Optimization of a protocol for the evaluation of antibody responses to human papillomavirus (HPV) vaccination in low-resource settings.

INTRODUCTION: Available human papillomavirus (HPV) vaccines could have an important primary role in cervical cancer prevention once their long-term immunogenicity and safety are evaluated at the population level. The aim of this study was to optimize an assay to be used in evaluating the long-term durability of HPV vaccine response following a pilot vaccination of adolescent girls in Ghana. METHODS: A rapid, high-throughput, indirect enzyme-linked immunosorbent assay (ELISA) was optimized for the detection and quantitation of anti-HPV L1 (late expression protein: types 6, 11, 16 and 18) immunoglobulin G (IgG) in human serum (n = 89). The utility of the assay was demonstrated using serum collected from a cohort of pre-adolescent girls (n = 49) previously vaccinated with a quadrivalent vaccine and non-immune serum obtained from age-matched controls (n = 40). RESULTS: The assay showed good discrimination of antibody levels between cases and control sera: seroprevalence of anti-HPV IgG antibodies was significantly higher among vaccinated than unvaccinated girls for both HPV-16 (63.3% vs. 12.5%; p < 0.001) and HPV-18 (34.7% vs. 20.0%; p = 0.042), respectively. Thirty-six months after receiving the third dose of vaccine, significantly higher mean anti-HPV-16 (0.618 vs. 0.145), anti-HPV-18 (0.323 vs. 0.309), and anti-HPV-6 (1.371 vs. 0.981) antibody levels were measured, compared to unvaccinated girls (all p < 0.05). A correlation between optical density and antibody activity indicated assay sensitivity to increasing levels of antibody activity. CONCLUSION: We have successfully optimized and implemented a robust and sensitive assay for the evaluation of antibody responses among immunized adolescent girls for monitoring future large-scale HPV vaccination studies in low-income settings. Our results demonstrated greater immunoglobulin G antibody activity within serum drawn from adolescent girls immunized 36 months prior.

Rollout of rapid point of care tests for antenatal syphilis screening in Ghana: healthcare provider perspectives and experiences.

BACKGROUND: Effective implementation of rapid point of care tests (POCTs) for antenatal syphilis screening especially in settings where antenatal care attendance is high, can significantly increase screening coverage and treatment uptake. The operational challenges of introducing rapid syphilis POCTs at scale needs to be investigated. This study explores healthcare providers' experiences and challenges in antenatal syphilis screening following the national rollout of rapid syphilis POCTs in Ghana. METHODS: Prior to the main study, we undertook a desk review of key syphilis policy documents, and conducted key stakeholder interviews and a baseline survey of syphilis screening practices. Antenatal syphilis screening had been poorly implemented mainly due to inadequate technical and logistic support, and lack of monitoring and supervision. For the main research, semi-structured interviews were conducted with 51 purposively selected healthcare staff involved in antenatal syphilis screening in 15 health facilities in three regions, representative of all levels of healthcare in Ghana and two regional programme coordinators, at least four months after the rollout. The interviews were supplemented with an audit of the conduct of antenatal care, syphilis-related supplies and other maternal and newborn interventions. Qualitative data were coded and analysed using Nvivo software. RESULTS: Syphilis screening with rapid POCTs was integrated into antenatal care in almost all (13/15) the facilities surveyed. Testing and treatment were offered free of charge to pregnant women, their partners and babies. In most facilities, midwives were performing syphilis tests together with HIV tests. Operational challenges included: inadequate training and lack of refresher training, lack of clear testing guidelines, clear channels of communication, supervision, and guidance on treatment and referral procedures, frequent stockouts of, or expired test kits, staff overload, and poor documentation of test results and treatment. CONCLUSION: Although syphilis screening with rapid syphilis POCTs was integrated into antenatal care, key challenges, particularly around supply chain and supervision, need to be addressed to improve and sustain such a programme.

Performance of Syphilis Sentinel Surveillance in the context of endemic Treponematoses: experience from Ghana.

BACKGROUND: Use of treponemal tests to screen for syphilis (caused by Treponema pallidum pallidum) poses challenges with infection status classification, especially in settings where other treponemal infections are endemic. This study aimed to determine the validity of the syphilis surveillance testing strategy implemented since 2004 using two treponemal tests, and estimate the seroprevalence of active syphilis infection in Ghana where yaws (caused by Treponema pallidum pertenue) is endemic. METHODS: We retested sera from the 2007 HIV sentinel survey (HSS) using a traditional algorithm, quantitative rapid plasma reagin test followed by qualitative Treponema pallidum haemagglutination assay. The adjusted seroprevalence of active syphilis was calculated by applying the proportions of active syphilis within identified categories of HSS samples during the retesting, to the entire population of HSS samples. The 95% confidence intervals (CIs) were calculated for each proportion, and the t-test was used to assess differences in proportions. RESULTS: Of 2,214 samples that were retested, 203 (9.2%) had active syphilis infection, 21 (0.9%) were biological false reactions, 640 (28.9%) were past or treated syphilis infections, and 1,350 (61%) were uninfected. The current syphilis testing strategy overestimated the seroprevalence of active syphilis infection by a third (HSS versus traditional algorithm: 6.0% (95% CI: 5.6-6.3) vs. 4.5% (95% CI: 4.2-4.8); p < 0.001), and had low positive predictive value (16.8%) for detecting active syphilis infection. More than half (51.9%) of HSS syphilis positive cases were actually past/treated treponemal infections, possibly previous exposure to yaws. CONCLUSION: There is an urgent need to review the current syphilis sentinel surveillance testing strategy in Ghana in the context of concurrent endemic treponematoses, to better inform policy.

Factors associated with failure to screen for syphilis during antenatal care in Ghana: a case control study.

BACKGROUND: There is little data regarding the effect of ramping up new screening interventions on their uptake by target populations into routine care services in developing countries. This study aimed to determine patient-level factors associated with failure of pregnant women to get screened for syphilis during antenatal care, in the context of a national rollout of rapid syphilis point of care tests (POCTs) in Ghana. METHODS: An unmatched 1:2 case control study conducted among women admitted for delivery in two district hospitals in the Ashanti Region of Ghana from August to October 2010, 7 to 9 months after the introduction of POCTs in the region. Cases were women who had not been screened for syphilis during antenatal care and controls were women who had been screened. Patient-reported factors for being unscreened were examined using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: 160 consecutive unscreened and 327 screened women were recruited. Most women had good knowledge of syphilis (58.7% among unscreened women vs. 64.2% among screened; P=0.24). Factors associated with failure to get screened were: attending antenatal care in a private health facility (adjusted OR, 11.09; 95% CI 5.48-22.48), previous adverse pregnancy outcome (adjusted OR, 1.98; 95% CI 1.22-3.23) and not being screened for HIV during the current pregnancy (adjusted OR, 2.78; 95% CI 1.50-5.13). The odds of being unscreened also increased with decreasing doses of intermittent preventive treatment for malaria in pregnancy received (P trend<0.001) and decreasing education level (P trend=0.02). CONCLUSION: Significant risk factors for not being screened, following the national rollout of syphilis POCTs, related to the type of health facility where antenatal care was received and some of the women's personal characteristics. Targeting of private medical facilities to include syphilis POCTs and support other neglected public health interventions should be a priority.

Stillbirths and very low Apgar scores among vaginal births in a tertiary hospital in Ghana: a retrospective cross-sectional analysis.

BACKGROUND: Data pertaining to risk factors associated with stillbirths and very low Apgar scores is very sparse. This study was conducted to determine the prevalence of, and examine the socio-demographic and obstetric factors associated with stillbirths and very low Apgar scores among vaginal births in a tertiary health facility, Ghana. METHODS: A retrospective cross-sectional review of vaginal deliveries conducted at a teaching hospital in Ghana from 1st January to 31st December, 2009. Background characteristics and obstetric history of the mother as well as the vital status of the baby at birth were extracted. Risk factors associated with stillbirths and very low Apgar scores were examined using binomial regression with a log-link function, and population attributable fractions calculated for significant risk factors. RESULTS: Of the 8,758 deliveries which met the inclusion criteria, 5.9% of the babies were stillbirths, and 6.5% and 1.9% of live births had very low Apgar scores in the first and fifth minutes respectively. Preterm delivery, hypertensive disorders in pregnancy, breech delivery and vacuum extraction were significant risk factors for stillbirths and very low Apgar scores in the fifth minute of life. Low birth weight was also a significant risk factor for very low Apgar scores. CONCLUSION: The prevalence of stillbirths and very low Apgar scores were high. Improving the quality of obstetric care during labour and delivery may help improve these adverse vaginal birth outcomes.

Quality of antenatal care and outcomes of Hypertensive Disorders in Pregnancy among antenatal attendees: A comparison of urban and periurban health facilities in Ghana.

Rural-urban-peri urban disparity assessments on health outcomes have been considered as critical determinants of health and health service outcomes. It is policy relevant in terms of the burden of disease and also provides focus on target interventions. This study aimed to assess the differences in the quality of Ante-natal Care (ANC) and the outcomes of Hypertensive Disorders in Pregnancy (HDPs) from selected health facilities in Ghana. This was a questionnaire-based cross-sectional study. Data on demographics, proportions of HDPs, quality of ANC and the outcomes of HDPs were collected. Logistic regression models were used to examine the association of the independent variables with the location of the health of facility. A total of 500 pregnant women were included in this study. There were 270 (54%) urban and 230 (46%) peri-urban dwellers. The proportion of HDPs varied with the location of the health facility. Women attending urban health facilities were more likely to be hypertensive (µ2 = 126.4; p<0.001), have chronic hypertension with superimposed pre-eclampsia (p< 0.001), have good quality ANC (µ2 = 41.28; p< 0.001), deliver full term (µ2 = 4.83; p = 0.028), and have excellent knowledge on HDPs (µ2 = 227.65; p< 0.001) compared to women receiving care in peri-urban health facilities. The method of delivery and outcome of birth did not statistically vary amongst the periurban and urban health facilities. There was an increase in the proportion in preterm in urban compared to periurban. The burden of HDPs was high in urban health facilities with high proportion of its mothers receiving quality ANC as well as having excellent knowledge on HDPs compared to mothers receiving care at the periurban health facilities. There is a need to target maternal care interventions to the periurban health facilities to improve obstetric health outcomes.

Prevalence, Awareness, and Control of Hypertensive Disorders amongst Pregnant Women Seeking Healthcare in Ghana.

Hypertensive disorders in pregnancy (HDPs) are no longer seen as "transitory diseases cured by delivery." It accounts for up to 50% of maternal deaths. Information concerning HDPs is less in developing countries like Ghana. This study was conducted to find out the prevalence, awareness, risk factors, control, and the birth outcomes of HDPs. This was a retrospective cohort study conducted among pregnant women seeking care in selected health facilities in the Ashanti Region. Data on demographics, HDPs, and its associated birth outcomes were collected. Logistic regression models were used to examine the association of the independent variables with HDPs. The burden of HDPs was 37.2% among the 500 mothers enrolled with chronic hypertension superimposed with preeclampsia accounting for 17.6%, chronic hypertension, 10.2%, and preeclampsia 6.8% whilst gestational hypertension was 2.6%. It was observed that 44% (220) of the mothers had excellent knowledge on HDPs. Oral nifedipine and methyldopa were frequently used for HDP management, and it resulted in a significant reduction in HDP burden from 37.2% to 26.6%. Factors that influenced the increased risk of HDPs were grand multigravida (AOR = 4.53; CI = 1.42-14.42), family history of hypertension (AOR = 3.61; CI = 1.89-6.90), and the consumption of herbal preparations (AOR = 2.92; CI = 1.15-7.41) and alcohol (AOR = 4.10; CI = 1.34-12.62) during pregnancy. HDPs increased the risk of preterm delivery (AOR = 2.66; CI = 1.29-5.89), stillbirth (AOR = 12.47; CI = 2.72-57.24), and undergoing caesarean section (AOR = 1.70; CI = 1.10-2.61) amongst mothers during delivery. The burden of HDPs is high amongst pregnant mothers seeking care in selected facilities. There is the need for intensified campaign on HDPs in the Ashanti Region of Ghana.

Public relations strategies employed by the Ghana Health Service to address COVID-19 vaccine hesitancy: a qualitative inquiry.

BACKGROUND: Strategies for developing and advancing good public relations can be recognized in nearly all fields of life without making an exception for the healthcare industry. In the wake of the COVID-19 pandemic, matters of public health have gathered more force. The importance of effective public relations for improving healthcare is highlighted by the position that immediate access to reliable health information should be the hallmark of a just society. However, the strategies available for addressing major threats to the uptake of public health services such as mass vaccination campaigns are not properly studied and documented in the Ghanaian context. This organizational case study explored strategies used by healthcare professionals working with the Ghana Health Service (GHS) to address COVID-19-related vaccine hesitancy in the country. METHODS: We performed a qualitative inquiry with semi-structured in-depth interviews conducted with 25 public health officials of the GHS. The interviews were timed to coincide with the mass deployment of COVID-19 vaccines in four Regions. Participants were recruited through purposive sampling. Data collected included demographic characteristics, perspectives on public relations strategies used in the past year to improve COVID-19 vaccine uptake as well as successes and pitfalls. Thematic analysis was performed with NVIVO software to generate themes from interview transcripts. RESULTS: Four main themes emerged from the data analysis and these are presented. Healthcare workers perceived vaccine hesitancy to be a threat with the potential to undermine an important strategic organizational goal related to COVID-19 illness. In terms of PR strategies, we determined that a combination of informative, motivational, persuasive and coercive public relations strategies was employed by the Ghana Health Service to address the challenge of vaccine hesitancy. We further found that PR strategies were deployed across both traditional (print, radio, TV) and emerging/social media networks. Officials were optimistic that the strategies would produce results, but were uncertain whether they could attribute current successes or failures to the PR strategies used. CONCLUSION: Since the onset of the COVID-19 pandemic, public relations strategies which have been employed by the Ghana Health Service to address vaccine hesitancy are characterized and catalogued. The nature of the audience and PR strategies employed suggests that the effect of these strategies may be short-lived unless they are constantly reinforced by the GHS. These findings show that effective PR strategies exist for addressing vaccine hesitancy in public health practice.

Advanced twin abdominal pregnancy: diagnostic and therapeutic challenges.

Abdominal pregnancy remains a diagnostic challenge despite the remarkable improvements and widespread availability of antenatal ultrasound. A case of advanced twin abdominal pregnancy that was diagnosed after failed induction of labor is presented highlighting the diagnostic and hemostatic challenges encountered. The role and limitations of antenatal ultrasound as well as the importance of adhering to basic ultrasound imaging principles are emphasized as a way of ensuring an early diagnosis and minimizing the devastating consequences associated with this rare variety of ectopic pregnancy.

Genital schistosomiasis leading to ectopic pregnancy and subfertility: a case for parasitic evaluation of gynaecologic patients in schistosomiasis endemic areas.

Female genital schistosomiasis is a significant risk factor for ectopic pregnancy and infertility in schistosomiasis-endemic areas. A case of one previous ectopic pregnancy and subsequent obstruction of the contralateral tube in a secondary subfertility patient with chronic genital schistosomiasis is presented, emphasizing the need for a detailed history and parasitic evaluation of patients presenting with ectopic pregnancy or subfertility in areas where the disease is endemic.