Salmonella enterica in farm environments in the Ashanti Region of Ghana.

BACKGROUND: Salmonella enterica are important foodborne pathogens and the third leading cause of death among diarrheal infections worldwide. This cross-sectional study investigated the frequency of antibiotic-resistant Salmonella enterica in commercial and smallholder farm environments in the Ashanti Region of Ghana. A total of 1490 environmental samples, comprising 800 (53.7%) soil (from poultry, pigs, sheep, goats and cattle farms), 409 (27.4%) pooled poultry fecal and 281 (18.9%) dust (from poultry farms) samples, were collected from 30 commercial and 64 smallholder farms. All samples were processed using standard culture methods. Isolates were identified by biochemical methods and confirmed using the VITEK 2 System. Antibiotic susceptibility testing was carried out by disk diffusion following the EUCAST guidelines. Serotyping was performed using the Kauffman White Le Minor Scheme. RESULTS: The overall Salmonella frequency was 6.0% (n/N = 90/1490); the frequency varied according to the type of sample collected and included: 8.9% for dust (n/N = 25/281), 6.5% for soil (n/N = 52/800) and 3.2% for pooled poultry fecal samples (n/N = 13/409). Salmonella was also recovered from commercial farm environments (8.6%, n/N = 68/793) than from smallholder farms (3.2%, n/N = 22/697) (PR = 2.7, CI: 1.7 - 4.4). Thirty-four different Salmonella serovars were identified, the two most common being Rubislaw (27.8%, n/N = 25/90) and Tamale (12.2%, n/N = 11/90). Serovar diversity was highest in strains from soil samples (70.6%, n/N = 24/34) compared to those found in the dust (35.2%, n/N = 12/34) and in fecal samples (29.4%, n/N = 10/34). Salmonella frequency was much higher in the rainy season (8.4%, n/N = 85/1007) than in the dry season (1.0%, n/N = 5/483) (PR = 8.4, 95% CI: 3.3 - 20.0). Approximately 14.4% (n/N = 13/90) of the isolates were resistant to at least one of the tested antimicrobials, with 84.6% (n/N = 11/13) being resistant to multiple antibiotics. All Salmonella Kentucky (n = 5) were resistant to ciprofloxacin. CONCLUSION: This study showed that farm environments represent an important reservoir for antibiotic-resistant Salmonella, which warrants monitoring and good husbandry practices, especially in commercial farms during the rainy season, to control the spread of this pathogen.

The East African Community mobile laboratory network prepares for monkeypox outbreaks.

In response to the largest recorded monkeypox virus outbreak outside of endemic Central and Western Africa, the East African Community (EAC), in cooperation with the Bernhard-Nocht- Institute for Tropical Medicine, coordinated an emergency monkeypox diagnostic training for the East African Region. As of June 2022, the Democratic Republic of Congo reported a steady increase of suspected monkeypox cases, increasing the risk of spill-over into the remaining six EAC Partner States. Within the existing EAC Mobile Laboratories project, laboratory experts of the National Public Health Laboratories of the remaining six EAC Partner States (Burundi, Rwanda, Tanzania, Kenya, Uganda, and South Sudan) participated in the workshop and were trained in the reception of suspect samples, DNA extraction and diagnosis using real-time polymerase chain reaction (RT-PCR). The EAC region is now equipped with the tools to prepare and rapidly respond to any emerging monkeypox outbreak.

The East African Community (EAC) mobile laboratory networks in Kenya, Burundi, Tanzania, Rwanda, Uganda, and South Sudan-from project implementation to outbreak response against Dengue, Ebola, COVID-19, and epidemic-prone diseases.

BACKGROUND: East Africa is home to 170 million people and prone to frequent outbreaks of viral haemorrhagic fevers and various bacterial diseases. A major challenge is that epidemics mostly happen in remote areas, where infrastructure for Biosecurity Level (BSL) 3/4 laboratory capacity is not available. As samples have to be transported from the outbreak area to the National Public Health Laboratories (NPHL) in the capitals or even flown to international reference centres, diagnosis is significantly delayed and epidemics emerge. MAIN TEXT: The East African Community (EAC), an intergovernmental body of Burundi, Rwanda, Tanzania, Kenya, Uganda, and South Sudan, received 10 million € funding from the German Development Bank (KfW) to establish BSL3/4 capacity in the region. Between 2017 and 2020, the EAC in collaboration with the Bernhard-Nocht-Institute for Tropical Medicine (Germany) and the Partner Countries' Ministries of Health and their respective NPHLs, established a regional network of nine mobile BSL3/4 laboratories. These rapidly deployable laboratories allowed the region to reduce sample turn-around-time (from days to an average of 8h) at the centre of the outbreak and rapidly respond to epidemics. In the present article, the approach for implementing such a regional project is outlined and five major aspects (including recommendations) are described: (i) the overall project coordination activities through the EAC Secretariat and the Partner States, (ii) procurement of equipment, (iii) the established laboratory setup and diagnostic panels, (iv) regional training activities and capacity building of various stakeholders and (v) completed and ongoing field missions. The latter includes an EAC/WHO field simulation exercise that was conducted on the border between Tanzania and Kenya in June 2019, the support in molecular diagnosis during the Tanzanian Dengue outbreak in 2019, the participation in the Ugandan National Ebola response activities in Kisoro district along the Uganda/DRC border in Oct/Nov 2019 and the deployments of the laboratories to assist in SARS-CoV-2 diagnostics throughout the region since early 2020. CONCLUSIONS: The established EAC mobile laboratory network allows accurate and timely diagnosis of BSL3/4 pathogens in all East African countries, important for individual patient management and to effectively contain the spread of epidemic-prone diseases.

Molecular epidemiology of respiratory syncytial virus in children in sub-Saharan Africa.

OBJECTIVES: This study investigated the molecular epidemiology of respiratory syncytial virus (RSV) among febrile children with acute respiratory tract infection in Ghana, Gabon, Tanzania and Burkina Faso between 2014 and 2017 as well as the evolution and diversification of RSV strains from other sub-Saharan countries. METHODS: Pharyngeal swabs were collected at four study sites (Agogo, Ghana: n = 490; Lambaréné, Gabon: n = 182; Mbeya, Tanzania: n = 293; Nouna, Burkina Faso: n = 115) and analysed for RSV and other respiratory viruses using rtPCR. For RSV-positive samples, sequence analysis of the second hypervariable region of the G gene was performed. A dataset of RSV strains from sub-Saharan Africa (2011-2017) currently available in GenBank was compiled. Phylogenetic analysis was conducted to identify the diversity of circulating RSV genotypes. RESULTS: In total, 46 samples were tested RSV positive (Ghana n = 31 (6.3%), Gabon n = 4 (2.2%), Tanzania n = 9 (3.1%) and Burkina Faso n = 2 (1.7%)). The most common RSV co-infection was with rhinovirus. All RSV A strains clustered with genotype ON1 strains with a 72-nucleotide duplication and all RSV B strains belonged to genotype BAIX. Phylogenetic analysis of amino acid sequences from sub-Saharan Africa revealed the diversification into 11 different ON1 and 22 different BAIX lineages and differentiation of ON1 and BAIX strains into potential new sub-genotypes, provisionally named ON1-NGR, BAIX-KEN1, BAIX-KEN2 and BAIX-KEN3. CONCLUSION: The study contributes to an improved understanding of the molecular epidemiology of RSV infection in sub-Saharan Africa. It provides the first phylogenetic data for RSV from Tanzania, Gabon and Burkina Faso and combines it with RSV strains from all other sub-Saharan countries currently available in GenBank.

Bloodstream infection with Acinetobacter baumanii in a Plasmodium falciparum positive infant: a case report.

BACKGROUND: The increasing incidence of multi-antibiotic-resistant bacterial infections, coupled with the risk of co-infections in malaria-endemic regions, complicates accurate diagnosis and prolongs hospitalization, thereby increasing the total cost of illness. Further, there are challenges in making the correct choice of antibiotic treatment and duration, precipitated by a lack of access to microbial culture facilities in many hospitals in Ghana. The aim of this case report is to highlight the need for blood cultures or alternative rapid tests to be performed routinely in malaria patients, to diagnose co-infections with bacteria, especially when symptoms persist after antimalarial treatment. CASE PRESENTATION: A 6-month old black female child presented to the Agogo Presbyterian Hospital with fever, diarrhea, and a 3-day history of cough. A rapid diagnostic test for malaria and Malaria microscopy was positive for P. falciparum with a parasitemia of 224 parasites/µl. The patient was treated with Intravenous Artesunate, parental antibiotics (cefuroxime and gentamicin) and oral dispersible zinc tablets in addition to intravenous fluids. Blood culture yielded Acinetobacter baumanii, which was resistant to all of the third-generation antibiotics included in the susceptibility test conducted, but sensitive to ciprofloxacin and gentamicin. After augmenting treatment with intravenous ciprofloxacin, all symptoms resolved. CONCLUSION: Even though this study cannot confirm whether the bacterial infection was nosocomial or otherwise, the case highlights the necessity to test malaria patients for possible co-infections, especially when fever persists after parasites have been cleared from the bloodstream. Bacterial blood cultures and antimicrobial susceptibility testing should be routinely performed to guide treatment options for febril illnesses in Ghana in order to reduce inappropriate use of broad-spectrum antibiotics and limit the development of antimicrobial resistance.

Socioeconomic Status and Temporal Urban Environmental Change in Accra: a Comparative Analysis of Area-based Socioeconomic and Urban Environmental Quality Conditions Between Two Time Points.

The influence of area-based socioeconomic (SE) conditions on environmental quality conditions has recently been reported showing the precise spatial relationship between area-based SE conditions and neighborhood environmental quality in an urban area in a low-income setting. Nonetheless, there is still a lack of understanding of the nature of the relationship on a temporal scale. This study aimed to investigate the dynamic temporal relationship between area-based SE conditions and urban environmental quality conditions over a decadal period in Accra, Ghana. The results showed that there were differences in environmental quality across the SE quintiles in space (with regard to per capita waste generation (p < 0.012), waste collection/clearing (p < 0.01), and waste deposition (p < 0.001) and that the urban environmental quality conditions had changed dramatically over the decade for most of the environmental variables (p < 0.001). Despite the enormous urban development initiatives, some of the environmental quality indicators (e.g., proportion of households without flush toilet/Water Closet, connection to central sewer p < 0.001) appeared to have worsened in the high class quintile, suggesting that a high proportion of households were without acceptable sanitation facilities. The study concludes that urban development in low-income countries will need to follow strictly international best practice by observing standardized building codes and guidelines, if progress should be made in meeting the Millennium Development Goals targets.

The usefulness of C-reactive protein in predicting malaria parasitemia in a sub-Saharan African region.

BACKGROUND: Malaria remains a leading cause of childhood mortality in sub-Saharan Africa. Identifying patients who are at risk for severe manifestations at presentation still remains challenging. This study examines whether a semi-quantitative test on C-Reactive Protein (CRP) could be useful for rapidly predicting the presence or absence of malarial parasitemia in febrile children. METHOD: Data were collected from children with fever or a history of fever at the Agogo Presbyterian Hospital in the Ashanti Region of Ghana. Haematological measurements, microscopic detection of plasmodium species and semi-quantitative CRP measurements with a membrane-based immunoassay for whole blood were performed. CRP was classified as positive when the measured level was ≥ 10 mg/l. RESULTS: During 548 visits, thick blood film results could be obtained from 541 patients, 270 (49.3%) yielded parasitemia with Plasmodium spp. Whereas malaria parasites were detected in only a few patients (7.1%) with normal CRP levels (< 10mg/l), more than a half of patients with an increased CRP concentration (≥ 10 mg/l) were parasite positive (OR 14.5 [CI 4.4-47.6], p<0.001). Patients with increased CRP levels had more than an eight-fold likelihood for parasitemia after correction for other parameters (adjusted OR 8.7 [CI 2.5-30.5], p<0.001). Sensitivity, specificity as well as positive predictive and negative predictive values of CRP for malaria were 99.3% (CI 96.2%-100%), 9.2% (CI 6.4%-12.8%), 31.7% (CI 27.4%-36.1%) and 97.0% (CI 84.2%-99.9%), respectively. CONCLUSION: The semi-quantitative method of measuring CRP is cheap, rapid and easy to perform but not useful in predicting parasitemia and malaria. However, due to its high negative predictive value, it could have a role in identifying those patients unlikely to be presenting with clinical malaria.

Lack of Association of CD55 Receptor Genetic Variants and Severe Malaria in Ghanaian Children.

In a recent report, the cellular receptor CD55 was identified as a molecule essential for the invasion of human erythrocytes by Plasmodium falciparum, the causal agent of the most severe form of malaria. As this invasion process represents a critical step during infection with the parasite, it was hypothesized that genetic variants in the gene could affect severe malaria (SM) susceptibility. We performed high-resolution variant discovery of rare and common genetic variants in the human CD55 gene. Association testing of these variants in over 1700 SM cases and unaffected control individuals from the malaria-endemic Ashanti Region in Ghana, West Africa, were performed on the basis of single variants, combined rare variant analyses, and reconstructed haplotypes. A total of 26 genetic variants were detected in coding and regulatory regions of CD55 Five variants were previously unknown. None of the single variants, rare variants, or haplotypes showed evidence for association with SM or P. falciparum density. Here, we present the first comprehensive analysis of variation in the CD55 gene in the context of SM and show that genetic variants present in a Ghanaian study group appear not to influence susceptibility to the disease.

Endothelial protein C receptor gene variants not associated with severe malaria in ghanaian children.

BACKGROUND: Two recent reports have identified the Endothelial Protein C Receptor (EPCR) as a key molecule implicated in severe malaria pathology. First, it was shown that EPCR in the human microvasculature mediates sequestration of Plasmodium falciparum-infected erythrocytes. Second, microvascular thrombosis, one of the major processes causing cerebral malaria, was linked to a reduction in EPCR expression in cerebral endothelial layers. It was speculated that genetic variation affecting EPCR functionality could influence susceptibility to severe malaria phenotypes, rendering PROCR, the gene encoding EPCR, a promising candidate for an association study. METHODS: Here, we performed an association study including high-resolution variant discovery of rare and frequent genetic variants in the PROCR gene. The study group, which previously has proven to be a valuable tool for studying the genetics of malaria, comprised 1,905 severe malaria cases aged 1-156 months and 1,866 apparently healthy children aged 2-161 months from the Ashanti Region in Ghana, West Africa, where malaria is highly endemic. Association of genetic variation with severe malaria phenotypes was examined on the basis of single variants, reconstructed haplotypes, and rare variant analyses. RESULTS: A total of 41 genetic variants were detected in regulatory and coding regions of PROCR, 17 of which were previously unknown genetic variants. In association tests, none of the single variants, haplotypes or rare variants showed evidence for an association with severe malaria, cerebral malaria, or severe malaria anemia. CONCLUSION: Here we present the first analysis of genetic variation in the PROCR gene in the context of severe malaria in African subjects and show that genetic variation in the PROCR gene in our study population does not influence susceptibility to major severe malaria phenotypes.

Mapping urban malaria and diarrhea mortality in Accra, Ghana: evidence of vulnerabilities and implications for urban health policy.

Historic increase in urban population numbers in the face of shrinking urban economies and declining social services has meant that a large proportion of the urban population lives in precarious urban conditions, which provide the grounds for high urban health risks in low income countries. This study aims to identify, investigate, and contrast the spatial patterns of vulnerability and risk of two major causes of mortality, viz malaria and diarrhea mortalities, in order to optimize resource allocation for effective urban environmental management and improvement in urban health. A spatial cluster analysis of the observed urban malaria and diarrhea mortalities for the whole city of Accra was conducted. We obtained routinely reported mortality data for the period 1998-2002 from the Ghana Vital Registration System (VRS), computed the fraction of deaths due to malaria and diarrhea at the census cluster level, and analyzed and visualized the data with Geographic Information System (GIS, ArcMap 9.3.1). Regions of identified hotspots, cold spots, and excess mortalities were observed to be associated with some socioeconomic and neighborhood urban environmental conditions, suggesting uneven distribution of risk factors for both urban malaria and diarrhea in areas of rapid urban transformation. Case-control and/or longitudinal studies seeking to understand the individual level factors which mediate socioenvironmental conditions in explaining the observed excess urban mortalities and to establish the full range of risk factors might benefit from initial vulnerability mapping and excess risk analysis using geostatistical approaches. This is key to evidence-based urban health policy reforms in rapidly urbanizing areas in low income economies.

Neighborhood urban environmental quality conditions are likely to drive malaria and diarrhea mortality in Accra, Ghana.

BACKGROUND: Urbanization is a process which alters the structure and function of urban environments. The alteration in the quality of urban environmental conditions has significant implications for health. This applies both to the ecology of insect vectors that may transmit diseases and the burden of disease. STUDY OBJECTIVES: To investigate the relationship between malaria and infectious diarrhea mortality and spatially varied neighborhood environmental quality conditions in a low-income economy. DESIGN: A one time point spatial analysis of cluster-level environmental conditions and mortality data using principal component analysis (PCA), one-way analysis of variance (ANOVA) and generalized linear models (GLMs). METHODS: Environmental variables were extracted from the Ghana Census 2000 database while mortality data were obtained from the Ghana Births and Deaths Registry in Accra over the period 1998-2002. RESULTS: Whereas there was a strong evidence of a difference in relative mortality of malaria across urban environmental zones of differing neighborhood environmental conditions, no such evidence of mortality differentials was observed for diarrhea. In addition, whereas bivariate analyses showed a weak to strong evidence of association between the environmental variables and malaria mortality, no evidence of association was found between diarrhea mortality and environmental variables. CONCLUSION: We conclude that environmental management initiatives intended for infectious disease control might substantially reduce the risk of urban malaria mortality and to a less extent that for urban diarrhea mortality in rapidly urbanizing areas in a low-income setting.

Comparative evaluation of two rapid field tests for malaria diagnosis: Partec Rapid Malaria Test® and Binax Now® Malaria Rapid Diagnostic Test.

BACKGROUND: About 90% of all malaria deaths in sub-Saharan Africa occur in children under five years. Fast and reliable diagnosis of malaria requires confirmation of the presence of malaria parasites in the blood of patients with fever or history suggestive of malaria; hence a prompt and accurate diagnosis of malaria is the key to effective disease management. Confirmation of malaria infection requires the availability of a rapid, sensitive, and specific testing at an affordable cost. We compared two recent methods (the novel Partec Rapid Malaria Test® (PT) and the Binax Now® Malaria Rapid Diagnostic Test (BN RDT) with the conventional Giemsa stain microscopy (GM) for the diagnosis of malaria among children in a clinical laboratory of a hospital in a rural endemic area of Ghana. METHODS: Blood samples were collected from 263 children admitted with fever or a history of fever to the pediatric clinic of the Agogo Presbyterian Hospital. The three different test methods PT, BN RDT and GM were performed independently by well trained and competent laboratory staff to assess the presence of malaria parasites. Results were analyzed and compared using GM as the reference standard. RESULTS: In 107 (40.7%) of 263 study participants, Plasmodium sp. was detected by GM. PT and BN RDT showed positive results in 111 (42.2%) and 114 (43.4%), respectively. Compared to GM reference standard, the sensitivities of the PT and BN RDT were 100% (95% CI: 96.6-100) and 97.2% (95% CI: 92.0-99.4), respectively, specificities were 97.4% (95% CI: 93.6-99.3) and 93.6% (95% CI: 88.5-96.9), respectively. There was a strong agreement (kappa) between the applied test methods (GM vs PT: 0.97; p < 0.001 and GM vs BN RDT: 0.90; p < 0.001). The average turnaround time per tests was 17 minutes. CONCLUSION: In this study two rapid malaria tests, PT and BN RDT, demonstrated a good quality of their performance compared to conventional GM. Both methods require little training, have short turnaround times, are applicable as well as affordable and can therefore be considered as alternative diagnostic tools in malaria endemic areas. The species of Plasmodium cannot be identified.

Hemoglobin estimation by the HemoCue® portable hemoglobin photometer in a resource poor setting.

BACKGROUND: In resource poor settings where automated hematology analyzers are not available, the Cyanmethemoglobin method is often used. This method though cheaper, takes more time. In blood donations, the semi-quantitative gravimetric copper sulfate method which is very easy and inexpensive may be used but does not provide an acceptable degree of accuracy. The HemoCue® hemoglobin photometer has been used for these purposes. This study was conducted to generate data to support or refute its use as a point-of-care device for hemoglobin estimation in mobile blood donations and critical care areas in health facilities. METHOD: EDTA blood was collected from study participants drawn from five groups: pre-school children, school children, pregnant women, non-pregnant women and men. Blood collected was immediately processed to estimate the hemoglobin concentration using three different methods (HemoCue®, Sysmex KX21N and Cyanmethemoglobin). Agreement between the test methods was assessed by the method of Bland and Altman. The Intraclass correlation coefficient (ICC) was used to determine the within subject variability of measured hemoglobin. RESULTS: Of 398 subjects, 42% were males with the overall mean age being 19.4 years. The overall mean hemoglobin as estimated by each method was 10.4 g/dl for HemoCue, 10.3 g/dl for Sysmex KX21N and 10.3 g/dl for Cyanmethemoglobin. Pairwise analysis revealed that the hemoglobin determined by the HemoCue method was higher than that measured by the KX21N and Cyanmethemoglobin. Comparing the hemoglobin determined by the HemoCue to Cyanmethemoglobin, the concordance correlation coefficient was 0.995 (95% CI: 0.994-0.996, p < 0.001). The Bland and Altman's limit of agreement was -0.389 - 0.644 g/dl with the mean difference being 0.127 (95% CI: 0.102-0.153) and a non-significant difference in variability between the two measurements (p = 0.843). After adjusting to assess the effect of other possible confounders such as sex, age and category of person, there was no significant difference in the hemoglobin determined by the HemoCue compared to Cyanmethemoglobin (coef = -0.127, 95% CI: -0.379 - 0.634). CONCLUSION: Hemoglobin determined by the HemoCue method is comparable to that determined by the other methods. The HemoCue photometer is therefore recommended for use as on-the-spot device for determining hemoglobin in resource poor setting.

A review of the structure and function of vital registration system in Ghana: towards improvement in mortality data quality for health policy analysis.

Vital registration systems (VRS) are important in the collection of routine data on indicators of development. These are particularly useful if they are properly built to address weaknesses in the system leading to poor data quality. For instance, routine data on health events (e.g. morbidity, mortality etc.) are crucial for rapid assessment of disease burden and mortality trends in the population. They are also useful in the identification of vulnerable groups in populations. Despite their usefulness, VRS in many developing countries including Ghana are poorly structured raising questions about the quality of the output data from these systems. The present study aimed at assessing and documenting the structure and function of the VRS in Ghana, as well as at identifying the structural features that potentially compromise the reliability and validity of the output data from the Ghanaian VRS. To perform this study, collection and review of policy and legal documents establishing the VRS, documentation and evaluation of component structures of the system, assessment of procedural protocols guiding data collection processes and in-depth interviews with staff at the Ghana Births and Deaths Registry were performed. The assessment of the structure of the Ghana VRS, policy documents setting it up and the operational procedures reveals important lapses (e.g. presence of outmoded practices, imperfections in Births and Deaths Registry Act, 1965, Act 301 and imperfect system design) in the system that could compromise validity and reliability of the data generated from the VRS in Ghana.

A study of autopsy procedures in Ghana: implications for the use of autopsy data in epidemiological analyses.

The study of cause of death certification remains a largely neglected field in many developing countries, including Ghana. Yet, mortality information is crucial for establishing mortality patterns over time and for estimating mortality attributed to specific causes. In Ghana, autopsies remain the appropriate option for determining the cause of deaths occurring in homes and those occurring within 48 hours after admission into health facilities. Although these organ-based autopsies may generate convincing results and are considered the gold standard tools for ascertainments of causes of death, procedural and practical constraints could limit the extent to which autopsy results can be accepted and/or trusted. The objective of our study was to identify and characterise the procedural and practical constraints as well as to assess their potential effects on autopsy outcomes in Ghana. We interviewed 10 Ghanaian pathologists and collected and evaluated procedural manuals and operational procedures for the conduct of autopsies. A characterisation of the operational constraints and the Delphi analysis of their potential influence on the quality of mortality data led to a quantification of the validity threats as moderate (average expert panel score = 1) in the generality of the autopsy operations in Ghana. On the basis of the impressions of the expert panel, it was concluded that mortality data generated from autopsies in urban settings in Ghana were of sufficiently high quality to guarantee valid use in health analysis.

Assessing the relationship between socioeconomic conditions and urban environmental quality in Accra, Ghana.

The influence of socioeconomic status (SES) on health inequalities is widely known, but there is still poor understanding of the precise relationship between area-based socioeconomic conditions and neighborhood environmental quality. This study aimed to investigate the socioeconomic conditions which predict urban neighbourhood environmental quality. The results showed wide variation in levels of association between the socioeconomic variables and environmental conditions, with strong evidence of a real difference in environmental quality across the five socioeconomic classes with respect to total waste generation (p < 0.001), waste collection rate (p < 0.001), sewer disposal rate (p < 0.001), non-sewer disposal (p < 0.003), the proportion of households using public toilets (p = 0.005). Socioeconomic conditions are therefore important drivers of change in environmental quality and urban environmental interventions aimed at infectious disease prevention and control if they should be effective could benefit from simultaneous implementation with other social interventions.

A Study of Autopsy Procedures in Ghana: Implications for the Use of Autopsy Data in Epidemiological Analyses

The study of cause of death certification remains a largely neglected field in many developing countries; including Ghana. Yet; mortality information is crucial for establishing mortality patterns over time and for estimating mortality attributed to specific causes. In Ghana; in deaths occurring in homes and those occurring within 48 hours after admission into health facilities; autopsies remain the appropriate option for determining the cause of death. Although these organ-based autopsies may generate convincing results and are considered the `gold standard' tools for ascertainments of causes of death; procedural and practical constraints could limit the extent to which autopsy results can be accepted and/or trusted. The objective of our study was to identify and characterise the procedural and practical constraints as well as to assess their potential effects on autopsy outcomes in Ghana. We interviewed 10 Ghanaian pathologists and collected and evaluated procedural manuals and operational procedures for the conduct of autopsies. A characterisation of the operational constraints and the Delphi analysis of their potential influence on the quality of mortality data led to a quantification of the validity threats as moderate (average expert panel score = 1) in the generality of the autopsy operations in Ghana. On the basis of the impressions of the expert panel; it was concluded that mortality data generated from autopsies in urban settings in Ghana were of sufficiently high quality to guarantee valid use in health analysis

Review of the Structure and Function of Vital Registration System in Ghana: Towards Improvement in Mortality Data Quality for Health Policy Analysis

Vital registration systems (VRS) are important in the collection of routine data on indicators of development. These are particularly useful if they are properly built to address weaknesses in the system leading to poor data quality. For instance; routine data on health events (e.g. morbidity; mortality etc.) are crucial for rapid assessment of disease burden and mortality trends in the population. They are also useful in the identification of vulnerable groups in populations. Despite their usefulness; VRS in many developing countries including Ghana are poorly structured raising questions about the quality of the output data from these systems. The present study aimed at assessing and documenting the structure and function of the VRS in Ghana; as well as at identifying the structural features that potentially compromise the reliability and validity of the output data the system. To perform this study; collection and review of policy and legal documents establishing the VRS; documentation and evaluation of component structures of the system; assessment of procedural protocols guiding data collection processes and in-depth interviews with staff at the Ghana Births and Deaths Registry were performed. The assessment of the structure of the Ghana VRS; policy documents setting it up and the operational procedures reveals important lapses (e.g. presence of outmoded practices; imperfections in Births and Deaths Registry Act; 1965; Act 301 and imperfect system design) in the system that could compromise validity and reliability of the data generated from the registration in Ghana

Malaria incidence and efficacy of intermittent preventive treatment in infants (IPTi).

BACKGROUND: Intermittent preventive antimalarial treatment in infants (IPTi) is currently evaluated as a malaria control strategy. Among the factors influencing the extent of protection that is provided by IPTi are the transmission intensity, seasonality, drug resistance patterns, and the schedule of IPTi administrations. The aim of this study was to determine how far the protective efficacy of IPTi depends on spatio-temporal variations of the prevailing incidence of malaria. METHODS: One thousand seventy infants were enrolled in a registered controlled trial on the efficacy of IPTi with sulphadoxine-pyrimethamine (SP) in the Ashanti Region, Ghana, West Africa (ClinicalTrial.gov: NCT00206739). Stratification for the village of residence and the month of birth of study participants demonstrated that the malaria incidence was dependent on spatial (range of incidence rates in different villages 0.6-2.0 episodes/year) and temporal (range of incidence rates in children of different birth months 0.8-1.2 episodes/year) factors. The range of spatio-temporal variation allowed ecological analyses of the correlation between malaria incidence rates, anti-Plasmodium falciparum lysate IgG antibody levels and protective efficacies provided by IPTi. RESULTS: Protective efficacy of the first SP administration was positively correlated with malaria incidences in children living in a distinct village or born in a distinct month (R2 0.48, p < 0.04 and R2 0.63, p < 0.003, respectively). Corresponding trends were seen after the second and third study drug administration. Accordingly, IgG levels against parasite lysate increased with malaria incidence. This correlation was stronger in children who received IPTi, indicating an effect modification of the intervention. CONCLUSION: The spatial and temporal variations of malaria incidences in a geographically and meteorologically homogeneous study area exemplify the need for close monitoring of local incidence rates in all types of intervention studies. The increase of the protective efficacy of IPTi with malaria incidences may be relevant for IPTi implementation strategies and, possibly, for other malaria control measures.

Capillary refill time as an independent prognostic indicator in severe and complicated malaria.

OBJECTIVES: To improve algorithms for the identification of children at risk of dying of malaria in endemic areas. STUDY DESIGN: In a prospective study of 2446 children with severe and complicated malaria admitted to a tertiary referral center in Ghana, West Africa, 12 clinical and laboratory signs were evaluated as indicators of death. RESULTS: A prolonged (> 2 seconds) capillary refill time (pCRT) was identified as an independent prognostic indicator of death along with acidosis, coma, and respiratory distress. Among the clinical signs, pCRT increased the risk of dying from 4-fold to 11-fold when present in addition to coma and respiratory distress. CONCLUSIONS: The recognition of pCRT as an independent indicator of death justifies its inclusion as a defining criterion of severe and complicated malaria and improves the use of clinical examinations in the triage of patients with malaria. As pCRT has been shown to reflect circulatory disturbances in children, it should be included in upcoming studies as a possible sign to indicate the need for intravenous fluid administration.