High-risk human papillomavirus genotype distribution among women living with HIV; implication for cervical cancer prevention in a resource limited setting

BACKGROUND

For women living with HIV (WLHIV), the burden of persistent HPV infection, cervical pre-cancerous lesions and cancer have been demonstrated to be higher than among HIV-negative women. As Ghana and other lower-middle-income countries (LMIC) work toward developing national cervical cancer programmes, it is essential that local scientific evidence be provided to guide policy decisions, especially for such special populations. The objective of this study was to determine the distribution of high-risk HPV genotype and related factors among WLHIV and its implication for the prevention of cervical cancer prevention efforts.

METHODS

A cross-sectional study was conducted at the Cape Coast Teaching Hospital in Ghana. WLHIV, aged 25-65 years, who met the eligibility criteria were recruited through a simple random sampling method. An interviewer-administered questionnaire was used to gather socio-demographic, behavioural, clinical and other pertinent information. The AmpFire HPV detection system (Atila BioSystem, Mointain View, CA was used to detect 15 high-risk HPV genotypes from self-collected cervico-vaginal samples. The data collected were exported to STATA 16.0 for statistical analysis.

RESULTS

In all, 330 study participants, with mean age of 47.2 years (SD ± 10.7), were involved. Most (69.1%, n = 188/272) had HIV viral loads < 1000 copies/ml and 41.2% (n = 136) had ever heard of cervical screening. The overall hr-HPV prevalence was 42.7% (n = 141, 95% CI 37.4-48.1) and the five commonest hr-HPV types among screen positives were HPV59 (50.4%), HPV18 (30.5%), HPV35 (26.2%), HPV58 (17%) and HPV45 (14.9%). Most infected women (60.3%, n = 85) had multiple hr-HPV infections, with about 57.4% (n = 81) having 2-5 h-HPV types, while 2.8% (n = 4) had more than five hr-HPV types. A total of 37.6% (n = 53) had HPV16 and/or18, while 66.0% (n = 93) had the hr-HPV genotypes covered by the nonavalent vaccine. Women with HIV viral load ≥ 1000copies/ml (AOR = 5.58, 95% CI 2.89-10.78, p < 0.001) had a higher likelihood of being co-infected.

CONCLUSION

This study found out that the prevalence of hr-HPV still remains high in women with HIV, with a notable occurrence of multiple infections and infection with genotypes 16 and/or18. Additionally, an association was established between hr-HPV and infection HIV viral load.. Therefore, comprehensive HIV care for these women should include awareness of cervical cancer, consideration of vaccination and implementation of screening and follow-up protocols. National programmes in LMIC, such as Ghana, should consider using HPV-based screen-triage-treat approach with partial genotyping.

Psychometric assessment of HIV stigma in patients attending a tertiary facility: An initial validation of the Berger HIV stigma scale in a Ghanaian perspective

BACKGROUND

HIV-related stigma and discrimination are major challenges to people living with HIV (PLWHIV) and are due to misconceptions. Due to socioeconomic variations, there is increased stigma experienced by PLWHIV in sub-Saharan Africa (SSA). Stigma affects adherence to antiretroviral medications by PLWHIV and defeats the goal of achieving viral suppression. This study evaluated the Bergers HIV stigma scale in PLWHIV in Ghana regarding construct validity and reliability and assessed which aspect of stigma is critical for immediate redress.

METHODS

The Berger et al. HIV stigma scale (39 items) and some selected questions from HIV stigma and discrimination measurement tool of the International Centre for Research on Women, Washington, DC were administered to a cohort of PLWHIV in Ghana (n = 160). Clinico- demographic data was collected from their folders and verbally. The psychometric assessment included exploratory factor analysis whiles scale reliability was evaluated as internal consistency by calculating Cronbach's α.

RESULTS

The exploratory factor analysis suggested a four-factor solution which is like the original Berger HIV scale with sub-scales personalised stigma, disclosure concerns, negative self- image, and concerns with public attitudes. Items in the sub-scales personalised stigma (15- items), disclosure concerns (6), negative self-image (7) and concerns with public attitudes (6) were reduced compared to the original scale. Cronbach's α for the overall HIV stigma scale (34-items) was 0.808 whiles the sub-scales α ranged from 0.77 to 0.89. Analysis suggested the prevalence of a fundamental one-dimensional factor solution which yielded a 34-item scale after removing items for low factor loadings. Disclosure concerns was the highest ranked subscale although our study also found that about 65% of PLWHIV among our study participants had disclosed their status.

CONCLUSION

Our 34-item abridged Berger HIV stigma scale showed sufficient reliability with high Cronbach's α and construct validity. Disclosure concerns ranked high among the sub-scales on the scale. Exploring specific interventions and strategies to address stigma concerns in our population will aid in the reduction of HIV-related stigma and associated consequences.

Effectiveness of school-based interventions for preventing tobacco smoking initiation among young people in low- and middle-income countries: a systematic review protocol

BACKGROUND

Despite the commendable progress made globally in tobacco control, the world is falling short of achieving a 30% relative reduction in current tobacco use by 2025. The African region remains the least in the efforts in fighting the tobacco epidemic and is most exploited by the tobacco industry. Schools have been continuously used for over three decades as a setting for delivering youth smoking prevention programmes; however, the evidence of the effectiveness of those school-based interventions provides varying outcomes. Also, interventions that proved to be effective, in high-income countries (HICs), may not necessarily be effective in the African region as a result of cultural differences and other contrasting factors. An existing systematic review that explored school-based tobacco prevention programmes among the youth in African countries from 2000 to 2016 showed partial effectiveness. This review will address the gap by updating the 2016 review to examine studies in LMICs to generate findings to help target resources which have the potential to save lives by preventing smoking initiation among young people.

METHODS

The JBI methodology for systematic reviews of effectiveness will guide the conduct of this review. A comprehensive strategic search will be developed to retrieve both published and unpublished studies that evaluate school-based interventions to prevent tobacco smoking initiation among in-school young people in LMICs compared to non-intervention programmes. Published studies would be from databases such as MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials. Sources of grey literature would be ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove. The databases will be searched for published studies in the English language. The processes of study selection, critical appraisal, data extraction, and data synthesis will be in accordance with the JBI approach for reviews of effectiveness with a minimum of two reviewers at each stage. The primary outcome of the review will be the non-initiation of tobacco smoking by the youth.

DISCUSSION

The review will provide synthesized evidence on the effectiveness of school-based smoking initiation prevention among young people in LMICs. The findings of the review would support policymakers and programme implementers to develop targeted interventions for effective tobacco control initiatives.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021246206.

Treating Hepatitis B Virus in Times of COVID-19: The Case for Clinical Pharmacogenomics Research in Tenofovir-Induced Kidney Toxicity

The current pandemic has markedly shifted the focus of the global research and development ecosystem toward infectious agents such as SARS-CoV-2, the causative agent for COVID-19. A case in point is the chronic liver disease associated with hepatitis B virus (HBV) infection that continues to be a leading cause of severe liver disease and death globally. The burden of HBV infection is highest in the World Health Organization designated western Pacific and Africa regions. Tenofovir disoproxil fumarate (TDF) is a nucleoside analogue used in treatment of HBV infection but carries a potential for kidney toxicity. TDF is not metabolized by the cytochrome P450 enzymes and, therefore, its clearance in the proximal tubule of the renal nephron is controlled mostly by membrane transport proteins. Clinical pharmacogenomics of TDF with a focus on drug transporters, discussed in this perspective article, offers a timely example where resource-limited countries and regions of the world with high prevalence of HBV can strengthen the collective efforts to fight both COVID-19 and liver diseases impacting public health. We argue that precision/personalized medicine is invaluable to guide this line of research inquiry. In all, our experience in Ghana tells us that it is important not to forget the burden of chronic diseases while advancing research on infectious diseases such as COVID-19. For the long game with COVID-19, we need to address the public health burden of infectious agents and chronic diseases in tandem.

Association of maternal characteristics with child feeding indicators and nutritional status of children under-two years in Rural Ghana

Background

Optimal nutrition during the first two years of a child’s life is critical for the reduction of morbidity and mortality. In Ghana, majority of children miss out on optimal nutrition and only few (13%) of children receive a Minimum Acceptable Diet (MAD). Several studies have investigated the influence of community-level factors on infants and young children feeding (IYCF) practices. However, little is known about the influence of maternal factors on IYCF practices in rural settings. Therefore, this study assessed the influence of maternal factors on the feeding indicators and nutritional status of children aged 6–23 months in two administrative districts in Ghana.

Methods

Data were collected among 935 mothers who had children aged 6–23 months and accessed 21 Child Welfare Clinics within the study area. The study involved a face- to-face interview using structured questionnaires to capture maternal characteristics, dietary intake and anthropometric measurements of children. Multivariate logistic regression was used to study the association between maternal factors and child nutrition outcomes (MAD, dietary diversity score (DDS) and anthropometric indicators) using Stata 16.0 software.

Results

Being employed (AOR = 3.07, 95% CI: 1.71—5.49, p < 0.001) and attaining secondary or higher education (AOR = 2.86, 95% CI: 1.42—5.78, p = 0.003) were significant predictors of children receiving MAD. Similarly, having an average decision-making autonomy increased the child’s odds of receiving MAD (AOR = 1.68, 95% CI: 1.02—2.76, p = 0.040). Children of mothers who attained secondary or a higher level of education (AOR = 0.59, 95% CI: 0.36 -0.97, p = 0.040) and those whose mothers were employed (AOR = 0.71, 95% CI: 0.47—1.07, p = 0.043) were associated with a reduced risk of underweight and stunting respectively. Children of mothers with average financial independence status were more likely to receive diversified meals (AOR = 1.55, 95% CI: 1.01–2.38, p = 0.045).

Conclusions

High educational level and being employed have positive influence on MAD, stunting and underweight of children. High decision-making power and average financial independence of mothers are good predictors of children receiving MAD. Family planning, women empowerment in decision-making, providing employment opportunities for mothers and promoting girl-child education are recommended.

Predictors of anti-glycaemic medication-taking among adults with diabetes mellitus seeking care in a tertiary hospital in Cape Coast, Ghana

Objectives: This study sought to assess the level of anti-glycaemic medication-taking and its predictors among adults living with diabetes receiving treatment at Cape Coast Teaching Hospital (CCTH).Design: This was a cross-sectional study carried out among adults living with diabetes and receiving care at CCTH. Data on socio-demographic characteristics and anti-glycaemic medication-taking were gathered using a structured questionnaire. A scale consisting of 4 domains (filling prescribed medication; taking medications appropriately ac-cording to the instructions of healthcare professionals; practising behavioural modifications, and showing up for fol-low-up appointments) and eight items was used to measure the level of anti-glycaemic medication-taking. Descriptive statistics, chi-square test (and Fisher’s exact test where appropriate), bivariate and multivariate logistic regression models were used in analysing the data.Setting: The study was carried out in the diabetes clinic in Cape Coast Teaching Hospital.Participants: The total enumerative sampling technique was used to select 250 adults living with diabetes and receiv-ing care at CCTH.Main outcome measures: Anti-glycaemic medication-takingResults: Out of 250 participants studied, 42% had high anti-glycaemic medication-taking. Predictors of anti-glycae-mic medication-taking included; forgetfulness (aOR=0.02, 95% CI: 0.00-0.64, p<0.001), patient’s involvement in treatment plan (aOR=0.12, 95% CI: 0.02-0.64, p=0.014) and having good knowledge about one’s medication (aOR=2.34, 95% CI: 1.10-4.98, p=0.028).Conclusion: Less than half of the sample population (42%) had high anti-glycaemic medication-taking, with forget-fulness, involvement in the treatment plan and good knowledge about anti-glycaemic medications, predicting medi-cation-taking.

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

Background/Significance:

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

Methods

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

Results

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

Conclusion

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

Prevalence of COVID-19 genomic variation in Africa: a living systematic review protocol

OBJECTIVE

The objective of this living systematic review is to synthesize the available evidence on the prevalence of types of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomic variations in Africa.

INTRODUCTION

The burden of the coronavirus disease 2019 (COVID-19) pandemic on the health, well-being, and global economy (especially the fragile economies of African countries) is significant. Profiling the genomic and geographical variations of SARS-CoV-2, a causative agent of COVID-19, may be important for future decision-making, policy guidelines, and development of drugs and vaccines. However, little is known about the up-to-date prevalence of genomic and geographical variations of SARS-CoV-2 virus on the African continent.

INCLUSION CRITERIA

This living systematic review will include studies on the prevalence of SARS-CoV-2 genetic strains and mutations obtained from sequencing data of samples from individuals of all ages and sexes using the next generation sequencing approaches in studies conducted in Africa.

METHODS

The search strategy will be developed to retrieve both published and unpublished data. Published data will be obtained from electronic databases. Unpublished data will be obtained from conference proceedings, preprints, theses/dissertations, electronic search engines, and COVID-19-dedicated websites. Relevant published or unpublished data in the English language from January 2020 will be considered. Studies will be selected based on the inclusion criteria of the review. The selected studies will be critically appraised for methodological quality by two independent reviewers and data extracted from eligible studies. Finally, meta-analysis will be done, if feasible, to pool prevalence estimates after heterogeneity of the data has been analyzed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020211451.

Neonatal mortality in the central districts of Ghana: analysis of community and composition factors

BACKGROUND

Communities and their composition have an impact on neonatal mortality. However, considering the smallest health administrative units as communities and investigating the impact of these communities and their composition on neonatal mortality in Ghana have not been studied. Therefore, this study aimed to investigate the effect of community-, household- and individual-level factors on the risk of neonatal mortality in two districts in Ghana.

METHODS

This was a longitudinal study that used the Kintampo Health and Demographic Surveillance System as a platform to select 30,132 neonatal singletons with 634 deaths. Multilevel cox frailty model was used to examine the effect of community-, household- and individual-level factors on the risk of neonatal mortality.

RESULTS

Regarding individual-level factors, neonates born to mothers with previous adverse pregnancy (aHR = 1.38, 95% CI: 1.05-1.83), neonates whose mothers did not receive tetanus toxoid vaccine (aHR = 1.32, 95% CI: 1.08-1.60) and neonates of mothers with Middle, Junior High School or Junior Secondary School education (aHR = 1.30, 95% CI: 1.02-1.65) compared to mothers without formal education, had a higher risk of neonatal mortality. However, female neonates (aHR = 0.61, 95% CI: 0.51-0.73) and neonates whose mother had secondary education or higher (aHR = 0.37, 95% CI: 0.18-0.75) compared to those with no formal education had a lower risk of mortality. Neonates with longer gestation period (aHR = 0.95, 95% CI: 0.94-0.97) and those who were delivered at home (aHR = 0.56, 95% CI: 0.45-0.70), private maternity home (aHR = 0.45, 95% CI: 0.30-0.68) or health centre/clinic (aHR = 0.40, 95% CI: 0.26-0.60) compared to hospital delivery had lower risk of mortality. Regarding the household-level, neonates belonging to third quintile of the household wealth (aHR = 0.70, 95% CI: 0.52-0.94) and neonates belonging to households with crowded sleeping rooms (aHR = 0.91, 95% CI: 0.85-0.97) had lower risk of mortality.

CONCLUSION

The findings of the study suggest the risk of neonatal mortality at the individual- and household-levels in the Kintampo Districts. Interventions and strategies should be tailored towards the high-risk groups identified in the study.

Post Hepatitis B vaccination sero-conversion among health care workers in the Cape Coast Metropolis of Ghana

Background

HBV vaccine is known to offer protection against transmission of HBV infection. Health care workers are mandated to have this vaccination as part of their occupational health safety measures. Post vaccination response data for HCWs in our setting is not available. This study therefore aimed to evaluate the anti-HBs titre levels after Hepatitis B vaccination among HCWs from selected heath facilities in the Cape Coast Metropolis, Ghana.

Methods

A multicenter (3 selected sites) analytical cross-sectional study involving 711 HCWs was conducted. Five (5mls) of blood samples were collected from each study participant and the serum used for HBV immunological profile testing anti-HBs quantification by ELISA test (Fortress Diagnostics Limited, Northern Ireland, United Kingdom). Data analyses were performed using Stata version 14.0 software (STATA Corp, Texas USA).

Results

The median age of participants was 29 years (IQR = 26–35 years). Majority (80.9%, n = 575) took their vaccination from Government health facilities compared with 19.1% (n = 136) from private vaccination sources. A total of 7 (3 males and 4 females) were found to be HBsAg positive giving prevalence of 1%. In all, 8.2% (n = 58) of the HCWs had anti-HBs titre levels <10IU/ml giving a sero-protection rate of 91.8%. HCWs who received 3 doses of HBV vaccine were more likely to be sero-protected as compared to those who received only one dose in multivariate analysis (aOR = 3.39, 95%CI: 1.08–10.67), p<0.037). Gender, cigarette smoking and alcohol consumption were not found to be associated with sero-protection.

Conclusion

There is a high HBV vaccine efficacy among HCWs in the Cape Coast Metropolis of Ghana with higher prevalence of anti-HBs titre level associated with full vaccine dose adherence. Post vaccination antibody titre determination could be an integral part of HBV vaccination protocol for HCWs in Ghana.

The Accuracy and Perception of Test-Based Management of Malaria at Private Licensed Chemical Shops in the Middle Belt of Ghana

The sale of artemisinin-based combination therapy (ACT) by private licensed chemical shops (LCS) without testing is contrary to current policy recommendations. This study assessed the accuracy and perception of test-based management of malaria using malaria rapid diagnostic test (mRDT) kits at private LCS in two predominantly rural areas in the middle part of Ghana. Clients presenting at LCS with fever or other signs and symptoms suspected to be malaria in the absence of signs of severe malaria were tested with mRDT by trained attendants and treated based on the national malaria treatment guidelines. Using structured questionnaires, exit interviews were conducted within 48 hours and a follow-up interview on day 7 (±3 days). Focus group discussions and in-depth interviews were also conducted to assess stakeholders' perception on the use of mRDT at LCS. About 79.0% (N = 1,797) of clients reported with a fever. Sixty-six percent (947/1,426) of febrile clients had a positive mRDT result. Eighty-six percent (815/947) of clients with uncomplicated malaria were treated with the recommended ACT. About 97.8% (790/808) of clients with uncomplicated malaria treated with ACT were reported to be well by day 7. However, referral for those with negative mRDT results was very low (4.1%, 27/662). A high proportion of clients with a positive mRDT result received the recommended malaria treatment. Test-based management of malaria by LCS attendants was found to be feasible and acceptable by the community members and other stakeholders. Successful implementation will however require effective referral, supervision and quality control systems.

Effectiveness of population based risk reduction programs for risky sexual behavior among young people in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of population based (public health) risk reduction interventions (programs and services) on sexual risk taking among young people (aged 10 to 24 years old) in low- and middle-income countries (LMICs).The specific review questions are.

Longitudinal estimation of Plasmodium falciparum prevalence in relation to malaria prevention measures in six sub-Saharan African countries

BACKGROUND

Plasmodium falciparum prevalence (PfPR) is a widely used metric for assessing malaria transmission intensity. This study was carried out concurrently with the RTS,S/AS01 candidate malaria vaccine Phase III trial and estimated PfPR over ≤ 4 standardized cross-sectional surveys.

METHODS

This epidemiology study (NCT01190202) was conducted in 8 sites from 6 countries (Burkina Faso, Gabon, Ghana, Kenya, Malawi, and Tanzania), between March 2011 and December 2013. Participants were enrolled in a 2:1:1 ratio according to age category: 6 months-4 years, 5-19 years, and ≥ 20 years, respectively, per year and per centre. All sites carried out surveys 1-3 while survey 4 was conducted only in 3 sites. Surveys were usually performed during the peak malaria parasite transmission season, in one home visit, when medical history and malaria risk factors/prevention measures were collected, and a blood sample taken for rapid diagnostic test, microscopy, and haemoglobin measurement. PfPR was estimated by site and age category.

RESULTS

Overall, 6401 (survey 1), 6411 (survey 2), 6400 (survey 3), and 2399 (survey 4) individuals were included in the analyses. In the 6 months-4 years age group, the lowest prevalence (assessed using microscopy) was observed in 2 Tanzanian centres (4.6% for Korogwe and 9.95% for Bagamoyo) and Lambaréné, Gabon (6.0%), while the highest PfPR was recorded for Nanoro, Burkina Faso (52.5%). PfPR significantly decreased over the 3 years in Agogo (Ghana), Kombewa (Kenya), Lilongwe (Malawi), and Bagamoyo (Tanzania), and a trend for increased PfPR was observed over the 4 surveys for Kintampo, Ghana. Over the 4 surveys, for all sites, PfPR was predominantly higher in the 5-19 years group than in the other age categories. Occurrence of fever and anaemia was associated with high P. falciparum parasitaemia. Univariate analyses showed a significant association of anti-malarial treatment in 4 surveys (odds ratios [ORs]: 0.52, 0.52, 0.68, 0.41) and bed net use in 2 surveys (ORs: 0.63, 0.68, 1.03, 1.78) with lower risk of malaria infection.

CONCLUSION

Local PfPR differed substantially between sites and age groups. In children 6 months-4 years old, a significant decrease in prevalence over the 3 years was observed in 4 out of the 8 study sites. Trial registration Clinical Trials.gov identifier: NCT01190202:NCT. GSK Study ID numbers: 114001.

A systematic review and synthesis of the strengths and limitations of measuring malaria mortality through verbal autopsy

Background

Lack of valid and reliable data on malaria deaths continues to be a problem that plagues the global health community. To address this gap, the verbal autopsy (VA) method was developed to ascertain cause of death at the population level. Despite the adoption and wide use of VA, there are many recognized limitations of VA tools and methods, especially for measuring malaria mortality. This study synthesizes the strengths and limitations of existing VA tools and methods for measuring malaria mortality (MM) in low- and middle-income countries through a systematic literature review.

Methods

The authors searched PubMed, Cochrane Library, Popline, WHOLIS, Google Scholar, and INDEPTH Network Health and Demographic Surveillance System sites’ websites from 1 January 1990 to 15 January 2016 for articles and reports on MM measurement through VA. Inclusion criteria: article presented results from a VA study where malaria was a cause of death; article discussed limitations/challenges related to measurement of MM through VA. Two authors independently searched the databases and websites and conducted a synthesis of articles using a standard matrix.

Results

The authors identified 828 publications; 88 were included in the final review. Most publications were VA studies; others were systematic reviews discussing VA tools or methods; editorials or commentaries; and studies using VA data to develop MM estimates. The main limitation were low sensitivity and specificity of VA tools for measuring MM. Other limitations included lack of standardized VA tools and methods, lack of a ‘true’ gold standard to assess accuracy of VA malaria mortality.

Conclusions

Existing VA tools and methods for measuring MM have limitations. Given the need for data to measure progress toward the World Health Organization’s Global Technical Strategy for Malaria 2016–2030 goals, the malaria community should define strategies for improving MM estimates, including exploring whether VA tools and methods could be further improved. Longer term strategies should focus on improving countries’ vital registration systems for more robust and timely cause of death data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-2071-x) contains supplementary material, which is available to authorized users.

Dynamics in multiplicity of Plasmodium falciparum infection among children with asymptomatic malaria in central Ghana

Background

The determinants of malaria parasite virulence is not entirely known, but the outcome of malaria infection (asymptomatic or symptomatic) has been associated with carriage of distinct parasite genotypes. Alleles considered important for erythrocyte invasion and selected as candidate targets for malaria vaccine development are increasingly being shown to have distinct characteristics in infection outcomes. Any unique/distinct patterns or alleles linked to infection outcome should be reproducible for a given malaria-cohort regardless of location, time or intervention. This study compared merozoite surface protein 2 (MSP2) genotypes from children with asymptomatic malaria at same geographical location, from two time periods.

Results

As the prevalence and incidence of malaria (measured for other studies) significantly reduced between 2004 (time point one) and 2009 (time point two), MSP2 multiplicity of infections (MOI) also reduced significantly from 2.3 at time point (TP) one to 1.9 at TP two. IC/3D7 genotypes out-numbered FC27 genotypes at both time points. At TP2 however, FC27 allele diversity was more than the IC/3D7 allele diversity. A decrease in the IC/3D7:FC27 genotype proportions from 2:1 at TP1 to 1:1 at TP2, seemed to be driven mainly by a decrease in carriage of IC/3D7 alleles. MOI was higher in the dry season than in the subsequent wet season, but the decrease was not significant at TP2.

Conclusion

MSP2 MOI was higher in the dry season than in the subsequent wet season, while the carriage of IC/3D7 alleles decreased over this time period. It may be that decreases in transmission are related specifically to the IC/3D7 allelic family. The influence of transmission on MSP2 allele diversity needs to be clearly deciphered in studies which should include the use of sensitive methods for the detection of polymorphic parasite markers for both symptomatic and asymptomatic malaria. Such studies will enable better understanding of associations between allelic variants, MOI, transmission, malaria infection and disease.

Community health workers' experiences of mobile device-enabled clinical decision support systems for maternal, newborn and child health in developing countries: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize evidence on the experiences of community health workers (CHWs) of mobile device-enabled clinical decision support systems (CDSSs) interventions designed to support maternal newborn and child health (MNCH) in low-and middle-income countries.Specific objectives.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

FUNDING

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

Evaluation of the diagnostic accuracy of CareStart G6PD deficiency Rapid Diagnostic Test (RDT) in a malaria endemic area in Ghana, Africa

BACKGROUND

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most widespread enzyme defect that can result in red cell breakdown under oxidative stress when exposed to certain medicines including antimalarials. We evaluated the diagnostic accuracy of CareStart G6PD deficiency Rapid Diagnostic Test (RDT) as a point-of-care tool for screening G6PD deficiency.

METHODS

A cross-sectional study was conducted among 206 randomly selected and consented participants from a group with known G6PD deficiency status between February 2013 and June 2013. A maximum of 1.6ml of capillary blood samples were used for G6PD deficiency screening using CareStart G6PD RDT and Trinity qualitative with Trinity quantitative methods as the "gold standard". Samples were also screened for the presence of malaria parasites. Data entry and analysis were done using Microsoft Access 2010 and Stata Software version 12. Kintampo Health Research Centre Institutional Ethics Committee granted ethical approval.

RESULTS

The sensitivity (SE) and specificity (SP) of CareStart G6PD deficiency RDT was 100% and 72.1% compared to Trinity quantitative method respectively and was 98.9% and 96.2% compared to Trinity qualitative method. Malaria infection status had no significant (P=0.199) change on the performance of the G6PD RDT test kit compared to the "gold standard".

CONCLUSIONS

The outcome of this study suggests that the diagnostic performance of the CareStart G6PD deficiency RDT kit was high and it is acceptable at determining the G6PD deficiency status in a high malaria endemic area in Ghana. The RDT kit presents as an attractive tool for point-of-care G6PD deficiency for rapid testing in areas with high temperatures and less expertise. The CareStart G6PD deficiency RDT kit could be used to screen malaria patients before administration of the fixed dose primaquine with artemisinin-based combination therapy.

Baseline malaria vector transmission dynamics in communities in Ahafo mining area in Ghana

BACKGROUND

Malaria vector dynamics are relevant prior to commencement of mining activities. A baseline entomology survey was conducted in Asutifi and Tano (referred to as Ahafo) in the Brong-Ahafo geo-political region of Ghana during preparatory stages for mining by Newmont Ghana Gold Limited.

METHODS

Between November 2006 and August 2007, eight Centre for Disease Control light traps were set daily (Monday-Friday) to collect mosquitoes. Traps were hanged in rooms that were selected from a pool of 1,100 randomly selected houses. Types of materials used in construction of houses were recorded and mosquito prevention measures were assessed from occupants.

RESULTS

A total of 5,393 mosquitoes were caught that comprised Anopheles gambiae (64.8%), Anopheles funestus (4.2%), as well as Culicines, comprising of Culex (30.4%) and Aedes species (0.6%). The entomological inoculation rate in Asutifi (279 infective bites/person/month) and Tano (487 infective bites/person/month) demonstrate relatively high malaria transmission in Ahafo. The presence or absence of Anopheles vectors in rooms was influenced by the type of roofing material (OR 2.33, 95%CI: 1.29-4.22, p = 0.01) as well as the presence of eaves gaps (OR 1.80, 95%CI: 1.37-2.37, p < 0.01). It was also associated with bed net availability in the room (OR 1.39, 95%CI: 1.08-1.80, p = 0.01). Over 80% of the houses were roofed with corrugated zinc sheets. Over 60% of the houses in Ahafo had no eaves gaps to give access to mosquito entry and exit into rooms and mosquito bed net coverage was over 50%. Other measures used in preventing mosquito bites included; coil (22.1%), insecticide spray (9.4%), repellent cream (4.0%) and smoky fires (1.1%), contributed minimally to individual mosquito preventive measures in impact areas. Similarly, levels of protection; coil (16.9%), insecticide spray (2.8%) and repellent cream (0.3%) for the non-impact areas, depict low individual prevention measures.

CONCLUSIONS

The survey identified areas where intensified vector control activities would be beneficial. It also demonstrates that transmission in Asutifi and Tano is high even before the commencement of mining operations. This study serves as baseline information to assess impact of mining activities in relation to future vector control interventions.

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

Background

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

Methods

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

Results

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

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

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

Conclusion

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

Electronic supplementary material

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

Associations between red cell polymorphisms and Plasmodium falciparum infection in the middle belt of Ghana

BACKGROUND

Red blood cell (RBC) polymorphisms are common in malaria endemic regions and are known to protect against severe forms of the disease. Therefore, it is important to screen for these polymorphisms in drugs or vaccines efficacy trials. This study was undertaken to evaluate associations between clinical malaria and RBC polymorphisms to assess biological interactions that may be necessary for consideration when designing clinical trials.

METHOD

In a cross-sectional study of 341 febrile children less than five years of age, associations between clinical malaria and common RBC polymorphisms including the sickle cell gene and G6PD deficiency was evaluated between November 2008 and June 2009 in the middle belt of Ghana, Kintampo. G6PD deficiency was determined by quantitative methods whiles haemoglobin variants were determined by haemoglobin titan gel electrophoresis. Blood smears were stained with Giemsa and parasite densities were determined microscopically.

RESULTS

The prevalence of clinical malarial among the enrolled children was 31.9%. The frequency of G6PD deficiency was 19.0% and that for the haemoglobin variants were 74.7%, 14.7%, 9.1%, 0.9% respectively for HbAA, HbAC, HbAS and HbSS. In Multivariate regression analysis, children with the HbAS genotype had 79% lower risk of malaria infection compared to those with the HbAA genotypes (OR = 0.21, 95% CI: 0.06-0.73, p = 0.01). HbAC genotype was not significantly associated with malaria infection relative to the HbAA genotype (OR = 0.70, 95% CI: 0.35-1.42, p = 0.33). G6PD deficient subgroup had a marginally increased risk of malaria infection compared to the G6PD normal subgroup (OR = 1.76, 95% CI: 0.98-3.16, p = 0.06).

CONCLUSION

These results confirm previous findings showing a protective effect of sickle cell trait on clinical malaria infection. However, G6PD deficiency was associated with a marginal increase in susceptibility to clinical malaria compared to children without G6PD deficiency.

Placental malaria and the risk of malaria in infants in a high malaria transmission area in ghana: a prospective cohort study

BACKGROUND

Whether the risk of malaria is increased in infants born to mothers who experience malaria during pregnancy is uncertain.

METHODS

 We investigated malaria incidence among an infant cohort born to 355 primigravidae and 1500 multigravidae with or without placental malaria (PM) in a high malaria transmission area of Ghana. PM was assessed using placental histology.

RESULTS

The incidence of all episodes of malaria parasitemia or clinical malaria was very similar among 3 groups of infants: those born to multigravidae without PM, multigravidae with PM, and primigravidae with PM. Infants born to primigravidae without PM experienced a lower incidence of malaria parasitemia or clinical malaria than the other 3 groups: adjusted hazard ratio, 0.64 (95% confidence interval [CI], .48-.86, P < .01) and 0.60 (95% CI, .43-.84, P < .01), respectively. The incidence of malaria parasitemia or clinical malaria was about 2 times higher in most poor infants compared to least poor infants.

CONCLUSIONS

There was no suggestion that exposure to PM directly increased incidence of malaria among infants of multigravidae. In our study area, absence of placental malaria in primigravidae is a marker of low exposure, and this probably explains the lower incidence of malaria-related outcomes among infants of PM-negative primigravidae.

The benefits or otherwise of managing malaria cases with or without laboratory diagnosis: the experience in a district hospital in Ghana

Background

This study was conducted at the Kintampo Municipal Hospital in Ghana to determine whether there was any benefit (or otherwise) in basing the management of cases of suspected malaria solely on laboratory confirmation (microscopy or by RDT) as compared with presumptive diagnosis.

Method

Children under five years who reported at the Out-Patient Department of the Hospital with axillary temperature ≥37.5°C or with a 48 hr history of fever were enrolled and had malaria microscopy and RDT performed. The attending clinician was blinded from laboratory results unless a request for these tests had been made earlier. Diagnosis of malaria was based on three main methods: presumptive or microscopy and/or RDT. Cost implication for adopting laboratory diagnosis or not was determined to inform malaria control programmes.

Results

In total, 936 children were enrolled in the study. Proportions of malaria diagnosed presumptively, by RDT and microscopy were 73.6% (689/936), 66.0% (618/936) and 43.2% (404/936) respectively. Over 50% (170/318) of the children who were RDT negative and 60% (321/532) who were microscopy negative were treated for malaria when presumptive diagnoses were used. Comparing the methods of diagnoses, the cost of malaria treatment could have been reduced by 24% and 46% in the RDT and microscopy groups respectively; the reduction was greater in the dry season (43% vs. 50%) compared with the wet season (20% vs. 45%) for the RDT and microscopy confirmed cases respectively.

Discussion/Conclusion

Over-diagnosis of malaria was prevalent in Kintampo during the period of the study. Though the use of RDT for diagnosis of malaria might have improved the quality of care for children, it appeared not to have a cost saving effect on the management of children with suspected malaria. Further research may be needed to confirm this.

Trends in multiplicity of Plasmodium falciparum infections among asymptomatic residents in the middle belt of Ghana

Background

Malaria is the most important cause of mortality and morbidity in children living in the Kintampo districts in the middle part of Ghana. This study has investigated the multiplicity of infection (MOI) within asymptomatic residents of the Kintampo districts, and the influence of age and seasonality on MOI, by studying the distribution of the polymorphic Plasmodium falciparum antigen merozoite surface protein 2 (MSP2).

Methods

DNA was extracted from an asymptomatic cohort of children and adults infected with P. falciparum during the period November 2003 to October 2004. Polymerase chain reaction was carried out and multiplicity of infection (MOI) was determined.

Results

Children under 10 years of age had an average MOI of 2.3 while adults 18 years and above had an average MOI of 1.4. Children below five years had high and low average MOIs of 2.8 in the March/April survey and 0.9 in the May/June survey respectively. A similar trend in the monthly distribution of MOI was observed for the entire cohort. IC/3D7 strains outnumbered the FC27 strains throughout the year by a ratio of about 4:1 with the difference between the prevalence of the two strains being least marked in the March/April survey, at the beginning of the rainy season. MOI was not linked to the level of malaria transmission as measured by the entomological inoculation rate.

Discussion/conclusion

The impact of interventions, introduced since this baseline study was carried out on the parasite diversity of asymptomatic residents will be the subject of further investigations.

A phase 3 trial of RTS,S/AS01 malaria vaccine in African infants

BACKGROUND

The candidate malaria vaccine RTS,S/AS01 reduced episodes of both clinical and severe malaria in children 5 to 17 months of age by approximately 50% in an ongoing phase 3 trial. We studied infants 6 to 12 weeks of age recruited for the same trial.

METHODS

We administered RTS,S/AS01 or a comparator vaccine to 6537 infants who were 6 to 12 weeks of age at the time of the first vaccination in conjunction with Expanded Program on Immunization (EPI) vaccines in a three-dose monthly schedule. Vaccine efficacy against the first or only episode of clinical malaria during the 12 months after vaccination, a coprimary end point, was analyzed with the use of Cox regression. Vaccine efficacy against all malaria episodes, vaccine efficacy against severe malaria, safety, and immunogenicity were also assessed.

RESULTS

The incidence of the first or only episode of clinical malaria in the intention-to-treat population during the 14 months after the first dose of vaccine was 0.31 per person-year in the RTS,S/AS01 group and 0.40 per person-year in the control group, for a vaccine efficacy of 30.1% (95% confidence interval [CI], 23.6 to 36.1). Vaccine efficacy in the per-protocol population was 31.3% (97.5% CI, 23.6 to 38.3). Vaccine efficacy against severe malaria was 26.0% (95% CI, -7.4 to 48.6) in the intention-to-treat population and 36.6% (95% CI, 4.6 to 57.7) in the per-protocol population. Serious adverse events occurred with a similar frequency in the two study groups. One month after administration of the third dose of RTS,S/AS01, 99.7% of children were positive for anti-circumsporozoite antibodies, with a geometric mean titer of 209 EU per milliliter (95% CI, 197 to 222).

CONCLUSIONS

The RTS,S/AS01 vaccine coadministered with EPI vaccines provided modest protection against both clinical and severe malaria in young infants. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619.).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Estimating the cost to rural ambulating HIV/AIDS patients on highly active antiretroviral therapy (HAART) in rural Ghana: a pilot study

BACKGROUND

Subsidized antiretroviral therapy programs obviously lowers the cost of antiretroviral drugs but other major costs are still incurred, which makes the overall cost of accessing and consuming antiretroviral treatment very high and sometimes catastrophic. The objective of this study was to estimate the total cost to rural ambulating HIV/AIDS patients on highly active antiretroviral therapy in a rural area of the middle belt of Ghana.

METHODS

This was a convenient cross-sectional study of people diagnosed with HIV/AIDS receiving outpatient care and carried out from September to October 2009 involving 80 HIV/AIDS patients on HAART. Data was derived from patients' medical records on health care utilization and a completed pre tested questionnaire used to obtain the cost of transportation and estimates of individual earned income from which the labor productivity loses (opportunity cost) for days not worked as a result of attending the antiretroviral clinic were derived.

RESULTS

The median total, indirect and direct annual costs to rural ambulating HIV/AIDS patients on HAART were estimated to be $US71.18 (115.16 Ghana cedis), $US2.740 (3.92 Ghana cedis) and $US53.04 (75.00 Ghana cedis) respectively.

CONCLUSION

Although the cost of antiretroviral drugs has been subsidized by government from $360 to $41.38 per annum, HIV/AIDS patients on HAART spend double of this subsidized amount out of their pocket seeking health care. We recommend that agencies associated with HIV/AIDS activities, supplements government's effort by helping to get antiretroviral closer to the door step of patients so as to reduce this huge financial burden which constitutes more than 100% of their median annual earned income.

Perceived Facilitators and Barriers to Interventions Aimed at Reducing Unintended Pregnancies among Adolescents in Low and Middle Income (Developing) Countries: a Systematic Review of Qualitative Evidence

BACKGROUND

Adolescent pregnancies are most often the result of sexual risk taking. Such pregnancies are in themselves "risks" perpetuating other adverse social outcomes on the adolescents who go through such pregnancies. Of the close to 14 million births among adolescents each year, between one-third and two-thirds are unplanned. Unplanned pregnancies coupled with societal restrictions result in adolescents opting for abortions under unsafe conditions.

OBJECTIVES

The objective of this review is to present the best available evidence on perceived facilitators and barriers to successful outcomes of programs aimed at reducing pregnancies among adolescents in low and middle income countries.

INCLUSION CRITERIA

Persons aged between 10 and 19 years residing in low and middle income countries, but during the review process, those up to 25 years, adults and opinion leaders were included.Perceived facilitators and barriers to interventions aimed at reducing pregnancies among adolescents in developing countries.The review considered studies that used qualitative study designs, including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioural studies, case studies and feminist research.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies in English over the period of January, 1960 to December, 2010.

METHODOLOGICAL QUALITY

Critical appraisal of papers was conducted using standardized tools from the Joanna Briggs Institute by two independent reviewers.

DATA COLLECTION

Data was extracted using standardized tools from the Joanna Briggs Institute.

DATA SYNTHESIS

Findings were synthesized on the basis of similarity of meaning using software from the Joanna Briggs Institute.

RESULTS

Fourteen studies were included in the review which generated 103 findings, grouped into 22 categories and then further grouped into 11 synthesized findings, based on similarity of meaning. Seventeen categories (eight synthesized findings) described perceived barriers and five categories (three synthesized findings) described perceived facilitators.

CONCLUSIONS

Synthesized findings on both the barriers and facilitators encompassed adolescent, parental, community, health facility, care providers, school environment and societal contributing factors.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR RESEARCH: Further research should be conducted into the following.

First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children

BACKGROUND

An ongoing phase 3 study of the efficacy, safety, and immunogenicity of candidate malaria vaccine RTS,S/AS01 is being conducted in seven African countries.

METHODS

From March 2009 through January 2011, we enrolled 15,460 children in two age categories--6 to 12 weeks of age and 5 to 17 months of age--for vaccination with either RTS,S/AS01 or a non-malaria comparator vaccine. The primary end point of the analysis was vaccine efficacy against clinical malaria during the 12 months after vaccination in the first 6000 children 5 to 17 months of age at enrollment who received all three doses of vaccine according to protocol. After 250 children had an episode of severe malaria, we evaluated vaccine efficacy against severe malaria in both age categories.

RESULTS

In the 14 months after the first dose of vaccine, the incidence of first episodes of clinical malaria in the first 6000 children in the older age category was 0.32 episodes per person-year in the RTS,S/AS01 group and 0.55 episodes per person-year in the control group, for an efficacy of 50.4% (95% confidence interval [CI], 45.8 to 54.6) in the intention-to-treat population and 55.8% (97.5% CI, 50.6 to 60.4) in the per-protocol population. Vaccine efficacy against severe malaria was 45.1% (95% CI, 23.8 to 60.5) in the intention-to-treat population and 47.3% (95% CI, 22.4 to 64.2) in the per-protocol population. Vaccine efficacy against severe malaria in the combined age categories was 34.8% (95% CI, 16.2 to 49.2) in the per-protocol population during an average follow-up of 11 months. Serious adverse events occurred with a similar frequency in the two study groups. Among children in the older age category, the rate of generalized convulsive seizures after RTS,S/AS01 vaccination was 1.04 per 1000 doses (95% CI, 0.62 to 1.64).

CONCLUSIONS

The RTS,S/AS01 vaccine provided protection against both clinical and severe malaria in African children. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619 .).

Malaria epidemiology in the Ahafo area of Ghana

Background

Plasmodium falciparum malaria remains endemic in sub-Saharan Africa including Ghana. The epidemiology of malaria in special areas, such as mining areas needs to be monitored and controlled. Newmont Ghana Gold Limited is conducting mining activities in the Brong Ahafo Region of Ghana that may have an impact on the diseases such as malaria in the mining area.

Methods

Prior to the start of mining activities, a cross-sectional survey was conducted in 2006/2007 to determine malaria epidemiology, including malaria parasitaemia and anaemia among children < 5 years and monthly malaria transmission in a mining area of Ghana.

Results

A total of 1,671 households with a child less than five years were selected. About 50% of the household heads were males. The prevalence of any malaria parasitaemia was 22.8% (95% CI 20.8 - 24.9). Plasmodium falciparum represented 98.1% (95% CI 96.2 - 99.2) of parasitaemia. The geometric mean P. falciparum asexual parasite count was 1,602 (95% CI 1,140 - 2,252) and 1,195 (95% CI 985 - 1,449) among children < 24 months and ≥ 24 months respectively. Health insurance membership (OR 0.60, 95% CI 0.45 - 0.80, p = 0.001) and the least poor (OR 0.57, 95% CI 0.37 - 0.90, p = 0.001) were protected against malaria parasitaemia. The prevalence of anaemia was high among children < 24 months compared to children ≥ 24 months (44.1% (95% CI 40.0 - 48.3) and 23.8% (95% CI 21.2 - 26.5) respectively. About 69% (95% CI 66.3 - 70.9) of households own at least one ITN. The highest EIRs were record in May 2007 (669 ib/p/m) and June 2007 (826 ib/p/m). The EIR of Anopheles gambiae were generally higher than Anopheles funestus.

Conclusion

The baseline malaria epidemiology suggests a high malaria transmission in the mining area prior to the start of mining activities. Efforts at controlling malaria in this mining area have been intensified but could be enhanced with increased resources and partnerships between the government and the private sector.

T cell responses to the RTS,S/AS01(E) and RTS,S/AS02(D) malaria candidate vaccines administered according to different schedules to Ghanaian children

BACKGROUND

The Plasmodium falciparum pre-erythrocytic stage candidate vaccine RTS,S is being developed for protection of young children against malaria in sub-Saharan Africa. RTS,S formulated with the liposome based adjuvant AS01(E) or the oil-in-water based adjuvant AS02(D) induces P. falciparum circumsporozoite (CSP) antigen-specific antibody and T cell responses which have been associated with protection in the experimental malaria challenge model in adults.

METHODS

This study was designed to evaluate the safety and immunogenicity induced over a 19 month period by three vaccination schedules (0,1-, 0,1,2- and 0,1,7-month) of RTS,S/AS01(E) and RTS,S/AS02(D) in children aged 5-17 months in two research centers in Ghana. Control Rabies vaccine using the 0,1,2-month schedule was used in one of two study sites.

RESULTS

Whole blood antigen stimulation followed by intra-cellular cytokine staining showed RTS,S/AS01(E) induced CSP specific CD4 T cells producing IL-2, TNF-α, and IFN-γ. Higher T cell responses were induced by a 0,1,7-month immunization schedule as compared with a 0,1- or 0,1,2-month schedule. RTS,S/AS01(E) induced higher CD4 T cell responses as compared to RTS,S/AS02(D) when given on a 0,1,7-month schedule.

CONCLUSIONS

These findings support further Phase III evaluation of RTS,S/AS01(E). The role of immune effectors and immunization schedules on vaccine protection are currently under evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00360230.

The experience of living with chronic manifestations of Lymphatic Filariasis among patients 15 years and older in developing countries: a systematic review

BACKGROUND

Lymphatic filariasis is considered a disease of the poor with painful and profoundly disfiguring consequences. It is transmitted by the mosquito. Lymphatic filariasis is found among persons residing in rural areas and at the periphery of communities predominantly in developing countries in the tropics.

OBJECTIVES

To present the best evidence regarding the experiences of persons living with chronic manifestations of lymphatic filariasis, their experiences of treatment strategies and how the condition influences their social relationships within the context of developing countries.

INCLUSION CRITERIA

Study subjects were persons 15 years and older with chronic lymphatic filariasis living in developing countries.Phenomena of interest Publications that were selected considered the experiences of persons living with chronic lymphatic filariasis, their experiences of treatment measures and their social relationships.Types of studies Qualitative research papers (including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioral studies, case studies and feminist research) exploring the experiences of persons living with chronic manifestations of lymphatic filariasis within the context of developing countries SEARCH STRATEGY: A three-step search strategy was utilised to search for published and unpublished studies over the period of 1980-2007. MEDLINE and CINAHL were initially searched for keywords and index terms that were then used to search across all the other data bases and finally the reference list of identified studies.

METHODOLOGICAL QUALITY

Eligible publications were assessed by two independent reviewers for methodological validity using the standardised critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) DATA EXTRACTION: Data extraction was conducted using the standardised data extraction tools of the JBI-QARI. Extracted information consisted of details on relevant aspects of the identified studies.

DATA SYNTHESIS

Study findings were categorised according to the JBI-QARI degrees of credibility scale, and placed in categories of similar meaning. Categories were finally meta-synthesised.

RESULTS

Six (6) included studies yielded 41 findings that were placed in 8 categories and finally meta-synthesised into 3 synthesised findings: CONCLUSION: Policy guidelines on chronic lymphatic filariasis management need to provide a holistic approach with the involvement of communities.

IMPLICATIONS FOR RESEARCH

Much more research into elephantiasis management should be encouraged; so should qualitative research with rigorous methodological approaches into all aspects of lymphatic filariasis.

IMPLICATIONS FOR PRACTICE

Interventions should address in concert with other needs the psycho-emotional health of patients. Counseling should be incorporated into surgical management of hydroceles to allay fears of death.

Adherence to Artesunate-Amodiaquine Therapy for Uncomplicated Malaria in Rural Ghana: A Randomised Trial of Supervised versus Unsupervised Drug Administration

Introduction. To enhance effective treatment, african nations including Ghana changed its malaria treatment policy from monotherapy to combination treatment with artesunate-amodiaquine (AS+AQ). The major challenge to its use in loose form is adherence. Objective. The objectives of this study were to investigate adherence and treatment outcome among patients treated with AS+AQ combination therapy for acute uncomplicated malaria. Methodology. The study was conducted in two rural districts located in the middle belt of Ghana using quantitative methods. Patients diagnosed with acute uncomplicated malaria as per the Ghana Ministry of Health malaria case definitions were randomly allocated to one of two groups. All patients in both groups were educated about the dose regimen of AS+AQ therapy and the need for adherence. Treatment with AS+AQ was supervised in one group while the other group was not supervised. Adherence was assessed by direct observation of the blister package of AS+AQ left on day 2. Results. 401 participants were randomized into the supervised (211) and unsupervised (190) groups. Compliance in both supervised (95.7%) and unsupervised (92.6%) groups were similar (P = .18). The commonest side-effects reported on day 2 among both groups were headaches, and body weakness. Parasite clearance by day 28 was >95% in both groups. Discussion/Conclusions. Administration of AS-AQ in both groups resulted in high levels of adherence to treatment regimen among adolescent and adult population in central Ghana. It appears that high level of adherence to AS-AQ is achievable through a rigorous education programme during routine clinic visits.

Randomized controlled trial of RTS,S/AS02D and RTS,S/AS01E malaria candidate vaccines given according to different schedules in Ghanaian children

Background

The target delivery channel of RTS,S candidate malaria vaccines in malaria-endemic countries in Africa is the World Health Organisation Expanded Program on Immunization. As an Adjuvant System, age de-escalation and schedule selection step, this study assessed 3 schedules of RTS,S/AS01_E and RTS,S/AS02_D in infants and young children 5–17 months of age in Ghana.

Methodology

A Phase II, partially-blind randomized controlled study (blind to vaccine, not to schedule), of 19 months duration was conducted in two (2) centres in Ghana between August 2006 and May 2008. Subjects were allocated randomly (1∶1∶1∶1∶1∶1) to one of six study groups at each study site, each defining which vaccine should be given and by which schedule (0,1-, 0,1,2- or 0,1,7-months). For the 0,1,2-month schedule participants received RTS,S/AS01_E or rabies vaccine at one center and RTS,S/AS01_E or RTS,S/AS02_D at the other. For the other schedules at both study sites, they received RTS,S/AS01_E or RTS,S/AS02_D. The primary outcome measure was the occurrence of serious adverse events until 10 months post dose 1.

Results

The number of serious adverse events reported across groups was balanced. One child had a simple febrile convulsion, which evolved favourably without sequelae, considered to be related to RTS,S/AS01_E vaccination. Low grade reactions occurred slightly more frequently in recipients of RTS,S/AS than rabies vaccines; grade 3 reactions were infrequent. Less local reactogenicity occurred with RTS,S/AS01_E than RTS,S/AS02_D. Both candidate vaccines were highly immunogenic for anti-circumsporozoite and anti-Hepatitis B Virus surface antigen antibodies. Recipients of RTS,S/AS01_E compared to RTS,S/AS02_D had higher peak anti-circumsporozoite antibody responses for all 3 schedules. Three dose schedules were more immunogenic than 2 dose schedules. Area under the curve analyses for anti-circumsporozoite antibodies were comparable between the 0,1,2- and 0,1,7-month RTS,S/AS01_E schedules.

Conclusions

Both candidate malaria vaccines were well tolerated. Anti-circumsporozoite responses were greater with RTS,S/AS01_E than RTS,S/AS02_D and when 3 rather than 2 doses were given. This study supports the selection of RTS,S/AS01_E and a 3 dose schedule for further development in children and infants.

Trial Registration

ClinicalTrials.gov NCT00360230

Epidemiology of malaria in the forest-savanna transitional zone of Ghana

Background

Information on the epidemiology of malaria is essential for designing and interpreting results of clinical trials of drugs, vaccines and other interventions. As a background to the establishment of a site for anti-malarial drugs and vaccine trials, the epidemiology of malaria in a rural site in central Ghana was investigated.

Methods

Active surveillance of clinical malaria was carried out in a cohort of children below five years of age (n = 335) and the prevalence of malaria was estimated in a cohort of subjects of all ages (n = 1484) over a 12-month period. Participants were sampled from clusters drawn around sixteen index houses randomly selected from a total of about 22,000 houses within the study area. The child cohort was visited thrice weekly to screen for any illness and a blood slide was taken if a child had a history of fever or a temperature greater than or equal to 37.5 degree Celsius. The all-age cohort was screened for malaria once every eight weeks over a 12-month period. Estimation of Entomological Inoculation Rate (EIR) and characterization of Anopheline malaria vectors in the study area were also carried out.

Results

The average parasite prevalence in the all age cohort was 58% (95% CI: 56.9, 59.4). In children below five years of age, the average prevalence was 64% (95% CI: 61.9, 66.0). Geometric mean parasite densities decreased significantly with increasing age. More than 50% of all children less than 10 years of age were anaemic. Children less than 5 years of age had as many as seven malaria attacks per child per year. The attack rates decreased significantly with increasing cut-offs of parasite density. The average Multiplicity of Infection (MOI) was of 6.1. All three pyrimethamine resistance mutant alleles of the Plasmodium falciparum dhfr gene were prevalent in this population and 25% of infections had a fourth mutant of pfdhps-A437G. The main vectors were Anopheles funestus and Anopheles gambiae and the EIR was 269 infective bites per person per year.

Conclusion

The transmission of malaria in the forest-savanna region of central Ghana is high and perennial and this is an appropriate site for conducting clinical trials of anti-malarial drugs and vaccines.

Vitamin A supplementation enhances infants' immune responses to hepatitis B vaccine but does not affect responses to Haemophilus influenzae type b vaccine

Vitamin A supplementation reduces child mortality and severe morbidity in less developed countries, and the Expanded Program on Immunization (EPI) offers an ideal opportunity to deliver supplements in developing countries. High-dose vitamin A supplementation has been shown to have no effect on the immunogenicity of oral polio vaccine, tetanus toxoid, pertussis, or on measles vaccine given at 9 mo, but a negative effect on measles vaccine administered at 6 mo and a potentiating effect on diphtheria vaccine. Its effect on the antibody response to hepatitis B and Haemophilus influenzae type b antigens has not yet been established. To assess these effects, the present trial was carried out in the Offinso district of Ghana; 1077 infants were enrolled shortly after birth and randomized either to receive or not to receive 15 mg retinol equivalent with vitamin A together with the pentavalent "diphtheria-polio-tetanus-Haemophilus influenzae b-hepatitis B" vaccine at 6, 10, and 14 wk of age. All mothers received a postpartum supplement of 120 mg retinol equivalent vitamin A as per national policy. Blood samples were taken from infants at 6 and 18 wk of age. The results are based on 888 infants (82.4%) who completed the trial. The vitamin A supplementation did not affect the immune response to Haemophilus influenzae type b, but there was a significant improvement in the immune response to hepatitis B vaccine (93.9 vs. 90.2%, P = 0.04). However, given the high percentage of infants with seroprotection in the control group, it is doubtful that inclusion of vitamin A in the EPI would be justified on these grounds alone.