Foodborne disease outbreak in a resource-limited setting: a tale of missed opportunities and implications for response

Introduction: Foodborne diseases (FBD) have emerged as a major public health problem worldwide. Though the global burden of FBD is currently unknown, foodborne diarrhoeal diseases kill 1.9 million children globally every year. On 25th September 2014, health authorities in Eastern Region of Ghana were alerted of a suspected FBD outbreak involving patrons of a community food joint. We investigated to determine the magnitude, source and implement control and preventive measures. Methods: A retrospective cohort study was conducted. We reviewed medical records for data on demographics and clinical features. A suspected foodborne disease was any person in the affected community with abdominal pain, vomiting and or diarrhea between 25th and 30th September 2014 and had eaten from the food joint. We conducted active case search, descriptive data analysis and calculated food specific attack rate ratios (ARR) and their corresponding 95% confidence intervals. Results: Of 43 case-patients, 44.2% (19/43) were males; median age was 19 years (interquartile range: 17-24 years). Overall attack rate was 43.4% (43/99) with no fatality. Case counts rose sharply for four hours to a peak and fell to baseline levels after 12 hours .Compared to those who ate other food items, patrons who ate “waakye” and “shitor” were more likely to develop foodborne disease [ARR=4.1 (95% CI=1.09-15.63)]. Food samples and specimens from case-patients were unavailable for testing. Laboratory diagnostic capacity was also weak. Conclusion: A point source FBD outbreak linked to probable contaminated “waakye” and or “shitor” occurred. Missed opportunities for definitive diagnosis highlighted the need for strengthening local response capacity.Pan African Medical Journal 2016; 2

Accuracy of the WHO Haemoglobin Colour Scale for the diagnosis of anaemia in primary health care settings in low-income countries: a systematic review and meta-analysis.

BACKGROUND: Anaemia is a major cause of morbidity and mortality in low-income countries. Primary health-care workers in resource-poor settings usually diagnose anaemia clinically, but this is inaccurate. The WHO Haemoglobin Colour Scale (HCS) is a simple, cheap quantitative method to assess haemoglobin concentration outside of the laboratory. We systematically reviewed the literature to assess the accuracy of the HCS in primary care to diagnose anaemia, and compared this with clinical assessment. METHODS: We searched the electronic databases including MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane library, CINAHL plus, Popline, Reproductive Health Library, and Google Scholar and regional databases up to Nov 14, 2014, "haemoglobin colour scale" in alternative spellings published in any language. Two reviewers independently screened studies, extracted data, and assessed quality using the QUADAS-2 instrument. Statistical analyses were carried out in STATA using the bivariate model. FINDINGS: Of 141 records and abstracts screened, 14 studies were included. The pooled sensitivity of the HCS to diagnose anaemia was 80% (95% CI 68-88) compared with 52% for clinical assessment ([95% CI 36-67]; p=0·008). Specificity was similar between the HCS (80% [95% CI 59-91]) and clinical assessment (75% [56-88]; p=0·8250). For severe anaemia, diagnostic accuracy was again higher overall for the HCS (p<0·0001); sensitivity was 57% (36-76) for the HCS and 45% (95% CI 12-83) for clinical assessment, but specificity was 99·6% (95% CI 95-99·9) versus 92% (62-99). Combining clinical assessment and the HCS could result in higher sensitivity (anaemia: 91% [95% CI 81-96]); severe anaemia 83% (33-98), but at the expense of specificity (anaemia: 59% [35-79]; severe anaemia 90% [40-99]). Individual studies were highly heterogeneous but pooled results did not differ substantially in a series of sensitivity analyses for indicators of study robustness. INTERPRETATION: In so-called real-life primary health-care conditions, HCS can significantly reduce misdiagnosis of anaemia compared with clinical assessment alone. Future research is required to optimise training, and assess clinical outcomes and cost-effectiveness. FUNDING: None

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways