Prevalence and correlates of diarrhoea among children under five in selected coastal communities in Ghana.

INTRODUCTION: Diarrhoea is a preventable disease affecting children under five years disproportionately. Globally, thousands of children die from diarrhoea related diseases each year, most deaths occuring in sub-Saharan Africa where Ghana is located. Coastal communities bear the greatest brunt due to poor sanitary conditions. We assess the prevalence of diarrhoea in selected coastal communities along the eastern coast of Ghana. METHODS: We conducted a cross-sectional study in Mumford, Opetekwei, Anyako, Anyauni and Ateteti communities in the Central, Greater Accra and Volta region respectively. We interviewed households with children under five years on the occurrence of diarrhoea and health seeking practices. We also used a checklist to assess the sanitary conditions of the household. Frequencies and proportions were generated. We determined significant differences using modified Poisson regression models at p < 0.05. Results were presented in tables and text. RESULTS: The prevalence ratio of diarrhoea was 36% (95% CI 33-40%). Most cases were from Anyako community. All interviewed households in Mumford and Opetekwei used improved water sources whiles 94% in Atetetio used improved water sources. Children who were fully vaccinated had 32% lower prevalence of diarrhoea compared to those who were not (aPR: 0.68, 95% CI 0.55-0.84). CONCLUSION: Diarrhoea prevalence was high inspite of the reported use of improved water sources and sanitation facilities by majority of households in the communities. Fully vaccinated children had a relatively lower prevalence of diarrhoea compared to children who were not fully vaccinated. We recommend in-depth analysis of the use of water and sanitation facilities in these settings to understand the reasons for the observed diarrhoea prevalence.

A study to evaluate WASH interventions and risk factors of diarrhoea among children under five years, Anloga district, Ghana: A research protocol.

INTRODUCTION: Good Water, Sanitation and Hygiene (WASH) practices, introduction of Rotavirus vaccination, zinc supplementation and improved nutrition have contributed significantly to the reduction of diarrhoea morbidity and mortality globally by 50%. In spite of these gains, diarrhoea still remains a leading cause of morbidity and mortality in children under-five. Causes of diarrhoea are multifaceted with many factors such as seasonality, behaviour, pathogenicity, epidemiology, etc. However, assessments on the causes of diarrhoea have generally been tackled in silos over the years focusing only on particular causes. In this study, we describe an integrated approach (evaluating WASH interventions implantation processes, assessing epidemiolocal risk factors, and identifying pathogens causing diarrhoea) for assessing determinants of diarrhoea. METHODS: The study has ethical approval from the Ghana Health Service Ethical Review Committee (GHSERC:020/07/22). It will employ three approaches; a process evaluation and a case-control study and laboratory analysis of diarrhoea samples. The process evaluation will assess the detailed procedures taken by the Anloga district to implement WASH interventions. A desk review and qualitative interviews with WASH stakeholders purposively sampled will be done. The evaluation will provide insight into bottlenecks in the implementation processes. Transcribed interviews will be analysed thematically and data triangulated with reviews. A 1:1 unmatched case-control study with 206 cases and 206 controls to determine risk factors associated with diarrhoea in children under-five will also be done. Odds ratios at 5.0% significance level would be calculated. Stool samples of cases will be taken and tested for diarrhoea pathogens using Standard ELISA and TAQMAN Array Card laboratory procedures. EXPECTED OUTCOME: It is expected that this framework proposed would become one of the robust approaches for assessing public health community interventions for diseases. Through the process evaluation, epidemiological case-control study and pathogen identification, we would be able to identify the gaps in the current diarrhoea assessments, come up with tailored recommendations considering the existing risk and assumptions and involve the relevant stakeholders in reducing the diarrhoea burden in a coastal setting in Ghana.

Dam-mediated flooding impact on outpatient attendance and diarrhoea cases in northern Ghana: a mixed methods study.

BACKGROUND: Floods are the most frequently occurring natural disaster and constitute a significant public health risk. Several operational satellite-based flood detection systems quantify flooding extent, but it is unclear how far the choice of satellite-based flood product affects the findings of epidemiological studies of associated public health risks. Few studies of flooding's health impacts have used mixed methods to enrich understanding of these impacts. This study therefore aims to evaluate the relationship between two satellite-derived flood products with outpatient attendance and diarrhoeal disease in northern Ghana, identifying plausible reasons for observed relationships via qualitative interviews. METHODS: A convergent parallel mixed methods design combined an ecological time series with focus group discussions and key informant interviews. Through an ecological time series component, monthly outpatient attendance and diarrhoea case counts from health facilities in two flood-prone districts for 2016-2020 were integrated with monthly flooding map layers classified via the Moderate Resolution Imaging Spectroradiometer (MODIS) and Landsat satellite sensors. The relationship between reported diarrhoea and outpatient attendance with flooding was examined using Poisson regression, controlling for seasonality and facility catchment population. Four focus group discussions with affected community members and four key informant interviews with health professionals explored flooding's impact on healthcare delivery and access. RESULTS: Flooding detected via Landsat better predicted outpatient attendance and diarrhoea than flooding via MODIS. Outpatient attendance significantly reduced as LandSat-derived flood area per facility catchment increased (adjusted Incidence Rate Ratio = 0.78, 95% CI: 0.61-0.99, p < 0.05), whilst reported diarrhoea significantly increased with flood area per facility catchment (adjusted Incidence Rate Ratio = 4.27, 95% CI: 2.74-6.63, p < 0.001). Key informants noted how flooding affected access to health services as patients and health professionals could not reach the health facility and emergency referrals were unable to travel. CONCLUSIONS: The significant reduction in outpatient attendance during flooding suggests that flooding impairs healthcare delivery. The relationship is sensitive to the choice of satellite-derived flood product, so future studies should consider integrating multiple sources of satellite imagery for more robust exposure assessment. Health teams and communities should plan spatially targeted flood mitigation and health system adaptation strategies that explicitly address population and workforce mobility issues.

Earth System's Gatekeeping of "One Health" Approach to Manage Climate-Sensitive Infectious Diseases.

Global response to climate-sensitive infectious diseases has been uncertain and slow. The understanding of the underlying vulnerabilities which forms part of changes created by forces within the Earth system has never before been critical until the coronavirus disease 2019, "COVID-19" pandemic with the initial developmental phase linked to weather elements and climate change. Hence, the heightened interest in climate-sensitive infectious diseases and GeoHealth, evident in the renewed calls for "One Health" approach to disease management. "One Health" explains the commonality of human and animal medicine, and links to the bio-geophysical environment, yet are at crossroads with how forces within the Earth system shape etiologies, incidences, and transmission dynamics of infectious diseases. Hence, the paper explores how these forces, which are multistage and driven by climate change impacts on ecosystems affect emerging infectious diseases, leading to the question "what drive the drivers of diseases?" Three questions that challenge broad theories of Earth system science on boundaries and connectivity emerged to guide study designs to further interrogating disease surveillance and health early warning systems. This is because, climate change (a) drives prevailing biological health hazards as part of forces within the Earth system, (b) shifts disease control services of ecosystems and functioning to effectively regulate disease incidence, and (c) modifies pathogen-species hosts relationships. Hence, the need to rethink pluralistic concepts of climate-sensitive diseases in their infection and management from a GeoHealth perspective, which "One Health" potentially conveys, and to also maintain ecosystem health.

Increased flooded area and exposure in the White Volta river basin in Western Africa, identified from multi-source remote sensing data.

Accurate information on flood extent and exposure is critical for disaster management in data-scarce, vulnerable regions, such as Sub-Saharan Africa (SSA). However, uncertainties in flood extent affect flood exposure estimates. This study developed a framework to examine the spatiotemporal pattern of floods and to assess flood exposure through utilization of satellite images, ground-based participatory mapping of flood extent, and socio-economic data. Drawing on a case study in the White Volta basin in Western Africa, our results showed that synergetic use of multi-temporal radar and optical satellite data improved flood mapping accuracy (77% overall agreement compared with participatory mapping outputs), in comparison with existing global flood datasets (43% overall agreement for the moderate-resolution imaging spectroradiometer (MODIS) Near Real-Time (NRT) Global Flood Product). Increases in flood extent were observed according to our classified product, as well as two existing global flood products. Similarly, increased flood exposure was also observed, however its estimation remains highly uncertain and sensitive to the input dataset used. Population exposure varied greatly depending on the population dataset used, while the greatest farmland and infrastructure exposure was estimated using a composite flood map derived from three products, with lower exposure estimated from each flood product individually. The study shows that there is considerable scope to develop an accurate flood mapping system in SSA and thereby improve flood exposure assessment and develop mitigation and intervention plans.

Species composition and risk of transmission of some Aedes-borne arboviruses in some sites in Northern Ghana.

Aedes-borne viral diseases mainly Yellow Fever (YF), Dengue (DEN), Zika (ZIK) and Chikungunya (CHK) have contributed to many deaths' in the world especially in Africa. There have been major outbreaks of these diseases in West Africa. Although, YF outbreaks have occurred in Ghana over the years, no outbreak of DEN, ZIK and CHK has been recorded. However, the risk of outbreak is high due to its proximity to West African countries where outbreaks have been recently been recorded. This study surveyed the mosquito fauna to assess the risk of transmission of Yellow fever (YFV), Dengue (DENV), Chikungunya (CHKV) and Zika (ZIKV) viruses in Larabanga and Mole Game Reserve areas in Northern Ghana. The immature and adult stages of Aedes mosquitoes were collected from Larabanga and Mole Game Reserve area. There was a significant (P>0.001) number of mosquitoes collected during the rainy season than the dry season. A total of 1,930 Aedes mosquitoes were collected during the rainy season and morphologically identified. Of these, 1,915 (99.22%) were Aedes aegypti and 15 (0.22%) were Aedes vittatus. During the dry season, 27 Ae. aegypti mosquitoes were collected. A total of 415 Ae. aegypti mosquitoes were molecularly identified to subspecies level of which Ae. (Ae) aegypti aegypti was the predominant subspecies. Both Ae. aegypti aegypti and Ae aegypti formosus exist in sympatry in the area. All Aedes pools (75) were negative for DENV, ZIKV and CHKV when examined by RT- PCR. Three Larval indices namely House Index, HI (percentage of houses positive for Aedes larvae or pupae), Container Index, CI (the percentage of containers positive for Aedes larvae or pupae) and Breteau Index, BI (number of positive containers per 100 houses inspected) were assessed as a measure for risk of transmission in the study area. The HI, CI and BI for both sites were as follows; Mole Game Reserve (HI, 42.1%, CI, 23.5% and BI, 100 for rainy season and 0 for all indices for dry season) and Larabanga (39%, 15.5% and 61 for rainy season and 2.3%, 1.3% and 2.3 for dry season). The spatial distribution of Aedes breeding sites in both areas indicated that Aedes larvae were breeding in areas with close proximity to humans. Lorry tires were the main source of Aedes larvae in all the study areas. Information about the species composition and the potential role of Aedes mosquitoes in future outbreaks of the diseases that they transmit is needed to design efficient surveillance and vector control tools.

The Incidence, Intensity, and Risk Factors for Soil Transmissible Helminthes Infections among Waste Handlers in a Large Coastal Periurban Settlement in Southern Ghana.

Soil-transmissible helminthes (STH) infections are among the most common sanitation-related public health problems in poor periurban settlements of tropical regions of low- and middle-income countries. In Ghana, research studies documenting the incidence rate, intensity, and occupational risk factors of STH infections among adults are scanty. A prospective cohort study of 261 waste handlers was conducted to investigate this. Stool samples were collected after 90 and 180 days of treatment with albendazole (400 mg per dose). The geometric mean intensity of STH among waste handlers after 180 days of treatment was 2.8 eggs/gram (light intensity), with an incidence rate of 1.5%. The proportion of waste handlers with light intensity STH infections was 4.8%. The odds of STH infection among female waste handlers were 80% lower when compared with male waste handlers (aOR = 0.2; 95% CI: 0.0-0.8). Waste handlers who used rubber gloves when working were 80% (aOR = 0.2: 95% CI: 0.2-1.9) protected from STH infections compared with those who did not use gloves. Infections with STH among the 261 waste handlers significantly correlated with the type of waste handling activities (LR χ 2 = 15.3; p=0.033) with the highest proportion of infection found among transporters, 2 (40%). Waste handlers should receive periodic antihelminthic treatment, at least once every six months, practice adequate hand hygiene, and use suitable personal protective equipment during work.

An Assessment of Inter-Observer Agreement in Water Source Classification and Sanitary Risk Observations.

Sanitary risk inspection, an observation protocol for identifying contamination hazards around water sources, is promoted for managing rural water supply safety. However, it is unclear how far different observers consistently identify contamination hazards and consistently classify water source types using standard typologies. This study aimed to quantify inter-observer agreement in hazard identification and classification of rural water sources. Six observers separately visited 146 domestic water sources in Siaya County, Kenya, in wet and dry seasons. Each observer independently classified the source type and conducted a sanitary risk inspection using a standard protocol. Water source types assigned by an experienced observer were cross-tabulated against those of his colleagues, as were contamination hazards identified, and inter-observer agreement measures calculated. Agreement between hazards observed by the most experienced observer versus his colleagues was significant but low (intra-class correlation = 0.49), with inexperienced observers detecting fewer hazards. Inter-observer agreement in classifying water sources was strong (Cohen's kappa = 0.84). However, some source types were frequently misclassified, such as sources adapted to cope with water insecurity (e.g. tanks drawing on both piped and rainwater). Observers with limited training and experience thus struggle to consistently identify hazards using existing protocols, suggesting observation protocols require revision and their implementation should be supported by comprehensive training. Findings also indicate that field survey teams struggle to differentiate some water source types based on a standard water source classification, particularly sources adapted to cope with water insecurity. These findings demonstrate uncertainties underpinning international monitoring and analyses of safe water access via household surveys.

Risk of faecal pollution among waste handlers in a resource-deprived coastal peri-urban settlement in Southern Ghana.

Resource-deprived coastal peri-urban settlements in Southern Ghana are characterized by indiscriminate solid waste disposal and open defecation practices. Persons engaged in waste handling in such communities perform their activities with little or no personal protective equipment. They are thus confronted with the risk of faecal pollution of the hands and other bodily parts. A mixed method approach was used to investigate 280 waste handlers performing different activities to estimate recent faecal pollution of their hands and to observe the utilization of personal protective equipment and sanitation/hygiene facilities during work. The log concentration of E. coli on hands of waste handlers after work (8.60 ± 4.20 CFU/hand, mean ± standard deviation) was significantly higher compared with the E. coli log concentration before work (2.95 ± 1.89 CFU/hand, mean ± standard deviation) (p<0.001). The odds of faecal pollution was significantly higher (aOR 4.2; 95% CI: 1.9-9.1) for workers aged 35 years and above compared with those less than 35 years; and for workers at public toilet facilities (aOR 3.0; 95% CI: 1.0-8.4) compared with those who worked for private waste handling companies. Female workers were, however, 60% less likely (aOR 0.4; 95% CI: 0.2-0.8) to experience faecal pollution of their hands compared with males. The workers had limited access to water and sanitation and hygiene facilities, and about one-fifth (n = 59; 21.1%) did not use personal protective equipment during work. Waste handlers should be provided and instructed in proper use of personal protective equipment, have access to sanitation facilities and adopt improved hygiene behaviour to avoid the risk of faecal pollution and associated disease risk.

The effect of occupational stress on depression and insomnia: a cross-sectional study among employees in a Ghanaian telecommunication company.

BACKGROUND: Depression and insomnia are major psychiatric conditions predicted by occupational stress. However, the influence of occupational stress on these two conditions is under-explored in telecommunication companies, especially in Africa. This research was conducted to assess occupational stress in a Ghanaian telecommunication company and its effect on depression and insomnia. METHODS: An analytical cross-sectional study was conducted among employees at a telecommunication company in Accra. Structured self-administered questionnaires were used in collecting data from 235 respondents using simple random sampling. The Chi-square test of independence and Wilcoxon Rank-Sum test were employed to assess the significance of associations with subsequent sensitivity analysis using Multiple logistic, Poisson and Probit regression models. Occupational stress was matched on four variables: age of the workers, marital status, responsibility for dependents and work experience, to improve on the estimation of its impact on symptomatic depression and insomnia using the coarsened exact matching procedure. RESULTS: More males (52.8%) than females participated in this study. The age range for study participants was 20-49 years with a mean of 30.8 ± 6.9 years. The prevalence of excessive occupational stress reported by the employees was 32.8% (95% CI = 26.7-38.8). More than half of respondents (51%) reported depressive symptoms in the past week and only a few (6%) reported being diagnosed with insomnia in the past year. Age, responsibility for dependents and work experience were the only background characteristics that were significantly associated with excessive occupational stress. After controlling for background characteristics, the estimated risk of reporting symptoms of depression among employees who reported excessive stress from work was only 5% higher [ARR; 95% CI = 1.05 (0.94-1.17)] whereas it was 2.58 times the risk of reporting insomnia [ARR; 95% CI = 2.58(0.83-8.00)] compared to those who did not report excessive stress from their jobs. The relative risk reduced to 2.46[ARR; 95% CI = 2.46(0.77-7.87)] and 1.03[ARR; 95% CI = 1.03(0.91-1.17)] for insomnia and depression respectively after employing Poisson regression with CEM. CONCLUSION: The study found a higher risk of insomnia among employees who reported excessive occupational stress compared to those who did not. However, this study did not find a statistically significant relationship between depression and occupational stress.

Spatiality in Health: The Distribution of Health Conditions Associated with Electronic Waste Processing Activities at Agbogbloshie, Accra.

Background: A walk through the Agbogbloshie e-waste recycling site shows a marked heterogeneity in the spatial distribution of the different e-waste processing activities, which are likely to drive clustering of health conditions associated with the different activity type in each space. Objective of study: To conduct a spatial assessment and analysis of health conditions associated with different e-waste activities at different activity spaces at Agbogbloshie. Methods: A choropleth showing the various activity spaces at the Agbogbloshie e-waste site was produced by mapping boundaries of these spaces using Etrex GPS device and individuals working in each activity spaces were recruited and studied. Upon obtaining consent and agreeing to participate in the study, each subject was physically examined and assessed various health outcomes of interest via direct physical examination while characterizing and enumerating the scars, lacerations, abrasions, skin condition and cuts after which both systolic and diastolic blood pressure values were recorded alongside the administration of open and close ended questionnaires. All individuals working within each activity space and consented to participate were recruited; giving a total of one hundred and twelve (112) subjects in all. Results: A study of the choropleth showed that health conditions associated e-waste processing activities were clustered in a fashion similar to the corresponding distribution of each activity. While a total of 96.2% of all the study subjects had cuts, the dismantlers had higher mix of scars, lacerations and abrasions. Abrasions were observed in 16.3% of the dismantlers. Scars were the most common skin condition and were observed on the skins of 93.6% of the subjects. Prevalence of burns among the study subjects was 23.1%. Developing hypertension was not associated with activity type and while a total of 90.2% of subjects had normal blood pressure and 9.8% of them were hypertensives. Finally, 98.2% of respondents felt the need to have a first aid clinic at the site with 96.4% and 97.3% willing to visit the clinic and pay for services respectively. Conclusion: We conclude that while the observed injuries were random and were due purely to accidents without any role of spatial determinants such as the configuration, slope, topography and other subterranean features of the activity spaces, a strong association between the injuries and activity type was observed.

Knowledge and Health Seeking Behaviour of Breast Cancer Patients in Ghana.

BACKGROUND: Breast cancer is a major contributor to cancer-related deaths among women worldwide, despite the numerous measures employed to prevent and manage the disease. This study explored the knowledge and health seeking behaviour of breast cancer patients at the Komfo Anokye Teaching Hospital. METHODS: A descriptive cross-sectional study was conducted at Komfo Anokye Teaching Hospital in Kumasi, Ghana, from June 2014 to July 2014. Thirty-five participants were purposively selected. The responses to questions about their experiences with breast cancer were determined using indepth interviews. Transcripts were coded and analysed using NVIVO version 10.0. RESULTS: Participants' knowledge about signs and symptoms of breast cancer after their diagnosis was high but low for risk factors. Screening for breast cancer through self-breast examination was infrequently performed prior to their diagnosis. The patients' first point of care was generally health facilities. Some patients reported late due to misinterpretation of signs and symptoms, cultural influences and fear of losing their breast to surgery, physician delay, health providers' laxity, and disinterest in breast cancer. Men, for example, husbands, decide on where and when breast cancer patients go for treatment. CONCLUSION: There is poor knowledge of the risk factors for developing breast cancer. Patients resorted to the hospital as first options for cure but were generally delayed in doing so. There is the need to create awareness about breast cancer among the general population.

Inducible nitric oxide synthase 2 promoter polymorphism and malaria disease severity in children in Southern Ghana.

OBJECTIVE: We assessed the association of mutant allele frequencies of nitric oxide synthase 2 (NOS2) gene at two SNPs (-954 and -1173) with malaria disease severity in children from a malaria endemic area in Southern Ghana. METHOD: Using children recruited at the hospital, assigned into clinical subgroups of uncomplicated and severe malaria and matching with their "healthy control" counterparts, we designed a case control study. Genomic DNA was extracted and genotyping using Restriction Fragment Polymorphism was done. RESULT: A total of 123 malaria cases (91 uncomplicated, 32 severe) and 100 controls were sampled. Their corresponding mean Hbs were 9.6, 9.3 and 11.2g/dl and geometric mean parasite densities of 32097, 193252 and 0 parasites/ml respectively. Variant allele frequencies varied from 0.09 through 0.03 to 0.12 for G-954C and 0.06 through 0.03 to 0.07 for C-1173T in the uncomplicated, severe and healthy control groups respectively. There was a strong linkage disequilibrium between the two alleles (p<0.001). For the -954 position, the odds of developing severe malaria was found to be 2.5 times lower with the carriage of a C allele compared to those without severe malaria (χ2; p< 0.05) though this isn't the case with -1173. CONCLUSION: The carriage of a mutant allele in the -954 NOS2 gene may have a protective effect on malaria among Southern Ghanaian children.

Environmental surveillance for Vibrio cholerae in selected households' water storage systems in Accra Metropolitan Area (AMA) prior to the 2014 cholera outbreak in Accra, Ghana.

Cholera is a global public health problem with high endemicity in many developing countries in Africa. In 2014, Ghana experienced its largest epidemic with more than 20,000 cases and 200 deaths; most of it occurred in the Accra Metropolitan Area (AMA). Ghana's disease surveillance system is mainly clinically based and focused on case detection and management. Environmental exploration for the etiological agents is missing from the surveillance strategy. This study therefore assessed the occurrence of toxigenic Vibrio cholerae in water storage systems in selected high risk areas in the AMA area prior to the 2014 outbreak. Three hundred twenty water samples from 80 households' water storage systems were analyzed for toxigenic Vibrio cholerae using the bacterial culture method. Presumptive V. cholerae was isolated from 83.8% of households' water storage systems. The viable cells ranged from 1 to 1400 CFU/100 ml. Vibrio cholerae O1 serotype was isolated from five households in Old Fadama, one household in Shiabu, and one household in Bukom in the month of May and a similar trend was observed for the months of June and July. The presence of Vibro cholerae in the water storage vessels used for drinking confirms the need to consider environmental surveillance for toxigenic Vibro cholerae particularly in high-risk areas to strengthen the existing surveillance system.

Livestock ownership and microbial contamination of drinking-water: Evidence from nationally representative household surveys in Ghana, Nepal and Bangladesh.

BACKGROUND: Current priorities for diarrhoeal disease prevention include use of sanitation and safe water. There have been few attempts to quantify the importance of animal faeces in drinking-water contamination, despite the presence of potentially water-borne zoonotic pathogens in animal faeces. OBJECTIVES: This study aimed to quantify the relationship between livestock ownership and point-of-consumption drinking-water contamination. METHODS: Data from nationally representative household surveys in Nepal, Bangladesh, and Ghana, each with associated water quality assessments, were used. Multinomial regression adjusting for confounders was applied to assess the relationship between livestock ownership and the level of drinking-water contamination with E. coli. RESULTS: Ownership of five or more large livestock (e.g. cattle) was significantly associated with drinking-water contamination in Ghana (RRR=7.9, 95% CI=1.6 to 38.9 for medium levels of contamination with 1-31cfu/100ml; RRR=5.2, 95% CI=1.1-24.5 for high levels of contamination with >31cfu/100ml) and Bangladesh (RRR=2.4, 95% CI=1.3-4.5 for medium levels of contamination; non-significant for high levels of contamination). Ownership of eight or more poultry (chickens, guinea fowl, ducks or turkeys) was associated with drinking-water contamination in Bangladesh (RRR=1.5, 95% CI=1.1-2.0 for medium levels of contamination, non-significant for high levels of contamination). CONCLUSIONS: These results suggest that livestock ownership is a significant risk factor for the contamination of drinking-water at the point of consumption. This indicates that addressing human sanitation without consideration of faecal contamination from livestock sources will not be sufficient to prevent drinking-water contamination.

Sensitivity of health sector indicators' response to climate change in Ghana.

There is accumulating evidence that the emerging burden of global climate change threatens the fidelity of routine indicators for disease detection and management of risks to public health. The threat partially reflects the conservative character of the health sector and the reluctance to adopt new indicators, despite the growing awareness that existing environmental health indicators were developed to respond to risks that may no longer be relevant, and are too simplistic to also act as indicators for newer global-scale risk factors. This study sought to understand the scope of existing health indicators, while aiming to discover new indicators for building resilience against three climate sensitive diseases (cerebro spinal meningitis, malaria and diarrhea). Therefore, new potential indicators derived from human and biophysical origins were developed to complement existing health indicators, thereby creating climate-sensitive battery of robust composite indices of resilience in health planning. Using Ghana's health sector as a case study systematic international literature review, national expert consultation, and focus group outcomes yielded insights into the relevance, sensitivity and impacts of 45 indicators in 11 categories in responding to climate change. In total, 65% of the indicators were sensitive to health impacts of climate change; 24% acted directly; 31% synergistically; and 45% indirectly, with indicator relevance strongly associated with type of health response. Epidemiological indicators (e.g. morbidity) and health demographic indicators (e.g. population structure) require adjustments with external indicators (e.g. biophysical, policy) to be resilient to climate change. Therefore, selective integration of social and ecological indicators with existing public health indicators improves the fidelity of the health sector to adopt more robust planning of interdependent systems to build resilience. The study highlights growing uncertainties in translating research into protective policies when new indicators associated with non-health sources are needed to complement existing health indicators that are expected to respond to climate change.

Minimising invasiveness in diagnostics: developing a rapid urine-based monoclonal antibody dipstick test for malaria.

OBJECTIVE: To generate monoclonal antibodies (MAbs) for developing a rapid malaria diagnostic urine-based assay (RUBDA), using Plasmodium-infected human urinary antigens. METHODS: Plasmodium-infected human urinary (PAgHU) and cultured parasite (CPfAg) antigens were used to generate mouse MAbs. The reactivity and accuracy of the MAbs produced were then evaluated using microplate ELISA, SDS-PAGE, Western blotting assay, microscopy and immunochromatographic tests. RESULTS: Ninety-six MAb clones were generated, of which 68.8% reacted to both PAgHU and CPfAg, 31.3% reacted to PAgHU only, and none reacted to CPfAg only. One promising MAb (UCP4W7) reacted in WBA, to both PAgHU and CPfAg, but not to Plasmodium-negative human urine and blood, Schistosoma haematobium and S. mansoni antigens nor measles and poliomyelitis vaccines. CONCLUSION: MAb UCP4W7 seems promising for diagnosing Plasmodium infection. Urine is a reliable biomarker source for developing non-invasive malaria diagnostic tests. SDS-PAGE and MAb-based WBA appear explorable in assays for detecting different levels of Plasmodium parasitaemia.

Subsidized Sachet Water to Reduce Diarrheal Disease in Young Children: A Feasibility Study in Accra, Ghana.

Use of drinking water sold in plastic bags (sachet water) is growing rapidly in west Africa. The impact on water consumption and child health remains unclear, and a debate on the taxation and regulation of sachet water is ongoing. This study assessed the feasibility of providing subsidized sachet water to low-income urban households in Accra and measured the resultant changes in water consumption. A total of 86 children, 6-36 months of age in neighborhoods lacking indoor piped water, were randomized to three study arms. The control group received education about diarrhea. The second arm received vouchers for 15 L/week/child of free water sachets (value: $0.63/week) plus education. The third arm received vouchers for the same water sachet volume at half price plus education. Water consumption was measured at baseline and followed for 4 months thereafter. At baseline, 66 of 81 children (82%) drank only sachet water. When given one voucher/child/week, households redeemed an average 0.94 vouchers/week/child in the free-sachet-voucher arm and 0.82 vouchers/week/child in the half-price arm. No change in water consumption was observed in the half-price arm, although the study was not powered to detect such differences. In the free-sachet-voucher arm, estimated sachet water consumption increased by 0.27 L/child/day (P = 0.03). The increase in sachet water consumption by children in the free-sachet-voucher arm shows that provision of fully subsidized water sachets might improve the quality of drinking water consumed by children. Further research is needed to quantify this and any related child health impacts.

Effects of Sachet Water Consumption on Exposure to Microbe-Contaminated Drinking Water: Household Survey Evidence from Ghana.

There remain few nationally representative studies of drinking water quality at the point of consumption in developing countries. This study aimed to examine factors associated with E. coli contamination in Ghana. It drew on a nationally representative household survey, the 2012-2013 Living Standards Survey 6, which incorporated a novel water quality module. E. coli contamination in 3096 point-of-consumption samples was examined using multinomial regression. Surface water use was the strongest risk factor for high E. coli contamination (relative risk ratio (RRR) = 32.3, p < 0.001), whilst packaged (sachet or bottled) water use had the greatest protective effect (RRR = 0.06, p < 0.001), compared to water piped to premises. E. coli contamination followed plausible patterns with digit preference (tendency to report values ending in zero) in bacteria counts. The analysis suggests packaged drinking water use provides some protection against point-of-consumption E. coli contamination and may therefore benefit public health. It also suggests viable water quality data can be collected alongside household surveys, but field protocols require further revision.

Little Polymorphism at the K13 Propeller Locus in Worldwide Plasmodium falciparum Populations Prior to the Introduction of Artemisinin Combination Therapies.

The emergence and spread of artemisinin-resistant Plasmodium falciparum is of huge concern for the global effort toward malaria control and elimination. Artemisinin resistance, defined as a delayed time to parasite clearance following administration of artemisinin, is associated with mutations in the Pfkelch13 gene of resistant parasites. To date, as many as 60 nonsynonymous mutations have been identified in this gene, but whether these mutations have been selected by artemisinin usage or merely reflect natural polymorphism independent of selection is currently unknown. To clarify this, we sequenced the Pfkelch13 propeller domain in 581 isolates collected before (420 isolates) and after (161 isolates) the implementation of artemisinin combination therapies (ACTs), from various regions of endemicity worldwide. Nonsynonymous mutations were observed in 1% of parasites isolated prior to the introduction of ACTs. Frequencies of mutant isolates, nucleotide diversity, and haplotype diversity were significantly higher in the parasites isolated from populations exposed to artemisinin than in those from populations that had not been exposed to the drug. In the artemisinin-exposed population, a significant excess of dN compared to dS was observed, suggesting the presence of positive selection. In contrast, pairwise comparison of dN and dS and the McDonald and Kreitman test indicate that purifying selection acts on the Pfkelch13 propeller domain in populations not exposed to ACTs. These population genetic analyses reveal a low baseline of Pfkelch13 polymorphism, probably due to purifying selection in the absence of artemisinin selection. In contrast, various Pfkelch13 mutations have been selected under artemisinin pressure.