Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: the importance of quality surveillance.

This study compares two antivenoms used to treat Echis ocellatus snake bite patients at Mathias Hospital, Yeji, central Ghana. FAV-Afrique antivenom (Aventis Pasteur) was given to 278 patients during 2001--2003, whilst Asna Antivenom C (Bharat Serum and Vaccines Ltd) was used in 2004 to treat 66 patients. The two groups had comparable patient attributes, time from snake bite to treatment and staff adherence to the tested treatment protocol. The antivenom C group required more repeat doses and twice the amount of antivenom to treat coagulopathy. Of greater concern, the antivenom C mortality rate was 12.1%, a marked rise from the 1.8% rate in the earlier FAV-Afrique antivenom group. In this study, antivenom C was ineffective as treatment for West African E. ocellatus snake venom. This illustrates the absolute need for regional pilot tests to assess the effectiveness of a new antivenom against local snake venoms before its sole and general distribution in a region is initiated.

Dual fortification of salt with iron and iodine in women and children in rural Ghana.

OBJECTIVE: To test the efficacy of double-fortified salt (DFS) on the anaemia and iodine deficiency (ID) status of women and their children. DESIGN: Double-blind randomised controlled trial. SETTING: Sekyere West District of Ghana. SUBJECTS: In this eight-month trial, mildly anaemic or non-anaemic, non-pregnant, non-lactating women were randomised into three groups receiving: DFS plus weekly placebo (n = 61); iodised salt plus weekly 70 mg iron supplement (n = 65); or iodised salt (IS) plus weekly placebo (control group, n = 58). Correspondingly, their mildly anaemic and non-anaemic children aged 1-5 years were randomised into two groups receiving either the DFS (n = 23) or IS alone (control group, n = 59). RESULTS: At the end of the intervention, prevalence of anaemia in women remained unchanged in the DFS or IS plus weekly iron supplement group, but significantly increased by 19.5% in the control group (P = 0.039). In children, prevalence of anaemia in the DFS group significantly decreased by 21.7% (P = 0.025) while no change was observed in the control group. ID decreased significantly in all groups of women (P < 0.001) and children (P < 0.05), with no difference among groups of women and children. CONCLUSION: While the use of DFS prevented anaemia in women, it had a significant role in both the prevention and treatment of anaemia in children. Both the DFS and IS significantly reduced ID in women and children to a similar degree.

The role of community-based surveillance in health outcomes measurement.

UNLABELLED: Summary SETTING: Community Health Planning and Service (CHPS) strategy was started in Ashanti Region in 2001. It aimed to improve geographic access to comprehensive health care. The Region used community-based surveillance (CBS) as an entry point. OBJECTIVES: were to obtain baseline data and define the magnitude and extent of specific health outcomes. DESIGN: Districts were divided into health zones and health workers (HWs) assigned. CBS Volunteers were identified, trained to register households, births, deaths, diseases and vaccinations. The Regional level tracked the implementation process and HEALTH OUTCOMES which were evaluated after a year. RESULTS: Two hundred and eighty-two (282) zones were created, 1-8 per sub-district with populations 1,029-43,998 and communities 1-29. 86.2% zones had HWs assigned, 40.6% resident. Most HWs (89.3%) were community health nurses. 65.7% zones had health institutions, 20.6% chemical shops and 83.7% basic drugs. 2,325 (91%) communities had registers and 2,278 CBS volunteers. Twenty-six thousand, three hundred and sixty (26,360) births were registered (CBR 10.2/1000pop), deaths 5,694 (CDR 2.6/1000pop), Under-one deaths 967 (IMR 36.4/1000Lbs), child deaths 229 (CMR 8.3/1000Lbs), under-5 deaths 1,196 (U5MR 47.1/1000Lbs) and maternal deaths 76 (MMR 288.3/100,000Lbs). Reported diseases included AFP 18, Neonatal tetanus 38, Buruli Ulcer 80 and Guinea worm 34. The challenges were in data management and use. CONCLUSIONS: We conclude that health institutional data may only represent the ear of the hippopotamus and complimented by CBS, health outcomes can be well defined in the CHPS concept and thus contribute immensely to community action with stakeholders.

Protocol and monitoring to improve snake bite outcomes in rural Ghana.

A study was conducted in Mathias Hospital, Yeji, an area of Ghana, where snake bite cases are an important cause of morbidity and mortality, with a case fatality rate of 11% (8/72). Case management difficulties included uncertainty about the assessment of the severity of envenoming, the dosage of antivenom, and the response to treatment. An intervention with several components was introduced: development of a treatment protocol, staff training, monitoring of compliance and patient education. During a 33-month post-intervention period there was excellent protocol compliance, fewer snake bite complications, and a fall in mortality rate to 1.3% (3/238) compared with a 15-month baseline review. There was a 50% increase in snake bite admissions and fewer delays. To improve snake bite outcomes in comparable settings, particularly if inexperienced staff are involved in care, we recommend a similar quality assurance project, involving case review and use of a treatment protocol with monitoring of compliance to sustain an improved approach.

Upgrading obstetric care at the health center level, Juaben, Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Inventory and observations at Juaben Teaching Health Center (JTHC) revealed an inability to treat obstetric complications. Women with complications needed to be referred to other institutions, resulting in delays. INTERVENTIONS: During 1993 and 1994, an operating theater and blood bank were established and equipped, the maternity refurbished, and a revolving drug fund created. A physician was posted and trained in obstetrics, and midwives were trained in life-saving skills. A running water supply was established. Subsequent community interventions focused on improving access and reducing the delay in seeking care. RESULTS: The number of women with complications coming for care increased almost three-fold, from 26 in 1993 to 73 in 1995 and the proportion of these who were referred for treatment dropped from 42 to 14%. Surgical obstetric procedures performed at JTHC increased from 23 in 1993 to 90 in 1995. Midwives performed 32% of manual removals, 58% of vacuum extractions and 98% of episiotomy repairs. No deaths occurred among the women treated. COSTS: The cost of improvements was approximately US $30,000, mostly for equipment and supplies. Forty percent came from project funds, 36% from non-governmental organizations (NGOs), 15% from government and 9% from community members. The salary of the new physician cost an additional $4700 annually. CONCLUSIONS: Modest improvements can increase the provision and utilization of emergency obstetric care. Collaboration with NGOs, government and the community can be beneficial.

Community education to improve utilization of emergency obstetric services in Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Focus group studies in the Ashanti region showed that people avoided utilizing health facilities because of lack of confidence in the services and concern about the availability of drugs and supplies, among other reasons. INTERVENTIONS: After services at the health center were upgraded, community education activities began in early 1994. These activities were carried out through existing mechanisms--e.g. Ministry of Health (MOH) outreach workers and village health workers, public health nurses and midwives, and village health committees. They addressed a variety of audiences, including women's and church groups, emphasizing early recognition and treatment of obstetric complications, and the improved availability of services. RESULTS: The number of women with obstetric complications admitted to the health center rose from 26 in 1993 to 73 in 1995. It was the impression of the health center staff that women were also coming for treatment more promptly. COSTS: The cost of this intervention was US$1950. This was mostly project funds, with the government and community together contributing approximately one-fifth. CONCLUSIONS: Once services are available, community education and information activities can enhance utilization. The cost of such activities can be reduced, and sustainability promoted, by involving MOH personnel and community groups.

[Primary health care in Ghana: no pay no cure?]. / Primary health care in Ghana: no pay no cure?

PIP: Between 1975 and 1983 health care expenditures in Ghana dropped to a low point as a consequence of the structural readjustment program instituted by the World Bank. During 1975-76 only 15% of available funds were spent on primary health care (PHC), which was officially introduced in the late 1970s. PHC made up 20-25% of the health care expenditures by 1991 with about 25% of health personnel engaged in PHC. 2/3 of health care delivery covered urban areas when 60% of the population lived in the countryside. The district of Ejisu-Juaben in the Ashanti region had high morbidity. Tetanus, polio, whooping-cough, and diphtheria had been brought under control, but measles, diarrhea, and malnutrition were still widespread among children under 5 years old. Malaria, bilharzia, intestinal parasites, respiratory infections, hepatitis, anemia, hypertension, and vitamin A deficiency were also grave problems. AIDS was on the rise. Child mortality amounted to 130/1000 live births and maternal mortality to 1400/100,000 cases. The medical structure of the district comprises 10 health posts (6 governmental and 4 mission). Only 72 villages and 120,000 people are cared for. Each post has a mobile team. In 1993 a new community-based health care program began funded by Save the Children Netherlands. In 60 villages a village health committee existed but they were substandard. They were either reactivated or new committees were set up. Training activities were also started in prenatal care, delivery, care of malnutrition and diarrhea, hygiene, and sanitation. Two years later safe motherhood indicators had improved; postnatal care increased from 16% to 49%; medical deliveries increased from 27% to 37%; the share of families with contraceptive acceptance increased from 7% to 21%; and tetanus vaccination among mothers was estimated to have increased from 27% to 86%.^ieng