Dog Bites and Rabies in the Eastern Region of Ghana in 2013-2015: A Call for a One-Health Approach.

BACKGROUND: A One-Health approach is advocated to ensure effective rabies surveillance in sub-Saharan Africa. Information is needed to assess the current state of dog bites and rabies in Ghana. We analyzed data on reported events in the Eastern Region of Ghana from 2013 to 2015 to generate information that can be used for rabies elimination in Ghana through the One-Health approach. METHOD: We extracted data on dog bites and rabies from the database of the regional health service and performed descriptive analysis using Epi Info version 7™. We followed up with interviews with three key informants from the health and veterinary services on issues related to surveillance and data quality. RESULTS: Overall, 4821 dog bites were reported over the three-year period. This translated into an annual incidence of 172 cases per a population of 100,000. Most of cases were in children aged less than 10 yrs. Fifteen (53.3% males) cases of rabies were recorded in seven out of the 26 municipalities and districts, translating into a rabies to dog bite ratio of 3: 1000. The median age of victims was 9 years (range: 3-72 years). A parallel and uncoordinated system of rabies surveillance is maintained by the health and veterinary services, with gross disparities in the number of reported events and overall impression of underreporting. CONCLUSION: Rabies remains an important cause of preventable deaths in this region. An integrated approach to surveillance based on the One-Health concept needs to be adopted.

Uncommon mixed outbreak of pneumococcal and meningococcal meningitis in Jirapa District, Upper West Region, Ghana, 2016.

OBJECTIVE: The Jirapa District in Ghana falls within the African meningitis belt where over 500 million people are at risk of epidemic meningitis. The district suffered an outbreak of Neisseria meningitides, W (NMW) in 2012 and a mixed outbreak of Streptococcus pneumonia and NMW in early 2016. We investigated the outbreak to identify the source, causative agents, and magnitude and assess health facility preparedness and propose control measures. DESIGN AND SETTING: We conducted a descriptive study in all sub-districts of Jirapa, between 28th February to 10th April 2016. We reviewed records at health facilities, assessed health facility preparedness, searched for cases, traced contacts of case to administer chemoprophylaxis and collect CSF for laboratory analysis. Data were entered in Microsoft excel cleaned, and exported to stata-13 for analysis by person place and time. RESULTS: A total 233 meningitis cases were reported with mean age of 22.4years and standard deviation 21.6. Males were (57%), females (43%) and 60.8% were less than 19 years. Attack rate of meningitis was 214/100,000 with case fatality rate (CFR) of 12.4% (29/233). Causative agents were NMW (69.5%) and streptococcus pneumonia (27.1%), mainly serotype STN1 and H. influenza (3.4%). The index case had travel history to dollar power, close to Tain District which is the epicentre for the 2016 meningitis outbreak in Ghana. CONCLUSION: The Jirapa district experienced a mixed outbreak of streptococcal and meningococcal meningitis in early 2016, facilitated by migration. Active surveillance and mass vaccination with multivalent vaccines is required to protect the population. FUNDING: Ghana Field Epidemiology and Laboratory Training Programme (GFELTP).

Secondary analysis of snake bite data in the Western Region of Ghana: 2006-2010.

BACKGROUND: A snake bite is an injury caused by a bite from a snake, often resulting in puncture wounds, amputations and sometimes envenomation. Envenoming resulting from snake bite is a particularly important public health problem in rural areas of tropical and sub-tropical countries in Africa. This paper reports the incidence of snake bites and its associated mortality in the Western Region of Ghana. METHOD: The study was a descriptive cross-sectional review of 2006 - 2010 snake bite secondary data generated by the Western Regional Health Information Office in Ghana. Data was extracted from the District Health Information Management System (DHIMS) database. Data was managed and analyzed using SPSS Version 16.0. Univariate analyses were expressed as percentages and graphs. RESULTS: The year 2009 recorded the highest incidence of Snake bites in the Western Region with Juabeso district recording the highest incidence of snake bites over the study period. Over the period about 55% of the incidence was between 50 - 100 per 100,000 population. The total number of snake bites recorded in the region for the period was 7,275, of which 52% (3,776) were males. About 60% of the patients were of the age group 15-49 years. A total of 12 reported snake bite deaths were recorded, of which 67% were men. This study recommends to the Districts Health Directorates in the Western Region to regularly organize community education on snake bite and the use of protective clothing by the farmers. FUNDING: None declared.

Outbreak of foodborne gastroenteritis in a senior high school in South-eastern Ghana: a retrospective cohort study.

BACKGROUND: On 4th February 2015, a group of Senior High School students from Fanteakwa district presented to the emergency unit of the district hospital with complaints of abdominal pain, vomiting and diarrhoea. All the students had eaten from a specific food vendor and had neither eaten any other common meal that day nor the previous day. A foodborne disease outbreak was suspected. We investigated to verify the outbreak, determine its magnitude, identify the source and implement control measures. METHODS: A retrospective cohort study was conducted. We reviewed medical records and interviewed patrons of the food vendor. We collected data on age, sex, signs and symptoms, date of illness onset, date of admission, date of discharge, treatments given and outcome. A case of foodborne disease was any person in the school with abdominal pain, vomiting and or diarrhoea from 4th to 11th February 2015 and had eaten from the food vendor. We conducted active case search to identify more cases. We conducted environmental assessment and collected clinical and food samples for laboratory testing. Descriptive and inferential statistical analyses were performed using Stata 12.0. RESULTS: A total of 68 cases were recorded giving overall attack rate of 35.79 % (68/190) with no death. Of these, 51.47 % (35/68) were males. Mean age of case-patients was 17.8 (standard deviation +/-1.62). The index case, a 17-year-old female student ate from the food vendor on 4th February at 9:00 am and fell ill at 3:40 pm later that day. Compared to those who ate other food items, students who drank water from container at the canteen were more likely to develop foodborne disease at statistically significant levels [RR = 2.6, 95 % CI = (2.11-3.15)]. Clostridium perfringens (C. perfringens) and Salmonella species (Salmonella spp) were isolated from water and stew respectively. Clinical features of case-patients were compatible with both organisms. CONCLUSION: A foodborne gastroenteritis outbreak occurred in a Senior High School in Fanteakwa District from 4th to 7th February 2015. The most probable aetiologic agent was C. perfringens with contaminated water at canteen as the vehicle of transmission. Concurrent Salmonella spp infection could not be ruled out. Rapid outbreak response helped in controlling the outbreak.

Foodborne disease outbreak in a resource-limited setting: a tale of missed opportunities and implications for response.

INTRODUCTION: Foodborne diseases (FBD) have emerged as a major public health problem worldwide. Though the global burden of FBD is currently unknown, foodborne diarrhoeal diseases kill 1.9 million children globally every year. On 25th September 2014, health authorities in Eastern Region of Ghana were alerted of a suspected FBD outbreak involving patrons of a community food joint. We investigated to determine the magnitude, source and implement control and preventive measures. METHODS: A retrospective cohort study was conducted. We reviewed medical records for data on demographics and clinical features. A suspected foodborne disease was any person in the affected community with abdominal pain, vomiting and or diarrhea between 25(th) and 30(th) September 2014 and had eaten from the food joint. We conducted active case search, descriptive data analysis and calculated food specific attack rate ratios (ARR) and their corresponding 95% confidence intervals. RESULTS: Of 43 case-patients, 44.2% (19/43) were males; median age was 19 years (interquartile range: 17-24 years). Overall attack rate was 43.4% (43/99) with no fatality. Case counts rose sharply for four hours to a peak and fell to baseline levels after 12 hours. Compared to those who ate other food items, patrons who ate "waakye" and "shitor" were more likely to develop foodborne disease [ARR = 4.1 (95% CI = 1.09-15.63)]. Food samples and specimens from case-patients were unavailable for testing. Laboratory diagnostic capacity was also weak. CONCLUSION: A point source FBD outbreak linked to probable contaminated "waakye" and or "shitor" occurred. Missed opportunities for definitive diagnosis highlighted the need for strengthening local response capacity.

Training Ghanaian frontline healthcare workers in public health surveillance and disease outbreak investigation and response.

INTRODUCTION: Beyond initial formal academic education, the need for continuous professional development through in-service workforce capacity improvement programs that are aimed at enhancing knowledge and skills of public healthcare workers has assumed immense priority worldwide. This has been heightened by the on-going Ebola Virus Disease outbreak, which is exposing the weak public health systems in West Africa. In response to this need, the Ghana Field Epidemiology and Laboratory Program organized a short-course for frontline health workers in the Greater Accra region of Ghana in order to augment their surveillance and outbreak response capacity. METHODS: Human and veterinary health workers were trained using Field Epidemiology and Laboratory Training Program short course model. A two-week didactic course was conducted with a 10-week field placement. Evaluation of the course was done by assessment of participants' outputs during the training as well as pretest and posttest methods. RESULTS: A total of 32 frontline health workers from both the human and veterinary health services benefited from the two-week initial training of the 12-week course. There was a significant gain in knowledge by the participants after the training course. Participants developed concept papers and implemented their fieldwork projects. Overall assessment of the workshop by the participants was very good. CONCLUSION: Capacity of the health workers has been improved in the area of public health surveillance, outbreak investigation and response. We recommend a scale-up of this training course to other regions.

Bovine Tuberculosis Surveillance System Evaluation, Greater-Accra Region, Ghana, 2006-2011.

INTRODUCTION: Bovine tuberculosis (bTB) is a chronic, zoonotic, multi-species disease of cattle caused by Mycobacterium bovis. In developed countries, effective surveillance and enforcement of regulations on bTB control resulted in significant reduction of infections in cattle and hence, humans. However, in developing countries, weak surveillance systems affect accurate and timely reporting of bTB in humans and cattle. In Ghana, transhumance movement of cattle increases the risk of bTB importation and spread, however, the extent to which surveillance detects bTB is unknown. We therefore evaluated the bTB surveillance system in the Greater-Accra Region to determine its performance and assessed its attributes. METHODS: We interviewed stakeholders, and reviewed bTB surveillance data for all ten districts in the region from 2006-2011 using the CDC Guidelines for Evaluation of public health surveillance systems. RESULTS: From 2006-2011, bTB was suspected in 284/244,576 (0.12%) cattle slaughtered, of which 7/284 (2.5%) were submitted for laboratory confirmation and all tested positive. Predictive value positive was 100%. There is no standard case definition which guides bTB detection. Fifty percent of carcasses slip through inspection, and confirmed cases are not traced back. There were 99/284 (34.9%) condemnations from suspected carcasses and 57/97 (58.8%) from positive reactors from screening. Ninety percent (9/10) of districts submitted reports late to the region whereas representativeness was 30%. Regional and district data were manually stored with no electronic backups. The region's cattle population is unknown. CONCLUSION: Although the bTB surveillance system is sensitive, it is under performing, and the possibility of bTB transmission from cattle to humans is high.

Outcome of Streptomycin-Rifampicin treatment of Buruli Ulcer in two Ghanaian districts.

INTRODUCTION: Buruli ulcer (BU) is an infectious skin disease, caused by Mycobacterium ulcerans, endemic in more than 30 countries worldwide especially Africa. Brong-Ahafo Region implemented WHO recommended daily treatment with streptomycin and rifampicin for eight weeks (SR8). Yet limited assessment of therapy exists. This study seeks to determine the outcome of SR8 therapy on BU in two endemic districts in Brong-Ahafo. METHODS: Longitudinal study was done with laboratory confirmed Buruli ulcer patients selected consecutively and put on SR8. Patient follow-up involved daily administration of SR8 and Bi-Weekly monitoring of treatment in the form of measurement of wound size and taking photographs. RESULTS: The mean age of participants was 34.6 ± 16.6 years with minimum and maximum ages of 10 to 65 respectively. Those in the 10-19year age group 13 (26%) were most affected. Majority, 26 (52%) had no formal education and 27 (54.0%) were peasant farmers. Thirty-eight (76.0%) had previously used traditional treatment. Forty completed treatment and of these, 28 (70.0%) healed completely and 12 (30. 0%) improved by 80%-90%. Duration of lesion before seeking healthcare (P =0.04), use of traditional treatment P < 0.001, clinical form of lesion P = 0.04, lesion category (p = 0.01), significantly affected healing. Mean time to healing, was 7.7 weeks (95% CI, 7.3 - 7.9). CONCLUSION: Though SR8 is effective in curing BU, late reporting, use of herbs and access to health care impeded wound healing. This calls for provision of accessible health care and education to improve early reporting.

Direct observation of outpatient management of malaria in a rural Ghanaian district.

INTRODUCTION: In Ghana, malaria continues to top outpatient morbidities; accounting for about 40% of all attendances. Effective case-management is key to its control. We evaluated case-management practices of uncomplicated malaria in Kwahu South District (KSD) health facilities to determine their conformity to guidelines. METHODS: We conducted a cross sectional survey at all public health facilities in three randomly selected sub-districts in KSD. A non-participatory observation of suspected malaria consultations was conducted. Suspected malaria was defined as any person with fever (by history or measured axillary temperature > or equal 37.5 oC) presenting at the selected health facilities between 19th and 29th April 2013. Findings were expressed as frequencies, relative frequencies, mean (± standard deviation) and median. RESULTS: Of 70 clinical observations involving 10 prescribers in six health facilities, 40 (57.1%) were females and 16 (22.9%) were below five years. Median age was 18 years (interquartile range: 5-33). Overall, 63 (90.0%) suspected case-patients had diagnostic tests. Two (3.6%) were treated presumptively. All 31 confirmed and 10 (33.3%) of the test negative case-patients received Artemisinin-based Combination Therapies (ACTs). However, only 12 (27.9%) of the 43 case-patients treated with ACT received Artesunate-Amodiaquine (AA). Only three (18.8%) of the under-fives were examined for non-malarial causes of fever. Mean number of drugs per patient was 3.7 drugs (± 1.1). Only 45 (64.3%) patients received at least one counseling message. CONCLUSION: Conformity of malaria case-management practices to guidelines in KSD was suboptimal. Apart from high rate of diagnostic testing and ACT use, prescription of AA, physical examination and counseling needed improvement.