Universal coverage and utilization of free long-lasting insecticidal nets for malaria prevention in Ghana: a cross-sectional study

BackgroundMalaria continues to be one of the leading causes of mortality and morbidity, especially among children and pregnant women. The use of Long-Lasting Insecticide Nets (LLINs) has been recognized and prioritized as a major intervention for malaria prevention in Ghana. This study aims to establish the factors influencing the universal coverage and utilization of LLINs in Ghana.MethodsThe data used for this study was from a cross-sectional survey carried out to assess LLINs ownership and use in 9 out of the 10 old regions of Ghana from October 2018 to February 2019 where free LLIN distribution interventions were implemented. The EPI “30 × 7” cluster sampling method (three-stage sampling design) was modified to “15 × 14” and used for the study. A total of 9,977 households were interviewed from 42 districts. Descriptive statistics using percentages as well as tests of associations such as Pearson Chi-square and the magnitude of the associations using simple and multivariable logistic regression were implemented.ResultsOf the 9,977 households in the study, 88.0% of them owned at least one LLIN, universal coverage was 75.6%, while utilization was 65.6% among households with at least one LLIN. In the rural and urban areas, 90.8% and 83.2% of households, respectively, owned at least one LLIN. The was a 44% increase in universal coverage of LLINs in rural areas compared to urban areas (AOR: 1.44, 95% CI: 1.02–2.02). There were 29 higher odds of households being universally covered if they received LLIN from the PMD (AOR: 29.43, 95% CI: 24.21–35.79). Households with under-five children were 40% more likely to utilize LLIN (AOR: 1.40, 95% CI: 1.26–1.56). Respondents with universal coverage of LLIN had 25% increased odds of using nets (AOR: 1.25 95% CI: 1.06–1.48). Rural dwelling influences LLIN utilization, thus there was about 4-fold increase in household utilization of LLINs in rural areas compared to urban areas (AOR: 3.78, 95% CI: 2.73–5.24). Household size of more than 2 has high odds of LLINs utilization and awareness of the benefit of LLINs (AOR: 1.42, 95% CI: 1.18–1.71).ConclusionAbout nine in 10 households in Ghana have access at least to one LLIN, three-quarters had universal coverage, and over two-thirds of households with access used LLIN. The predictors of universal coverage included region of residence, rural dwellers, and PMD campaign, while households with child under-five, in rural areas, and with universal coverage were positively associated with utilization

Pilot implementation of community health advocacy teams to improve the effectiveness of long-lasting insecticide net distribution through both campaigns and continuous channels in Ghana: a qualitative study of opportunities and barriers to implementation

IntroductionIn Ghana, the National Malaria Elimination Programme (NMEP) distributes long-lasting insecticide net (LLIN) to households for free through the periodic point mass distribution (PMD) campaign and continuous distribution to populations most vulnerable to malaria. It is known that the existence of effective and functional community-based groups could influence positive behaviours regarding health interventions promoted through health campaigns. However, there is no evidence of functional community-based groups that aim to improve the effectiveness of LLIN distribution campaigns by transitioning into primary healthcare delivery. This study aimed to explore the opportunities and barriers to the pilot implementation of co-created community health advocacy teams (CHATs) to improve the effectiveness of LLIN distribution through both campaigns and continuous channels in Ghana.MethodsA qualitative research approach was used among 43 CHAT members across six communities in the Eastern and Volta regions of Ghana. The CHAT constitutes significant community actors whose roles are centred on key elements of community/social mobilisation and capacity building, all nested in social and behaviour change communication (SBCC) strategies. The CHATs were pilot implemented in all study communities for 4 months after which we identified opportunities and barriers during implementation. CHAT members participated in six focus group discussions which were audio recorded, transcribed verbatim, and analysed thematically using the NVivo 13.ResultsCHATs were instrumental in sensitising community members through SBCC strategies. Moreover, there were changes in the behaviour of community members who were receptive towards and participated in CHAT activities. Community members were accurately informed about malaria (e.g., causes and preventive measures). However, the CHAT experienced barriers during implementation, including a lack of financial support to aid in transportation, organisation of meetings, and outreach activities. Additionally, the level of participation by CHAT members in activities and the medium of communication among members were key areas of concern.ConclusionThe CHATs would be instrumental in promoting LLINs' use during and after PMD campaigns through community outreaches. It is therefore necessary to provide resources to support their operations and a good network to address communication barriers. Finally, continuous capacity strengthening of CHAT members by the NMCP is important

Effectiveness of intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) in Ghana.

INTRODUCTION: Ghana adopted the revised WHO recommendation on intermittent preventive treatment in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in 2012. This study has assessed the effectiveness and safety of this policy in Ghana. METHODS: A total of 1926 pregnant women enrolled at antenatal care (ANC) clinics were assessed for birth outcomes at delivery, and placental histology results for malaria infection were obtained from 1642 participants. Association of reduced placental or peripheral malaria, anaemia and low birth weight (LBW) in women who received ≥4 IPTp-SP doses compared with 3 or ≤2 doses was determined by logistic regression analysis. RESULTS: Among the 1926 participants, 5.3% (103), 19.2% (369), 33.2% (640) and 42.3% (817) of women had received ≤1, 2, 3 or ≥4 doses, respectively. There was no difference in risk of active placental malaria (PM) infection in women who received 3 doses compared with ≥4 doses (adjusted OR (aOR) 1.00, 95% CI 0.47 to 2.14). The risk of overall PM infection was 1.63 (95% CI 1.07 to 2.48) in 2 dose group and 1.06 (95% CI 0.72 to 1.57) in 3 dose group compared with ≥4 dose group. The risk of LBW was 1.55 (95% CI 0.97 to 2.47) and 1.06 (95% CI 0.68 to 1.65) for 2 and 3 dose groups, respectively, compared with the ≥4 dose group. Jaundice in babies was present in 0.16%, and 0% for women who received ≥4 doses of SP. CONCLUSION: There was no difference in the risk of PM, LBW or maternal anaemia among women receiving 3 doses compared with ≥4 doses. Receiving ≥3 IPTp-SP doses during pregnancy was associated with a lower risk of overall PM infection compared with 2 doses. As there are no safety concerns, monthly administration of IPTp-SP offers a more practical opportunity for pregnant women to receive ≥3 doses during pregnancy

Therapeutic efficacy of dihydroartemisinin-piperaquine combination for the treatment of uncomplicated malaria in Ghana

In 2020, Dihydroartemisinin-Piperaquine (DHAP) was adopted as a second-line antimalarial for treatment of uncomplicated malaria in Ghana following a review of the country’s antimalarial medicines policy. Available data obtained in 2007 had shown PCR-uncorrected therapeutic efficacy of 93.3% using a 28-day follow-up schedule. In 2020, the standard 42-day follow-up schedule for DHAP was used to estimate efficacy levels among febrile children aged 6 months to 9 years in three malaria sentinel sites representing the three main ecological zones of the country- savannah, forest, and coastal. PCR genotyping distinguished between recrudescence and re-infection using merozoite surface protein 2 (MSP2)-specific primers for FC27 and 3D7 strains. Per protocol analyses showed day 28 efficacy of 100% in all three sentinel sites with day 42 PCR-corrected efficacy ranging between 90.3% (95% CI: 80.1 – 96.4%) in the savannah zone and 100% in the forest and coastal zones, yielding a national average of 97.0% (95% CI: 93.4 – 98.8). No day 3 parasitemia was observed in all three sites. Prevalence of measured fever (axillary temperature ≥ 37.5°C) declined from 50.0 - 98.8% on day 0 to 7.1-11.5% on day 1 whilst parasitemia declined from 100% on day 0 to 1.2 - 2.3% on day 1. Mean haemoglobin levels on days 28 and 42 were significantly higher than pre-treatment levels in all three sites. We conclude that DHAP is highly efficacious in the treatment of uncomplicated malaria in Ghana. This data will serve as baseline for subsequent DHAP efficacy studies in the country

Patterns of aggregated cases of uncomplicated malaria for the (a) Guinea savannah, (b) Transitional forest, (c) Coastal savannah by month for 2008 to 2016.

<p>Patterns of aggregated cases of uncomplicated malaria for the (a) Guinea savannah, (b) Transitional forest, (c) Coastal savannah by month for 2008 to 2016.</p

Map of Ghana showing the administrative regions and ecological zones.

<p>(<b>Data source:</b> <a href="https://data.humdata.org/dataset/ghana-administrative-boundaries" target="_blank">https://data.humdata.org/dataset/ghana-administrative-boundaries</a>).</p

Time series multivariable regression estimates of the relationship between average monthly rainfall, temperature and cases of malaria confirmed by zone.

<p>Time series multivariable regression estimates of the relationship between average monthly rainfall, temperature and cases of malaria confirmed by zone.</p

(Top panel) Patterns of uncomplicated malaria morbidity, (Middle panel) average rainfall (mm) and (Lower panel) average temperature (°C) by year for the Guinea savannah, Transitional forest and Coastal savannah zones.

<p>(Top panel) Patterns of uncomplicated malaria morbidity, (Middle panel) average rainfall (mm) and (Lower panel) average temperature (°C) by year for the Guinea savannah, Transitional forest and Coastal savannah zones.</p

Summary statistics of data series for Guinea savannah, Transitional forest and Coastal savannah zones.

<p>Summary statistics of data series for Guinea savannah, Transitional forest and Coastal savannah zones.</p

Spatio-temporal distribution of under-five malaria morbidity and mortality hotspots in Ghana, 2012 – 2017: a case for evidence-based targeting of malaria interventions

Introduction: The spatiotemporal variation in malaria burden underpins the need for targeted malaria interventions. Despite the scale-up of malaria control interventions in Ghana, malaria remains the leading cause of hospital admissions and deaths among children below 5 years (U5). We described spatiotemporal distribution of U5 malaria morbidity and mortality from 2012 to 2017 to provide evidence for deployment of specific malaria interventions to regions of hotspots in Ghana. Methods: We conducted a retrospective review of district-level malaria surveillance data from 2012 to 2017. We obtained confirmed U5 malaria case and population data for all districts in Ghana, and computed yearly smoothed malaria incidence and mortality rates. Hotspot analysis was performed using GeoDa’s Global and Local Moran I tests of spatial autocorrelation. Results: Overall, 8,132,769 U5 malaria cases and 5,932 deaths were reported, with case fatality rate of 0.1%. Under-five malaria incidence increased from 16.4% in 2012 to 31.3% in 2017, and the mortality rate per 100,000 decreased from 30.2 in 2012 to 6.1 in 2017. We found variation in morbidity hotspots from 8 to 23 in the western, south-western and north-eastern areas of the country each year, and six persistent mortality hotspots in the north-eastern areas. Conclusion: Over the review period, U5 malaria morbidity increased while mortality decreased. Variability in morbidity hotspots occurred across the western and northern regions unlike persistence of mortality hotspots in the north-eastern region. We recommend that the National Malaria Control Program systematically deploys preventive and case management interventions to areas of hotspots and also conduct a further evaluation to identify the causes of high mortality in the northeastern areas