Detection of Dengue Virus among Children with Suspected Malaria, Accra, Ghana.

We report new molecular evidence of locally acquired dengue virus infections in Ghana. We detected dengue viral RNA among children with suspected malaria by using a multipathogen real-time PCR. Subsequent sequence analysis revealed a close relationship with dengue virus serotype 2, which was implicated in a 2016 outbreak in Burkina Faso.

Assessing the impact of differences in malaria transmission intensity on clinical and haematological indices in children with malaria.

BACKGROUND: Malaria control interventions have led to a decline in transmission intensity in many endemic areas, and resulted in elimination in some areas. This decline, however, will lead to delayed acquisition of protective immunity and thus impact disease manifestation and outcomes. Therefore, the variation in clinical and haematological parameters in children with malaria was assessed across three areas in Ghana with varying transmission intensities. METHODS: A total of 568 children between the ages of 2 and 14 years with confirmed malaria were recruited in hospitals in three areas with varying transmission intensities (Kintampo > Navrongo > Accra) and a comprehensive analysis of parasitological, clinical, haematological and socio-economic parameters was performed. RESULTS: Areas of lower malaria transmission tended to have lower disease severity in children with malaria, characterized by lower parasitaemias and higher haemoglobin levels. In addition, total white cell counts and percent lymphocytes decreased with decreasing transmission intensity. The heterozygous sickle haemoglobin genotype was protective against disease severity in Kintampo (P = 0.016), although this was not significant in Accra and Navrongo. Parasitaemia levels were not a significant predictor of haemoglobin level after controlling for age and gender. However, higher haemoglobin levels in children were associated with certain socioeconomic factors, such as having fathers who had any type of employment (P < 0.05) and mothers who were teachers (P < 0.05). CONCLUSIONS: The findings demonstrate significant differences in the haematological presentation and severity of malaria among areas with different transmission intensity in Ghana, indicating that these factors need to be considered in planning the management of the disease as the endemicity is expected to decline after control interventions.

Malaria case detection using rapid diagnostic test at the community level in Ghana: consumer perception and practitioners' experiences.

BACKGROUND: Ghana has scaled-up malaria control strategies over the past decade. Much as malaria morbidity and mortality seem to have declined with these efforts, there appears to be increased consumption of artemisinin-based combination therapy (ACT). This study explored the perception and experiences of community members and medicines outlet practitioners on malaria case detection using rapid diagnostic test (RDTs) to guide malaria therapy. METHODS: This was a cross-sectional study using both quantitative and qualitative approaches for data. In-depth interviews with structured questionnaires were conducted among 197 practitioners randomly selected from community pharmacies and over-the-counter medicine sellers shops within two metropolis (Kumasi and Obuasi) in the Ashanti Region of Ghana. Two focus group discussions were also held in the two communities among female adult caregivers. RESULTS: Medicine outlet practitioners and community members often used raised body temperature of individuals as an index for malaria case detection. The raised body temperature was presumptively determined by touching the forehead with hands. Seventy percent of the practitioners' perceived malaria RDTs are used in hospitals and clinics but not in retail medicines outlets. Many of the practitioners and community members agreed to the need for using RDT for malaria case detection at medicine outlets. However, about 30% of the practitioners (n = 59) and some community members (n = 6) held the view that RDT negative results does not mean no malaria illness and would use ACT. CONCLUSIONS: Though malaria RDT use in medicines outlets was largely uncommon, both community members and medicine outlet practitioners welcomed its use. Public education is however needed to improve malaria case detection using RDTs at the community level, to inform appropriate use of ACT.

Baseline malaria vector transmission dynamics in communities in Ahafo mining area in Ghana.

BACKGROUND: Malaria vector dynamics are relevant prior to commencement of mining activities. A baseline entomology survey was conducted in Asutifi and Tano (referred to as Ahafo) in the Brong-Ahafo geo-political region of Ghana during preparatory stages for mining by Newmont Ghana Gold Limited. METHODS: Between November 2006 and August 2007, eight Centre for Disease Control light traps were set daily (Monday-Friday) to collect mosquitoes. Traps were hanged in rooms that were selected from a pool of 1,100 randomly selected houses. Types of materials used in construction of houses were recorded and mosquito prevention measures were assessed from occupants. RESULTS: A total of 5,393 mosquitoes were caught that comprised Anopheles gambiae (64.8%), Anopheles funestus (4.2%), as well as Culicines, comprising of Culex (30.4%) and Aedes species (0.6%). The entomological inoculation rate in Asutifi (279 infective bites/person/month) and Tano (487 infective bites/person/month) demonstrate relatively high malaria transmission in Ahafo. The presence or absence of Anopheles vectors in rooms was influenced by the type of roofing material (OR 2.33, 95%CI: 1.29-4.22, p = 0.01) as well as the presence of eaves gaps (OR 1.80, 95%CI: 1.37-2.37, p < 0.01). It was also associated with bed net availability in the room (OR 1.39, 95%CI: 1.08-1.80, p = 0.01). Over 80% of the houses were roofed with corrugated zinc sheets. Over 60% of the houses in Ahafo had no eaves gaps to give access to mosquito entry and exit into rooms and mosquito bed net coverage was over 50%. Other measures used in preventing mosquito bites included; coil (22.1%), insecticide spray (9.4%), repellent cream (4.0%) and smoky fires (1.1%), contributed minimally to individual mosquito preventive measures in impact areas. Similarly, levels of protection; coil (16.9%), insecticide spray (2.8%) and repellent cream (0.3%) for the non-impact areas, depict low individual prevention measures. CONCLUSIONS: The survey identified areas where intensified vector control activities would be beneficial. It also demonstrates that transmission in Asutifi and Tano is high even before the commencement of mining operations. This study serves as baseline information to assess impact of mining activities in relation to future vector control interventions.

Community perceptions of a malaria vaccine in the Kintampo districts of Ghana.

BACKGROUND: Malaria remains the leading cause of morbidity and mortality in sub-Saharan Africa despite tools currently available for its control. Making malaria vaccine available for routine use will be a major hallmark, but its acceptance by community members and health professionals within the health system could pose considerable challenge as has been found with the introduction of polio vaccinations in parts of West Africa. Some of these challenges may not be expected since decisions people make are many a time driven by a complex myriad of perceptions. This paper reports knowledge and perceptions of community members in the Kintampo area of Ghana where malaria vaccine trials have been ongoing as part of the drive for the first-ever licensed malaria vaccine in the near future. METHODS: Both qualitative and quantitative methods were used in the data collection processes. Women and men whose children were or were not involved in the malaria vaccine trial were invited to participate in focus group discussions (FGDs). Respondents, made up of heads of religious groupings in the study area, health care providers, traditional healers and traditional birth attendants, were also invited to participate in in-depth interviews (IDIs). A cross-sectional survey was conducted in communities where the malaria vaccine trial (Mal 047RTS,S) was carried out. In total, 12 FGDs, 15 IDIs and 466 household head interviews were conducted. RESULTS: Knowledge about vaccines was widespread among participants. Respondents would like their children to be vaccinated against all childhood illnesses including malaria. Knowledge of the long existing routine vaccines was relatively high among respondents compared to hepatitis B and Haemophilus influenza type B vaccines that were introduced more recently in 2002. There was no clear religious belief or sociocultural practice that will serve as a possible barrier to the acceptance of a malaria vaccine. CONCLUSION: With the assumption that a malaria vaccine will be as efficacious as other EPI vaccines, community members in Central Ghana will accept and prefer malaria vaccine to malaria drugs as a malaria control tool. Beliefs and cultural practices as barriers to the acceptance of malaria vaccine were virtually unknown in the communities surveyed.

Trends in multiplicity of Plasmodium falciparum infections among asymptomatic residents in the middle belt of Ghana.

BACKGROUND: Malaria is the most important cause of mortality and morbidity in children living in the Kintampo districts in the middle part of Ghana. This study has investigated the multiplicity of infection (MOI) within asymptomatic residents of the Kintampo districts, and the influence of age and seasonality on MOI, by studying the distribution of the polymorphic Plasmodium falciparum antigen merozoite surface protein 2 (MSP2). METHODS: DNA was extracted from an asymptomatic cohort of children and adults infected with P. falciparum during the period November 2003 to October 2004. Polymerase chain reaction was carried out and multiplicity of infection (MOI) was determined. RESULTS: Children under 10 years of age had an average MOI of 2.3 while adults 18 years and above had an average MOI of 1.4. Children below five years had high and low average MOIs of 2.8 in the March/April survey and 0.9 in the May/June survey respectively. A similar trend in the monthly distribution of MOI was observed for the entire cohort. IC/3D7 strains outnumbered the FC27 strains throughout the year by a ratio of about 4:1 with the difference between the prevalence of the two strains being least marked in the March/April survey, at the beginning of the rainy season. MOI was not linked to the level of malaria transmission as measured by the entomological inoculation rate. DISCUSSION/CONCLUSION: The impact of interventions, introduced since this baseline study was carried out on the parasite diversity of asymptomatic residents will be the subject of further investigations.

Prostration and the prognosis of death in African children with severe malaria.

OBJECTIVES: Malaria is still one of the main reasons for hospitalization in children living in sub-Saharan Africa. Rapid risk stratification at admission is essential for optimal medical care and improved prognosis. Whereas coma, deep breathing, and, to a lesser degree, severe anemia are established predictors of malaria-related death, the value of assessing prostration for risk stratification is less certain. METHODS: Here we used a retrospective multi-center analysis comprising over 33,000 hospitalized children from four large studies, including two observational studies from the Severe Malaria in African Children network, a randomized controlled treatment study, and the phase-3-clinical RTS,S-malaria vaccine trial, to evaluate known risk factors of mortality and with a specific emphasis on the role of prostration. RESULTS: Despite comparable age profiles of the participants, we found significant inter- and intra-study variation in the incidence of fatal malaria as well as in the derived risk ratios associated with the four risk factors: coma, deep breathing, anemia, and prostration. Despite pronounced variations, prostration was significantly associated with an increased risk of mortality (P <0.001) and its consideration resulted in improved predictive performance, both in a multivariate model and a univariate model based on the Lambaréné Organ Dysfunction Score. CONCLUSION: Prostration is an important clinical criterion to determine severe pediatric malaria with possible fatal outcomes.

The COVID-19 pandemic and its impacts on diet quality and food prices in sub-Saharan Africa.

BACKGROUND: Sub-Saharan Africa faces prolonged COVID-19 related impacts on economic activity, livelihoods and nutrition, with recovery slowed down by lagging vaccination progress. OBJECTIVE: This study investigated the economic impacts of COVID-19 on food prices, consumption and dietary quality in Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania. METHODS: We conducted a repeated cross-sectional study using a mobile platform to collect data from July-December, 2021 (round 2). We assessed participants' dietary intake of 20 food groups over the previous seven days and computed the primary outcome, the Prime Diet Quality Score (PDQS), and Dietary Diversity Score (DDS), with higher scores indicating better quality diets. We used generalized estimating equation (GEE) linear regression models to assess factors associated with diet quality during COVID-19. RESULTS: Most of the respondents were male and the mean age was 42.4 (±12.5) years. Mean PDQS (±SD) was low at 19.4(±3.8), out of a maximum score of 40 in this study. Respondents (80%) reported higher than expected prices for all food groups. Secondary education or higher (estimate: 0.73, 95% CI: 0.32, 1.15), medium wealth status (estimate: 0.48, 95% CI: 0.14, 0.81), and older age were associated with higher PDQS. Farmers and casual laborers (estimate: -0.60, 95% CI: -1.11, -0.09), lower crop production (estimate: -0.87, 95% CI: -1.28, -0.46) and not engaged in farming (estimate: -1.38, 95% CI: -1.74, -1.02) were associated with lower PDQS. CONCLUSION: Higher food prices and lower diet quality persisted during the COVID-19 pandemic. Economic and social vulnerability and reliance on markets (and lower agriculture production) were negatively associated with diet quality. Although recovery was evident, consumption of healthy diets remained low. Systematic efforts to address the underlying causes of poor diet quality through transforming food system value chains, and mitigation measures, including social protection programs and national policies are critical.

A genomic appraisal of invasive Salmonella Typhimurium and associated antibiotic resistance in sub-Saharan Africa.

Invasive non-typhoidal Salmonella (iNTS) disease manifesting as bloodstream infection with high mortality is responsible for a huge public health burden in sub-Saharan Africa. Salmonella enterica serovar Typhimurium (S. Typhimurium) is the main cause of iNTS disease in Africa. By analysing whole genome sequence data from 1303 S. Typhimurium isolates originating from 19 African countries and isolated between 1979 and 2017, here we show a thorough scaled appraisal of the population structure of iNTS disease caused by S. Typhimurium across many of Africa's most impacted countries. At least six invasive S. Typhimurium clades have already emerged, with ST313 lineage 2 or ST313-L2 driving the current pandemic. ST313-L2 likely emerged in the Democratic Republic of Congo around 1980 and further spread in the mid 1990s. We observed plasmid-borne as well as chromosomally encoded fluoroquinolone resistance underlying emergences of extensive-drug and pan-drug resistance. Our work provides an overview of the evolution of invasive S. Typhimurium disease, and can be exploited to target control measures.

Genetic diversity of SARS-CoV-2 infections in Ghana from 2020-2021.

The COVID-19 pandemic is one of the fastest evolving pandemics in recent history. As such, the SARS-CoV-2 viral evolution needs to be continuously tracked. This study sequenced 1123 SARS-CoV-2 genomes from patient isolates (121 from arriving travellers and 1002 from communities) to track the molecular evolution and spatio-temporal dynamics of the SARS-CoV-2 variants in Ghana. The data show that initial local transmission was dominated by B.1.1 lineage, but the second wave was overwhelmingly driven by the Alpha variant. Subsequently, an unheralded variant under monitoring, B.1.1.318, dominated transmission from April to June 2021 before being displaced by Delta variants, which were introduced into community transmission in May 2021. Mutational analysis indicated that variants that took hold in Ghana harboured transmission enhancing and immune escape spike substitutions. The observed rapid viral evolution demonstrates the potential for emergence of novel variants with greater mutational fitness as observed in other parts of the world.

Malaria epidemiology in the Ahafo area of Ghana.

BACKGROUND: Plasmodium falciparum malaria remains endemic in sub-Saharan Africa including Ghana. The epidemiology of malaria in special areas, such as mining areas needs to be monitored and controlled. Newmont Ghana Gold Limited is conducting mining activities in the Brong Ahafo Region of Ghana that may have an impact on the diseases such as malaria in the mining area. METHODS: Prior to the start of mining activities, a cross-sectional survey was conducted in 2006/2007 to determine malaria epidemiology, including malaria parasitaemia and anaemia among children < 5 years and monthly malaria transmission in a mining area of Ghana. RESULTS: A total of 1,671 households with a child less than five years were selected. About 50% of the household heads were males. The prevalence of any malaria parasitaemia was 22.8% (95% CI 20.8-24.9). Plasmodium falciparum represented 98.1% (95% CI 96.2-99.2) of parasitaemia. The geometric mean P. falciparum asexual parasite count was 1,602 (95% CI 1,140-2,252) and 1,195 (95% CI 985-1,449) among children < 24 months and ≥ 24 months respectively. Health insurance membership (OR 0.60, 95% CI 0.45-0.80, p = 0.001) and the least poor (OR 0.57, 95% CI 0.37-0.90, p = 0.001) were protected against malaria parasitaemia. The prevalence of anaemia was high among children < 24 months compared to children ≥ 24 months (44.1% (95% CI 40.0-48.3) and 23.8% (95% CI 21.2-26.5) respectively. About 69% (95% CI 66.3-70.9) of households own at least one ITN. The highest EIRs were record in May 2007 (669 ib/p/m) and June 2007 (826 ib/p/m). The EIR of Anopheles gambiae were generally higher than Anopheles funestus. CONCLUSION: The baseline malaria epidemiology suggests a high malaria transmission in the mining area prior to the start of mining activities. Efforts at controlling malaria in this mining area have been intensified but could be enhanced with increased resources and partnerships between the government and the private sector.

Open defecation and attainment of Sustainable Development Goal Six: evidence from Kintampo Surveillance System, Ghana.

Objective: This study examined whether the open-defecation (OD) free target is achievable by 2030. Design: Longitudinal study. Setting: Seven sub-Districts of Kintampo North Municipal, and five sub-Districts of Kintampo South District. Data source: Kintampo health and demographic surveillance system. Participants: Data was collected from household heads or their representatives over a 12-year period from 2005 to 2016. Main outcome: Open-defecation and attainment of OD free by 2030. Results: In an exploratory analysis, the correlation between the total number of households, year, and total number of OD households was obtained. The average percentage yearly increase or decrease in OD was computed and used to project the percentage of OD for the years 2020, 2025 and 2030. In addition, geo-spatial technology was used to visualize variability in OD across the twelve sub-Districts. The results showed that the OD free target is not achievable in 2030 or even if the current trend continues. In 2016, 44.2 per cent of the 31,571 households defecated openly. In six out of the 12 sub-Districts, more than half of the households openly defecated. Four out of these six sub-Districts were in the Kintampo North Municipality. Conclusion: The 2030 OD free target is not achievable in the Kintampo districts of Ghana if the current trend continues. Funding: Kintampo Health Research Centre funded this work.

Community perceptions of malaria and malaria treatment behaviour in a rural district of Ghana: implications for artemisinin combination therapy.

BACKGROUND: Artesunate-amodiaquine (AS-AQ) was introduced in Ghana as the first line drug for treatment of uncomplicated malaria in 2004. We report the perceptions of malaria and malaria treatment behaviour, the community awareness of and perceptions about AS-AQ two years after the introduction of this ACT treatment for malaria. METHODS: Two surveys were conducted; a cross-sectional survey of 729 randomly selected household heads (urban-362, rural-367) and 282 women with children < 5 years (urban-121, rural-161) was conducted in 2006. A district wide survey was conducted in 2007 to assess awareness of AS-AQ. These were complemented with twenty-eight focus group discussions (FGDs) and 16 key informant interviews (KII) among community members and major stakeholders in the health care delivery services. All nine (9) health facilities and five (5) purposively selected drug stores were audited in order to identify commonly used anti-malarials in the study area at the time of the survey. RESULTS: Majority of respondents ( > 75%) in the sampled survey mentioned mosquito bites as the cause of malaria. Other causes mentioned include environmental factors (e.g. dirty surroundings) and standing in the sun. Close to 60% of the household heads and 40% of the care-givers interviewed did not know about AS-AQ. The community respondents who knew about and had ever taken AS-AQ perceived it to be a good drug; although they mentioned they had experienced some side effects including headaches and body weakness. Co-blistered AS-AQ was available in all the government health facilities in the study area. Different formulations of ACTs were however found in urban chemical shops but not in rural chemical stores where monotherapy antimalarials were predominant. CONCLUSION: The knowledge of fever as a symptom of malaria is high among the study population. The awareness of AS-AQ therapy and its side-effect was low in the study area. Community education and sensitization, targeting all categories of the population, has to be intensified to ensure an efficient implementation process.

Blood Lead Levels among Blood Donors and High-Risk Occupational Groups in a Mining Area in Ghana: Implications for Blood Transfusion among Vulnerable Populations.

Lead poisoning has been a major global health problem for decades, and blood transfusion has been suspected as a neglected potential source of lead exposure. Children and pregnant women are most vulnerable to the toxic effects of lead and over 40 percent of blood transfused in Ghana is given to children under 5 years. However, there is little data on the levels of lead in donor blood and the main sources of lead exposure in the Ghanaian population. This study compared blood lead levels (BLL) among selected occupations at risk of lead exposure with healthy blood donors in nonexposed occupations in a Ghanaian mining area. We enrolled 40 participants each from the following high-risk occupational groups: small scale miners, painters/sprayers, drivers/fuel station attendants, and auto-mechanics as well as 40 healthy blood donors (made up of teachers, traders, and office workers). One millilitre of blood was collected from each participant for determination of their BLL, haemoglobin concentration, and blood film morphology. A total of 200 participants made up of 186 (93%) males and 14 (7%) females were enrolled. The mean age of participants was 28.6 ± 8.2 years and their geometric mean (GM) BLL was 6.3 GSD 1.4 µg/dL [95% CI: 6.0 - 6.6]. Participants in high risk occupations had significantly higher GM BLL of 6.7 µg/dL [95% CI :6.4-7.0] compared to 5.0 µg/dL [95% CI: 4.4-5.7] for healthy blood donors [p < 0.001]. The prevalence of elevated BLL (≥5 µg/dL) among the entire study participants, high risk occupations and blood donors was 84.5%, 89.4% and 65% respectively. There was significant association between elevated BLLs and working in an at-risk occupational group [aOR = 3.58, p = 0.014]. Haemoglobin concentration was not significantly associated with elevated BLLs. Basophilic stippling was not observed in any of the blood smears. Blood lead levels were high in blood donors and at-risk occupations in the study area and occupation was associated with elevated BLLs. It is important that measures to safeguard the integrity of donor blood go beyond screening for infectious diseases to include screening individuals in high-risk occupations for lead and other heavy metals to ensure that donor blood from such individuals is safe and does not pose potential danger to the health of vulnerable populations such as children and pregnant women.

Safety, reactogenicity, and immunogenicity of a chimpanzee adenovirus vectored Ebola vaccine in children in Africa: a randomised, observer-blind, placebo-controlled, phase 2 trial.

BACKGROUND: During the large 2013-16 Ebola virus outbreak caused by the Zaire Ebola virus, about 20% of cases were reported in children. This study is the first, to our knowledge, to evaluate an Ebola vaccine in children younger than 6 years. We aimed to evaluate the safety, reactogenicity, and immunogenicity of a monovalent, recombinant, chimpanzee adenovirus type-3 vectored Zaire Ebola glycoprotein vaccine (ChAd3-EBO-Z) in a paediatric population. METHODS: This phase 2, randomised, observer-blind, controlled trial was done in a vaccine centre in Mali and a university hospital centre in Senegal. Healthy children were randomly assigned through a web-based system (1:1; stratified by age group, gender, and centre) to receive ChAd3-EBO-Z (day 0) and meningococcal serogroups A,C,W-135,Y tetanus toxoid conjugate vaccine (MenACWY-TT; month 6), or MenACWY-TT (day 0) and ChAd3-EBO-Z (month 6). The study was observer-blind from study start until interim day 30 analysis and became single-blind as of interim analysis. Primary outcomes assessed were serious adverse events (up to study end, month 12), solicited local or general adverse events (7 days post-vaccination), unsolicited adverse events (30 days post-vaccination), haematological or biochemical abnormalities, and clinical symptoms of thrombocytopenia (day 0-6). As secondary endpoints, we evaluated anti-glycoprotein Zaire Ebola virus antibody titres (ELISA) pre-vaccination and 30 days post-vaccination. This study is registered with ClinicalTrials.gov, NCT02548078. FINDINGS: From Nov 11, 2015, to May 9, 2016, of 776 children screened for eligibility, 600 were randomly assigned (200 [33%] in each age strata: 1-5, 6-12, 13-17 years), 300 (50%) to the ChAd3-EBO-Z/MenACWY-TT group and 300 (50%) to the MenACWY-TT/ChAd3-EBO-Z group; all were included in the total vaccinated cohort. Post-day 0 vaccination, the most common solicited injection site symptom was pain (127 [42%] of 300 in the ChAd3-EBO-Z/MenACWY-TT group vs 60 [20%] of 300 in the MenACWY-TT/ChAd3-EBO-Z group); the most common solicited general adverse event was fever (95 [32%] of 300 in the ChAd3-EBO-Z/MenACWY-TT group vs 28 [9%] of 300 in the MenACWY-TT/ChAd3-EBO-Z group). Unsolicited adverse events post-day 0 vaccination were reported by 41 (14%) of 300 participants in the ChAd3-EBO-Z/MenACWY-TT group and 24 (8%) of 300 MenACWY-TT/ChAd3-EBO-Z recipients. Serious adverse events were reported for two (1%) of 300 children in each group; none were considered vaccination related. No clinical symptoms of thrombocytopenia were reported. At day 30, anti-glycoprotein Ebola virus antibody geometric mean concentrations (GMC) in the ChAd3-EBO-Z/MenACWY-TT group were 1564 (95% CI 1340-1826) for those aged 13-17 years, 1395 (1175-1655) for 6-12 years, and 2406 (1942-2979) for 1-5 years. Anti-glycoprotein Ebola virus IgG antibody responses persisted up to 12 months post-vaccination, with a GMC of 716 (95% CI 619-828) for those aged 13-17 years, 752 (645-876) for 6-12 years, and 1424 (1119-1814) for 1-5 years. INTERPRETATION: ChAd3-EBO-Z was immunogenic and well tolerated in children aged 1-17 years. This study provides the first ChAd3-EBO-Z data in a paediatric population. Further development should focus on multivalent approaches including Sudan and Marburg strains, and heterologous prime-boost strategies, for instance using modified vaccinia Ankara-based vaccine to boost the immune response. FUNDING: EU's Horizon 2020 research and innovation programme and GlaxoSmithKline Biologicals SA.

Safety, reactogenicity, and immunogenicity of a chimpanzee adenovirus vectored Ebola vaccine in adults in Africa: a randomised, observer-blind, placebo-controlled, phase 2 trial.

BACKGROUND: The 2014 Zaire Ebola virus disease epidemic accelerated vaccine development for the virus. We aimed to assess the safety, reactogenicity, and immunogenicity of one dose of monovalent, recombinant, chimpanzee adenovirus type-3 vectored Zaire Ebola glycoprotein vaccine (ChAd3-EBO-Z) in adults. METHODS: This phase 2, randomised, observer-blind, controlled trial was done in study centres in Cameroon, Mali, Nigeria, and Senegal. Healthy adults (≥18 years) were randomly assigned with a web-based system (1:1; minimisation procedure accounting for age, gender, centre) to receive ChAd3-EBO-Z (day 0), or saline placebo (day 0) and ChAd3-EBO-Z (month 6). The study was observer-blind until planned interim day 30 analysis, single-blind until month 6, and open-label after month 6 vaccination. Primary outcomes assessed in the total vaccinated cohort, which comprised all participants with at least one study dose administration documented, were serious adverse events (up to study end, month 12); and for a subcohort were solicited local or general adverse events (7 days post-vaccination), unsolicited adverse events (30 days post-vaccination), haematological or biochemical abnormalities, and clinical symptoms of thrombocytopenia (day 0-6). Secondary endpoints (subcohort; per-protocol cohort) evaluated anti-glycoprotein Ebola virus antibody titres (ELISA) pre-vaccination and 30 days post-vaccination. This study is registered with ClinicalTrials.gov, NCT02485301. FINDINGS: Between July 22, 2015, and Dec 10, 2015, 3030 adults were randomly assigned; 3013 were included in the total vaccinated cohort (1509 [50·1%] in the ChAd3-EBO-Z group and 1504 [49·9%] in the placebo/ChAd3-EBO-Z group), 17 were excluded because no vaccine was administered. The most common solicited injection site symptom was pain (356 [48%] of 748 in the ChAd3-EBO-Z group vs 57 [8%] of 751 in the placebo/ChAd3-EBO-Z group); the most common solicited general adverse event was headache (345 [46%] in the ChAd3-EBO-Z group vs 136 [18%] in the placebo/ChAd3-EBO-Z group). Unsolicited adverse events were reported by 123 (16%) of 749 in the ChAd3-EBO-Z group and 119 (16%) of 751 in the placebo/ChAd3-EBO-Z group. Serious adverse events were reported for 11 (1%) of 1509 adults in the ChAd3-EBO-Z group, and 18 (1%) of 1504 in the placebo/ChAd3-EBO-Z group; none were considered vaccination-related. No clinically meaningful thrombocytopenia was reported. At day 30, anti-glycoprotein Ebola virus antibody geometric mean concentration was 900 (95% CI 824-983) in the ChAd3-EBO-Z group. There were no treatment-related deaths. INTERPRETATION: ChAd3-EBO-Z was immunogenic and well tolerated in adults. Our findings provide a strong basis for future development steps, which should concentrate on multivalent approaches (including Sudan and Marburg strains). Additionally, prime-boost approaches should be a focus with a ChAd3-based vaccine for priming and boosted by a modified vaccinia Ankara-based vaccine. FUNDING: EU's Horizon 2020 research and innovation programme and GlaxoSmithKline Biologicals SA.

Randomised comparison of two household survey modules for measuring stillbirths and neonatal deaths in five countries: the Every Newborn-INDEPTH study.

BACKGROUND: An estimated 5·1 million stillbirths and neonatal deaths occur annually. Household surveys, most notably the Demographic and Health Survey (DHS), run in more than 90 countries and are the main data source from the highest burden regions, but data-quality concerns remain. We aimed to compare two questionnaires: a full birth history module with additional questions on pregnancy losses (FBH+; the current DHS standard) and a full pregnancy history module (FPH), which collects information on all livebirths, stillbirths, miscarriages, and neonatal deaths. METHODS: Women residing in five Health and Demographic Surveillance System sites within the INDEPTH Network (Bandim in Guinea-Bissau, Dabat in Ethiopia, IgangaMayuge in Uganda, Matlab in Bangladesh, and Kintampo in Ghana) were randomly assigned (individually) to be interviewed using either FBH+ or FPH between July 28, 2017, and Aug 13, 2018. The primary outcomes were stillbirths and neonatal deaths in the 5 years before the survey interview (measured by stillbirth rate [SBR] and neonatal mortality rate [NMR]) and mean time taken to complete the maternity history section of the questionnaire. We also assessed between-site heterogeneity. This study is registered with the Research Registry, 4720. FINDINGS: 69 176 women were allocated to be interviewed by either FBH+ (n=34 805) or FPH (n=34 371). The mean time taken to complete FPH (10·5 min) was longer than for FBH+ (9·1 min; p<0·0001). Using FPH, the estimated SBR was 17·4 per 1000 total births, 21% (95% CI -10 to 62) higher than with FBH+ (15·2 per 1000 total births; p=0·20) in the 5 years preceding the survey interview. There was strong evidence of between-site heterogeneity (I2=80·9%; p<0·0001), with SBR higher for FPH than for FBH+ in four of five sites. The estimated NMR did not differ between modules (FPH 25·1 per 1000 livebirths vs FBH+ 25·4 per 1000 livebirths), with no evidence of between-site heterogeneity (I2=0·7%; p=0·40). INTERPRETATION: FPH takes an average of 1·4 min longer to complete than does FBH+, but has the potential to increase reporting of stillbirths in high burden contexts. The between-site heterogeneity we found might reflect variations in interviewer training and survey implementation, emphasising the importance of interviewer skills, training, and consistent implementation in data quality. FUNDING: Children's Investment Fund Foundation.

"Every Newborn-INDEPTH" (EN-INDEPTH) study protocol for a randomised comparison of household survey modules for measuring stillbirths and neonatal deaths in five Health and Demographic Surveillance sites.

BACKGROUND: Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH+) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH+ may underestimate mortality rates particularly for stillbirths. METHODS: This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, International Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH+ and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68 000 pregnancies to assess if there is ≥15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank's Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken. CONCLUSIONS: This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes.

Prevalence of chloroquine and antifolate drug resistance alleles in Plasmodium falciparum clinical isolates from three areas in Ghana.

Background: The emergence and spread of resistance in Plasmodium falciparum to chloroquine (CQ) and the antifolate drug sulfadoxine-pyrimethamine (SP) necessitated the change from CQ to artemisinin-based combination therapies (ACTs) as first-line drug for the management of uncomplicated malaria in Ghana in 2005. Methods: To examine the prevalence of molecular markers associated with CQ and antifolate drug resistance in Ghana, we genotyped single nucleotide polymorphisms (SNPs) in the P. falciparum chloroquine resistance transporter ( pfcrt, PF3D7_0709000), multidrug resistance ( pfmdr1, PF3D7_0523000), bifunctional dihydrofolate reductase-thymidylate synthase ( pfdhfr, PF3D7_0417200) and dihydropteroate synthase ( pfdhps, PF3D7_0810800) genes in children with malaria reporting to hospitals in three different epidemiological areas of Ghana (Accra, Kintampo and Navrongo) between 2012 and 2017. Results: The overall prevalence of the CQ resistance-associated pfcrt 76T allele was 8%, whereas pfmdr1 86Y and 184F alleles were present in 10% and 65% of infections respectively. Most of the isolates harboured the antifolate resistance-associated pfdhfr 51I, 59R and 108N alleles, including 68% of them with the triple mutant pfdhfr I 51 R 59 N 108 combination. Pfdhps 437G and 540E were detected in 90.6% and 0.7% of infections, respectively. We observed no significant difference across the three study sites for all the polymorphisms except for pfdhps 437G , which was more common in Accra than at the other sites. Across both pfdhfr and pfdhps genes, a large proportion (61%) of the isolates harboured the quadruple mutant combination ( I 51 R 59 N 108/ G 437). Conclusion: Comparison of the present results to previously published data shows a significant decrease in the prevalence of CQ resistance alleles during the 12 years after CQ withdrawal, but an increase in the alleles that mediate SP resistance, which could be due to the continuous use of antifolate drugs for prophylaxis.