articles identified in our search.

STUDY SELECTION

Cohort/longitudinal and incident case-control studies assessing the relation between mold/dampness and new asthma were included.

DATA EXTRACTION

Three authors independently evaluated eligible articles and extracted relevant information using a structured form.

SYNTHESIS

SIXTEEN STUDIES WERE INCLUDED: 11 cohort and 5 incident case-control studies. The summary effect estimates (EE) based on the highest and lowest estimates for the relation between any exposure and onset of asthma were for the highest estimates 1.48 (95% confidence interval [CI] 1.23-1.78, random-effects model, Q-statistic 38.75 (16), P = 0.001) ; and for the lowest estimates: 1.27 (95% CI 1.06-1.53, random-effects model, Q-statistic 38.12 (16), P = 0.000) [corrected].The summary effect estimates were significantly elevated for dampness (fixed-effects model: EE 1.33, 95% CI 1.12-1.56, Q-statistic 8.22 (9), P = 0.413), visible mold (random-effects model; EE 1.29, 95% CI 1.04-1.60, 30.30 (12), P = 0.001), and mold odor (random-effects model; EE 1.73, 95% CI 1.19-2.50, Q-statistics 14.85 (8), P = 0.038), but not for water damage (fixed-effects model; EE 1.12, 95% CI 0.98-1.27). Heterogeneity was observed in the study-specific effect estimates.

CONCLUSION

The evidence indicates that dampness and molds in the home are determinants of developing asthma. The association of the presence of visible mold and especially mold odor to the risk of asthma points towards mold-related causal agents.

Cooking fuel choices and garbage burning practices as determinants of birth weight: a cross-sectional study in Accra, Ghana

BACKGROUND

Effect of indoor air pollution (IAP) on birth weight remains largely unexplored but yet purported as the most important environmental exposure for pregnant women in developing countries due to the effects of second-hand smoke. We investigated the associations between the determinants of indoor air quality in households and birth weight.

METHODS

A cross-sectional study of 592 mothers and their newborns using postnatal services at the Korle Bu Teaching Hospital located in Accra, Ghana was conducted in 2010 to collect information on characteristics of indoor environment and other potential determinants of fetal growth. Birth weight was recorded from hospital records.

RESULTS

Household cooking fuel choices and garbage burning practices were determinants of birth weight. Multivariate linear regression analysis adjusting for age, social class, marital status and gravidity of mothers, and sex of neonate resulted in a 243 g (95% CI: 496, 11) and 178g (95% CI: 421, 65) reduction in birth weight for use of charcoal, and garbage burning respectively compared with use of LPG only. The estimated reductions in birth weight was not statistically significant. Applying the ordinal scale exposure parameter nonetheless revealed a significant exposure-response relationship between maternal exposures from charcoal use and garbage burning, and birth weight. Generalized linear models adjusting for confounders resulted in a 41% (risk ratio [RR] = 1.41; 95% CI: 0.62, 3.23) and 195% (RR=2.95; 95% CI: 1.10, 7.92) increase in the risk of low birth weight (LBW) for use of charcoal, and garbage burning respectively compared with use of LPG only. A combination of charcoal use and household garbage burning during pregnancy on fetal growth resulted in a 429 g (95% CI: 259, 599) reduction in birth weight and 316% (RR=4.16; 95% CI: 2.02, 8.59) excess risk of LBW. Sensitivity analysis performed by restricting the analysis to term births produced similar results.

CONCLUSIONS

Maternal use of charcoal as a cooking fuel during pregnancy and burning of garbage at home are strong determinants of average fetal growth and risk of LBW. Efforts to reduce maternal exposures to IAP are thus important to improve birth outcomes.

Effects of regular exercise on adult asthma

Although many guidelines recommend regular exercise for adults with asthma, the empirical evidence on the effect of exercise on adult asthma has been inconsistent and there are no previous systematic reviews on this topic. To fill in this gap of knowledge, we synthesized the data on the effects of regular exercise on physical fitness, asthma control and quality of life of adult asthmatics. We performed a Medline search from 1980 through June 2011. In the systematic review we included all clinical trials that provided information on the effects of regular exercise on adult asthma. We conducted meta-analyses of maximal oxygen consumption (VO(2)max) and forced expiratory volume in 1 s (FEV(1)) based on 9 studies. A total of 11 studies were included in the analyses, but only 6 of them had a non-exercising reference group of asthmatics. The meta-analyses of randomized controlled trials showed that regular exercise significantly improved VO(2)max. There was no obvious improvement in lung function measurements. Some individual studies showed evidence of improvement in quality of life and asthma control. Meta-analyses provided evidence that regular physical exercise improves physical fitness of adult asthmatics. The results on effects on lung function were inconclusive. There is insufficient evidence to assess the effects of exercise on asthma control and quality of life.

Work as a nurse and a midwife and adverse pregnancy outcomes: a Finnish nationwide population-based study

OBJECTIVE

To assess whether work as a nurse and a midwife during pregnancy increases the risk of adverse pregnancy outcomes.

METHODS

We identified from the 1990-2006 Finnish Medical Birth Registry all singleton births to nurses (n=109,542), midwives (n=3,009), and teachers (n=23,454) (referents). The main outcomes were sexual differentiation, low and high birth weight, preterm and postterm delivery, small and large for gestational age, and perinatal death.

RESULTS

The prevalence of low birth weight (2.9% vs. 2.5%), preterm delivery (4.4% vs. 4.1%), postterm delivery (4.7% vs. 4.1%), small for gestational age (1.8% vs. 1.4%), perinatal death (0.45% vs. 0.41%) and stillbirth (0.30% vs. 0.25%) was higher among the newborns of nurses than those of teachers. The adjusted odds ratio (OR) from generalized estimating equations was 1.17 (95% confidence interval [CI] 1.07-1.26) for low birth weight, 1.09 (95% CI 1.02-1.16) for preterm delivery, 1.11 (95% CI 1.03-1.18) for postterm delivery, 1.17 (95% CI 1.05-1.30) for small for gestational age, 1.12 (95% CI 0.90-1.35) for perinatal death, and 1.27 (95% CI 0.98-1.56) for stillbirth. For midwives, the risk of small for gestational age (OR=1.25, 95% CI 0.95-1.55) was elevated, but the 95% CI included unity. There was no substantial difference in the sex distribution.

CONCLUSIONS

This study provides evidence that work as a nurse may reduce fetal growth and duration of pregnancy. The inference is based on the newborns of teachers as the reference group. However, the prevalence of most of the outcomes was higher among the newborns of all other working women combined than in the newborns of both nurses and teachers.

Paternal and maternal exposure to welding fumes and metal dusts or fumes and adverse pregnancy outcomes

OBJECTIVE

We assessed whether paternal exposure prior to conception and maternal exposure during pregnancy to welding fumes (WF) and metal dusts or fumes (MD/F) independently and jointly increases the risk of preterm delivery, low birth weight, and small-for-gestational age.

METHODS

The study population was selected from The Finnish Prenatal Environment and Health Study of 2,568 newborns (response rate 94%) and included 1,670 women who worked during pregnancy of which 68 were exposed either to WF and/or MD/F.

RESULTS

The risk of SGA was related to maternal exposure to WF only (adjusted OR = 1.78; 95% CI 0.53-5.99), MD/F only (adjusted OR = 1.77; 95% CI 0.38-8.35) and both exposures (2.92; 1.26-6.78). The corresponding effect estimates for preterm delivery were 2.66 (0.32-22.08), 5.64 (1.14-27.81) and for birth weight below 3,000 g 3.79 (1.09-13.19), 1.85 (0.56-6.14) and 1.70 (0.70-4.15), respectively. There was some suggestive, inconsistent evidence that the risk of preterm delivery and SGA is related to paternal exposure to WF.

CONCLUSIONS

The present results provide evidence that maternal exposure to WF or MD/F combination during pregnancy may reduce fetal growth and suggestive evidence that paternal exposure to WF may increase the risk of preterm delivery and small-for-gestational age. The small number of exposed women and the lack of data for exposure concentrations suggest the need for further study to verify our findings.

Preterm delivery and asthma: a systematic review and meta-analysis

BACKGROUND

Accumulating evidence suggests that reduced duration of pregnancy predicts increased risk of asthma, but the studies published have been inconsistent.

OBJECTIVE

We sought to synthesize the evidence on the relation between preterm delivery and the risk of asthma later in life and to assess differences between the studies as potential sources for heterogeneity of the results.

METHODS

We conducted a MEDLINE search (until the end of May 2005). The outcome was asthma. The determinant of interest was preterm delivery defined as a gestational age of less than 37 weeks.

RESULTS

We identified 19 articles that provided estimates for the meta-analysis. The summary effect estimates for asthma (fixed-effects odds ratio, 1.074 [95% CI, 1.072-1.075]; heterogeneity P = .000; random-effects odds ratio, 1.366 [95% CI, 1.303-1.432]) showed an increased risk in relation to preterm delivery, with substantial heterogeneity between study-specific estimates. The effect of preterm delivery on asthma was stronger in cross-sectional studies; studies with broad outcome criteria, a small sample size, and a younger study population; and studies conducted in English-speaking populations, outside Europe, and published more recently. In metaregression, adjusting for other determinants, the effect estimate was significantly associated only with the mean age of the study population.

CONCLUSIONS

The weight of evidence shows that preterm babies have an increased risk of asthma compared with term babies.

CLINICAL IMPLICATIONS

Recognition of prematurity as a determinant of asthma emphasizes the importance of active treatment of physiologic airflow obstruction and a need for special preventive measures against known environmental determinants of asthma in preterm babies.

Harmful postures and musculoskeletal symptoms among sanitation workers of a fish processing factory in ghana: a preliminary investigation

This study investigated musculoskeletal symptoms among sanitation workers of a fish-processing factory. The methods used included administration of a questionnaire, walk through observation, interview, task analysis and future workshop. All 27 male participants answered and submitted their questionnaires. Of the 11 operations identified, all except one was considered safe. Bent back, bent legs, and heavy manual handling were observed to impose intolerable health risk on participants. This corresponds with questionnaire results in which musculoskeletal symptoms were mostly prevalent in the neck, the shoulder, the low back, the wrists/hands and the upper back regions. Poor psychosocial complaints were also made on the job. There was no significant correlation (p < .05) between musculoskeletal symptoms and age, working hours and length of service. Neither was any significant correlation observed (p < .05) between psychosocial work factors and musculoskeletal symptoms. Recommendations such as task redesign to eliminate high-risk elements in operations, workplace changes and worker training were suggested.