Cultural epidemiology for malaria control in Ghana

Malaria is a threat to more than 40% of the world’s population and responsible for more than 300 million acute cases each year, which resulted in 1.2 million deaths in 2002. Over 80% of the malaria-related morbidity and mortality occur in sub-Saharan Africa with children under five and pregnant women at highest risk. The malaria situation in Ghana is typical of sub-Saharan Africa, where malaria is ranked first among the ten diseases most frequently seen in most health facilities in the country. Due to widespread poverty, however, many households depend on a combination of herbs and overthe- counter drugs, usually consisting of inadequate doses of antimalarials, chiefly chloroquine and analgesics. In Ghana, as in other parts of sub-Saharan Africa, where malaria is due mainly to Plasmodium falciparum and potentially fatal, early and effective treatment saves lives by preventing disease progression to severe malaria. In view of this, prompt recognition and effective timely treatment of malaria is a critical element of global malaria control strategies. The overall goal of this study was to determine the occurrence, distribution, and determinants of MRI experiences, meanings and behaviours, inasmuch as these affect risk, and protective behaviours relevant for intervention to reduce malaria-related morbidity and mortality in children and pregnant women. The study was carried out in two rural communities (Obosomasi, located in the forest vegetation zone, and Galo-Sota, in the coastal savannah zone) in Ghana, over the period from October 2002 to April 2004. This was a cultural epidemiological study employing two-stage data collection strategies. The first stage was ethnographic study, which made use of free listing and rating, participatory mapping, focus group discussions and in-depth interviews to generate relevant local malariarelated illness experiences, meanings and behaviours. The second stage made use of these relevant categories and representations to design EMIC (insiders’ perspective) interviews, which are tools to assess the occurrence, determinants and distributions of these categories to guide appropriate interventions for all segments of the population studied. Results indicate that: Malaria is recognised as a leading health problem in these communities, affecting children and pregnant women more than other segments of the population. Mosquitoes were identifies as the leading causes of malaria-related illness without convulsions, a finding at odds with earlier studies in southern Ghana, indicating changing\ud local perceptions. Local people reported that heat from the sun is a major cause of malaria-related illness without convulsions, and this finding suggests a need for further study to determine the link between heat from the sun and triggers of clinical malaria episodes. Home treatment for malaria-related illness is very common and entails the use of herbal and biomedical medications. The clinic and hospital were preferred sites for treatment of MRI, including convulsions, outside the home, but most patients get there rather late. Convulsions were identified as a component of the malaria-related illness complex, and mosquito bites and febrile malaria episodes were identified as two important causes of MRI with convulsions. This finding was also a departure from most previous reports from sub- Saharan Africa. Despite relating mosquito, malaria and convulsions to one another, local people continue to implicate supernatural forces among causes of convulsions, but explaining that spirits take advantage of malaria attacks to make their mischief. Local healers continue to play an important role in the management of convulsions, but mainly as one aspect of the holistic healing process, involving both rituals to drive away mischievous spirits and biomedical treatments. That is, local healers perform rituals to drive away the spirit causing the convulsions, which paves the way for biomedical treatment and a complete cure. Local healers are also reputed to have ‘medicine’ to protect children from convulsive attacks. Despite the general agreement between the accounts of pregnant women and the general population, there were some significant differences suggesting the need for gender-specific interventions to control malaria-related illness in pregnancy. The recent introduction of intermittent preventive treatment appears responsive to this need, but it may need to be extended as a community programme to achieve the goal of reducing the malaria-related disease burden in pregnancy. Vignette-based interviews evoke responses specifying categories of malaria-related illness experiences, meanings, and behaviours similar to case-based interviews, but with differences in frequencies of reporting these categories. This is the first time that the cultural epidemiology framework has been applied to study the sociocultural aspects of malaria covered in this thesis, and it substantially adds to the growing body of knowledge of the importance of sociocultural factors in malaria control. The implications of the findings for interventions are discussed in individual papers presented in the thesis, and in consisting of a discussion of the overall study and conclusions

Molecular epidemiology of Mycobacterium africanum in Ghana

BACKGROUND: Mycobacterium africanum comprises two phylogenetic lineages within the M. tuberculosis complex (MTBC) and is an important cause of human tuberculosis (TB) in West Africa. The reasons for this geographic restriction of M. africanum remain unclear. Here, we performed a prospective study to explore associations between the characteristics of TB patients and the MTBC lineages circulating in Ghana. METHOD: We genotyped 1,211 MTBC isolates recovered from pulmonary TB patients recruited between 2012 and 2014 using single nucleotide polymorphism typing and spoligotyping. Associations between patient and pathogen variables were assessed using univariate and multivariate logistic regression. RESULTS: Of the 1,211 MTBC isolates analysed, 71.9 % (871) belonged to Lineage 4; 12.6 % (152) to Lineage 5 (also known as M. africanum West-Africa 1), 9.2 % (112) to Lineage 6 (also known as M. africanum West-Africa 2) and 0.6 % (7) to Mycobacterium bovis. Univariate analysis revealed that Lineage 6 strains were less likely to be isoniazid resistant compared to other strains (odds ratio = 0.25, 95 % confidence interval (CI): 0.05-0.77, P < 0.01). Multivariate analysis showed that Lineage 5 was significantly more common in patients from the Ewe ethnic group (adjusted odds ratio (adjOR): 2.79; 95 % CI: 1.47-5.29, P < 0.001) and Lineage 6 more likely to be found among HIV-co-infected TB patients (adjOR = 2.2; 95 % confidence interval (CI: 1.32-3.7, P < 0.001). CONCLUSION: Our findings confirm the importance of M. africanum in Ghana and highlight the need to differentiate between Lineage 5 and Lineage 6, as these lineages differ in associated patient variables

An evaluation of Wb123 antibody elisa in individuals treated with ivermectin and albendazole, and implementation challenges in Africa

The development of antibody testing for the diagnosis of lymphatic filariasis (LF) is intended to enhance the monitoring and evaluation activities of the Global Program for the Elimination of LF. This is due to the fact that antibody tests are expected to be the most sensitive at detecting exposure to LF compared to antigen that takes longer to develop. To this end a new antibody-based enzyme linked immunosorbent assay (ELISA) to Wuchereria bancrofti antigen Wb123 has been developed and further designed into a point of care rapid diagnostic test, under evaluation. In pretreatment surveys, individuals were tested for antigen using the immuno-chromatographic test (ICT) card, and night blood microfilariae, after which all positives were treated using Ivermectin and Albendazole. The Wb123 ELISA was tested in antigen positive individuals, three months after they were treated. Samples were also tested for ICT and night blood microfilariae. The results revealed a reduction in microfilariae and ICT prevalence after treatment. Antigen and antibody prevalence increased with age. However, there was no correlation with the antibody responses observed. The mean WB123 antibody titers were higher among ICT positives, but not significantly different from ICT negative persons. While the Wb123 is targeted for use in untreated populations, further evaluations and guidelines will be required to define its use in populations that have undergone treatment for the control of LF.Keywords: Lymphatic filariasis, elephantiasis, antigen, antibody, Wb123, Ghan

Understanding the gap between access and use: a qualitative study on barriers and facilitators to insecticide-treated net use in Ghana

Mass and continuous distribution channels have significantly increased access to insecticide-treated nets (ITNs) in Ghana since 2000. Despite these gains, a large gap remains between ITN access and use.; A qualitative research study was carried out to explore the individual and contextual factors influencing ITN use among those with access in three sites in Ghana. Eighteen focus group discussions, and free listing and ranking activities were carried out with 174 participants; seven of those participants were selected for in-depth case study. Focus group discussions and case study interviews were audio-recorded, transcribed verbatim, and analysed thematically.; ITN use, as described by study participants, was not binary; it varied throughout the night, across seasons, and over time. Heat was the most commonly cited barrier to consistent ITN use and contributed to low reported ITN use during the dry season. Barriers to ITN use throughout the year included skin irritation; lack of airflow in the sleeping space; and, in some cases, a lack of information on the connection between the use of ITNs and malaria prevention. Falling ill or losing a loved one to malaria was the most powerful motivator for consistent ITN use. Participants also discussed developing a habit of ITN use and the economic benefit of prevention over treatment as facilitating factors. Participants reported gender differences in ITN use, noting that men were more likely than women and children to stay outdoors late at night and more likely to sleep outdoors without an ITN.; The study results suggest the greatest gains in ITN use among those with access could be made by promoting consistent use throughout the year among occasional and seasonal users. Opportunities for improving communication messages, such as increasing the time ITNs are aired before first use, as well as structural approaches to enhance the usability of ITNs in challenging contexts, such as promoting solutions for outdoor ITN use, were identified from this work. The information from this study can be used to inform social and behaviour change messaging and innovative approaches to closing the ITN use gap in Ghana

Prevalence of asymptomatic malaria parasitaemia following mass testing and treatment in Pakro sub-district of Ghana.

BACKGROUND: Global efforts to scale-up malaria control interventions are gaining steam. These include the use of Long-Lasting Insecticide Nets, Indoor Residual Spraying, Intermittent Preventive Treatment and Test, Treat and Track. Despite these, the drive for malaria elimination is far from being realistic in endemic communities in Africa. This is partly due to the fact that asymptomatic parasite carriage, not specifically targeted by most interventions, remains the bedrock that fuels transmission. This has led to mass testing, treatment and tracking (MTTT) as an alternative strategy to target asymptomatic individuals. We report the impact of MTTT on the prevalence of asymptomatic malaria parasitaemia over a one-year period in Ghana, hypothesizing that implementing MTTT could reduce the rate of asymptomatic parasitaemia. METHODS: A population of about 5000 individuals in seven communities in the Pakro sub-district of Ghana participated in this study. A register was developed for each community following a census. MTTT engaged trained community-based health volunteers who conducted house-to-house testing using RDTs every 4 months and treated positive cases with Artemisinin-based Combination Therapy. Between interventions, community-based management of malaria was implemented for symptomatic cases. RESULTS: MTTT Coverage was 98.8% in July 2017 and 79.3% in July 2018. Of those tested, asymptomatic infection with malaria parasites reduced from 36.3% (1795/4941) in July 2017 to 32.9% (1303/3966) in July 2018 (p = 0.001). Prevalence of asymptomatic parasitaemia among children under 15 years declined from 52.6% (1043/1984) in July 2017 to 47.5% (820/1728) in July 2018 (p = 0.002). Implementing MTTT significantly reduced asymptomatic parasitaemia by 24% from July 2017 to July 2018 after adjusting for age, ITN use and axillary temperature (OR = 0.76, CI = 0.67, 0.85 p ≤ 0.001). CONCLUSION: This study has demonstrated that implementing MTTT is feasible and could reduce the prevalence of asymptomatic malaria parasitaemia in children under 15 years of age. Furthermore, the use of community-based health volunteers could ensure high coverage at lower cost of implementation

Improving access to lymphatic filariasis MMDP services through an enhanced evidence-based, cascaded training model for health worker capacity strengthening in Ghana: an evaluation study

IntroductionGhana has made significant progress in reducing the transmission rate of lymphatic filariasis. However, very little progress has been made in the provision of morbidity management and disability prevention (MMDP) services, which is one of the key requirements for certification of elimination as a disease of public health importance. This study was designed to compare pre-post- intervention to determine the feasibility and effectiveness of a cascade training model for health worker capacity strengthening in Ghana, using the WHO recommended minimum intervention package to improve access to MMDP services.MethodsThis study used a quasi-experimental design to assess the impact of evidence-based training of patients with lymphatic filariasis (LF) in the Upper West region of Ghana. All lymphedema patients who were available at the time of data collection participated in the study before and after the training.ResultsThe mean age of respondents was 54.67 years (SD ± 16.89 years) at baseline and 54.70 years (SD ± 15.80 years) at evaluation. The majority (i.e., 76.30% at baseline and 80.50% at evaluation) of the respondents were female. Most of the respondents had not completed primary school (83.82% at baseline and 85.40% at evaluation). We found an improvement in the quality of life among LF patients, that is, the proportion of respondents who reported having a high quality of life increased from 2.9% at baseline to 20.12% at evaluation (p &lt; 0.001). The lymphedema management practice of “hygiene/washing and drying of affected limb” was reported by 73.17% of respondents at evaluation compared with only 32.95% of respondents at baseline (p &lt; 0.001). The acute attack management technique of “cooling the affected limb in cool water/cold compress” was reported by 70.15% of respondents at evaluation compared with 23.70% of respondents at baseline (p &lt; 0.001).ConclusionThe research confirmed that LF-related perceptions remained generally the same at baseline and evaluation among community members. The implementation of the LF-related morbidity management (MMDP) project has led to a significant improvement in the morbidity management practices among patients at evaluation compared with baseline. Our findings also showed that self-care led to an improvement in patients’ quality of life. This justifies the need for investment in morbidity management interventions in endemic communities

The Effect of Mass Testing, Treatment and Tracking on the Prevalence of Febrile Illness in Children under 15 in Ghana

Background: Malaria remains a serious threat to children under 15 years of age in sub-Sahara Africa. Mass testing, treatment and tracking (MTTT) of malaria has been reported to reduce parasite load significantly. However, the impact of MTTT on the prevalence of febrile illnesses in children under 15 is not yet clear. This study explores the impact of MTTT complemented by prompt home-based management of malaria on febrile illnesses and their treatment in children under 15 years old. Methods: A cohort of 460 children under 15 years were recruited from the Pakro subdistrict in Ghana during a community-wide implementation of a quarterly MTTT intervention. The MTTT implementation involved testing all household members for malaria using RDTs, and positive cases were treated with Artemisinin-based combination therapy (ACT). Febrile illnesses among this cohort in the two weeks prior to the prevalence survey at baseline and endline were recorded to constitute date for analysis. Results: The prevalence of febrile illnesses, such chills, convulsion, fever, diarrhoea, headache, vomit, cough/rashes or stomachache, etc., were recorded). Asymptomatic parasitaemia prevalence at baseline was 53.3%, which dropped to 44.1% at evaluation. An overall decrease in the parasitaemia prevalence of 33.0% (OR = 0.67, CI = 0.50, 0.89) was observed at evaluation compared to baseline after adjusting for age, ITN use and temperature. A 67% decrease in severe anaemia cases (Hb &lt; 7) was observed at evaluation. Conclusion: Our findings suggest that implementing MTTT complemented by home-based timely management of malaria does not only reduce febrile illnesses and for that matter malaria prevalence, but could also reduce severe anaemia in children under 15 years old

A Comparative Study of Lymphatic Filariasis-Related Perceptions among Treated and Non-Treated Individuals in the Ahanta West Municipality of Ghana

Background: Ghana joined the Global Programme to Eliminate Lymphatic Filariasis (GPELF), established in the year 2000, with the aim of eliminating the disease as a public health problem through annual mass treatment of entire endemic populations. Since 2001, the country has implemented mass drug administration (MDA) in endemic districts, with great reductions in the population at risk for infection. However, in many districts, the elimination programme is faced with the presence of hotspots, which may be due in part to individuals not taking part in MDA (either intentionally or unintentionally) who may serve as reservoirs to sustain transmission. This paper compares the LF-related perceptions among individuals who regularly take the MDA drugs and those who seldom or never take part in the MDA in the Ahanta West Municipality of Ghana to determine community acceptable ways to implement an intervention aimed to track, engage, and treat individuals who regularly miss MDA or to test individuals who intentionally refuse MDA and treat them if positive for LF. Methods: This was a mixed method study employing questionnaire surveys and focus group discussions (FDG) for data collection. Survey participants were randomly selected from the 2019 treatment register to stratify respondents into treated and non-treated groups. FGD participants were selected purposively such that there are at least two non-treated persons in each discussion session. Results: Over 90% of the respondents were aware of the disease. Poor hygiene/dirty environment was wrongly reported by most respondents (76.8%) as the causes. MDA awareness was very high among both treated (96.9%) and non-treated (98.6%) groups. A low sense of vulnerability to LF infection was evident by a reduction in the number of people presenting clinical manifestations of the disease in communities. Slightly more, 65 (29.0%) of the non-treated group compared to the 42 (19.4%) treated group reported ever experiencing adverse effects of the MDA drugs. Barriers to MDA uptake reported in both groups were poor planning and implementation of the MDA, lack of commitments on the part of drug distributors, and adverse drug reactions. About 51% of the non-treated group reported never taking the drugs even once in the last five years, while 61% among the treated group took the MDA drug consistently in the past five years. Respondents in both groups believed that, when engaged properly, most non-treated persons will accept to take the drug but insisted community drug distributors (CDDs) must be trained to effectively engage people and have time for those they will be engaging in dialogue. The chiefs emerged as the most influential people who can influence people to take MDA drugs. Conclusions: The reduction in risk perception among respondents, adverse reactions and the timing of MDA activities may be influencing MDA non-participation in the study area; however, respondents think that non-treated individuals will accept the interventions when engaged properly by the CDDs

Additional file 2: Table S2. of Molecular epidemiology of Mycobacterium africanum in Ghana

Genotyping profile of 1211 MTBC isolates from Ghana. (DOC 577 kb