Impact of Point-of-Care Rapid Diagnostic Tests on Antibiotic Prescription Among Patients Aged <18 Years in Primary Healthcare Settings in 2 Peri-Urban Districts in Ghana: Randomized Controlled Trial Results.

BACKGROUND: Inappropriate antibiotic prescriptions are a known driver of antimicrobial resistance in settings with limited diagnostic capacity. This study aimed to assess the impact of diagnostic algorithms incorporating rapid diagnostic tests on clinical outcomes and antibiotic prescriptions compared with standard-of-care practices, of acute febrile illness cases at outpatient clinics in Shai-Osudoku and Prampram districts in Ghana. METHODS: This was an open-label, centrally randomized controlled trial in 4 health facilities. Participants aged 6 months to <18 years of both sexes with acute febrile illness were randomized to receive a package of interventions to guide antibiotic prescriptions or standard care. Clinical outcomes were assessed on day 7. RESULTS: In total, 1512 patients were randomized to either the intervention (n = 761) or control (n = 751) group. Majority were children aged <5 years (1154 of 1512, 76.3%) and male (809 of 1512, 53.5%). There was 11% relative risk reduction of antibiotic prescription in intervention group (RR, 0.89; 95% CI, .79 to 1.01); 14% in children aged <5 years (RR, 0.86; 95% CI, .75 to .98), 15% in nonmalaria patients (RR, 0.85; 95% CI, .75 to .96), and 16% in patients with respiratory symptoms (RR, 0.84; 95% CI, .73 to .96). Almost all participants had favorable outcomes (759 of 761, 99.7% vs 747 of 751, 99.4%). CONCLUSIONS: In low- and middle-income countries, the combination of point-of-care diagnostics, diagnostic algorithms, and communication training can be used at the primary healthcare level to reduce antibiotic prescriptions among children with acute febrile illness, patients with nonmalarial fevers, and respiratory symptoms. CLINICAL TRIALS REGISTRATION: NCT04081051.

Using routine healthcare data to determine the factors associated with hospital length of stay for hypertensive inpatients in Ghana, 2012-2017.

OBJECTIVE: Hospitalisation for hypertension continues to rise in Ghana. It has been revealed that in Ghana, patients hospitalised for hypertension spend between 1 and 91 days on admission. This study therefore sought to estimate the hospital length of stay (LoS) of hypertensive patients and individual or health-related factors that may influence the hospitalisation duration in Ghana. METHODS: We employed a retrospective study design that used routinely collected health data on hospitalised hypertensive patients in Ghana from the District Health Information Management System database between 2012 and 2017 to model LoS using survival analysis. The cumulative incidence function for discharge stratified by sex was computed. To investigate the factors that influence hospitalisation duration, multivariable Cox regression was used. RESULTS: Out of a total of 106 372 hypertension admissions, about 72 581 (68.2%) were women. The mean age of the patients was 55.3 (SD=17.5) years. Overall, the median LoS was 3 days with almost 90% of all patients being discharged by the 10th day of admission. Patients admitted in Volta region (HR: 0.89, p<0.001) and Eastern region (HR: 0.96, p=0.002) experienced late discharge as compared with patients admitted in Greater Accra. It was revealed that women (HR: 1.09, p<0.001) were discharged earlier than men. However, having a surgical procedure (HR: 1.07, p<0.001) and having comorbidities such as diabetes (HR: 0.76, p<0.001) and cardiovascular diseases other than hypertension (HR: 0.77, p<0.001) increased the LoS of patients. CONCLUSION: This study provides the first comprehensive assessment of factors influencing hospitalisation duration of admissions due to hypertension in Ghana. Female sex, all regions except Volta region and Eastern region, experienced early discharge. However, patients with a surgical intervention and comorbidity experienced late discharge.

The contribution of smoking and smokeless tobacco to oesophageal squamous cell carcinoma risk in the African oesophageal cancer corridor: Results from the ESCCAPE multicentre case-control studies.

Tobacco use is a well-established risk factor for oesophageal squamous cell carcinoma (ESCC) but the extent of its contribution to the disease burden in the African oesophageal cancer corridor has not been comprehensively elucidated, including by type of tobacco use. We investigated the contribution of tobacco use (smoking and smokeless) to ESCC in Tanzania, Malawi and Kenya. Hospital-based ESCC case-control studies were conducted in the three countries. Incident cases and controls were interviewed using a comprehensive questionnaire which included questions on tobacco smoking and smokeless tobacco use. Logistic regression models were used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of ESCC associated with tobacco, adjusted for age, sex, alcohol use, religion, education and area of residence. One thousand two hundred seventy-nine cases and 1345 controls were recruited between August 5, 2013, and May 24, 2020. Ever-tobacco use was associated with increased ESCC risk in all countries: Tanzania (OR 3.09, 95%CI 1.83-5.23), and in Malawi (OR 2.45, 95%CI 1.80-3.33) and lesser in Kenya (OR 1.37, 95%CI 0.94-2.00). Exclusive smokeless tobacco use was positively associated with ESCC risk, in Tanzania, Malawi and Kenya combined (OR 1.92, 95%CI 1.26-2.92). ESCC risk increased with tobacco smoking intensity and duration of smoking. Tobacco use is an important risk factor of ESCC in Tanzania, Malawi and Kenya. Our study provides evidence that smoking and smokeless tobacco cessation are imperative in reducing ESCC risk.

Population-based investigation of common and deviating patterns of gastric cancer and oesophageal cancer incidence across populations and time.

BACKGROUND: The subtypes of gastric cancer (GC) and oesophageal cancer (EC) manifest distinct epidemiological profiles. Here, we aim to examine correlations in their incidence rates and to compare their temporal changes globally, both overall and by subtype. METHODS: Long-term incidence data were obtained from population-based registries available from the Cancer Incidence in Five Continents series. Variation in the occurrence of EC and GC (overall and by subtype) was assessed using the GC:EC ratio of sex-specific age-standardised rates (ASR) in 2008-2012. Average annual per cent changes were estimated to assess temporal trends during 1998-2012. RESULTS: ASRs for GC and EC varied remarkably across and within world regions. In the countries evaluated, the GC:EC ratio in men exceeded 10 in several South American countries, Algeria and Republic of Korea, while EC dominated in most sub-Saharan African countries. High rates of both cardia gastric cancer and oesophageal squamous cell carcinoma (ESCC) were observed in several Asian populations. Non-cardia gastric cancer rates correlated positively with ESCC rates (r=0.60) and negatively with EAC (r=-0.79). For the time trends, while GC incidence has been uniformly decreasing by on average 2%-3% annually over 1998-2012 in most countries, trends for EC depend strongly on histology, with several but not all countries experiencing increases in EAC and decreases in ESCC. CONCLUSIONS: Correlations between GC and EC incidence rates across populations are positive or inverse depending on the GC subsite and EC subtype. Multisite studies that include a combination of populations whose incidence rates follow and deviate from these patterns may be aetiologically informative.

Describing and Modeling the Burden of Hospitalization of Patients With Neoplasms in Ghana Using Routine Health Data for 2012-2017.

PURPOSE: The increasing cancer burden calls for reliable data on current and future associated hospitalizations to enable health care resource planning, especially in low- and middle-income countries. We provide nationwide estimates of the current and future burden of hospitalization because of neoplasms in Ghana. METHODS: We conducted secondary data (2012-2017) analysis using nationwide routine administrative inpatient health data from the Ghana Health Service. Multivariable Poisson regression was used to model spatial and temporal hospitalization trends stratified by sex and 5-year age group. In conjunction with official population projections, the model was used to predict future hospitalization up to 2032. RESULTS: Out of 2,915,936 hospitalization records extracted for 6 years, 26,627 (1.0%) were for neoplasms, most of them benign (D10-D36, 15,362; 57.7%) and in female patients (20,159; 76%). In total, 9,463 (35.5%) patients with malignancies were mostly female (5,307; 56.1%), had a median age 50 years (interquartile range, 34-66 years) and a median duration of stay of 4 days (interquartile range, 2-8 days). Poisson regression for the malignant cancers revealed an annual increase in hospitalizations with a relative rate of 1.23 (95% CI, 1.19 to 1.27). The estimated hospitalization rate for malignancies of female patients was 1.5 times higher than that of male patients (relative rate, 1.53; 95% CI, 1.00 to 2.34), adjusted for age. We predicted an increase of 67.5% malignant cancer hospitalizations from the empirical years (2012-2017) into the prediction years (2022-2032) in Ghana. CONCLUSION: In the absence of a national population-based cancer registry, this nationwide study used secondary health services data on hospitalizations as a proxy for neoplasm morbidity burden. Our results can support planning public health resources and building evidence-based advocacy campaigns for neoplasm-prevention efforts.

A very-hot food and beverage thermal exposure index and esophageal cancer risk in Malawi and Tanzania: findings from the ESCCAPE case-control studies.

BACKGROUND: Consumption of very-hot beverages/food is a probable carcinogen. In East Africa, we investigated esophageal squamous cell carcinoma (ESCC) risk in relation to four thermal exposure metrics separately and in a combined score. METHODS: From the ESCCAPE case-control studies in Blantyre, Malawi (2017-20) and Kilimanjaro, Tanzania (2015-19), we used logistic regression models adjusted for country, age, sex, alcohol and tobacco, to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for self-reported thermal exposures whilst consuming tea, coffee and/or porridge. RESULTS: The study included 849 cases and 906 controls. All metrics were positively associated with ESCC: temperature of drink/food (OR 1.92 (95% CI: 1.50, 2.46) for 'very hot' vs 'hot'), waiting time before drinking/eating (1.76 (1.37, 2.26) for <2 vs 2-5 minutes), consumption speed (2.23 (1.78, 2.79) for 'normal' vs 'slow') and mouth burning (1.90 (1.19, 3.01) for ≥6 burns per month vs none). Amongst consumers, the composite score ranged from 1 to 12, and ESCC risk increased with higher scores, reaching an OR of 4.6 (2.1, 10.0) for scores of ≥9 vs 3. CONCLUSIONS: Thermal exposure metrics were strongly associated with ESCC risk. Avoidance of very-hot food/beverage consumption may contribute to the prevention of ESCC in East Africa.

Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers.

BACKGROUND: Ghana's national tuberculosis (TB) prevalence survey conducted in 2013 showed higher than expected TB prevalence indicating that many people with TB were not being identified and treated. Responding to this, we assessed barriers to TB case finding from the perspective, experiences and practices of healthcare workers (HCWs) in rural and urban health facilities in the Volta region, Ghana. METHODS: We conducted structured clinic observations and in-depth interviews with 12 HCWs (including five trained in TB case detection) in four rural health facilities and a municipal hospital. Interview transcripts and clinic observation data were manually organised, triangulated and analysed into health system-related and HCW-related barriers. RESULTS: The key health system barriers identified included lack of TB diagnostic laboratories in rural health facilities and no standard referral system to the municipal hospital for further assessment and TB testing. In addition, missed opportunities for early diagnosis of TB were driven by suboptimal screening practices of HCWs whose application of the national standard operating procedures (SOP) for TB case detection was inconsistent. Further, infection prevention and control measures in health facilities were not implemented as recommended by the SOP. HCW-related barriers were mainly lack of training on case detection guidelines, fear of infection (exacerbated by lack of appropriate personal protective equipment [PPE]) and lack of motivation among HCWs for TB work. Solutions to these barriers suggested by HCWs included provision of at least one diagnostic facility in each sub-municipality, provision of transport subsidies to enable patients' travel for testing, training of newly-recruited staff on case detection guidelines, and provision of appropriate PPE. CONCLUSION: TB case finding was undermined by few diagnostic facilities; inconsistent referral mechanisms; poor implementation, training and quality control of a screening tool and guidelines; and HCWs fearing infection and not being motivated. We recommend training for and quality monitoring of TB diagnosis and treatment with a focus on patient-centred care, an effective sputum transport system, provision of the TB symptom screening tool and consistent referral pathways from peripheral health facilities.

Trends in hospitalization of patients with diabetes mellitus in Ghana from 2012 to 2017 with predictions to 2032.

BACKGROUND: This study explores sociodemographic and health factors associated with hospitalizing diabetes mellitus (DM) patients and estimates the number of future hospitalizations for DM in Ghana. METHODS: We conducted a secondary analysis using nationally representative patient hospitalization data provided by the Ghana Health Service and projected population counts from the Ghana Statistical Service. Data were stratified by year, age, sex and region. We employed Poisson regression to determine associations between sociodemographic and health factors and hospitalization rates of DM patients. Using projected population counts, the number of DM-related hospitalizations for 2018 through 2032 were predicted. We analysed 39 846 DM records from nearly three million hospitalizations over a 6-y period (2012-2017). RESULTS: Most hospitalized DM patients were elderly, female and from the Eastern Region. The hospitalization rate for DM was higher among patients ages 75-79 y (rate ratio [RR] 23.7 [95% confidence interval {CI} 18.6 to 30.3]) compared with those ages 25-29 y, females compared with males (RR 1.9 [95% CI 1.4 to 2.5]) and the Eastern Region compared with the Greater Accra Region (RR 1.9 [95% CI 1.7 to 2.2]). The predicted number of DM hospitalizations in 2022 was 11 202, in 2027 it was 12 414 and in 2032 it was 13 651. CONCLUSIONS: Females and older patients are more at risk to be hospitalized, therefore these groups need special surveillance with targeted public health education aimed at behavioural changes.

Sociodemographic factors associated with time to discharge for hospitalised patients with asthma and asthma exacerbation using the Ghana Health Service District Information Management System 2 (DHIMS-2) database, 2012-2017.

OBJECTIVE: Data on asthma hospitalisations are a useful source of patient morbidity information. In Ghana, the length of stay (LoS) and sociodemographic factors of patients hospitalised for asthma and its exacerbation are understudied. We aimed to investigate the time to discharge and assessed factors associated with length of hospital stays of asthmatics in Ghana. METHODS: Retrospective analysis of hospitalised patient with asthma records between 2012 and 2017 from the nationwide Ghana Health Service District Health Information Management System 2 database. We calculated the cumulative incidence function for discharge stratified by age group and sex. Multivariable Cox regression was used to investigate the association of sociodemographic characteristics with the LoS. RESULTS: Of 19 926 asthma-associated hospitalisations, 730 (3.7%) were due to asthma exacerbation. Overall mean age was 34 years (SD=24.6), in 12 000 (60.2%) hospitalisations, patients were female. There were 224 deaths (1.1%). Median LoS was 2 days (IQR: 1-3) with almost 90% of all patients discharged by the seventh day. Age and region were among the covariates showing significant association with LoS. Age below 10 years (HR: 1.39 (1.11 to 1.78)) was associated with early discharge while comorbidity and health insurance ownership were associated with late discharge (p<0.001). LoS did not vary by sex. Compared with the Greater Accra region, patients in other regions had shorter LoS, especially the Ashanti and Upper West regions (p<0.001). LoS increased annually, but was highest in 2016 (HR: 0.94 (0.90 to 0.98)). CONCLUSION: Disparities in LoS across regions, and an overall increasing annual trend in Ghana call for tailored healthcare resource allocation. Longer LoS implies that patients are often absent from school or work leading to substantial financial and emotional costs to individuals and families.

Time trends, sociodemographic and health factors associated with discharge and length of stay of hospitalised patients with sickle cell disease in Ghana: a retrospective analysis of national routine health database.

OBJECTIVE: Patients with sickle cell disease (SCD) are prone to multiple episodes resulting in frequent hospital visits. We determined the time trends, sociodemographic and health factors associated with length of stay (LoS) for patients with SCD in Ghana. DESIGN, PARTICIPANTS, SETTING: We retrospectively analysed SCD hospitalisation records of 22 680 patients from a nationwide database of the Ghana Health Service from 2012 to 2017. OUTCOME MEASURES: Factors associated with LoS were estimated using Cox regression, while the cumulative incidence of being discharged alive was estimated with in-hospital death as a competing risk. RESULTS: Patients admitted for SCD over 6 years constituted 22 680 (0.8%) of nearly 3 million admissions. The median age and LoS for the patients were 16 years (IQR=8-24) and 3 days (IQR=2-4), representing 14 202 (62.6%) of the patients discharged alive by the third day. Patients with sickle cell anaemia (6139, 52.6%) with a crisis were more frequent than those without a crisis. Increasing age was associated with shorter LoS when comparing age groups 10-14 years (HR=1.08, 95% CI 1.01 to 1.14) and 25-29 years (HR=1.27, 95% CI 1.17 to 1.37) to patients aged 0-4 years. Patients with comorbidities had a longer LoS compared with those without (HR=0.88, 95% CI 0.86 to 0.90). CONCLUSION: This is the largest study to date documenting factors associated with LoS for patients admitted for SCD. The association of younger age with increased LoS supports recent calls for early SCD screening, especially newborns. The emerging trends and factors accounting for SCD admission require a multisector approach as these patients already experience frequent episodes of pain and hospital visits.

Epidemiology of intussusception in infants less than one year of age in Ghana, 2012-2016.

INTRODUCTION: we examined the epidemiology, clinical and demographic characteristics of intussusception in Ghanaian infants. METHODS: active sentinel surveillance for pediatric intussusception was conducted at Komfo Anokye Teaching Hospital in Kumasi and Korle Bu Teaching Hospital in Accra. From March 2012 to December 2016, infants < 1 year of age who met the Brighton Collaboration level 1 diagnostic criteria for intussusception were enrolled. Data were collected through parental interviews and medical records abstraction. RESULTS: a total of 378 children < 1 year of age were enrolled. Median age at onset of intussusception was 27 weeks; only 12 cases (1%) occurred in infants < 12 weeks while most occurred in infants aged 22-34 weeks. Median time from symptom onset until referral to a tertiary hospital was 2 days (IQR: 1-4 days). Overall, 35% of infants were treated by enema, 33% had surgical reduction and 32% required surgical reduction and bowel resection. Median length of hospital stay was 5 days (IQR: 3-8 days) with most patients (95%) discharged home. Eleven (3%) infants died. Infants undergoing enema reduction were more likely than those treated surgically to present for treatment sooner after symptom onset (median 1 vs 3 days; p < 0.0001) and have shorter hospital stays (median 3 vs 7 days; p < 0.001). CONCLUSION: Ghanaian infants had a relatively low case fatality rate due to intussusception, with a substantial proportion of cases treated non-surgically. Early presentation for treatment, possibly enhanced by community-based health education programs and health information from various media platforms during the study period might contribute to both the low fatality rate and high number of successful non-surgical treatments in this population.

Geophagia and risk of squamous cell esophageal cancer in the African esophageal cancer corridor: Findings from the ESCCAPE multicountry case-control studies.

Geophagia, the intentional practice of consuming soil, occurs across the African esophageal cancer corridor, particularly during pregnancy. We investigated whether this practice is linked to endemic esophageal squamous cell carcinoma (ESCC) in this region. We conducted ESCC case-control studies in Tanzania, Malawi and Kenya. Cases were patients with incident histologically/clinically confirmed ESCC and controls were hospital patients/visitors without digestive diseases. Participants were asked if they had ever eaten soil (never/regularly/pregnancy-only). Odds ratios (OR) are adjusted for sex, age, tobacco, alcohol, country, religion and marital status. Overall, 934 cases (Malawi 535, Tanzania 304 and Kenya females 95) and 995 controls provided geophagia information. Among controls, ever-geophagia was common in women (Malawi 49%, Kenya 43% and Tanzania 29%) but not in men (10% Malawi, <1% Tanzania). In women, ESCC ORs were 1.25 (95% CI: 0.70, 2.22) for regular versus never geophagia and 0.88 (95% CI: 0.64, 1.22) for pregnancy-only versus never. Findings were stronger based on comparisons of cases with hospital visitor controls and were null using hospital patients as controls. In conclusion, geophagia is too rare to contribute to the male ESCC burden in Africa. In women, the practice is common but we did not find consistent evidence of a link to ESCC. The study cannot rule out selection bias masking modest effects. Physical effects of geophagia do not appear to have a large impact on overall ESCC risk. Research with improved constituent-based geophagia exposure assessment is needed.

Missed opportunities for tuberculosis investigation in a municipal hospital in Ghana: evidence from patient exit interviews.

BACKGROUND: We assessed coverage of symptom screening and sputum testing for tuberculosis (TB) in hospital outpatient clinics in Ghana. METHODS: In a cross-sectional study, we enrolled adults (≥18 years) exiting the clinics reporting ≥1 TB symptom (cough, fever, night sweats or weight loss). Participants reporting a cough ≥2 weeks or a cough of any duration plus ≥2 other TB symptoms (per national criteria) and those self-reporting HIV-positive status were asked to give sputum for testing with Xpert MTB/RIF. RESULTS: We enrolled 581 participants (median age 33 years [IQR: 24-48], 510/581 [87.8%] female). The most common symptoms were fever (348, 59.9%), chest pain (282, 48.5%) and cough (270, 46.5%). 386/581 participants (66.4%) reported symptoms to a healthcare worker, of which 157/386 (40.7%) were eligible for a sputum test per national criteria. Only 31/157 (19.7%) had a sputum test requested. Thirty-two additional participants gave sputum among 41 eligible based on positive HIV status. In multivariable analysis, symptom duration ≥2 weeks (adjusted odds ratio [aOR] 6.99, 95% confidence interval [CI] 2.08-23.51) and previous TB treatment (aOR: 6.25, 95% CI: 2.24-17.48) were the strongest predictors of having a sputum test requested. 6/189 (3.2%) sputum samples had a positive Xpert MTB/RIF result. CONCLUSION: Opportunities for early identification of people with TB are being missed in health facilities in Ghana.

Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana.

BACKGROUND: Ghana's national prevalence survey showed higher than expected tuberculosis (TB) prevalence, indicating that many people with TB are not identified and treated. This study aimed to identify gaps in the TB diagnostic cascade prior to starting treatment. METHODS: A prospective cohort study was conducted in urban and rural health facilities in south-east Ghana. Consecutive patients routinely identified as needing a TB test were followed up for two months to find out if sputum was submitted and/or treatment started. The causal effect of health facility location on submitting sputum was assessed before risk factors were investigated using logistic regression. RESULTS: A total of 428 persons (mean age 48 years, 67.3% female) were recruited, 285 (66.6%) from urban and 143 (33.4%) from rural facilities. Of 410 (96%) individuals followed up, 290 (70.7%) submitted sputum, among which 27 (14.1%) had a positive result and started treatment. Among those who visited an urban facility, 245/267(91.8%) submitted sputum, compared to 45/143 (31.5%) who visited a rural facility. Participants recruited at the urban facility were far more likely to submit a sputum sample (odds ratio (OR) 24.24, 95%CI 13.84-42.51). After adjustment for confounding, there was still a strong association between attending the urban facility and submitting sputum (adjusted OR (aOR) 9.52, 95%CI 3.87-23.40). Travel distance of >10 km to the laboratory was the strongest predictor of not submitting sputum (aOR 0.12, 95%CI 0.05-0.33). CONCLUSION: The majority of presumptive TB patients attending a rural health facility did not submit sputum for testing, mainly due to the long travel distance to the laboratory. Bridging this gap in the diagnostic cascade may improve case detection.

The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana.

INTRODUCTION: The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas. METHODS: In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas. RESULTS: Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women's education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model. CONCLUSIONS: Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.

Accuracy of glycosuria, random blood glucose and risk factors as selective screening tools for gestational diabetes mellitus in comparison with universal diagnosing.

OBJECTIVE: Despite the short-term and long-term health implications of gestational diabetes mellitus (GDM), opinions are divided on selective vis-à-vis universal screening. We validated the accuracy of screening tests for GDM. RESEARCH DESIGN AND METHODS: Pregnant women (n=491) were recruited to this prospective, blind comparison with a gold standard study. We did selective screening between 13 and 20 weeks using reagent-strip glycosuria, random capillary blood glucose (RBG) and the presence of ≥1 risk factor(s). Between 20 and 34 weeks, we did universal screening following the 'one-step' approach using glycated hemoglobin (HbA1c), fasting venous plasma glucose (FPG), and the 1-hour and the 'gold standard' 2-hour oral glucose tolerance test (OGTT). Tests accuracy was estimated following the WHO and the National Institute for Health and Care Excellence (NICE) diagnostic criteria. Overall test performance was determined from the area under the receiver operating characteristic curve (AUC). RESULTS: GDM prevalence per 2-hour OGTT was 9.0% for the WHO criteria and 14.3% for the NICE criteria. Selective screening using glycosuria, RBG and risk factors missed 97.4%, 87.2% and 45.7% of cases, respectively. FPG threshold ≥5.1 mmol/L had the highest clinically relevant sensitivity (68%) and specificity (81%), but FPG threshold ≥5.6 mmol/L had higher positive predictive value. Although sensitivity of 1-hour OGTT was 39.5%, it had the highest accuracy and diagnostic OR. Regarding test performance, 1-hour OGTT and FPG were very good (AUC>0.8), RBG was poor (AUC≈0.60), whereas HbA1c was invaluable (AUC<0.5). CONCLUSIONS: Selective screening using glycosuria and random blood glucose is unnecessary due to its low sensitivity. Fasting glucose ≥5.1 mmol/L could be applicable for screening at the population level. Where 2-hour OGTT is not available, FPG ≥5.6 mmol/L, complemented by the presence of risk factors, could be useful in making therapeutic decision.

Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa.

BACKGROUND: Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries. METHODS: Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method. RESULTS: Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk. CONCLUSIONS: The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.).

Rotavirus strain distribution in Ghana pre- and post- rotavirus vaccine introduction.

BACKGROUND: Ghana introduced the monovalent rotavirus vaccine (Rotarix) into its national paediatric vaccination programme in May2012. Vaccine introduction was initiated nationwide and achieved >85% coverage within a few months. Rotavirus strain distribution pre- and post-RV vaccine introduction is reported. METHODS: Stool samples were collected from diarrhoeic children <5 years of age hospitalized between 2009 and 2016 at sentinel sites across Ghana and analyzed for the presence of group A rotavirus by enzyme immunoassay. Rotavirus strains were characterized by RT-PCR and sequencing. RESULTS: A total of 1363 rotavirus EIA-positive samples were subjected to molecular characterization. These were made up of 823 (60.4%) and 540 (39.6%) samples from the pre- and post-vaccine periods respectively. Rotavirus VP7 genotypes G1, G2 and G3, and VP4 genotypes P[6] and P[8] constituted more than 65% of circulating G and P types in the pre-vaccine period. The common strains detected were G1P[8] (20%), G3P[6] (9.2%) and G2P[6] (4.9%). During the post-vaccine period, G12, G1 and G10 genotypes, constituted more than 65% of the VP7 genotypes whilst P[6] and P[8] made up more than 75% of the VP4 genotypes. The predominant circulating strains were G12P[8] (26%), G10P[6] (10%) G3P[6] (8.1%) and G1P[8] (8.0%). We also observed the emergence of the unusual rotavirus strain G9P[4] during this period. CONCLUSION: Rotavirus G1P[8], the major strain in circulation during the pre-vaccination era, was replaced by G12P[8] as the most predominant strain after vaccine introduction. This strain replacement could be temporary and unrelated to vaccine introduction since an increase in G12 was observed in countries yet to introduce the rotavirus vaccine in West Africa. A continuous surveillance programme in the post-vaccine era is necessary for the monitoring of circulating rotavirus strains and the detection of unusual/emerging genotypes.

Cost-effectiveness of rotavirus vaccination in Ghana: Examining impacts from 2012 to 2031.

BACKGROUND: Diarrhea causes about 10% of all deaths in children under five years globally, with rotavirus causing about 40% of all diarrhea deaths. Ghana introduced rotavirus vaccination as part of routine immunization in 2012 and it has been shown to be effective in reducing disease burden in children under five years. Ghana's transition from low to lower-middle income status in 2010 implies fewer resources from Gavi as well as other major global financing mechanisms. Ghana will soon bear the full cost of vaccines. The aim of this study was to estimate the health impact, costs and cost-effectiveness of rotavirus vaccination in Ghana from introduction and beyond the Gavi transition. METHODS: The TRIVAC model is used to estimate costs and effects of rotavirus vaccination from 2012 through 2031. Model inputs include demographics, disease burden, health system structure, health care utilization and costs as well as vaccine cost, coverage, and efficacy. Model inputs came from local data, the international literature and expert consultation. Costs were examined from the health system and societal perspectives. RESULTS: The results show that continued rotavirus vaccination could avert more than 2.2 million cases and 8900 deaths while saving US$6 to US$9 million in costs over a 20-year period. The net cost of vaccination program is approximately US$60 million over the same period. The societal cost per DALY averted is US$238 to US$332 with cost per case averted ranging from US$27 to US$38. The cost per death averted is approximately US$7000. CONCLUSION: The analysis shows that continued rotavirus vaccination will be highly cost-effective, even for the period during which Ghana will assume responsibility for purchasing vaccines after transition from Gavi support.

Effectiveness of two community-based strategies on disease knowledge and health behaviour regarding malaria, diarrhoea and pneumonia in Ghana.

BACKGROUND: Ghana has developed two community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia, and to improve household and family practices: integrated Community Case Management (iCCM) and Community-based Health Planning and Services (CHPS). The objective of the study was to assess the effectiveness of iCCM and CHPS on disease knowledge and health behaviour regarding malaria, diarrhoea and pneumonia. METHODS: A household survey was conducted two and eight years after implementation of iCCM in the Volta and Northern Regions of Ghana respectively, and more than ten years of CHPS implementation in both regions. The study population included 1356 carers of children under- five years of age who had fever, diarrhoea and/or cough in the two weeks prior to the interview. Disease knowledge was assessed based on the knowledge of causes and identification of signs of severe disease and its association with the sources of health education messages received. Health behaviour was assessed based on reported prompt care seeking behaviour, adherence to treatment regime, utilization of mosquito nets and having improved sanitation facilities, and its association with the sources of health education messages received. RESULTS: Health education messages from community-based agents (CBAs) in the Northern Region were associated with the identification of at least two signs of severe malaria (adjusted Odds Ratio (OR) 1.8, 95%CI 1.0, 3.3, p = 0.04), two practices that can cause diarrhoea (adjusted OR 4.7, 95%CI 1.4, 15.5, p = 0.02) 0and two signs of severe pneumonia (adjusted OR 7.7, 95%CI2.2, 26.5, p = 0.01)-the later also associated with prompt care seeking behaviour (p = 0.04). In the Volta Region, receiving messages on diarrhoea from CHPS was associated with the identification of at least two signs of severe diarrhoea (adjusted OR 3.6, 95%CI 1.4, 9.0), p = 0.02). iCCM was associated with prompt care seeking behaviour in the Volta Region and CHPS with prompt care seeking behaviour in the Northern Region (p < 0.5). CONCLUSIONS: Both iCCM and CHPS were associated with disease knowledge and health behaviour, but this was more pronounced for iCCM and in the Northern Region. HBC should continue to be considered as the strategy through which community-IMCI is implemented.