Incidence of typhoid fever in Burkina Faso, Democratic Republic of the Congo, Ethiopia, Ghana, Madagascar, and Nigeria (the Severe Typhoid in Africa programme): a population-based study

BACKGROUND

Typhoid Fever remains a major cause of morbidity and mortality in low-income settings. The Severe Typhoid in Africa programme was designed to address regional gaps in typhoid burden data and identify populations eligible for interventions using novel typhoid conjugate vaccines.

METHODS

A hybrid design, hospital-based prospective surveillance with population-based health-care utilisation surveys, was implemented in six countries in sub-Saharan Africa. Patients presenting with fever (≥37·5°C axillary or ≥38·0°C tympanic) or reporting fever for three consecutive days within the previous 7 days were invited to participate. Typhoid fever was ascertained by culture of blood collected upon enrolment. Disease incidence at the population level was estimated using a Bayesian mixture model.

FINDINGS

27 866 (33·8%) of 82 491 participants who met inclusion criteria were recruited. Blood cultures were performed for 27 544 (98·8%) of enrolled participants. Clinically significant organisms were detected in 2136 (7·7%) of these cultures, and 346 (16·2%) Salmonella enterica serovar Typhi were isolated. The overall adjusted incidence per 100 000 person-years of observation was highest in Kavuaya and Nkandu 1, Democratic Republic of the Congo (315, 95% credible interval 254-390). Overall, 46 (16·4%) of 280 tested isolates showed ciprofloxacin non-susceptibility.

INTERPRETATION

High disease incidence (ie, >100 per 100 000 person-years of observation) recorded in four countries, the prevalence of typhoid hospitalisations and complicated disease, and the threat of resistant typhoid strains strengthen the need for rapid dispatch and implementation of effective typhoid conjugate vaccines along with measures designed to improve clean water, sanitation, and hygiene practices.

FUNDING

The Bill & Melinda Gates Foundation.

Cohort profile: Research on Obesity and Diabetes among African Migrants in Europe and Africa Prospective (RODAM-Pros) cohort study

PURPOSE

The Research on Obesity and Diabetes among African Migrants (RODAM) prospective (RODAM-Pros) cohort study was established to identify key changes in environmental exposures and epigenetic modifications driving the high burden of cardiovascular disease (CVD) risk among sub-Saharan African migrants.

PARTICIPANTS

All the participants in the RODAM cross-sectional study that completed the baseline assessment (n=5114) were eligible for the follow-up of which 2165 participants (n=638 from rural-Ghana, n=608 from urban-Ghana, and n=919 Ghanaian migrants in Amsterdam, the Netherlands) were included in the RODAM-Pros cohort study. Additionally, we included a subsample of European-Dutch (n=2098) to enable a comparison to be made between Ghanaian migrants living in the Netherlands and the European-Dutch host population.

FINDINGS TO DATE

Follow-up data have been collected on demographics, socioeconomic status, medical history, psychosocial environment, lifestyle factors, nutrition, anthropometrics, blood pressure, fasting blood, urine and stool samples. Biochemical analyses included glucose metabolism, lipid profile, electrolytes and renal function, liver metabolism and inflammation. In a subsample, we assessed DNA methylation patterns using Infinium 850K DNA Methylation BeadChip. Baseline results indicated that migrants have higher prevalence of CVD risk factors than non-migrants. Epigenome-wide association studies suggest important differences in DNA methylation between migrants and non-migrants. The follow-up study will shed further light on key-specific environmental exposures and epigenetic modifications contributing to the high burden of CVD risk among sub-Saharan African migrants.

FUTURE PLANS

Follow-up is planned at 5-year intervals, baseline completed in 2015 and first follow-up completed in 2021.

User experiences of a mobile phone-based health information and surveillance system (mHISS): A case of caregivers of children under-five in rural communities in Ghana

Background

The rapid advancement of mobile technology has fueled the use of mobile devices for health interventions and for improving healthcare provision in underserved communities. Despite the potential of mHealth being used as a health information and surveillance tool, its scale-up has been challenging and, in most cases, unable to advance beyond the pilot stage of implementation. The purpose of this study was to explore user experiences of a mobile phone-based interactive voice response (IVR) system among caregivers of children under-five in rural communities in the Asante Akim North District of Ghana.

Methods

The study adopted an exploratory design. A convenience sampling technique was used to recruit 35 participants who had used an IVR system for at least six months for the study. About 11 in-depth interviews and three focus group discussions were conducted among participants using a semi-structured interview guide. Thematic content analysis was utilized for the analysis of data in this study.

Result

The system was found to be acceptable, and the attitude of caregivers towards the system was also positive. The study discovered that the mobile phone-based Health Information and Surveillance System (mHISS) was useful for improving access to healthcare, communicating with health professionals, served as a decision support system, and improved caregivers’ awareness about self-management of childhood illnesses. Poor network quality, unstable electricity power supply, and dropped/cut calls served as significant barriers to using the mHISS system.

Conclusion

The mHISS system was generally acceptable and could help improve access to healthcare and identify children with severe health conditions during outbreaks of diseases.

'This disease is not meant for the hospital, it is Asram': Implications of a traditionally-defined illness on healthcare seeking for children under-5 in rural Ashanti, Ghana

Every child has the right to survive, grow and develop. However, in spite of the considerable global gains that have been made in child survival, Sub-Saharan Africa still has the highest child mortality rates and accounts for the greatest burden of mortality globally. The majority of these children die without ever reaching a health facility. The practice of appropriate healthcare-seeking behaviour has a great potential to reduce the occurrence of severe and life-threatening childhood illnesses. Several factors, however, influence healthcare-seeking behaviour, including perceptions of the cause of illness and socio-cultural perspectives. This study seeks to understand local concepts of a traditionally-defined illness complex, Asram, and its influence on healthcare seeking behavior of mothers/caregivers. This qualitative study was conducted from October 2019 to February 2020. Four Focus Group Discussions were conducted with mothers/caregivers of children under-5 and 22 Key Informant Interviews with mothers/caregivers of children who had Asram, health workers at district, facility, and community levels, and Asram healers. Participants were selected from two rural communities, Akutuase and Wioso of the Asante Akim North district in the Ashanti region of Ghana. Data analysis was carried out iteratively throughout data collection, using a thematic analysis approach. The study shows that Asram is a childhood illness complex that is perceived to have been acquired spiritually and/or inherited. Nine types of Asram were described. This childhood illness was said to be treatable by Asram healers who had sub-specialties in treatment approaches that were determined by the Asram type reported. Mothers/caregivers trusted Asram healers and preferred to call on them first. This was found to be the main reason for delays in seeking healthcare for children under-5 who showed symptoms of Asram. Asram is a childhood illness complex that is believed to be better managed outside the health facility setting. This study complements existing knowledge and creates opportunities for further research and the introduction of more effective interventions in the effort to improve child survival in rural communities.

The burden of drug resistance tuberculosis in Ghana; results of the First National Survey

Resistance to Tuberculosis drugs has become a major threat to the control of tuberculosis (TB) globally. We conducted the first nation-wide drug resistance survey to investigate the level and pattern of resistance to first-line TB drugs among newly and previously treated sputum smear-positive TB cases. We also evaluated associations between potential risk factors and TB drug resistance. Using the World Health Organization (WHO) guidelines on conducting national TB surveys, we selected study participants from 33 health facilities from across the country, grouped into 29 clusters, and included them into the survey. Between April 2016 and June 2017, a total of 927 patients (859 new and 68 previously treated) were enrolled in the survey. Mycobacterium tuberculosis complex (MTBC) isolates were successfully cultured from 598 (65.5%) patient samples and underwent DST, 550 from newly diagnosed and 48 from previously treated patients. The proportion of patients who showed resistance to any of the TB drugs tested was 25.2% (95% CI; 21.8–28.9). The most frequent resistance was to Streptomycin (STR) (12.3%), followed by Isoniazid (INH) (10.4%), with Rifampicin (RIF), showing the least resistance of 2.4%. Resistance to Isoniazid and Rifampicin (multi-drug resistance) was found in 19 (3.2%; 95% CI: 1.9–4.9) isolates. Prevalence of multidrug resistance was 7 (1.3%; 95% CI: 0.5–2.6) among newly diagnosed and 12 (25.0%; 95% CI: 13.6–39.6) among previously treated patients. At both univariate and multivariate analysis, MDR-TB was positively associated with previous history of TB treatment (OR = 5.09, 95% CI: 1.75–14.75, p = 0.003); (OR = 5.41, 95% CI: 1.69–17.30, p = 0.004). The higher levels of MDR-TB and overall resistance to any TB drug among previously treated patients raises concerns about adherence to treatment. This calls for strengthening existing TB programme measures to ensure a system for adequately testing and monitoring TB drug resistance.

Determinants of a mobile phone-based Interactive Voice Response (mIVR) system for monitoring childhood illnesses in a rural district of Ghana: Empirical evidence from the UTAUT model

Background

The use of a mobile phone-based Interactive Voice Response (mIVR) System for real time monitoring of childhood illnesses provides an opportunity to improve childhood survival and health systems. However, little is known about the factors that facilitate its use. This study sought to identify key determinants and moderators of mIVR system use among caregivers in a rural district of Ghana using the Unified Theory of Acceptance and Use of Technology (UTAUT) model.

Methods

The mIVR system was designed to provide real-time data on common symptoms of childhood illnesses after answering several questions by caregivers with sick children. A structured questionnaire with closed questions was used to collect data from 354 caregivers of children under-five living in rural communities, four (4) months after introducing the system. Regression analysis was used to identify key determinants and moderating factors that facilitate the use of the system based on the UTAUT model.

Results

A total of 101 (28.5%) caregivers had used the system and 328 (92.7%) had intention to use the mIVR system. Caregivers’ level of education and household wealth were associated with use of the mIVR systems (p<0.001). Behavioural intention (BI) to use mIVR system was positively influenced by performance expectancy (PE) (β = 0.278, 95% CI: 0.207, 0.349), effort expectancy (EE) (β = 0.242, 95% CI: 0.159, 0.326) and social influence (SI) (β = 0.081, 95% CI: 0.044, 0.120). Facilitating conditions (FC) (β = 0.609, 95% CI: 0.502, 0.715) and behavioural intention (β = 0.426, 95% CI: 0.255, 0.597) had a positive influence on user behaviour (UB). Mobile phone experience and household wealth significantly moderated the effect of PE, EE, SI, and FC on behavioural intention and usage of mIVR systems.

Conclusion

The perceived usefulness of the mIVR system, ease of use, social influences, and facilitating conditions are key determinants of users’ attitude and use of mIVR system. These relationships are significantly moderated by users’ phone experience and wealth status.

Use of social media in a national Tuberculosis Drug Resistance Survey: lessons from the first anti-tuberculosis drug resistance survey in Ghana

Background: The widespread use of social media applications on mobile phones indicate that smart phones have become more than just a simple medium for voice calling. Several studies have shown the potential benefit of these social media applications in discussing many health conditions. We report on tracking sample transport by public and private transport providers using WhatsApp during the first nationwide drug resistance tuberculosis (TB) survey in Ghana. Methods: The survey was conducted between February 2016 and June 2017, and involved 33 TB diagnostic sites selected on the basis of a two-stage cluster randomized sampling design on both anticipated yield and probability proportional to size method. We engaged the services of privately and publicly owned vehicles’ union to transport samples to the Bacteriology department at the Kumasi Centre for Collaborative Research in Tropical Medicine laboratories for further laboratory processing. We created a mobile social group platform (‘National TBDRS’) on WhatsApp consisting of two representatives from each site as well as other stakeholders. The purpose was to notify a laboratory team in Kumasi, on the following details of the sample: date and time of dispatch, driver’s name, car number, estimated time of arrival, and bus terminal name.  Results: A total 3077 WhatsApp messages were received during the survey period. Of these, 2879 (93.57%) messages were related to the survey. We observed a positive correlation between the total number of messages received and the total number of well-packaged sputum samples sent (r=0.89, p=0.02). There were no major transport delays (11:44±03:50) and all samples arrived within a 3-day window from the survey sites. Conclusions: Using WhatsApp as a platform of communication can aid in improving tracking of samples, enhance accountability of for example drivers handling the samples over at a road crossing and communication across health facilities.

Use of social media in a national Tuberculosis Drug Resistance Survey: lessons from the first anti-tuberculosis drug resistance survey in Ghana

Background: The widespread use of social media applications on mobile phones indicate that smart phones have become more than just a simple medium for voice calling. Several studies have shown the potential benefit of these social media applications in discussing many health conditions. We report on tracking sample transport by public and private transport providers using WhatsApp during the first nationwide drug resistance tuberculosis (TB) survey in Ghana. Methods: The survey was conducted between February 2016 and June 2017, and involved 33 TB diagnostic sites selected on the basis of a two-stage cluster randomized sampling design on both anticipated yield and probability proportional to size method. We engaged the services of privately and publicly owned vehicles’ union to transport samples to the central laboratories in Kumasi for further laboratory processing. We created a mobile social group platform (‘National TBDRS’) on WhatsApp consisting of two representatives from each site as well as other stakeholders. The purpose was to notify a laboratory team in Kumasi, on the following details of the sample: date and time of dispatch, driver’s name, car number, estimated time of arrival, and bus terminal name.  Results: A total 3077 WhatsApp messages were received during the survey period. Of these, 2879 (93.57%) messages were related to the survey. We observed a positive correlation between the total number of messages received and the total number of well-packaged sputum samples sent (r=0.89, p=0.02). There were no major transport delays (11:44±03:50) and all samples arrived within a 3-day window from the survey sites. Conclusions: Using WhatsApp as a platform of communication can significantly aid in improving tracking of samples, enhance accountability of for example drivers handling the samples over at a road crossing and communication across health facilities.