Maternal profiles and social determinants of malnutrition and the MDGs: What have we learnt?

BACKGROUND: Maternal socio-demographic and health profiles are important determinants of malnutrition in children. In the 1990s, malnutrition was associated with low-birth-weight, young mothers and low maternal socio-economic status at Princess Marie Louise Children's Hospital (PML). It is not known how this has changed by efforts to achieve the Millennium Development Goals. We examined socio-demographic and health profiles of mothers of children with acute malnutrition and those without the condition to identify risk factors for malnutrition and focus on preventive efforts. METHODS: An unmatched case-control study was conducted in 2013 at PML, the largest facility for treating malnourished children in Ghana in 2013. Mothers of children with moderate and severe acute malnutrition were compared with mothers of well-nourished children. Weight-for-height was used to classify malnutrition. Record forms and a semi-structured questionnaire were used for data collection. An analysis was done with Stata 11.0 software. RESULTS: Altogether, 371 mothers were studied consisting of 182 mothers of malnourished children and 189 mothers of well-nourished children. Mothers of malnourished children were more likely to be unmarried or cohabiting, have lower family incomes, HIV infection and chronic disease. They were less likely to stay with or provide alternative care for their child. Awareness and use of social services, health insurance and a cash transfer programme were low. A remarkable reduction in the number of malnourished children occurred when families earned more than $250 USD a month. Over-nutrition was present in both groups of mothers. CONCLUSION: Low family income, unmarried status and type of child care were the main social determinants of malnutrition. There appears to be a reduction in the number of other poor socio-demographic characteristics in both the study and control groups compared to results from a previous study at the same centre, probably because of efforts toward attaining the MDGs. These findings suggest that prevention and optimum management need to involve multidisciplinary teams consisting of health professionals, social workers and/or key workers to enable families at risk to access social care and social protection interventions (MDG 1). This will make the management of malnutrition more effective, prevent relapse, protect the next child and address maternal over-nutrition.

Under-five mortality pattern and associated risk factors: a case-control study at the Princess Marie Louise Children's Hospital in Accra, Ghana.

BACKGROUND: Millions of children under the age of 5 years die every year. Some of these deaths occur in hospitals and are related to both clinical characteristics and modifiable risk factors. This study investigates the association between malnutrition and mortality and profiles the presenting features in a case-control study of children under 5 years of age who attended Princess Marie Louise Children's Hospital (PML) in 2011. METHODS: A total of 120 cases of children under the age of 5 years who were admitted to hospital and died there were matched by sex and age to 120 controls who were children who survived on 1:1 basis from a record of patients admitted to PML in 2011. Data on socio-demographic and clinical characteristics were extracted from the medical records of the study participants. The association between malnutrition and mortality was determined by conditional logistic regression reported as odds ratios (OR) and their 95 % confidence interval (95 % CI). P < 0.05 was considered significant in all analyses. RESULTS: Malnutrition was significantly associated with mortality in children under-5 years of age attending PML. In the adjusted analysis, the odds of dying was significantly higher in malnourished children compared with well-nourished children (adjusted OR = 4.32 [95 % CI, 1.33-13.92], p = 0.014]). In addition, a previous episode of diarrhoea within the last year was associated with mortality (adjusted OR = 7.25 [95 % CI, 1.68-31.22], p = 0.008). The proportion of patients with noisy or difficulty breathing, pallor, lethargic appearance, ill-looking appearance, febrile convulsion, altered sensorium, skin lesions, hepatomegaly or oedema was significantly higher among cases than in controls (p < 0.05). CONCLUSIONS: Malnutrition and a previous episode of diarrhoea within the last year were the main risk factors for mortality. Efforts to prevent malnutrition and diarrhoea must be intensified and a protocol to follow-up diarrhoea patients may be beneficial. Six out of the nine clinical features that were proportionally higher in children who died than those who survived, are captured by the Emergency Triage Assessment and Treatment (ETAT) screening protocol as emergency or priority signs, giving credence to the use of ETAT in this setting. Thus education of health professionals on the use of the tool to triage patients should be on-going. However, further studies are needed to establish whether the other clinical signs are consistently associated with mortality and if so, whether they can be included among triage criteria, danger signs or in a prognostic scoring system for this setting.

Adverse events and adherence to HIV post-exposure prophylaxis: a cohort study at the Korle-Bu Teaching Hospital in Accra, Ghana.

BACKGROUND: There is strong evidence that post-exposure prophylaxis (PEP) with antiretroviral drugs in the timely management of occupational exposures sustained by healthcare workers decreases the risk of HIV infection and PEP is now widely used. Antiretroviral drugs have well documented toxicities and produce adverse events in patients living with HIV/AIDS. In the era of "highly active antiretroviral therapy", non-adherence to treatment has been closely linked to the occurrence of adverse events in HIV patients and this ultimately influences treatment success but the influence of adverse events on adherence during PEP is less well studied. METHODS: Following the introduction of a HIV post-exposure prophylaxis program in the Korle-Bu Teaching Hospital in January 2005, the incidence of adverse events and adherence were documented in occupationally-exposed healthcare workers (HCWs) and healthcare students (HCSs). Cohort event monitoring was used in following-up on exposed HCWs/HCSs for the two study outcomes; adverse events and adherence. All adverse events reported were grouped by MedDRA system organ classification and then by preferred term according to prophylaxis regimen. Adherence was determined by the completion of prophylaxis schedule. Cox proportional regression analysis was applied to determine the factors associated with the cohort study outcomes. Differences in frequencies were tested using the Chi square test and p < 0.05 was considered statistically significant. RESULTS: A total of 228 exposed HCWs/HCSs were followed up during the study, made up of 101 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 3 days; 75 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 28 days; and 52 exposed HCWs/HCSs administered lamivudine/zidovudine/lopinavir-ritonavir (3TC/AZT/LPV-RTV) for 28 days. The frequency of adverse events was 28% (n = 28) in exposed HCWs/HCSs administered 3TC/AZT for 3 days, 91% (n = 68) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 96% (n = 50) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. Nausea was the most commonly reported adverse events in all three regimens. Adherence was complete in all exposed HCWs/HCSs administered 3TC/AZT for 3days, 56% (n = 42) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 62% (n = 32) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. In the Cox regression multi-variate analysis, exposed HCWs/HCSs administered 3TC/AZT for 3 days were 70% less likely to report adverse events compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 0.30 [95% CI, 0.18-0.48], p < 0.001). Exposed HCWs/HCSs administered 3TC/AZT for 3 days were 75% more likely to adhere to the schedule compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 1.75 [95% CI, 1.16-2.66], p = 0.008). CONCLUSION: The intolerance to adverse events was cited as the sole reason for truncating PEP, thereby indicating the need for adequate, appropriate and effective counselling, education, active follow-up (possibly through mobile /phone contact) and management of adverse events. Education on the need to complete PEP schedule (especially for exposed HCWs/HCSs on 28-day schedule) can lead to increased adherence, which is very critical in minimizing the risk of HIV sero-conversion. The present results also indicate that cohort event monitoring could be an effective pharmacovigilance tool in monitoring adverse events in exposed HCWs/HCSs on HIV post-exposure prophylaxis.

Factors affecting malnutrition in children and the uptake of interventions to prevent the condition.

BACKGROUND: Malnutrition is a major cause of child morbidity and mortality. There are several interventions to prevent the condition but it is unclear how well they are taken up by both malnourished and well nourished children and their mothers and the extent to which this is influenced by socio-economic factors. We examined socio-economic factors, health outcomes and the uptake of interventions to prevent malnutrition by mothers of malnourished and well-nourished in under-fives attending Princess Marie Louise Children's Hospital (PML). METHODS: An unmatched case control study of malnourished and well-nourished children and their mothers was conducted at PML, the largest facility for managing malnutrition in Ghanaian children. Malnourished children with moderate and severe acute malnutrition were recruited and compared with a group of well-nourished children attending the hospital. Weight-for-height was used to classify nutritional status. Record forms and a semi-structured questionnaire were used for data collection, which was analysed with Stata 11.0 software. RESULTS: In all, 182 malnourished and 189 well-nourished children and their mothers/carers participated in the study. Children aged 6-12 months old formed more than half of the malnourished children. The socio-demographic factors associated with malnutrition in the multivariate analysis were age ≤24 months and a monthly family income of ≤200 GH Cedis. Whereas among the health outcomes, low birth weight, an episode of diarrhoea and the presence of developmental delay were associated with malnutrition. Among the interventions, inadequate antenatal visits, faltering growth and not de-worming one's child were associated with malnutrition in the multivariate analysis. Immunisation and Vitamin A supplementation were not associated with malnutrition. Missed opportunities for intervention were encountered. CONCLUSION: Poverty remains an important underlying cause of malnutrition in children attending Princess Marie Louise Children's Hospital. Specific and targeted interventions are needed to address this and must include efforts to prevent low birthweight and diarrhoea, and reduce health inequalities. Regular antenatal clinic attendance, de-worming of children and growth monitoring should also be encouraged. However, further studies are needed on the timing and use of information on growth faltering to prevent severe forms of malnutrition.

Trends in Neonatal Mortality at Princess Marie Louise Children's Hospital, Accra, and the Newborn Strategic Plan: Implications for Reducing Mortality in Hospital and the Community.

BACKGROUND: In low and middle-income countries, close to half of the mortality in children under the age of five years occurs in neonates. OBJECTIVES: We examined the trend, medical conditions and factors associated with newborn deaths at the Princess Marie Louise Children's Hospital (PML), Accra, from 2014 to 2017 (4 years). METHODS: The study was a cross-sectional study. Data on age, sex, date of admission, date of discharge, cause of death and place of residence of these babies were obtained from the records department. This was transferred into an Access database and analyzed. Components of the Newborn Strategic Plan implemented at the hospital were described. RESULTS: Neonatal sepsis, pneumonia and kernicterus were the major causes of death. Admissions increased and 5.4% of the neonates died, declining from 6.5% in 2014 to 4.2% in 2017 due to deliberate actions to reduce neonatal death. The highest mortality occurred in babies residing in an area more than 1 hour's drive away from the hospital. CONCLUSION: Implementing the Newborn Strategic Plan was associated with a drop in mortality. A preponderance of community-acquired infections was observed. Thus, locality-specific interventions targeted at known determinants and implementing the newborn strategic plan are essential for reducing neonatal mortality.

Hypertension and associated factors among patients attending HIV clinic at Korle-Bu Teaching Hospital.

Objectives: This study determined the prevalence of hypertension and its associated factors among patients attending the HIV clinic at the Korle-Bu Teaching Hospital (KBTH). Design: A hospital-based cross-sectional study was conducted at KBTH. The prevalence of hypertension was estimated among study participants, and socio-demographic, lifestyle, anthropometric, metabolic and HIV/ART-related factors associated with hypertension were determined by logistic regression modelling. Setting: Study participants were recruited from the HIV clinic at the KBTH. Participants: A total of 311 Persons Living with HIV were recruited as study participants. Interventions: Simple random sampling technique was used to recruit study participants. A questionnaire adapted from the WHO STEPwise approach to chronic disease risk-factor surveillance was used to collect study participants' data. Results: The prevalence of hypertension was 36.7%, and the factors associated with hypertension were increasing age, positive family history of hypertension, minimal exercising, current BMI ≥25.0 kg/m2, total cholesterol level ≥5.17 mmol/L, exposure to anti-retroviral therapy (ART) and increasing duration of ART exposure. Conclusions: This study shows a high prevalence of hypertension among patients attending the HIV clinic at KBTH, associated with exposure to ART and increasing duration of this exposure. Blood pressure monitoring should move from routine to a more purposeful screening of patients for hypertension. Patients with the identified risk factors should be encouraged to have regular blood pressure measurements at home and not only when they visit the HIV clinic. Funding: Office of Research, Innovation and Development (ORID) of the University of Ghana. The funding agency was not involved in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Anti-ulcerogenic activity of the root bark extract of the African laburnum "Cassia sieberiana" and its effect on the anti-oxidant defence system in rats.

BACKGROUND: Despite the widespread use of roots of Cassia sieberiana in managing several health conditions including gastric ulcer disease, there is little scientific data to support the rational phytotherapeutics as an anti-ulcer agent. This paper reports an evaluation of the in vivo anti-oxidant properties of an aqueous root bark extract of C. sieberiana in experimental gastric ulcer rats in a bid to elucidate its mechanism of action. METHODS: Fisher 344 (F(344)) rats received pretreatment of C. sieberiana root bark extract (500, 750, and 1000 mg/kg body wt.) for 7 days after which there was induction of gastric injury with absolute ethanol. The mean ulcer index (MUI) was calculated and serum total anti-oxidant level determined. Gastric mucosal tissues were prepared and the activity level of the enzymes superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and myeloperoxidase (MPO) were measured together with the level of lipid hydroperoxides (LPO). Statistical difference between treatment groups was analysed using one-way analysis of variance (ANOVA) followed by Dunnett's post hoc t test. Statistical significance was calculated at P< 0.05. RESULTS: The administration of ethanol triggered severe acute gastric ulcer and pretreatment with C. sieberiana root bark extract significantly and dose dependently protected against this effect. The root bark extract also dose dependently and significantly inhibited the ethanol induced decrease in activity levels of the enzymes SOD, CAT and GPx. The extract also inhibited the ethanol-induced decrease in level of serum total anti-oxidant capacity. The increase in ethanol-induced LPO level and MPO activity were also significantly and dose-dependently inhibited by the root bark extract. CONCLUSIONS: The gastro-cytoprotective effect, inhibition of decrease in activity of gastric anti-oxidant enzymes and MPO as well as the inhibition of gastric LPO level suggests that one of the anti-ulcer mechanisms of C. sieberiana is the anti-oxidant property.

Antioxidant and gastric cytoprotective prostaglandins properties of Cassia sieberiana roots bark extract as an anti-ulcerogenic agent.

BACKGROUND: Cassia sieberiana is a savannah tree with a wide phytotherapeutic application including the use of its roots in the management of various stomach disorders including gastric ulcer, stomach pains and indigestion. The aim of the study is to evaluate the antioxidant, gastric cytoprotective prostaglandins, secretory phospholipase A2, phytochemical and acute toxicity properties of Cassia sieberiana roots bark extract in a bid to justify its phytotherapeutic applications in gastric ulcer. METHODS: Antioxidant and radical scavenging activities of the roots bark extract of Cassia sieberiana were assayed. Serum secretory phospholipase A2 (sPLA2) concentration and activity and the formation of gastric mucosal prostaglandins E2 (PGE2) and I2 (PGI2) were also assessed. Comparisons between means were performed using analysis of variance (ANOVA) followed by Students Standard Newman-Keuls post hoc analysis to determine statistical significance. P < 0.05 was considered significant. RESULTS: The extract was found to possess significant ferric reducing antioxidant power and can scavenge hydroxyl radicals. The extract also possesses DPPH scavenging activity, can chelate ferrous ion and a dose-dependent protective effect against lipid peroxidation and free radical generation. Prostaglandin studies showed that the roots bark extract dose dependently increased gastric mucosal PGE2 and PGI2 levels and also decreased serum sPLA2 activity. Phytochemical analyses suggest that the roots extract contains polyhydroxyl/phenolic substances. Acute toxicity test showed no sign of toxicity up to a dose level of 2000 mg/kg body weight p.o. CONCLUSIONS: C. sieberiana roots extract possesses significant antioxidant and gastric cytoprotective prostaglandin properties as well as serum secretory phospholipase A2 inhibitory activity which could be due to its content of polyhydroxy and/or phenolic substances. This may justify its use as an anti-ulcerogenic agent in traditional medicine in West Africa.

Alarming Levels of Multidrug Resistance in Aerobic Gram-Negative Bacilli Isolated from the Nasopharynx of Healthy Under-Five Children in Accra, Ghana.

Nasopharyngeal carriage of aerobic Gram-negative bacilli (GNB) may precede the development of invasive respiratory infections. We assessed the prevalence of nasopharyngeal carriage of aerobic GNB and their antimicrobial resistance patterns among healthy under-five children attending seven selected day-care centres in the Accra metropolis of the Greater Accra region of Ghana from September to December 2016. This cross-sectional study analysed a total of 410 frozen nasopharyngeal samples for GNB and antimicrobial drug resistance. The GNB prevalence was 13.9% (95% CI: 10.8-17.6%). The most common GNB were Escherichia coli (26.3%), Klebsiella pneumoniae (24.6%), and Enterobacter cloacae (17.5%). Resistance was most frequent for cefuroxime (73.7%), ampicillin (64.9%), and amoxicillin/clavulanic acid (59.6%). The organisms were least resistant to gentamicin (7.0%), amikacin (8.8%), and meropenem (8.8%). Multidrug resistance (MDR, being resistant to ≥3 classes of antibiotics) was observed in 66.7% (95% CI: 53.3-77.8%). Extended-spectrum beta-lactamase (ESBL)-producing bacteria constituted 17.5% (95% CI: 9.5-29.9%), AmpC-producing bacteria constituted 42.1% (95% CI: 29.8-55.5%), and carbapenemase-producing bacteria constituted 10.5% (95% CI: 4.7-21.8%) of isolates. The high levels of MDR are of great concern. These findings are useful in informing the choice of antibiotics in empiric treatment of GNB infections and call for improved infection control in day-care centres to prevent further transmission.

Rubella virus IgM and IgG antibodies with avidity in pregnant women and outcomes at a tertiary facility in Ghana.

BACKGROUND: Congenital rubella syndrome (CRS) is a recognised cause of childhood deafness and blindness caused by the transplacental transmission of rubella virus during pregnancy. Women in the reproductive age group, and by extension their unborn babies may therefore be at increased risk. The prevalence of Rubella virus specific IgM and IgG antibodies, including IgG avidity, was determined in pregnant women attending the antenatal clinic at a Teaching Hospital in Ghana. METHODS: One hundred and forty-five women in their second and third trimesters of pregnancy from the outpatient clinic were recruited over a period of 2 months after written informed consent was obtained. Study participants completed a questionnaire and venous blood drawn for IgM, IgG, and avidity testing using SERION ELISA (SERION® Immunologics, Würzburg, Germany). Babies of mothers with positive or indeterminate IgM and low avidity IgG antibodies were offered specialist cardiological, ophthalmological or hearing assessment during follow up. RESULTS: One hundred and twenty-eight (88.3%) had only IgG antibodies, 5 (3.4%) had IgM and IgG antibodies, while 12 (8.3%) had no antibodies. No patient had IgM antibodies alone. Ten women (6.9%) had indeterminate levels of IgM antibodies. Majority of the women had high avidity IgG antibodies, while 5 (3.4%) had low avidity antibodies. No patient had IgM with low avidity antibodies. There was no statistical association between socio-demographic factors and the presence of IgM, IgG (low or high avidity) antibodies. Of all the children followed, none had the clinical definition of CRS. CONCLUSIONS: Consistent with the World Health Organization elimination strategy for measles and rubella viruses, non-immune women in the reproductive age group should be vaccinated. The immunization programme should be expanded to include teenagers and adults. Though Congenital Rubella Syndrome was not detected, the risk still remains.

Bloodstream Infections at Two Neonatal Intensive Care Units in Ghana: Multidrug Resistant Enterobacterales Undermine the Usefulness of Standard Antibiotic Regimes.

BACKGROUND: Bloodstream infections (BSIs) are a major cause of morbidity and mortality in hospitalized neonates. Data on antibiotic resistance in neonatal BSIs and their impact on clinical outcomes in Africa are limited. METHODS: We conducted a prospective cohort study at 2 tertiary level neonatal intensive care units (NICUs) in Ghana. All neonates admitted to the NICUs were included from October 2017 to September 2019. We monitored BSI rates and analyzed the effect of BSI and antibiotic resistance on mortality and duration of hospitalization. RESULTS: Of 5433 neonates included, 3514 had at least one blood culture performed and 355 had growth of a total of 368 pathogenic microorganisms. Overall incidence of BSI was 1.0 (0.9-1.1) per 100 person days. The predominant organisms were Klebsiella pneumoniae 49.7% (183/368) and Streptococcus spp. 10.6% (39/368). In addition, 512 coagulase negative Staphylococci were isolated but considered probable contaminants. Among K. pneumoniae, resistance to gentamicin and amikacin was 91.8% and 16.4%, respectively, while carbapenem resistance was 4.4%. All-cause mortality among enrolled neonates was 19.7% (1066/5416). The mortality rate was significantly higher in neonates with BSI compared with culture-negative neonates in univariate analysis (27.9%, n = 99/355 vs. 16.5%, n = 520/3148; hazard ratio 1.4, 95% confidence interval 1.07-1.70) but not in multivariate analysis. CONCLUSION: The diversity of etiologic agents and the high-risk of antibiotic resistance suggest that standard empirical treatment is unlikely to improve the outcome of BSIs in low and middle income. Such improvements will depend on access to reliable clinical microbiologic services.

Unexpected elevated alanine aminotransferase, aspartate aminotransferase levels and hepatitis E virus infection among persons who work with pigs in accra, Ghana.

BACKGROUND: Several studies have suggested that elevated serum alanine aminotransferase (ALT) and asparte aminotransferase (AST) may be markers of hepatitis E virus (HEV) infection. Thus, individuals with elevated ALT and AST may have ongoing subclinical infection of HEV. We estimated the prevalence of anti-HEV antibodies and serum ALT and AST levels among persons who work with pigs in Accra, Ghana. RESULTS: Three hundred and fifty- persons who work with pigs provided blood samples for unlinked anonymous testing for the presence of antibodies to HEV, ALT and AST levels. The median age of participants was 32.85±11.38 years (range 15-70 years). HEV seroprevelance was 34.84%. Anti-HEV IgG was detected in 19.26% while anti-HEV IgM was detected in 15.58% of the persons who tested positive. On multivariate analysis, the independent determinants of HEV infection were, being employed on the farm for less than six months [odds ratio (OR) 8.96; 95% confidence interval (95% CI) 5.43-14.80], having piped water in the household and/or on the farm (OR 13.33; 95% CI 5.23-33.93) and consumption of alcohol (OR 4.91: 95% CI 2.65-9.10). Levels>3× the expected maximum were found for both ALT and AST among individuals who tested positive for anti-HEV IgG (ALT, 210.17±11.64 U/L; AST, 127.18±11.12 U/L) and anti-HEV IgM (ALT, 200.97±10.76 U/L; AST, 120.00±15.96 U/L). CONCLUSION: Consistent with similar studies worldwide, the results of our studies revealed a high prevalence of HEV infection, ALT and AST values in pig handlers.

The pattern of neonatal admissions and mortality at a regional and district hospital in the Upper West Region of Ghana; a cross sectional study.

BACKGROUND: High global neonatal deaths have triggered efforts to improve facility-based care. However, the outcomes achievable at different levels of care are unclear. This study compared morbidity and mortality patterns of newborns admitted to a regional and a district hospital in Ghana to determine outcome, risk and modifiable factors associated with mortality. OBJECTIVE: This study compared morbidity and mortality patterns of newborns admitted to a regional and a district hospital in Ghana to determine outcome, risk and modifiable factors associated with mortality. METHODS: A cross-sectional study involving a records-review over one year at the Upper West Regional Hospital, and three years at St Joseph's District Hospital, Jirapa was carried out. Age, sex, gestational age, weight, duration of admission, diagnosis, among others were examined. The data were analysed and statistical inference made. RESULTS: Altogether, 2004 newborns were examined, comprising 1,241(62%) from St Joseph's District Hospital and 763(38%) from Upper West Regional Hospital. The proportion of neonatal deaths was similar, 8.94% (St Joseph's District Hospital) and 8.91% (Upper West Regional Hospital). Prematurity, neonatal sepsis, birth asphyxia, low birth weight, neonatal jaundice and pneumonia contributed the most to mortality and suspected infections including malaria accounted for almost half (45.5%). Mortality was significantly associated with duration of stay of 48 hours, being premature, and being younger than 3 days. CONCLUSION: Majority of the mortality among the neonates admitted was due to preventable causes. Better stabilization and further studies on the epidemiology of sepsis, prematurity, low birth weight, including the contribution of malaria to these and outcome of transferred neonates are needed.

Pattern of drug utilization for treatment of uncomplicated malaria in urban Ghana following national treatment policy change to artemisinin-combination therapy.

BACKGROUND: Change of first-line treatment of uncomplicated malaria to artemisinin-combination therapy (ACT) is widespread in Africa. To expand knowledge of safety profiles of ACT, pharmacovigilance activities are included in the implementation process of therapy changes. Ghana implemented first-line therapy of artesunate-amodiaquine in 2005. Drug utilization data is an important component of determining drug safety, and this paper describes how anti-malarials were prescribed within a prospective pharmacovigilance study in Ghana following anti-malarial treatment policy change. METHODS: Patients with diagnosis of uncomplicated malaria were recruited from pharmacies of health facilities throughout Accra in a cohort-event monitoring study. The main drug utilization outcomes were the relation of patient age, gender, type of facility attended, mode of diagnosis and concomitant treatments to the anti-malarial regimen prescribed. Logistic regression was used to predict prescription of nationally recommended first-line therapy and concomitant prescription of antibiotics. RESULTS: The cohort comprised 2,831 patients. Curative regimens containing an artemisinin derivative were given to 90.8% (n = 2,574) of patients, although 33% (n = 936) of patients received an artemisinin-based monotherapy. Predictors of first-line therapy were laboratory-confirmed diagnosis, age >5 years, and attending a government facility. Analgesics and antibiotics were the most commonly prescribed concomitant medications, with a median of two co-prescriptions per patient (range 1-9). Patients above 12 years were significantly less likely to have antibiotics co-prescribed than patients under five years; those prescribed non-artemisinin monotherapies were more likely to receive antibiotics. A dihydroartemisinin-amodiaquine combination was the most used therapy for children under five years of age (29.0%, n = 177). CONCLUSION: This study shows that though first-line therapy recommendations may change, clinical practice may still be affected by factors other than the decision or ability to diagnose malaria. Age, diagnostic confirmation and suspected concurrent conditions lead to benefit:risk assessments for individual patients by clinicians as to which anti-malarial treatment to prescribe. This has implications for adherence to policy changes aiming to implement effective use of ACT. These results should inform education of health professionals and rational drug use policies to reduce poly-pharmacy, and also suggest a potential positive impact of increased access to testing for malaria both within health facilities and in homes.

Tenofovir-associated renal toxicity in a cohort of HIV infected patients in Ghana.

OBJECTIVE: Tenofovir disoproxil fumarate (TDF) is a nucleotide analogue recommended in international HIV treatment guidelines. Purpose of this study was to estimate the long term effects of TDF on renal profile in a cohort of HIV patients in Ghana. Three hundred (300) consecutive HIV-positive patients who initiated TDF-based antiretroviral treatment in 2008 at the Korle-Bu Teaching Hospital were sampled. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault equation at baseline and renal impairment was defined as CrCl values of 30.0-49.9 mL/min (moderate renal impairment) and < 30 mL/min (severe renal impairment) as per institutional guidelines for renal function test. RESULTS: Median follow up time was 2.9 years (IQR 2.3-3.4 years). At study endpoint, 63 participants (21.0% [95% CI 6.5-26.1]) recorded CrCl rate below 50 mL/min indicating incident renal impairment, made up of 18.3% moderate renal impairment and 2.3% severe renal impairment. Factors associated with incidence of renal impairment were increasing age, decrease in creatinine clearance rate at baseline, WHO HIV stage III/IV and participants with BMI of < 18.5 kg/m2. Patients with identified renal impairment risk factors at ART initiation should be targeted and monitored effectively to prevent renal injury.

Modern contraceptive use among women living with HIV/AIDS at the Korle Bu Teaching Hospital in Ghana.

OBJECTIVE: To examine factors influencing contraceptive use among women living with HIV/AIDS. METHODS: The present cross-sectional study included a randomly selected sample of sexually active females aged 15-60 years who were living with HIV/AIDS and receiving care at the HIV Clinic, Korle Bu Teaching Hospital, Accra, Ghana, between September 1 and November 31, 2016. Data were collected via a structured interviewer-administered questionnaire. RESULTS: Among 202 women who completed the survey, 50 (24.7%) were using contraceptives. Of the women using contraception, 39 (78%) were married and 6 (12%) were cohabiting. Twenty-eight (56%) reported that their primary sexual partners were HIV-positive, 14 (28%) had HIV-negative partners, and 8 (16%) did not know their partner's HIV status. Condoms were used by 42 (84%) women and the majority (41 [82%]) wanted to have more children; almost all (47 [94%]) had received counseling on contraceptive use. Overall, 133 (65.8%) and 45 (22.3%) women reported that they would prefer to share their family planning concerns with a doctor and nurse, respectively, at the HIV clinic. CONCLUSION: Women living with HIV/AIDS desired more children but preferred to share their family planning concerns with their clinician at the HIV clinic. Integrating HIV care and reproductive health services could help these women achieve childbearing goals safely.

Pre-Exposure Prophylaxis for HIV Prevention: Safety Concerns.

Available evidence supports the efficacy of pre-exposure prophylaxis (PrEP) in decreasing the incidence of human immunodeficiency virus (HIV) infection among high-risk individuals, especially when used in combination with other behavioural preventive methods. Safety concerns about PrEP present challenges in the implementation and use of PrEP. The aim of this review is to discuss safety concerns observed in completed clinical trials on the use of PrEP. We performed a literature search on PrEP in PubMed, global advocacy for HIV prevention (Aids Vaccine Advocacy Coalition) database, clinical trials registry " http://www.clinicaltrials.gov " and scholar.google, using combination search terms 'pre-exposure prophylaxis', 'safety concerns in the use of pre-exposure prophylaxis', 'truvada use as PrEP', 'guidelines for PrEP use', 'HIV pre-exposure prophylaxis' and 'tenofovir' to identify clinical trials and literature on PrEP. We present findings associated with safety issues on the use of PrEP based on a review of 11 clinical trials on PrEP with results on safety and efficacy as at April 2016. We also reviewed findings from routine real-life practice reports. The pharmacological intervention for PrEP was tenofovir disoproxil fumarate/emtricitabine in a combined form as Truvada® or tenofovir as a single entity. Both products are efficacious for PrEP and seem to have a good safety profile. Regular monitoring is recommended to prevent long-term toxic effects. The main adverse effects observed with PrEP are gastrointestinal related; basically mild to moderate nausea, vomiting and diarrhea. Other adverse drug effects worth monitoring are liver enzymes, renal function and bone mineral density. PrEP as an intervention to reduce HIV transmission appears to have a safe benefit-risk profile in clinical trials. It is recommended for widespread use but adherence monitoring and real-world safety surveillance are critical in the post-marketing phase to ensure that the benefits observed in clinical trials are maintained in real-world use.

Association Between the Occurrence of Adverse Drug Events and Modification of First-Line Highly Active Antiretroviral Therapy in Ghanaian HIV Patients.

INTRODUCTION: Patients initiated on highly active antiretroviral therapy (HAART) generally remain on medication indefinitely. A modification in the HAART regimen may become necessary because of possible acute or chronic toxicities, concomitant clinical conditions, development of virological failure or the advent of adverse drug events. The study documents adverse drug events of HIV-positive Ghanaian patients with HAART modifications. It also investigates the association between documented adverse drug events and HAART modification using an unmatched case-control study design. METHOD: The study was conducted in the Fevers Unit of the Korle Bu Teaching Hospital and involved patients who attended the HIV Care Clinic between January 2004 and December 2009. Data from 298 modified therapy patients (cases) were compared with 298 continuing therapy patients (controls) who had been on treatment for at least 1 month before the end of study. Controls were sampled from the same database of a cohort of HIV-positive patients on HAART, at the time a case occurred, in terms of treatment initiation ±1 month. Data were obtained from patients' clinical folders and the HIV clinic database linked to the pharmacy database. The nature of the documented adverse drug events of the cases was described and the association between the documented adverse drug events and HAART modification was determined by logistic regression with reported odds ratios (ORs) and their 95 % confidence interval (CI). RESULTS: Among the 298 modified therapy patients sampled in this study, 52.7 % of them had at least one documented adverse drug event. The most documented adverse drug event was anaemia, recorded in 18.5 % of modified therapy patients, all of whom were on a zidovudine-based regimen. The presence of documented adverse drug events was significantly associated with HAART modification [adjusted OR = 2.71 (95 % CI 2.11-3.48), p < 0.001]. CONCLUSION: Among HIV patients on HAART, adverse drug events play a major role in treatment modification. Occurrence of adverse drug events may be used as a predictor for possible therapy modification. We recommend the institution of active pharmacovigilance in HIV treatment programmes as it permits the proper identification and characterisation of drug-related adverse events. This can help develop approaches towards their management and also justify therapy modifications.

Observations from Mortality Trends at The Children's Hospital, Accra, 2003-2013.

OBJECTIVE: Facility-based studies provide an unparalleled opportunity to assess interventions deployed in hospitals to reduce child mortality which is not easily captured in the national data. We examined mortality trends at the Princess Marie Louise Children's Hospital (PML) and related it to interventions deployed in the hospital and community to reduce child mortality and achieve the Millennium Development Goal 4 (MDG 4). METHODS: The study was a cross-sectional review of data on consecutive patients who died at the hospital over a period of 11 years, between 2003 and 2013. The total admissions for each year, the major hospital-based and population-based interventions, which took place within the period, were also obtained. RESULTS: Out of a total of 37,012 admissions, 1,314 (3.6%) deaths occurred and admissions tripled during the period. The average annual change in mortality was -7.12% overall, -7.38% in under-fives, and -1.47% in children ≥5 years. The majority of the deaths, 1,187 (90.3%), occurred in under-fives. The observed decrease in under-five (and overall) mortality rate occurred in a specific and peculiar pattern. Most of the decrease occurred during the period between 2003 and 2006. After that there was a noticeable increase from 2006 to 2008. Then, the rate slowly decreased until the end of the study period in 2013. There was a concomitant decline in malaria mortality following a pattern similar to the decline observed in other parts of the continent during this period. Several interventions might have contributed to the reduction in mortality including the change in malaria treatment policy, improved treatment of malnutrition and increasing paediatric input. CONCLUSION: Under-fives mortality at PML has declined considerably; however, the reduction in mortality in older children has been minimal and thus requires special attention. Data collection for mortality reviews should be planned and commissioned regularly in hospitals to assess the effects of interventions and understand the context in which they occur. This will provide benchmarks and an impetus for improving care, identify shortfalls and ensure that the gains in child survival are maintained.

Changing Patterns of Disease and Mortality at the Children's Hospital, Accra: Are Infections Rising?

BACKGROUND: The Millennium Development Goals (MDGs) have led to reductions in child mortality world-wide. This has, invariably, led to the changes in the epidemiology of diseases associated with child mortality. Although facility based data do not capture all deaths, they provide an opportunity to confirm diagnoses and insight into these changes which are relevant for further disease control. OBJECTIVE: To identify changes in the disease pattern of children who died at the Princess Marie Louise Children's Hospital (PML) in Ghana from 2003-2013. METHODS: A cross sectional review of mortality data was carried out at PML. The age, sex, duration of admission and diagnosis of consecutive patients who died at the hospital between 2003 and 2013 were reviewed. This information was entered into an Access database and analysed using Stata 11.0 software. RESULTS: Altogether, 1314 deaths (3.6%) occurred out of a total of 37,012 admissions. The majority of the deaths, 1187 (90.3%), occurred in children under the age of 5 years. While deaths caused by malaria, malnutrition, HIV infection and diarrhoea decreased, deaths caused by pneumonia were rising. Suspected septicaemia and meningitis showed a fluctuating trend with only a modest decrease between 2012 and 2013. The ten leading causes of mortality among under-fives were malnutrition, 363 (30.6%); septicaemia, 301 (25.4%); pneumonia, 218 (18.4%); HIV infection, 183 (15.4%); malaria, 155 (13.1%); anaemia, 135 (11.4%); gastroenteritis/dehydration, 110 (9.3%); meningitis, 58 (4.9%); tuberculosis, 34 (2.9%) and hypoglycaemia, 27 (2.3%). For children aged 5-9 years, the leading causes of mortality were malaria, 42 (42.9%); HIV infection, 27 (27.6%); anaemia, 14 (14.3%); septicaemia, 12 (12.2%); meningitis, 10 (10.2%); malnutrition, 9 (9.2%); tuberculosis, 5 (5.1%); pneumonia, 4 (4.1%); encephalopathy, 3 (3.1%); typhoid fever, 3 (3.1%) and lymphoma, 3 (3.1%). In the adolescent age group, malaria, 8 (27.6%); anaemia, 6 (20.7%); HIV infection, 5 (17.2%); sickle cell disease, 3 (10.3%) and meningitis, 3 (10.3%) were most common. CONCLUSION: There has been a decline in the under-five mortality at PML over the years; however, deaths caused by pneumonia appear to be rising. This highlights the need for better diagnostic services, wider HIV screening and clinical audits to improve outcomes in order to achieve further reductions in child mortality and maintain the gains.