Hospital-Based Surveillance for Viral Hemorrhagic Fevers and Hepatitides in Ghana

<div><p>Background</p><p>Viral hemorrhagic fevers (VHF) are acute diseases associated with bleeding, organ failure, and shock. VHF may hardly be distinguished clinically from other diseases in the African hospital, including viral hepatitis. This study was conducted to determine if VHF and viral hepatitis contribute to hospital morbidity in the Central and Northern parts of Ghana.</p><p>Methodology/Principal Findings</p><p>From 2009 to 2011, blood samples of 258 patients with VHF symptoms were collected at 18 hospitals in Ashanti, Brong-Ahafo, Northern, Upper West, and Upper East regions. Patients were tested by PCR for Lassa, Rift Valley, Crimean-Congo, Ebola/Marburg, and yellow fever viruses; hepatitis A (HAV), B (HBV), C (HCV), and E (HEV) viruses; and by ELISA for serological hepatitis markers. None of the patients tested positive for VHF. However, 21 (8.1%) showed anti-HBc IgM plus HBV DNA and/or HBsAg; 37 (14%) showed HBsAg and HBV DNA without anti-HBc IgM; 26 (10%) showed anti-HAV IgM and/or HAV RNA; and 20 (7.8%) were HCV RNA-positive. None was positive for HEV RNA or anti-HEV IgM plus IgG. Viral genotypes were determined as HAV-IB, HBV-A and E, and HCV-1, 2, and 4.</p><p>Conclusions/Significance</p><p>VHFs do not cause significant hospital morbidity in the study area. However, the incidence of acute hepatitis A and B, and hepatitis B and C with active virus replication is high. These infections may mimic VHF and need to be considered if VHF is suspected. The data may help decision makers to allocate resources and focus surveillance systems on the diseases of relevance in Ghana.</p></div

Demographic data and symptoms of patients.

<p>Statistical analysis of the data: Each sub-group with diagnosis was tested vs. the sub-group without diagnosis for all quantitative variables and categories of a qualitative variable. Statistically significant differences are indicated by footnotes; all other differences were not significant.</p><p>Abbreviations: Q25, lower quartile, 25% of the data lie below this value; Q75, upper quartile, 75% of the data lie below this value.</p>a<p>18 patients were positive for anti-HAV IgM and HAV RNA; 7 patients were positive for anti-HAV IgM; 1 patient was positive for HAV RNA. Co-infections: 1 patient was positive for HBV DNA and HBsAg.</p>b<p>19 patients were positive for anti-HBc IgM, HBV DNA, and HBsAg; 2 patients were positive for anti-HBc IgM and positive for HBV DNA in two different PCR assays, but negative for HBsAg. Co-infections: 1 patient was HCV RNA positive.</p>c<p>All patients were positive for HBV DNA and HBsAg, but negative for anti-HBc IgM. Co-infections: 1 patient was anti-HAV IgM positive; 1 patient was HCV RNA positive.</p>d<p>All patients were HCV RNA positive. Co-infections: 1 patient was positive for anti-HBc IgM, HBV DNA, and HBsAg; 1 patient was positive for HBV DNA and HBsAg.</p>e<p>p = 0.001, no diagnosis vs. acute hepatitis A; p = 0.0001, no diagnosis vs. chronic hepatitis B; p = 0.00004, no diagnosis vs. acute & chronic hepatitis B combined; p = 0.005, no diagnosis vs. hepatitis C.</p>f<p>p<0.0001, no diagnosis vs. chronic hepatitis B; p<0.0001, no diagnosis vs. acute & chronic hepatitis B combined.</p>g<p>p<0.0001, no diagnosis vs. chronic hepatitis B; p = 0.0004, no diagnosis vs. acute & chronic hepatitis B combined.</p>h<p>p = 0.0005, no diagnosis vs. acute hepatitis A; p = 0.0003, no diagnosis vs. acute hepatitis B.</p

PCR assays used in the study.

a<p>Flaviviruses including YF and dengue virus.</p>b<p>Filoviruses including Ebola and Marburg virus.</p

Map of Ghana showing the study sites (triangles).

<p>The names of the hospitals and regions (numbers of study participants in parentheses) are: 1. Obuasi District Hospital, Obuasi, Ashanti (n = 7). 2. Sekyere South Hospital, Sekyere South, Ashanti (n = 1). 3. Holy Family Hospital, Techiman, Brong-Ahafo (n = 5). 4. Atebubu District Hospital, Atebubu, Brong-Ahafo (n = 14). 5. Kwame Danso Health Center, Kwame Danso, Brong-Ahafo (n = 11). 6. Yeji Mathias Hospital, Yeji, Brong-Ahafo Region (n = 37). 7. Salaga Government Hospital, Salaga, Northern (n = 5). 8. Bole Health Center, Bole, Northern (n = 6). 9. West Gonja Hospital, Damongo, Northern (n = 35). 10. Yendi Municipal Hospital, Yendi, Northern (n = 6). 11. Saboba Medical Center, Saboba, Northern (n = 9). 12. Gushiegu District Hospital, Gushiegu, Northern (n = 31). 13. Chereponi Health Center, Chereponi, Northern (n = 1). 14. Nalerigu Baptist Hospital, Nalerigu, Northern (n = 12). 15. Wa Regional Hospital, Wa, Upper West (n = 2). 16. Kaleo Health Center, Kaleo, Upper West (n = 3). 17. Nandom St. Theresa's Hospital, Nandom, Upper West (n = 72). 18. Bongo Hospital, Bongo, Upper East (n = 1). Damango in the Northern region was included due to its proximity to Mole, the largest National Park in the country harboring a wide range of wildlife. Catholic mission hospitals serve Damango, Techiman, and Nandom, while Nalerigu and Kaleo have Baptist and Ahmadian mission hospitals, respectively. The other sites are government hospitals or health posts. Most of the areas are characterized by prolonged dry season and a short rainy season. The vegetation in the north is typical Sahel savannah with short trees including baobab, Shea butter trees, and long grass. Majority of the inhabitants in the Northern and the Upper West and East regions are subsistence farmers who grow maize cashew, millet, and groundnut and keep livestock. The three regions in the north are the poorest of the country. The Brong-Ahafo and Ashanti regions, however, are in the forest zone and major cocoa and timber producing areas. Most of the people live in multi-family compounds of dispersed settlements. The houses built largely of mud with either thatched, mud or iron roofing are common in most villages and towns in Northern Ghana. The map is based on a UN map. Source: UN Cartographic Section (<a href="http://www.un.org/Depts/Cartographic/english/about.htm" target="_blank">http://www.un.org/Depts/Cartographic/english/about.htm</a>).</p

Phylogenetic analysis of HAV, HBV, and HCV sequences.

<p>The alignments to reconstruct the phylogenies included the novel sequences of HAV (467 nucleotides of VP1/2A junction), HBV (684 nucleotides of N terminal P protein region), and HCV (337 nucleotides of NS5B region) as well as sequences available from GenBank by December 2012. The latter are identified by GenBank accession numbers. Sequences of this study are highlighted in boldface (GenBank accession no. KC632110–KC632153). Primers used for amplification and sequencing are shown in <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002435#pntd-0002435-t001" target="_blank">Table 1</a>. Virus genotypes are indicated with the strains or right to the tree. If available, the geographic origin of a strain is indicated as well. Posterior probability values are shown on the branches if ≥0.5. Some branches with low support values were collapsed for clarity of presentation.</p

Representative results of VHF RT-PCR screening.

<p>Positive (P) and negative controls (N) were included in each PCR assay. The expected length of the PCR products is indicated right to the 100-base pair marker (M).</p

Clinical chemistry data for a subset of patients with hepatitis A, B, and C.

<p>Inclusion in this analysis depended on the availability of sufficient amount of serum. Statistical analysis was not performed. There are no missing values.</p><p>Abbreviations: AST, aspartate aminotransferase; ALT, alanine aminotransferase; LDH, lactate dehydrogenase.</p>a<p>Samples had been stored for ≥3 years at −20°C before analysis, which predictably leads to a certain loss of enzyme activity in serum, in particular of ALT <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002435#pntd.0002435-Donnelly1" target="_blank">[42]</a>, <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002435#pntd.0002435-Williams1" target="_blank">[43]</a>. Therefore, the data shown in the table tend to underestimate the true values. For selected parameters, the mean of all values in the pathological range are shown in parentheses. Units and pathological range are defined in the second column.</p>b<p>Reference values were taken from Kratz et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002435#pntd.0002435-Kratz1" target="_blank">[36]</a>.</p>c<p>Percentage of patients showing 2 or more pathological values for parameters that may indicate liver disease: albumin, total bilirubin, AST, ALT, and LDH.</p