Building the required skillsets for a resilient public health workforce: A decade of field epidemiology training in Ghana

The emergence and re-emergence of infectious and non-infectious diseases is a major issue of public health concern. The outbreak of Ebola, Lassa Fever, Meningitis and the ongoing COVID-19 pandemic has highlighted the need to have a multisectoral public health workforce with the requisite skillsets to effectively address these situations.As part of the strategies to build these skillsets for public health professionals, the United States Centers for Disease Control and Prevention (US CDC) has assisted countries and territories to establish Field Epidemiology Training Programs. The aim of the FETP training is to provide the public health workforces with the ability to prevent, early detect and respond to threats with the skills to collect, analyse and interrupt disease information so that prompt action can be taken to save live

Multimorbidity of chronic diseases among adult patients presenting to an inner-city clinic in Ghana.

BACKGROUND: Very little is known about multimorbidity and chronic diseases in low and middle income countries, particularly Sub-Saharan Africa, and more information is needed to guide the process of adapting the health systems in these countries to respond adequately to the increasing burden of chronic diseases. We conducted a hospital-based survey in an urban setting in Ghana to determine the prevalence of multimorbidity and its associated risk factors among adult patients presenting to an inner city clinic. METHODS: Between May and June 2012, we interviewed adult patients (aged 18 years and above) attending a routine outpatient clinic at an inner-city hospital in Accra using a structured questionnaire. We supplemented the information obtained from the interviews with information obtained from respondents' health records. We used logistic regression analyses to explore the risk factors for multimorbidity. RESULTS: We interviewed 1,527 patients and retrieved matching medical records for 1,399 (91.6%). The median age of participants was 52.1 years (37-64 years). While the prevalence of multimorbidity was 38.8%, around half (48.6%) of the patients with multimorbidity were aged between 18-59 years old. The most common combination of conditions was hypertension and diabetes mellitus (36.6%), hypertension and musculoskeletal conditions (19.9%), and hypertension and other cardiovascular conditions (11.4%). Compared with patients aged 18-39 years, those aged 40-49 years (OR 4.68, 95% CI: 2.98-7.34), 50-59 years (OR 12.48, 95% CI: 8.23-18.92) and 60 years or older (OR 15.80, 95% CI: 10.66-23.42) were increasingly likely to present with multimorbidity. While men were less likely to present with multimorbidity, (OR 0.71, 95% CI: 0.45-0.94, p = 0.015), having a family history of any chronic disease was predictive of multimorbidity (OR 1.43, 95% CI: 1.03-1.68, p = 0.027). CONCLUSIONS: Multimorbidity is a significant problem in this population. By identifying the risk factors for multimorbidity, the results of the present study provide further evidence for informing future policies aimed at improving clinical case management, health education and medical training in Ghana

Tuberculosis surveillance system evaluation: case of Ga West municipality, Ghana, 2011 to 2016

Background: Evaluate the Tuberculosis (TB) surveillance system in the Ga West Municipality to determine if it is achieving its objectives, and to assess its attributes and usefulness.Design: Descriptive analysis of primary and secondary dataData source: Stakeholder interviews and record reviews on the objectives and operation of the surveillance system at all levels of the system.Intervention: We evaluated the system’s operation from 2011-2015 using the Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance systems and the World Health Organisation (WHO) TB surveillance checklist for assessing the performance of national surveillance systems.Results: The TB surveillance system in the municipality was functional and operated at all levels for timely detection of cases, accurate diagnosis, and case management. The system improved management of TB/HIV co-infections. The average time taken to confirm a suspected TB case was one day. The registration of a confirmed case and subsequent treatment happen immediately after confirmation. The municipality detected 109 of 727 TB cases in 2015 (case detection rate=15%). The positive predictive value (PPV) was 6.4%. There was one diagnostic centre in the municipality. Private facilities involvement in TB surveillance activities was low (1/15).Conclusion: The Tuberculosis surveillance system in the Ga West Municipality is well structured but partially meeting its objectives. The system is timely, stable and acceptable by most stakeholders and useful at all levels. It has no major data quality issues. Private health facilities in the municipality should be well incorporated into TB surveillance.Keywords: tuberculosis, evaluation, surveillance system, system attributes, Ga WestFunding: This work was supported by Ghana Field Epidemiology and Laboratory Training Program (GFELTP), University of Ghana through the support of the West Africa Health Organization (Ref.: Prog/A17IEpidemSurveillN°57212014/mcrt) to B-Y

Direct observation of outpatient management of malaria in a rural ghanaian district

Introduction: in Ghana, malaria continues to top outpatient morbidities; accounting for about 40% of all attendances. Effective case-management is key to its control. We evaluated case-management practices of uncomplicated malaria in Kwahu South District (KSD) health facilities to determine their conformity to guidelines. Methods: we conducted a cross sectional survey at all public health facilities in three randomly selected sub-districts in KSD. A non-participatory observation of suspected malaria consultations was conducted. Suspected malaria was defined as any person with fever (by history or measured axillary temperature > or equal 37.5 oC) presenting at the selected health facilities between 19th and 29th April 2013. Findings were expressed as frequencies, relative frequencies, mean (± standard deviation) and median. Results: of 70 clinical observations involving 10 prescribers in six health facilities, 40 (57.1%) were females and 16 (22.9%) were below five years. Median age was 18 years (interquartile range: 5-33). Overall, 63 (90.0%) suspected case-patients had diagnostic tests. Two (3.6%) were treated presumptively. All 31 confirmed and 10 (33.3%) of the test negative case-patients received Artemisinin-based Combination Therapies (ACTs). However, only 12 (27.9%) of the 43 case-patients treated with ACT received Artesunate-Amodiaquine (AA). Only three (18.8%) of the under-fives were examined for non-malarial causes of fever. Mean number of drugs per patient was 3.7 drugs (± 1.1). Only 45 (64.3%) patients received at least one counseling message. Conclusion: conformity of malaria case-management practices to guidelines in KSD was suboptimal. Apart from high rate of diagnostic testing and ACT use, prescription of AA, physical examination and counseling needed improvement

Imminent meningitis outbreak prevented by early warning and response action: Nadowli-Kaleo District, Upper West Region, Ghana-2017

Introduction: On 20th February 2017, health officials in Nadowli-Kaleo District (NKD) of Ghana's Upper West Region received reports of an upsurge in the number of meningitis case-patients reporting to the district's health facilities. The number of cases had exceeded the alert but not epidemic threshold for meningitis for the district. We investigated to identify the aetiologic agent, determine the risk factors and implement control measures. Methods: We conducted an unmatched case-control study. A meningitis case-patient was any NKD resident with any of the following signs and symptoms: neck stiffness, convulsion, bulging fontanelle (infants), altered consciousness or other meningeal signs with or without fever, from 1st January to 30th March 2017. For each case-patient, 2 controls (neighbours of case-patients without meningitis signs and symptoms) were identified. Demographic and clinical data were obtained through records review and case-patient interviews. Cerebrospinal fluid (CSF) samples were collected for laboratory investigation. Significant risk factors were identified using multivariable logistic regression. Results: In all 67 case-patients comprising 35 (52.2%) males and two (3%) children aged < 5 years were identified. The median age of case-patients was 24 years (interquartile range: 15–46 years). Ten deaths were recorded (case fatality rate: 14.9%). Most affected age group was 15-24 years with 18 (26.9%) case-patients and an age-specific attack rate of 170.8/100000 population. Nadowli Central sub-district, the epicenter, recorded 14 (22.4%) cases. Dominant aetiologic agent was Neisseria meningitidis isolated from 17 (58.6%) of 29 culture-positive CSF samples. Compared to controls, meningitis case-patients had higher odds of living in single window rooms (adjusted odds ratio (aOR) =5.05; 95% confidence interval (CI) =1.35-11.66), or in rooms inhabited by more than two people (aOR=3.28, CI=1.57-7.73). Conclusion: Neisseria meningitidis caused the upsurge in meningitis cases in NKD, with the youth being the most affected age group. Living in poorly ventilated rooms and overcrowded rooms were risk factors. Prompt case-management and health education helped control the occurrence and prevented an outbreak

Geospatial clustering of meningitis: an early warning system (hotspot) for potential meningitis outbreak in upper east region of Ghana

Objective: We mapped and generated hot spots for potential meningitis outbreak from existing data in Upper East region, Ghana.Design: This was a cross-sectional study conducted in 2017Data Source: Meningitis data in the Upper East Region from January 2007, to December 2016.Main outcome measure: We used spatial tools in Quantum Geographic Information System (QGIS) and Geoda to draw choropleth map of meningitis incidence, case fatality and hotspot for potential meningitis outbreak Results: A total of 2312 meningitis cases (suspected and confirmed) were recorded from 2016-2017 with median incidence of 15.0cases/100,000 population (min 6.3, max 47.8). Median age of cases was 15 years (IQR: 6-31 years). Most (44.2%) of those affected were 10 years and below. Females (51.2%) constituted the highest proportion. Median incidence from 2007-2011 was 20cases/100,000 population (Min 11.3, Max 39.9) whilst from 2012-2016 was 11.1cases/100,000 populations (Min 6.3, Max 47.8). A total of 28 significant hotspot sub-districts clusters (p=0.024) were identified with 7 High-high risk areas as potential meningitis outbreak spots.Conclusion: The occurrence of meningitis is not random, spatial cluster with high –high-risk exist in some sub-districts. Overall meningitis incidence and fatality rate have declined in the region with district variations. Districts with high meningitis incidence and fatality rates should be targeted for intervention.Keywords: meningitis outbreak, geospatial clustering, Upper East Region, meningitis incidence, GhanaFunding: Author EA was supported by the West Africa Health Organization (Ref.: Prog/A17IEpidemSurveillN°57212014/mcrt)

Secondary analysis of snake bite data in the Western Region of Ghana: 2006- 2010

Background: A snake bite is an injury caused by a bite from a snake, often resulting in puncture wounds, amputations and sometimes envenomation. Envenoming resulting from snake bite is a particularly important public health problem in rural areas of tropical and sub-tropical countries in Africa. This paper reports the incidence of snake bites and its associated mortality in the Western Region of Ghana.Method: The study was a descriptive cross-sectional review of 2006 - 2010 snake bite secondary data generated by the Western Regional Health Information Office in Ghana. Data was extracted from the District Health Information Management System (DHIMS) database. Data was managed and analyzed using SPSS Version 16.0. Univariate analyses were expressed as percentages and graphs.Results: The year 2009 recorded the highest incidence of Snake bites in the Western Region with Juabeso district recording the highest incidence of snake bites over the study period. Over the period about 55% of the incidence was between 50 – 100 per 100,000 population. The total number of snake bites recorded in the region for the period was 7,275, of which 52% (3,776) were males. About 60% of the patients were of the age group 15-49 years. A total of 12 reported snake bite deaths were recorded, of which 67% were men. This study recommends to the Districts Health Directorates in the Western Region to regularly organize community education on snake bite and the use of protective clothing by the farmers.Funding: None declaredKeywords: Snake bite, Envenomation, Incidence, District Health Information Management System, Western Region, Ghan

Evaluation of the measles surveillance system of the Ga West Municipality, Ghana, 2017

Introduction: Over 140,000 people globally died from measles in 2018; most of which occurred in developing countries. In Ghana, measles is one of the diseases earmarked for elimination in the Integrated Disease Surveillance and Response (IDSR) strategy. The measles surveillance system seeks to monitor trends, detect outbreaks and report in a timely manner. In order to improve upon the performance of the Ga West Municipal Measles surveillance system, it was evaluated with the aim of determining its effectiveness. Methods: We used CDC updated guidelines for surveillance system evaluation to assess system attributes. Measles surveillance data from 2012 – 2016 were abstracted from the DHIMS. Case investigation forms, weekly and monthly IDSR reporting forms were reviewed to validate abstracted data. Key surveillance officers were interviewed on system operations. Data was analyzed descriptively to generate frequencies and relative frequencies. Results: The system operated with a reasonable number of disease variables and case definition was simple to apply. The system was found to be integrated with the national IDSR. Government facilities across all seven sub-districts, owned and contributed data to the system. Of the 48 suspected case-patients, 39 (81.0%) were investigated; none of which was positive giving a Predictive value positive (PVP) of 0%. Majority of facilities (though privately owned) did not contribute data to the system. All tested samples were received at the laboratory within the stipulated three (3) days. The system was stable with available case base forms. Over 56% (22/39) of the samples tested had no vaccination records. Data is used to guide routine and supplementary immunization activities. Conclusion: Ga west Municipal measles surveillance system is simple, flexible and generally acceptable. It is sensitive, timely, stable but with low representativeness. It is therefore effective. Municipal health officials have been sensitized on private sector participation and need for quality and timely data

One Health concept for strengthening public health surveillance and response through Field Epidemiology and Laboratory Training in Ghana

The lack of highly trained field epidemiologists in the public health system in Ghana has been known since the 1970s when the Planning Unit was established in the Ghana Ministry of Health. When the Public Health School was started in 1994, the decision was taken to develop a 1 academic-year general MPH course. The persisting need for well-trained epidemiologists to support the public health surveillance, outbreak investigation and response system made the development of the Field Epidemiology and Laboratory Training Programme (FELTP) a national priority. The School of Public health and the Ministry of Health therefore requested the technical and financial assistance of the United States Centers for Disease Control and Prevention (CDC) in organizing the Programme. The collaboration started by organizing short courses in disease outbreak investigations and response for serving Ghana Health Service staff. The success of the short courses led to development of the FELTP. By October 2007, the new FELTP curriculum for the award of a Masters of Philosophy in Applied Epidemiology and Disease Control was approved by the Academic Board of the University of Ghana and the programme started that academic year. Since then five cohorts of 37 residents have been enrolled in the two tracks of the programme. They consist of 12 physicians, 12 veterinarians and 13 laboratory scientists. The first two cohorts of 13 residents have graduated. The third cohort of seven has submitted dissertations and is awaiting the results. The fourth cohort has started the second year of field placement while the fifth cohort has just started the first semester. The field activities of the graduates have included disease outbreak investigations and response, evaluation of disease surveillance systems at the national level and analysis of datasets on diseases at the regional level. The residents have made a total of 25 oral presentations and 39 poster presentations at various regional and global scientific conferences. The Ghana FELTP (GFELTP) has promoted the introduction of the One Health concept into FELTP. It hosted the first USAID–supported workshop in West Africa to further integrate and strengthen collaboration of the animal and human health sectors in the FETP model. GFELTP has also taken the lead in hosting the first AFENET Center for Training in Public Health Leadership and Management, through which the short course on Management for Improving Public Health Interventions was developed for AFENET member countries. The GFELTP pre-tested the Integrated Avian Influenza Outbreak and Pandemic Influenza course in preparation for introducing the materials into the curriculum of other FELTP in the network. The leadership positions to which the graduates of the program have been appointed in the human and animal Public Health Services, improvement in disease surveillance, outbreak investigation and response along with the testimony of the health authorities about their appreciation of the outputs of the graduates at various fora, is a strong indication that the GFELTP is meeting its objectives. Pan African Medical Journal 2011;10(Supp1):

Who is marginalized in energy justice? Amplifying community leader perspectives of energy transitions in Ghana

There is a divide in energy access studies, between technologically-focused modeling papers in engineering and economics, and energy justice frameworks and principles grounded in social sciences. Quantitative computational models are necessary when analyzing energy, and more specifically electricity, systems, as they are technologically-complex systems that can diverge from intuitive patterns. To assure energy justice, these models must be reflective of, and informative to, a wide range of stakeholders, including households and communities alongside utilities, governments, and others. Yet, moving from a qualitative understanding of preferences to quantitative modeling is challenging. In this perspective piece, we pilot the use of the value-focused thinking framework to inform stakeholder engagement. The result is a strategic objective hierarchy that highlights the tradeoffs and the social, economic and technological factors that need to be measured in models. We apply the process in Ghana, using a survey, stakeholder workshops, and follow-up interviews to uncover key tradeoffs and stakeholder-derived objectives. We discuss three key areas that have been rarely, if ever, well-represented in energy models: (1) the relationship between the dynamics of electricity end-use and the technology and economic structure of the system; (2) explicit tradeoffs between electricity access, cost, and reliability as defined by stakeholders; and (3) the definition of new objectives, such as minimizing hazards related to theft. We conclude that this model of engagement provides an opportunity to tie together rigorous qualitative analysis and stakeholder engagement with crucial quantitative models of the electricity system