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Introduction: Essentially all women and babies irrespective of their economic and social status should reach their full potential for health and well-being. The study assessed the readiness of mothers and their preparedness for birth across three disadvantaged rural districts in Ghana. Methods: A multi-centre quantitative survey from January to December 2018 using a multistage sampling approach was employed. Using a structured questionnaire data from mothers attending antenatal and postnatal clinics in three main ecological zones of Ghana were collected. Women who provided informed consent were consecutively recruited until the sample size was achieved. For categorical data, summary tables, proportions and percentage are presented. Multivariate logistic regression analysis determined the effect of selected characteristics on birth preparedness. Ethics approval was obtained from the Navrongo Health Research Centre. Results: A total of 1058 mothers were enrolled: 33.6%, 33.4% and 33.0% respectively from the Ada west, Upper Denkyira west and Builsa south districts. About 94% of the women had prior knowledge of birth preparedness. Approximately 22.6% (95%CI 20.1, 25. 2) of the mothers were assessed to have poor birth preparedness: 8.0% in Builsa south, 27.8% in Ada west and 31.7% in Upper Denkyira west. Prenatal and postnatal data showed no statistically significant difference in poor preparedness (21.9% vs 23.3%; p-value > 0.05). Maternal age, employment status, religious affiliation and parity were not associated with birth preparedness (p-value > 0.05). Area of study (P < 0.001), educational level (P < 0.016), marital status (p < 0.001) and antenatal contacts (< 0.001) were significantly associated with birth preparedness. Conclusions: As an important safe motherhood strategy woman should plan their pregnancy and birth well to reduce maternal and neonatal mortality. Policy initiatives should take into consideration area of residence, education, marital status and antenatal contacts of women. [ABSTRACT FROM AUTHOR]

Background: The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.Methods: We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.Results: From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.Conclusions: The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed. [ABSTRACT FROM AUTHOR]

Reducing neonatal mortality rates (NMR) in developing countries is a key global health goal, but weak registration systems in the region stifle public health efforts. To calculate NMRs, investigate modifiable risk factors, and explore neonatal deaths by place of birth and death, and cause of death in two administrative areas in Ghana. Data on livebirths were extracted from the health and demographic surveillance systems in Navrongo (2004–2012) and Kintampo (2005–2010). Cause of death was determined from neonatal verbal autopsy forms. Univariable and multivariable logistic regression were used to analyse factors associated with neonatal death. Multiple imputations were used to address missing data. The overall NMR was 18.8 in Navrongo (17,016 live births, 320 deaths) and 12.5 in Kintampo (11,207 live births, 140 deaths). The annual NMR declined in both areas. 54.7% of the births occurred in health facilities. 70.9% of deaths occurred in the first week. The main causes of death were infection (NMR 4.3), asphyxia (NMR 3.7) and prematurity (NMR 2.2). The risk of death was higher among hospital births than home births: Navrongo (adjusted OR 1.14, 95% CI: 1.03–1.25, p = 0.01); Kintampo (adjusted OR 1.76, 95% CI: 1.55–2.00, p < 0.01). However, a majority of deaths occurred at home (Navrongo 61.3%; Kintampo 50.7%). Among hospital births dying in hospital, the leading cause of death was asphyxia; among hospital and home births dying at home, it was infection. The NMR in these two areas of Ghana reduced over time. Preventing deaths by asphyxia and infection should be prioritised, centred respectively on improving post-delivery care in health facilities and subsequent post-natal care at home. [ABSTRACT FROM AUTHOR]

Treatment adherence has been described as the process whereby patients take medications, follow diet, and effect other lifestyle changes that relate to agreed recommendations from healthcare providers. The determinants of such treatment adherence include patient, the health condition, therapy type, socioeconomic conditions, and the healthcare system. The study examined adherence in malaria patients treated with dihydroartemisinin-piperaquine in routine clinical care in northern Ghana. The study was conducted in Navrongo Health Research Centre in the Kassena-Nankana district of northern Ghana. Patients confirmed with uncomplicated malaria were prescribed dihydroartemisinin-piperaquine in blister packs to be taken daily for three days. Follow-up visits were made on days 3 and 28 after diagnosis to collect data on adherence, drug safety and therapeutic effectiveness. During follow-up visits, in-depth interviews were conducted and the blister packs directly observed for the number of tablets remaining. The in-depth interviews documented day-by-day account of doses taken, number of tablets taken during each dose, time of each dose, reasons for any leftover or missed dose, and whether or not there was vomiting. Treatment adherence was classified as definitely nonadherent, incomplete adherence, and completely adherent. A total of 405 patients were screened; 299 were positive by rapid diagnostic testing and 216 by microscopy. The average age was 12 years and females represented 54.0%. All participants completed day 3 follow-up but 12.7% had leftover pills. Treatment adherence was 50.9% (95% CI 44.1, 57.8), 36.1% (95% CI 29.7, 42.9), and 13.0% (95% CI 8.8, 18.2) for completely adherent, incomplete adherence, and definitely nonadherent, respectively. All completely adherent patients were free of parasitemia on day 28 of follow-up. A total of 49 adverse events related to malaria symptoms were documented. Effort to improve adherence should be individualized as it is dependent on a number of factors such as the patients' temperament, the disease, support at home, and complexity of treatment. [ABSTRACT FROM AUTHOR]

Background Studies suggest that diphtheria-tetanus-pertussis (DTP) vaccine administered simultaneously with measles vaccine (MV) or DTP administered after MV are associated with higher child mortality than having MV-after-DTP3 as most recent vaccination. We tested this in Northern Ghana where the prevalence of such out-of-sequence vaccinations has declined. Methods Using annual cohort data of children aged 12–23 months from 1996 to 2012 and Cox proportional hazards models, we assessed survival in relation to the most recent vaccination status within the next 12 months and until five years of age. We assessed whether mortality in children aged 12–59 months was higher when the most recent vaccine was non-live (DTP) rather than live (MV or OPV). Results Out-of-sequence vaccinations with DTP-containing vaccines and MV declined from 86% in 1989 to 24% in 1996 and 0.7% in 2012. Between 1996 and 2012, 38 070 children had their vaccinations status assessed: the adjusted hazard ratio (HR) for out-of-sequence vaccinations (DTP >= MV) compared with the recommended sequence of MV-after-DTP3 was 1.42(1.06–1.90) during the first 12 months after assessment of vaccination status and 1.29(1.03–1.60) with follow-up to five years of age; the HR was 2.58(1.14–5.84) before OPV or MV campaigns and 1.37(1.02–1.85) after the campaigns. Conclusion Out-of-sequence vaccinations with DTP and MV are associated with higher mortality than MV as most recent vaccination; the effect is unlikely to be due to confounding. Hence, the reduction in out-of-sequence vaccinations may have lowered child mortality. It is recommended not to give DTP with MV or DTP after MV. [ABSTRACT FROM AUTHOR]

Background: Uncommon and rare adverse events (AEs), with delayed onset may not be detected before new drugs are licensed and deployed. The present study examined the post licensure safety of dihydroartemisinin-piperaquine (DHP) as an additional treatment for malaria in Ghana. The relationship between the incidence of AEs, treatment completion rate, participant characteristics and concomitant medications are reported. Methods: A study conducted from September 2013 to June 2014 in Navrongo, Kintampo and Dodowa health research centres in Ghana is presented. Participants had confirmed malaria and no known allergy to study drug. Patients provided informed consent and had their symptoms and results of their clinical examinations documented. Treatment with Eurartesim® (20/160mg dihydroartemisinin and 40/320mg piperaquine by Sigma-Tau Incorporated) was given, according to the body weight of patients. First treatment doses were under observation but the second and third doses were taken at home except in a sub-study involving a nested cohort. Patients were contacted at Day 5 (± 2 days) either on telephone or by a home visit to document any AEs experienced. Patients were asked to report to the study team any other AEs that occurred within 28 days post-treatment. All patients in the nested cohort had electrocardiogram (ECG). Findings: A total of 4563 patients, 52.1% females and 48.2% <6 years completed the study. A total of 444 patients were enrolled into the nested cohort. About 33% had temperature ≥ 37.5°C at enrolment. Approximately 3.4% reported taking prior antimalarials, 19.4% other medications and 86% took at least one concomitant medication. Incidence of AEs was 7.6% including infections (4.6%), gastrointestinal disorders (1.0%) and local reactions at the site of venesection (0.5%). Others were respiratory disorders (0.4%) and nervous system disorders (0.3%). There were nine adverse events of special interest (AESI); itching/pruritus (7), dizziness (1), and skin lesions (1). Patients who took medications prior to enrolment had higher incidence of AEs compared with those without (9.3% vs. 6.1%; P<0.001). Statistically significant associations were found between the reported AEs and age of patients (P<0.001), their body mass index (BMI) (P< 0.001) and parasite densities (P< 0.001). Conclusion: Dihydroartemisinin-Piperaquine was well tolerated with no serious safety concerns identified. Obesity and prior enrolment medication were among significant factors associated with increased AEs reporting. [ABSTRACT FROM AUTHOR]

Background: Health facility data are more readily accessible for operational planning and evaluation of disease control programmes. The importance, potential challenges and limitations of using facility based survey as an alternative tool for monitoring changes in local malaria epidemiology were examined.Methods: The study involved six areas within the administrative divisions of The Gambia. The areas were selected to reflect socioeconomic and malaria transmission intensities across the country. The study design involved an age stratified cross sectional surveys that were conducted during the wet season in 2008 and in the 2009 during the dry season. Participants were patients attending clinics in six health centres and the representative populations from the catchment communities of the health centres.Results: Overall participants' characteristics were mostly not comparable in the two methodological approaches in the different seasons and settings. More females than males were enrolled (55.8 vs. 44.2 %) in all the surveys. Malaria infection was higher in the surveys in health centres than in the communities (p < 0.0001) and also in males than in females (OR = 1.3; p < 0.001). Males were less likely than females to sleep under an insecticide treated net in the communities (OR = 1.6; 95 % CI 1.3, 1.9) and in the health centres (OR = 1.3; 95 % CI 1.1, 1.5). Representativeness of the ethnic groups was better in the health centre surveys than in the community surveys when compared to the 2003 national population census in The Gambia.Conclusion: Health facility based survey though a potential tool for monitoring changes in the local epidemiology of malaria will require continuous validation of the facility and participants sociodemograhic characteristics as these may change over time. The effects of health seeking practices on service utilization and health facility surveys as an approach will also need continuous review. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization recommends artemisinin-based combination (ACT) for the treatment of uncomplicated malaria. Post-licensure safety data on newly registered ACT is critical for evaluating their risk/benefit profile in malaria endemic countries. The clinical safety of the newly registered combination, Eurartesim®, following its introduction into the public health system in four African countries was assessed. Methods: This was a prospective, observational, open-label, non-comparative, longitudinal, multi-centre study using cohort event monitoring. Patients with confirmed malaria had their first dose observed and instructed on how to take the second and the third doses at home. Patients were contacted on day 5 ± 2 to assess adherence and adverse events (AEs). Spontaneous reporting of AEs was continued till day 28. A nested cohort who completed full treatment course had repeated electrocardiogram (ECG) measurements to assess effect on QTc interval. Results: A total of 10,925 uncomplicated malaria patients were treated with Eurartesim®. Most patients,95% (10,359/10,925), did not report any adverse event following at least one dose of Eurartesim®. A total of 797 adverse events were reported. The most frequently reported, by system organ classification, were infections and infestations (3. 24%) and gastrointestinal disorders (1. 37%). In the nested cohort, no patient had QTcF > 500 ms prior to day 3 pre-dose 3. Three patients had QTcF > 500 ms (509 ms, 501 ms, 538 ms) three to four hours after intake of the last dose. All the QTcF values in the three patients had returned to <500 ms at the next scheduled ECG on day 7 (470 ms, 442 ms, 411 ms). On day 3 pre- and post-dose 3, 70 and 89 patients, respectively, had a QTcF increase of ≥ 60 ms compared to their baseline, but returned to nearly baseline values on day 7. Conclusion: Eurartesim® single course treatment for uncomplicated falciparum malaria is well-tolerated. QT interval prolongation above 500 ms may occur at a rate of three per 1,002 patients after the third dose with no association of any clinical symptoms. QT interval prolongation above 60 ms was detected in less than 10% of the patients without any clinical abnormalities. [ABSTRACT FROM AUTHOR]

Background Given increasing rates of resistance to existing therapy, new options for treatment and prophylaxis of malaria are needed. Methods Two randomized, comparative, non-inferiority studies were conducted in Africa, one doubleblinded and one open-label. Adults with fever, a positive peripheral blood smear, and a positive rapid diagnostic test for Plasmodium falciparum were randomized in both studies to either azithromycin (AZ) 1,000 mg plus chloroquine (CQ) 600-mg base (AZCQ 1,000 mg) once daily for three days or mefloquine hydrochloride (MQ) 1,250 mg (split dose). In the first study, an additional regimen of AZ 500 mg plus CQ 600-mg base (AZCQ 500 mg) once daily for three days was included. All study participants were hospitalized until three consecutive daily blood smears were negative for asexual P. falciparum parasitaemia. Study participants were evaluated weekly for 42 days, with Day 28 polymerase chain reaction (PCR)-corrected parasitological clearance rate as primary endpoint. Results A total of 467 subjects were randomized in the two studies. At 28 days' follow-up, PCRcorrected parasitological clearance rates in the per protocol population in the first study were 101/103 (98%) with AZCQ 1,000 mg compared with 102/103 (99%) with MQ (95% confidence interval [CI]: -5.2, 3.3). The AZCQ 500-mg regimen was stopped during an interim study review (six [86%] clearance of seven evaluable; two lost to follow-up). In the second study, clearance rates were similar: AZCQ 1,000 mg 107/107 (100%) vs MQ 111/112 (99%; 95% CI: -1.8, 3.6). Among the participating countries, in vitro CQ resistance based on pfcrt mutation frequency in the baseline isolates across both studies ranged from 20.8% (Zambia) to 96.1% (Uganda). Serious adverse events (AEs; all causality) were observed more frequently with MQ compared with AZCQ (four vs one, respectively), though discontinuations for AEs were similar (four vs three, respectively). Common AEs in the AZcontaining arms included pruritus, vomiting, dizziness, and headache. Conclusions Among adults with symptomatic uncomplicated falciparum malaria in Africa, the combination of AZ 1,000 mg and CQ 600-mg base once daily for three days resulted in Day- 28 PCR-corrected parasitological clearance rates of ⩾98% and was non-inferior to treatment with MQ. AZCQ was well tolerated. Trial registration ClinicalTrials.gov identifiers NCT00082576 and NCT00367653 [ABSTRACT FROM AUTHOR]

Background: As countries make progress in malaria control, transmission may be reduced to such an extent that few cases occur, and identification of the remaining foci of transmission may require a combination of surveillance tools. The study explored the usefulness of parasite prevalence, seroprevalence and model-estimated seroconversion rates for detecting local differences in malaria transmission in a West African country. Methods: Age-stratified cross-sectional surveys were conducted during the wet season in 2008 and the following dry season in 2009 in The Gambia. In each season, 20 village communities were sampled from six diverse areas throughout the country. A total of 7,586 participants were surveyed, 51% (3,870) during the wet season. Parasites were detected by thick film slide microscopy, and anti-MSP1-19 antibodies were detected by ELISA using eluted dried blood from filter papers. Results: Overall parasite prevalence was 12.4% in the wet season and 2.2% in the dry season, with village-specific parasite prevalence ranging from 1.4 to 45.9% in the wet season and from 0.0 to 13.2% in the dry season. Prevalence was highest in the eastern part of the country. Serological indices also varied between villages, indicating local heterogeneity in transmission, and there was a high correlation between wet and dry season estimates across the villages. The overall prevalence of anti-MSP119 antibodies was similar in the wet (19.5%) and in the dry (19.6%) seasons. Conclusion: The study illustrates the utility of measuring both parasite prevalence and serological indices for monitoring local variation in malaria transmission, which are more informative than single measures as control intensifies and malaria declines. Measurements of seropositivity have the logistical advantage of being relative stable seasonally so that sampling at any time of year may be conducted. [ABSTRACT FROM AUTHOR]

Located in the Kassena-Nankana districts of northern Ghana, the Navrongo health and demographic surveillance system (NHDSS) was established in 1992 by the Navrongo health research centre (NHRC). The NHRC is one of three research centres of the Ghana health service. The activities and potential of the NHDSS for collaborative research are described. The NHDSS monitors health and demographic dynamics of the two Kassena-Nankana districts of northern Ghana and facilitates evaluation of the morbidity and mortality impact of health and social interventions. The total population currently under surveillance is 152 000 residing in 32 000 households. Events monitored routinely include pregnancies, births, morbidity, deaths, migration, marriages and vaccination coverage. Data updates are done every 4 months by trained fieldworkers. The NHRC also undertakes biomedical and socio-economic studies. Additional features of the NHDSS include the community key informant system where trained volunteers routinely report key events, such as births and deaths as they occur in their locality and the verbal autopsy (VA) system for determining the probable causes of deaths that occur at the community level. Data from the NHDSS are shared with funders and collaborators and partners in the INDEPTH Network. The Director of the NHDSS is the contact person for potential collaboration with the NHDSS and the use of its data. [ABSTRACT FROM PUBLISHER]

Introduction: Despite the emphasis on reporting of Adverse Events Following Immunisation (AEFIs) during didactic training sessions, especially prior to new vaccine introductions, it remains low in Ghana. We explored the factors underlying the under-reporting of AEFI by healthcare workers (HCWs) to provide guidance on appropriate interventions to increase reporting. Methods: We conducted an exploratory descriptive in-depth study of the factors contributing to low reporting of AEFI among HCWs in four regions in Ghana. Key informant interviews (KII) were held with purposively selected individuals that are relevant to the AEFI reporting process at the district, regional, and national levels. We used KII guides to conduct in-depth interviews and used NVivo 10 qualitative software to analyse the data. Themes on factors influencing AEFI reporting were derived inductively from the data, and illustrative quotes from respondents were used to support the narratives. Results: We conducted 116 KIIs with the health managers, regulators and frontline HCWs and found that lack of information on reportable AEFIs and reporting structures, misunderstanding of reportable AEFIs, heavy workload, cost of reporting AEFIs, fear of blame by supervisors, lack of motivation, and inadequate feedback as factors responsible for underreporting of AEFIs. Respondents suggested that capacity building for frontline HCWs, effective supervision, the provision of motivation and feedback, simplification of reporting procedures, incentives for integrating AEFI reporting into routine monitoring and reporting, standardization of reporting procedures across regions, and developing appropriate interventions to address the fear of personal consequences would help improve AEFI reporting. Conclusion: From the perspectives of a broad range of key informants at all levels of the vaccine safety system, we found multiple factors (both structural and behavioural), that may impact HCW reporting of AEFI in Ghana. Improvements in line with the suggestions are necessary for increased AEFI reporting in Ghana. [ABSTRACT FROM AUTHOR]

Background: Presently, many malaria control programmes use health facility data to evaluate the impact of their interventions. Facility-based malaria data, although useful, have problems with completeness, validity and representativeness and reliance on routinely collected health facility data might undermine demonstration of the magnitude of the impact of the recent scaleups of malaria interventions. To determine whether carefully conducted health centre surveys can be reliable means of monitoring area specific malaria epidemiology, we have compared malaria specific indices obtained from surveys in health centres with indices obtained from cross-sectional surveys conducted in their catchment communities. Methods: A series of age stratified, seasonal, cross-sectional surveys were conducted during the peak malaria transmission season in 2008 and during the following dry season in 2009 in six ecologically diverse areas in The Gambia. Participants were patients who attended the health centres plus a representative sample from the catchment villages of these health facilities. Parasitaemia, anaemia, attributable proportion of fever and anti-MSP1-19 antibody seroprevalence were compared in the health facility attendees and community participants. Results: A total of 16,230 subjects completed the study; approximately half participated in the health centre surveys and half in the wet season surveys. Data from both the health centre and community surveys showed that malaria endemicity in The Gambia is now low, heterogeneous and seasonal. In the wet season, parasitaemia, seroprevalence and fever prevalence were higher in subjects seen in the health centres than in the community surveys. Age patterns of parasitaemia, attributable proportions of fever and seroprevalence rates were similar in subjects who participated in the community and health centre surveys. Conclusion: Health centre surveys have potential as a surveillance tool for evaluating area specific malaria control activities and for monitoring changes in local malaria epidemiology over time. [ABSTRACT FROM AUTHOR]

Study design: Severe falciparum malaria in children was studied as part of the characterization of the Kassena-Nankana District Ghana for future malaria vaccine trials. Children aged 6-59 months with diagnosis suggestive of acute disease were characterized using the standard WHO definition for severe malaria. Results: Of the total children screened, 45.2% (868/1921) satisfied the criteria for severe malaria. Estimated incidence of severe malaria was 3.4% (range: 0.4-8.3%) cases per year. The disease incidence was seasonal: 560 cases per year, of which 70.4% occurred during the wet season (June-October). The main manifestations were severe anaemia (36.5%); prolonged or multiple convulsions (21.6%); respiratory distress (24.4%) and cerebral malaria (5.4%). Others were hyperpyrexia (11.1%); hyperparasitaemia (18.5%); hyperlactaemia (33.4%); and hypoglycaemia (3.2%). The frequency of severe anaemia was 39.8% in children of six to 24 months of age and 25.9% in children of 25-60 months of age. More children (8.7%) in the 25-60 months age group had cerebral malaria compared with 4.4% in the 6-24 months age group. The overall case fatality ratio was 3.5%. Cerebral malaria and hyperlactataemia were the significant risk factors associated with death. Severe anaemia, though a major presentation, was not significantly associated with risk of death. Conclusion: Severe malaria is a frequent and seasonal childhood disease in northern Ghana and maybe an adequate endpoint for future malaria vaccine trials. [ABSTRACT FROM AUTHOR]

The study examined the efficacy of chloroquine (CQ), amodiaquine (AQ) and sulphadoxine–pyrimethamine (SP) for the treatment of uncomplicatedPlasmodium falciparummalaria in Ghana. A total of 351 children were randomized to receive either of the three study drugs. Patients were evaluated using the WHO 14-dayin vivoantimalarial testing guidelines. The 14-day adequate clinical and parasitological response analysis revealed that CQ, 46.7% (95% CI 37.5, 56.0) has the least efficacy compared with AQ, 86.1% (95% CI 78.3, 91.8) and SP, 77.6% (95% CI 68.9, 84.8). Late parasite failures were also lower and similar in the AQ and SP (9.6% and 10.3%) than in the CQ (32.5%) group. However, CQ and AQ groups showed better fever clearance compared with SP throughout except for day 7 and after when possibly due to its significant late clinical failures, clearance by CQ was lower. Our findings suggest that CQ is no longer useful in Ghana and should be replaced as a first-line treatment of malaria. Replacement of CQ preferably with AQ combination treatment will be an effective and an affordable alternative for the treatment of uncomplicated malaria. [ABSTRACT FROM AUTHOR]

Background: Utilization of antenatal care services in Ghana has substantially increased over the years, but the rates of mother-to-child transmission of HIV is still high. The high burden of HIV among pregnant women has serious implications for mother-to-child transmission. The main objective of this study was to assess the compliance of HIV testing and counseling provided at antenatal care clinics in two rural districts in northern Ghana by comparing reported practices to the national guidelines. Methods: This study was a descriptive qualitative study conducted in the Kassena-Nankana Districts of northern Ghana. In-depth interviews were conducted with 10 midwives, 10 mothers, and 2 public health nurses who were recruited through purposive and snowball sampling. All interviews were audio recorded, transcribed into English, and imported into NVivo 12.0 software for open, axial, and selective coding. Results: The findings indicate that not all pregnant women were informed prior to testing nor informed of their test results. Many mothers indicated that pre-test counseling is limited although the midwives claimed to provide it. Post-test counseling is primarily given to those who test positive, and several midwives agreed that there is no need to counsel HIV-negative women. Perceptions of the lack of confidentiality and privacy were pervasive among mothers despite the emphasis placed on its importance by the midwives. There were conflicting reports on whether HIV testing during antenatal care is voluntary or compulsory. The challenges with HIV testing and counseling that were mentioned by midwives include lack of adequate infrastructure, language barriers, and insufficient training. Conclusions: HIV testing and counseling provided at antenatal care is not uniform across all health facilities and does not strictly adhere to national guidelines. Future interventions that focus on standardization, monitoring, privacy, and capacity building are likely to prove valuable in ensuring quality services are provided. [ABSTRACT FROM AUTHOR]

Background: This study assessed knowledge, behaviors, and perceptions towards hypertension following community dissemination on cardiovascular disease (CVD) risk within the Navrongo Health and Demographic Surveillance Site in Northern Ghana. Methods: A cross-sectional mixed methods study was conducted among middle aged men and women following education on CVD and their risk factors. Knowledge and attitudes of participants regarding hypertension were measured in 310 participants using a survey tool and the resultant data was analyzed with descriptive statistics. Focus group discussions (FDG) were used to assess perceptions of 40 study participants on their lived experiences with hypertension. Recorded interviews were transcribed verbatim and coded into themes using Nvivo 12 software before thematic analysis. Results: Of the 310 surveyed participants, 54% were women and the mean age was 50 ± 6 years. The results showed that 84% of participants had heard about hypertension, 70% knew it was an increase in blood pressure and could be caused by excess salt intake, poor diet and physical inactivity. About 22.3% of participants were aware of the had hypertension. In terms of management, majority of the participants were aware that hypertension could be treated with antihypertensive medication and that untreated or uncontrolled hypertension could result in adverse health consequences. Few participants had ever had their blood pressure measured and did not access screening or healthcare care services and rather perceived the health system as inadequate to screen, and manage hypertension. Conclusion: Though, knowledge on hypertension was high, awareness of hypertension status and access to screening and healthcare services was low. Community beliefs and perceptions strongly influence treatment, and control of hypertension. Effective sustained community dissemination efforts addressing misperceptions could improve hypertension treatment and control. [ABSTRACT FROM AUTHOR]

The RTS,S/AS01 E malaria vaccine (RTS,S) was introduced by national immunisation programmes in Ghana, Kenya, and Malawi in 2019 in large-scale pilot schemes. We aimed to address questions about feasibility and impact, and to assess safety signals that had been observed in the phase 3 trial that included an excess of meningitis and cerebral malaria cases in RTS,S recipients, and the possibility of an excess of deaths among girls who received RTS,S than in controls, to inform decisions about wider use. In this prospective evaluation, 158 geographical clusters (66 districts in Ghana; 46 sub-counties in Kenya; and 46 groups of immunisation clinic catchment areas in Malawi) were randomly assigned to early or delayed introduction of RTS,S, with three doses to be administered between the ages of 5 months and 9 months and a fourth dose at the age of approximately 2 years. Primary outcomes of the evaluation, planned over 4 years, were mortality from all causes except injury (impact), hospital admission with severe malaria (impact), hospital admission with meningitis or cerebral malaria (safety), deaths in girls compared with boys (safety), and vaccination coverage (feasibility). Mortality was monitored in children aged 1–59 months throughout the pilot areas. Surveillance for meningitis and severe malaria was established in eight sentinel hospitals in Ghana, six in Kenya, and four in Malawi. Vaccine uptake was measured in surveys of children aged 12–23 months about 18 months after vaccine introduction. We estimated that sufficient data would have accrued after 24 months to evaluate each of the safety signals and the impact on severe malaria in a pooled analysis of the data from the three countries. We estimated incidence rate ratios (IRRs) by comparing the ratio of the number of events in children age-eligible to have received at least one dose of the vaccine (for safety outcomes), or age-eligible to have received three doses (for impact outcomes), to that in non-eligible age groups in implementation areas with the equivalent ratio in comparison areas. To establish whether there was evidence of a difference between girls and boys in the vaccine's impact on mortality, the female-to-male mortality ratio in age groups eligible to receive the vaccine (relative to the ratio in non-eligible children) was compared between implementation and comparison areas. Preliminary findings contributed to WHO's recommendation in 2021 for widespread use of RTS,S in areas of moderate-to-high malaria transmission. By April 30, 2021, 652 673 children had received at least one dose of RTS,S and 494 745 children had received three doses. Coverage of the first dose was 76% in Ghana, 79% in Kenya, and 73% in Malawi, and coverage of the third dose was 66% in Ghana, 62% in Kenya, and 62% in Malawi. 26 285 children aged 1–59 months were admitted to sentinel hospitals and 13 198 deaths were reported through mortality surveillance. Among children eligible to have received at least one dose of RTS,S, there was no evidence of an excess of meningitis or cerebral malaria cases in implementation areas compared with comparison areas (hospital admission with meningitis: IRR 0·63 [95% CI 0·22–1·79]; hospital admission with cerebral malaria: IRR 1·03 [95% CI 0·61–1·74]). The impact of RTS,S introduction on mortality was similar for girls and boys (relative mortality ratio 1·03 [95% CI 0·88–1·21]). Among children eligible for three vaccine doses, RTS,S introduction was associated with a 32% reduction (95% CI 5–51%) in hospital admission with severe malaria, and a 9% reduction (95% CI 0–18%) in all-cause mortality (excluding injury). In the first 2 years of implementation of RTS,S, the three primary doses were effectively deployed through national immunisation programmes. There was no evidence of the safety signals that had been observed in the phase 3 trial, and introduction of the vaccine was associated with substantial reductions in hospital admission with severe malaria. Evaluation continues to assess the impact of four doses of RTS,S. Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Unitaid. [ABSTRACT FROM AUTHOR]

This study investigated infant and young child‐feeding (IYCF) practices among mothers of well‐nourished children in northern Ghana. This was a qualitative study where in‐depth individual interviews were conducted with participants. The interviews were audio recorded, transcribed, and QSR Nvivo software version 11 was used to organize the data before thematic analysis. It was observed that mothers of well‐nourished children were likely to adhere to breastfeeding guidelines and also practice appropriate complementary feeding. Furthermore, these mothers mostly had some form of support from their husbands and mother‐in‐laws in feeding their infants. While adoption and adherence to appropriate IYCF practices contribute to improved nutrition outcomes in children, social support systems are needed to sustain the practice. [ABSTRACT FROM AUTHOR]

Background: The cardiovascular health index (CVHI) introduced by the American Heart Association is a valid, accessible, simple, and translatable metric for monitoring cardiovascular health in a population. Components of the CVHI include the following seven cardiovascular risk factors (often captured as life's simple 7): smoking, dietary intake, physical activity, body mass index, blood pressure, glucose, and total cholesterol. We sought to expand the evidence for its utility to under-studied populations in sub-Saharan Africa, by determining its association with common carotid intima-media thickness (CIMT).Methods: We conducted a cross-sectional study involving 9011 participants drawn from Burkina Faso, Ghana, Kenya, and South Africa. We assessed established classical cardiovascular risk factors and measured carotid intima-media thickness of the left and right common carotid arteries using B-mode ultrasonography. Adjusted multilevel mixed-effect linear regression was used to determine the association of CVHI with common CIMT. In the combined population, an individual participant data meta-analyses random-effects was used to conduct pooled comparative sub-group analyses for differences between countries, sex, and socio-economic status.Results: The mean age of the study population was 51 ± 7 years and 51% were women, with a mean common CIMT of 637 ± 117 μm and CVHI score of 10.3 ± 2.0. Inverse associations were found between CVHI and common CIMT (β-coefficients [95% confidence interval]: Burkina Faso, - 6.51 [- 9.83, - 3.20] μm; Ghana, - 5.42 [- 8.90, - 1.95]; Kenya, - 6.58 [- 9.05, - 4.10]; and South Africa, - 7.85 [- 9.65, - 6.05]). Inverse relations were observed for women (- 4.44 [- 6.23, - 2.65]) and men (- 6.27 [- 7.91, - 4.64]) in the pooled sample. Smoking (p < 0.001), physical activity (p < 0.001), and hyperglycemia (p < 0.001) were related to CIMT in women only, while blood pressure and obesity were related to CIMT in both women and men (p < 0.001).Conclusion: This large pan-African population study demonstrates that CVHI is a strong marker of subclinical atherosclerosis, measured by common CIMT and importantly demonstrates that primary prevention of atherosclerotic cardiovascular disease in this understudied population should target physical activity, smoking, obesity, hypertension, and hyperglycemia. [ABSTRACT FROM AUTHOR]

Background: There is limited knowledge on cost of treating malaria in children under-five years in northern Ghana which poses a challenge in determining whether interventions such as the National Health Insurance Scheme (NHIS) and Community-based Health Planning and Services (CHPS) have reduced the economic burden of malaria to households or not. This study examined the malaria care seeking and cost of treatment in children under-five years in the Upper West Region of Ghana. Methods: The study used a cross-sectional, quantitative design and data were collected between July and August 2016 in three districts in the Upper West Region of Ghana. A total of 574 women who had under-five children were interviewed. Socio-demographic characteristics of respondents, malaria seeking patterns for under-five children with malaria as well as direct medical and non-medical costs associated with treating under-five children with malaria were collected from the patient perspective. Analysis was performed using STATA 12. Results: Out of 574 women visited, about 63% (360) had children who had malaria and sought treatment. Most treatment was done at formal health facilities such as the health centres (37%) and the CHPS (35%) while 3% had self-treatment at home. The main reason for choice of place of treatment outside home was nearness to home (53%). The average direct medical and non-medical costs associated with treating an under-five child with malaria were US$4.13 and US$3.04 respectively. The average cost on transportation alone was US$2.64. Overall, the average direct medical and non-medical cost associated with treating an under-five child with malaria was US$4.91(range: minimum = US$0.13 –maximum = US$46.75). Children who were enrolled into the NHIS paid an average amount of US$4.76 compared with US$5.88 for those not enrolled, though the difference was not statistically significant (p-value = 0.15). Conclusions: The average cost to households in treating an under-five child with malaria was US$4.91. This amount is considerably high given the poverty level in the area. Children not insured paid a little over one US dollar for malaria treatment compared to those insured. Efforts to improve enrolment into the NHIS may be needed to reduce the cost of malaria treatment to households. Construction of more health facilities near to community members and at hard to reach areas will improve access to health care and reduce direct non-medical cost such as transportation costs. [ABSTRACT FROM AUTHOR]

Background: Twenty years after acknowledging the importance of joint responsibilities and male participation in maternal health programs, most health care systems in low income countries continue to face challenges in involving men. We explored the reasons for men's resistance to the adoption of a more proactive role in pregnancy care and their enduring influence in the decision making process during emergencies.Methods: Ten focus group discussions were held with opinion leaders (chiefs, elders, assemblymen, leaders of women groups) and 16 in-depth interviews were conducted with healthcare workers (District Directors of Health, Medical Assistants in-charge of health centres, and district Public Health Nurses and Midwives). The interviews and discussions were audio recorded, transcribed into English and imported into NVivo 10 for content analysis.Results: As heads of the family, men control resources, consult soothsayers to determine the health seeking or treatment for pregnant women, and serve as the final authority on where and when pregnant women should seek medical care. Beyond that, they have no expectation of any further role during antenatal care and therefore find it unnecessary to attend clinics with their partners. There were conflicting views about whether men needed to provide any extra support to their pregnant partners within the home. Health workers generally agreed that men provided little or no support to their partners. Although health workers had facilitated the formation of father support groups, there was little evidence of any impact on antenatal support.Conclusions: In patriarchal settings, the role of men can be complex and social and cultural traditions may conflict with public health recommendations. Initiatives to promote male involvement should focus on young men and use chiefs and opinion leaders as advocates to re-orient men towards more proactive involvement in ensuring the health of their partners. [ABSTRACT FROM AUTHOR]

Background: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. Methods: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus–post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. Results: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). Conclusions: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) prevalence is high in Ghana—but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors. Methods: We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes. Results: CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital. Conclusions: CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors–in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD–including its behavioral and mental health causes–in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise. [ABSTRACT FROM AUTHOR]

Introduction: diarrhoea disease is a global health concern, persisting as one of the top five causes of morbidity and mortality in children. Viral aetiology of childhood diarrhoea is often associated with rotavirus infection of which preventable vaccines exist. Here we document circulating strains of rotavirus in the Kassena-Nankana Districts of Northern Ghana nearly a decade after the introduction of the rotavirus vaccine. Methods: a cross-sectional survey of children aged 0-60 months was conducted in six health facilities within the Kassena-Nankana Districts. Faecal samples obtained from the children were analysed and characterized for rotavirus detection and genotyping using Semi-Nested Polymerase Chain Reaction. Results: a total of 263 stool samples were analyzed. Out of which 14.8% and 18.6% of the diarrhoea cases were of rotavirus and parasitic etiologies respectively, with 17.4% being coinfections. Almost 27.5% of rotavirus diarrhoeal cases resulted in hospitalization. Household size (p=0.035), location (p=0.018), treatment outcome (p=0.007), vomiting (p=0.039), season (p=0.017) and month of sampling (p=0.000) were significantly associated with rotavirus infection. The rotavirus genotypes identified were G1P8, G3P6, G4P9, G10P6 and G12P8. Rotavirus vaccinetype, G1P8 was absent in Kassena-Nankana West District. Conclusion: the prevalence of rotavirus was low compared to the pre-vaccination era. Also, a new rotavirus strain, G4P9 was identified to be circulating in the study area which calls for surveillance measures and more studies to better understand the situation for appropriate public health intervention. [ABSTRACT FROM AUTHOR]

Few studies have compared the utility of serum levels of lipid fractions in cardiovascular disease (CVD) risk assessment in sub-Saharan Africa (SSA). The current study interrogated this question among men and women aged 40–60 years in rural northern Ghana. This was a cross-sectional study in which data was collected on socio-demography, behaviour, health history, anthropometry and lipid levels. Adjusted multivariable logistic regression models were used to assess the association of various lipid metrics with CVD. All tests were considered statistically significant at P<0.05. Data were available for 1839 participants. The prevalence of self-reported CVD was 1.6% (n = 29). Non-HDL-C (median (interquartile range): 2.4 (1.9–3.0) vs 2.0 (1.6–2.5) mmol/L; P = 0.009), LDL-C/HDL-C (1.8 (1.4–2.4) vs 1.5 (1.1–2.6); P = 0.019) and TC/HDL-C (3.3 (2.9–3.9) vs 2.9 (2.4–3.5); P = 0.003) were all significantly higher in participants with self-reported CVD compared to those without. However, after adjusting for socioeconomic status (SES) and meals from vendors in a logistic regression model, only non-HDL-C (odds ratio [95% CIs]): (1.58 [1.05, 2.39]), P = 0.029 and LDL-C/HDL-C levels (odds ratio [95% CIs]): (1.26 [1.00, 1.59]), P = 0.045 remained significantly associated with self-reported CVD. While our findings suggest non-HDL-C and LDL-C/HDL-C measures may be appropriate biomarkers for assessing CVD risk in this population, further studies using established clinical endpoints are required to validate these findings in sub-Saharan Africans. [ABSTRACT FROM AUTHOR]

Background: Malaria remains a public health challenge in endemic countries of the world. The use of Long-lasting Insecticidal Nets (LLINs) is one of the major ways of malaria vector control. Recent evidence however suggests some LLINs are unable to maintain their effectiveness over their useful life span. This study assessed the bio-efficacy, physical integrity, use and attrition at 6 and 12-months post-distribution of LLINs (LifeNet). Methods: Following a mass distribution of LLINs in the West Mamprusi District of the North-East region of Ghana in 2018, a total of 147 LLINs were sampled for physical integrity and attrition assessment using hole size and the number of holes as a measure of the proportionate hole index (pHI). Bioassays were conducted on sixty randomly selected LLINs using the WHO guidelines for bio-efficacy testing (cone tests), (20 each at baseline, midline and endline) over a one-year study period. Bed net ownership and use as well as malaria vector resistance status were also assessed. Results: Findings indicate high bio-efficacy of approximately 100% average mortalities of mosquitoes at baseline, 6-months and 12-months post-distribution. A small proportion of LLINs (0.8% and 5.6% at the 6 and 12-months surveys respectively) were damaged beyond maintenance while 62.4% and 62.7% of LLINs were used the night before the survey for 6 and 12-months post-distribution respectively. Households with electricity were less likely to use LLINs compared to those without electricity (P-value = 0.016, OR = 0.39). There were 20 fewer LLINs recovered at the 12-months relative to the 6-months resulting in 14.3% attrition rate. Susceptibility testing showed high pyrethroid and organochlorine resistance (18%, 67.5% and 3.8%) to local malaria vectors respectively), whereas organophosphates and carbamates recorded vector susceptibility of 100% for pirimiphos-methyl and 98.7% for bendiocarb. Conclusion: Biological efficacy, physical integrity and net attrition during the study period were in conformity with respect to the WHOPES one year net use. LLINs remained effective after one-year of usage. Net ownership was high in the study households. There should be continuous and regular distribution campaigns to maintain high coverage. [ABSTRACT FROM AUTHOR]

[Display omitted] • Age-specific Plasmodium falciparum var diversity patterns were measured in a cohort of 1,541 individuals in Ghana. • We define 42,399 distinct var sequence variants organised as non-overlapping repertoires within individuals. • Risk of infection with parasites with diverse var repertoires exists at any age. • High seasonal turnover of parasites with diverse isolate var repertoires was also observed in individuals of all ages. • Simulations illustrate why adolescents and adults remain susceptible to blood stage infection, even with multiple genomes. Immunity to Plasmodium falciparum is non-sterilising, thus individuals residing in malaria-endemic areas are at risk of infection throughout their lifetime. Here we seek to find a genomic epidemiological explanation for why residents of all ages harbour blood stage infections despite lifelong exposure to P. falciparum in areas of high transmission. We do this by exploring, for the first known time, the age-specific patterns of diversity of variant antigen encoding (var) genes in the reservoir of infection. Microscopic and submicroscopic P. falciparum infections were analysed at the end of the wet and dry seasons in 2012–2013 for a cohort of 1541 residents aged from 1 to 91 years in an area characterised by high seasonal malaria transmission in Ghana. By sequencing the near ubiquitous Duffy-binding-like alpha domain (DBLα) that encodes immunogenic domains, we defined var gene diversity in an estimated 1096 genomes detected in sequential wet and dry season sampling of this cohort. Unprecedented var (DBLα) diversity was observed in all ages with 42,399 unique var types detected. There was a high degree of maintenance of types between seasons (>40% seen more than once), with many of the same types, especially upsA, appearing multiple times in isolates from different individuals. Children and adolescents were found to be significant reservoirs of var DBLα diversity compared with adults. Var repertoires within individuals were highly variable, with children having more related var repertoires compared to adolescents and adults. Individuals of all ages harboured multiple genomes with var repertoires unrelated to those infecting other hosts. High turnover of parasites with diverse isolate var repertoires was also observed in all ages. These age-specific patterns are best explained by variant-specific immune selection. The observed level of var diversity for the population was then used to simulate the development of variant-specific immunity to the diverse var types under conservative assumptions. Simulations showed that the extent of observed var diversity with limited repertoire relatedness was sufficient to explain why adolescents and adults in this community remain susceptible to blood stage infection, even with multiple genomes. [ABSTRACT FROM AUTHOR]

Background: Several studies have reported an association between malaria infection of the placenta and the risk of malaria in young children in the first year of life, but it is not known if this is causal, or influenced by malaria control measures during pregnancy. This paper compares the incidence of malaria in infants born to mothers who received either intermittent preventive treatment with sulfadoxine/pyrimethamine (IPTp-SP) or screening with a rapid diagnostic test and treatment with artemether--lumefantrine (ISTp-AL) during their pregnancy. Methods: From July 2011 to April 2013, 988 infants of women enrolled in a trial of IPTp-SP versus ISTp-AL in the Kassena-Nankana districts of northern Ghana were followed to determine the risk of clinical malaria during early life, and their risk of parasitaemia and anaemia at 6 and 12 months of age. In addition, the incidence of clinical malaria in infants whose mothers had malaria infection of the placenta was compared with that in infants born to women free of placental malaria. Results: The incidence of clinical malaria was 0.237 and 0.211 episodes per child year in infants whose mothers had received ISTp-AL or IPTp-SP, respectively. The adjusted incidence rate ratio and the adjusted rate difference were 0.94 (95 % CI 0.68, 1.33) and 0.029 (95 % CI -0.053, 0.110) cases per child year at risk respectively. The incidence of clinical malaria was similar in infants born to women with placental malaria (0.195 episodes per child year) and in infants of women without placental malaria (0.224 episodes per child year) (rate ratio = 0.86 [95 % CI 0.54, 1.37]). Conclusion: Infants born to women managed with ISTp-AL during pregnancy were not at greatly increased risk of malaria compared with infants born to women who had received IPTp-SP. The incidence of malaria in infants was similar whether or not their mother had had placental malaria. [ABSTRACT FROM AUTHOR]

Background: Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15–49. Methods: A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion. Results: Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13–0.39), marital status (OR = 0.45; CI 0.22–0.95), education (OR = 2.71; CI 1.11–6.57), transportation (OR = 1.97; CI 1.07–3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21–0.61). Conclusion: The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate. [ABSTRACT FROM AUTHOR]

Background. Group A meningococcal disease occurs in large epidemics within the meningitis belt of Africa that includes northern Ghana. Major epidemics in the meningitis belt have infection rates ranging from 100 to 800 per 100 000 population. In 2012, a group A meningococcal conjugate vaccine, PsA-TT (MenAfriVac), was introduced into the region in large campaigns. Methods. We report here on the safety of this vaccine when used in pregnant women in the Navrongo region of Ghana. Results. Rates of events in 1730 immunized pregnant women and their infants were compared to the rates of the same events in pregnant women who did not receive the vaccine during the campaign and also to women who were pregnant in the prior year. Conclusions. We found no evidence of any safety concerns when this vaccine was administered during pregnancy. [ABSTRACT FROM AUTHOR]

Objective (s): This study examined the association between maternal and child dietary diversity in a population-based national sample in Ghana. Methods: The data for this analysis are from the 2008 Ghana Demographic and Health Survey. We used data obtained from 1187 dyads comprised of mothers’ ages 15–49 and their youngest child (ages 6–36 months). Maternal and child dietary diversity scores (DDS) were created based on the mother’s recall of her own and her child’s consumption of 15 food groups, during the 24 hours prior to the in-home survey. The same food groups were used to compose both maternal and child DDS. Linear regression was used to assess the relationship between the predicted outcome – child DDS -- and maternal DDS, taking into account child age and sex, maternal factors (age, education, occupation, literacy, empowerment, number of antenatal visits as an indicator of health care use), household Wealth Index, and urban/rural place of residence. Results: There was a statistically significant positive association between child and maternal DDS, after adjusting for all other variables. A difference of one food group in mother’s consumption was associated with a difference of 0.72 food groups in the child’s food consumption (95% CI: 0.63, 0.82). Also, statistically significant positive associations were observed such that higher child DDS was associated with older child age, and with greater women’s empowerment. Conclusions: The results show a significant positive association between child and maternal DD, after accounting for the influence of child, maternal and household level factors. Since the likely path of influence is that maternal DDS impacts child DDS, public health efforts to improve child health may be strengthened by promoting maternal DDS due to its potential for a widened effect on the entire family. [ABSTRACT FROM AUTHOR]

Environmental exposures, such as ambient air pollution and household fuel use affect health and under-5 mortality (U5M) but there is a paucity of data in the Global South. This study examined early-life exposure to ambient particulate matter with a diameter of 2.5 µm or less (PM 2.5), alongside household characteristics (including self-reported household fuel use), and their relationship with U5M in the Navrongo Health and Demographic Surveillance Site (HDSS) in northern Ghana. We employed Satellite-based spatiotemporal models to estimate the annual average PM 2.5 concentrations with the Navrongo HDSS area (1998 to 2016). Early-life exposure levels were determined by pollution estimates at birth year. Socio-demographic and household data, including cooking fuel, were gathered during routine surveillance. Cox proportional hazards models were applied to assess the link between early-life PM2.5 exposure and U5M, accounting for child, maternal, and household factors. We retrospectively studied 48,352 children born between 2007 and 2017, with 1872 recorded deaths, primarily due to malaria, sepsis, and acute respiratory infection. Mean early-life PM 2.5 was 39.3 µg/m3, and no significant association with U5M was observed. However, Children from households using "unclean" cooking fuels (wood, charcoal, dung, and agricultural waste) faced a 73 % higher risk of death compared to those using clean fuels (adjusted HR = 1.73; 95 % CI: 1.29, 2.33). Being born female or to mothers aged 20–34 years were linked to increased survival probabilities. The use of "unclean" cooking fuel in the Navrongo HDSS was associated with under-5 mortality, highlighting the need to improve indoor air quality by introducing cleaner fuels. [ABSTRACT FROM AUTHOR]

Background: Following a 30-year development process, RTS,S/AS01E (GSK, Belgium) is the first malaria vaccine to reach Phase IV assessments. The World Health Organization-commissioned Malaria Vaccine Implementation Programme (MVIP) is coordinating the delivery of RTS,S/AS01E through routine national immunization programmes in areas of 3 countries in sub-Saharan Africa. The first doses were given in the participating MVIP areas in Malawi on 23 April, Ghana on 30 April, and Kenya on 13 September 2019. The countries participating in the MVIP have little or no baseline incidence data on rare diseases, some of which may be associated with immunization, a deficit that could compromise the interpretation of possible adverse events reported following the introduction of a new vaccine in the paediatric population. Further, effects of vaccination on malaria transmission, existing malaria control strategies, and possible vaccine-mediated selective pressure on Plasmodium falciparum variants, could also impact long-term malaria control. To address this data gap and as part of its post-approval commitments, GSK has developed a post-approval plan comprising of 4 complementary Phase IV studies that will evaluate safety, effectiveness and impact of RTS,S/AS01E through active participant follow-up in the context of its real-life implementation. Methods: EPI-MAL-002 (NCT02374450) is a pre-implementation safety surveillance study that is establishing the background incidence rates of protocol-defined adverse events of special interest. EPI-MAL-003 (NCT03855995) is an identically designed post-implementation safety and vaccine impact study. EPI-MAL-005 (NCT02251704) is a cross-sectional pre- and post-implementation study to measure malaria transmission intensity and monitor the use of other malaria control interventions in the study areas, and EPI-MAL-010 (EUPAS42948) will evaluate the P. falciparum genetic diversity in the periods before and after vaccine implementation. Conclusion: GSK's post-approval plan has been designed to address important knowledge gaps in RTS,S/AS01E vaccine safety, effectiveness and impact. The studies are currently being conducted in the MVIP areas. Their implementation has provided opportunities and posed challenges linked to conducting large studies in regions where healthcare infrastructure is limited. The results from these studies will support ongoing evaluation of RTS,S/AS01E's benefit-risk and inform decision-making for its potential wider implementation across sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Background Cipargamin (KAE609) is a potent antimalarial in a phase II trial. Here we report efficacy, pharmacokinetics, and resistance marker analysis across a range of cipargamin doses. These were secondary endpoints from a study primarily conducted to assess the hepatic safety of cipargamin (hepatic safety data are reported elsewhere). Methods This phase II, multicenter, randomized, open-label, dose-escalation trial was conducted in sub-Saharan Africa in adults with uncomplicated Plasmodium falciparum malaria. Cipargamin monotherapy was given as single doses up to 150 mg or up to 50 mg once daily for 3 days, with artemether-lumefantrine as control. Key efficacy endpoints were parasite clearance time (PCT), and polymerase chain reaction (PCR)–corrected and uncorrected adequate clinical and parasitological response (ACPR) at 14 and 28 days. Pharmacokinetics and molecular markers of drug resistance were also assessed. Results All single or multiple cipargamin doses ≥50 mg were associated with rapid parasite clearance, with median PCT of 8 hours versus 24 hours for artemether-lumefantrine. PCR-corrected ACPR at 14 and 28 days was >75% and 65%, respectively, for each cipargamin dose. A treatment-emerging mutation in the Pfatp4 gene, G358S, was detected in 65% of treatment failures. Pharmacokinetic parameters were consistent with previous data, and approximately dose proportional. Conclusions Cipargamin, at single doses of 50 to 150 mg, was associated with very rapid parasite clearance, PCR-corrected ACPR at 28 days of >65% in adults with uncomplicated P. falciparum malaria, and recrudescent parasites frequently harbored a treatment-emerging mutation. Cipargamin will be further developed with a suitable combination partner. Clinical Trials Registration ClinicalTrials.gov (NCT03334747). [ABSTRACT FROM AUTHOR]

Background: Following a 30-year development process, RTS,S/AS01E (GSK, Belgium) is the first malaria vaccine to reach Phase IV assessments. The World Health Organization-commissioned Malaria Vaccine Implementation Programme (MVIP) is coordinating the delivery of RTS,S/AS01E through routine national immunization programmes in areas of 3 countries in sub-Saharan Africa. The first doses were given in the participating MVIP areas in Malawi on 23 April, Ghana on 30 April, and Kenya on 13 September 2019. The countries participating in the MVIP have little or no baseline incidence data on rare diseases, some of which may be associated with immunization, a deficit that could compromise the interpretation of possible adverse events reported following the introduction of a new vaccine in the paediatric population. Further, effects of vaccination on malaria transmission, existing malaria control strategies, and possible vaccine-mediated selective pressure on Plasmodium falciparum variants, could also impact long-term malaria control. To address this data gap and as part of its post-approval commitments, GSK has developed a post-approval plan comprising of 4 complementary Phase IV studies that will evaluate safety, effectiveness and impact of RTS,S/AS01E through active participant follow-up in the context of its real-life implementation. Methods: EPI-MAL-002 (NCT02374450) is a pre-implementation safety surveillance study that is establishing the background incidence rates of protocol-defined adverse events of special interest. EPI-MAL-003 (NCT03855995) is an identically designed post-implementation safety and vaccine impact study. EPI-MAL-005 (NCT02251704) is a cross-sectional pre- and post-implementation study to measure malaria transmission intensity and monitor the use of other malaria control interventions in the study areas, and EPI-MAL-010 (EUPAS42948) will evaluate the P. falciparum genetic diversity in the periods before and after vaccine implementation. Conclusion: GSK's post-approval plan has been designed to address important knowledge gaps in RTS,S/AS01E vaccine safety, effectiveness and impact. The studies are currently being conducted in the MVIP areas. Their implementation has provided opportunities and posed challenges linked to conducting large studies in regions where healthcare infrastructure is limited. The results from these studies will support ongoing evaluation of RTS,S/AS01E's benefit-risk and inform decision-making for its potential wider implementation across sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Heightened food insecurity in the hunger season increases the risk of severe acute malnutrition (SAM) in childhood. This study examined the association of season of birth with SAM in a Guinean Sahelian ecological zone. We analyzed routine health and sociodemographic surveillance data from the Navrongo Health and Socio‐demographic Surveillance System collected between 2011 and 2018. January–June, the period of highest food insecurity, was defined as the hunger season. We defined moderate acute malnutrition as child mid‐upper arm circumference (MUAC) between 115 mm and 135 mm and SAM as MAUC ≤ 115 mm. We used adjusted logistic regression to quantify the association between the season of birth and SAM in children aged 6–35 months. From the 29,452 children studied, 24% had moderate acute malnutrition. Overall, 1.4% had SAM, with a higher prevalence (1.8%) in the hunger season of birth. Compared with those born October–December, adjusted odds ratios (aOR) and 95% confidence interval (95% CI) for SAM were increased for children born in the hunger season: January–March (1.77 [1.31–2.39]) and April–June (1.92 [1.44–2.56]). Low birth weight, age at an assessment of nutritional status, and ethno‐linguistic group were also significantly associated with SAM in adjusted analyses. Our study established that being born in the hunger season is associated with a higher risk of severe acute malnutrition. The result implies improvement in the food supply to pregnant and lactating mothers through sustainable agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition. Key Points: Children born in the hunger season are at a higher risk of severe acute malnutrition in this Guinea‐Sahelian ecological zone.Children born with low birth weight were at a higher risk of severe acute malnutrition Being female and of the Nankam ethno‐linguistic group increased ones odds of severe acute malnutrition.Our observations imply sustainable food supply to pregnant and lactating mothers through improved agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition. [ABSTRACT FROM AUTHOR]

Background: The novel anti-malarial cipargamin (KAE609) has potent, rapid activity against Plasmodium falciparum. Transient asymptomatic liver function test elevations were previously observed in cipargamin-treated subjects in two trials: one in malaria patients in Asia and one in volunteers with experimentally induced malaria. In this study, the hepatic safety of cipargamin given as single doses of 10 to 150 mg and 10 to 50 mg once daily for 3 days was assessed. Efficacy results, frequency of treatment-emerging mutations in the atp4 gene and pharmacokinetics have been published elsewhere. Further, the R561H mutation in the k13 gene, which confers artemisinin-resistance, was associated with delayed parasite clearance following treatment with artemether–lumefantrine in Rwanda in this study. This was also the first study with cipargamin to be conducted in patients in sub-Saharan Africa. Methods: This was a Phase II, multicentre, randomized, open-label, dose-escalation trial in adults with uncomplicated falciparum malaria in five sub-Saharan countries, using artemether–lumefantrine as control. The primary endpoint was ≥ 2 Common Terminology Criteria for Adverse Events (CTCAE) Grade increase from baseline in alanine aminotransferase (ALT) or aspartate transaminase (AST) during the 4-week trial. Results: Overall, 2/135 patients treated with cipargamin had ≥ 2 CTCAE Grade increases from baseline in ALT or AST compared to 2/51 artemether–lumefantrine patients, with no significant difference between any cipargamin treatment group and the control group. Cipargamin exposure was comparable to or higher than those in previous studies. Hepatic adverse events and general safety and tolerability were similar for all cipargamin doses and artemether–lumefantrine. Cipargamin was well tolerated with no safety concerns. Conclusions: This active-controlled, dose escalation study was a detailed assessment of the hepatic safety of cipargamin, across a wide range of doses, in patients with uncomplicated falciparum malaria. Comparison with previous cipargamin trials requires caution as no clear conclusion can be drawn as to whether hepatic safety and potential immunity to malaria would differ with ethnicity, patient age and or geography. Previous concerns regarding hepatic safety may have been confounded by factors including malaria itself, whether natural or experimental infection, and should not limit the further development of cipargamin. Trial registration ClinicalTrials.gov number: NCT03334747 (7 Nov 2017), other study ID CKAE609A2202 [ABSTRACT FROM AUTHOR]

Background: Household air pollution (HAP) from cooking with solid fuels has adverse health effects. REACCTING (Research on Emissions, Air quality, Climate, and Cooking Technologies in Northern Ghana) was a randomized cookstove intervention study that aimed to determine the effects of two types of "improved" biomass cookstoves on health using self-reported health symptoms and biomarkers of systemic inflammation from dried blood spots for female adult cooks and children, and anthropometric growth measures for children only.Methods: Two hundred rural households were randomized into four different cookstove groups. Surveys and health measurements were conducted at four time points over a two-year period. Chi-square tests were conducted to determine differences in self-reported health outcomes. Linear mixed models were used to assess the effect of the stoves on inflammation biomarkers in adults and children, and to assess the z-score deviance for the anthropometric data for children.Results: We find some evidence that two biomarkers of oxidative stress and inflammation, serum amyloid A and C-reactive protein, decreased among adult primary cooks in the intervention groups relative to the control group. We do not find detectable impacts for any of the anthropometry variables or self-reported health.Conclusions: Overall, we conclude that the REACCTING intervention did not substantially improve the health outcomes examined here, likely due to continued use of traditional stoves, lack of evidence of particulate matter emissions reductions from "improved" stoves, and mixed results for HAP exposure reductions.Clinical Trial Registry: ClinicalTrials.gov (National Institutes of Health); Trial Registration Number: NCT04633135 ; Date of Registration: 11 November 2020 - Retrospectively registered. URL: https://clinicaltrials.gov/ct2/show/NCT04633135?term=NCT04633135&draw=2&rank=1. [ABSTRACT FROM AUTHOR]

Background: In Sahelian Africa, the risk of malaria increases with the arrival of the rains, particularly in young children. Following successful trials, the World Health Organization (WHO) recommended the use of seasonal malaria chemoprevention (SMC) in areas with seasonal peak in malaria cases. This study evaluated the pilot implementation of SMC in Northern Ghana. Methods: Fourteen communities each serving as clusters were selected randomly from Lawra District of Upper West Region as intervention area and West Mamprusi District in the Northern Region as the non-intervention area. The intervention was undertaken by the National Malaria Control Programme in collaboration with regional health directorates using sulfadoxine-pyrimethamine plus amodiaquine and standard WHO protocols. Before and after surveys for malaria parasitaemia and haemoglobin levels as well as monitoring for malaria morbidity and mortality were undertaken. Results: At the end of the intervention, participant retention was 92.9% (697/731) and 89.5% (634/708) in the intervention and the non-intervention areas, respectively. The proportion of children with asexual parasites reduced by 19% (p = 0.000) in the intervention and increased by 12% (p = 0.000) in the non-intervention area. Incidence rates of severe malaria were 10 and 20 per 1000 person-years follow up in the intervention and comparison areas, respectively with P.E of 45% (p = 0.62). For mild malaria, it was 220 and 170 per 1000 person-years in intervention and comparison area, respectively with PE of - 25% (p = 0.31). The proportion of children with anaemia defined as Hb< 11.0 g/dl reduced from 14.2% (52.8–38.6%) in the intervention area as compared to an increase of 8.1% (54.5% to 62.6) the non-intervention arm, Mean Hb reduced by 0. 24 g/dl (p = 0.000) in the non-intervention area and increased of 0.39 g/dl (p = 000) in the intervention area. Conclusions: The feasibility and effectiveness of SMC introduction in Northern Ghana was demonstrated as evidenced by high study retention, reduction in malaria parasitaemia and anaemia during the wet season. [ABSTRACT FROM AUTHOR]

Reported efficacies from vaccine trials may depend heavily on the clinical case definition used in the trial. The dependence may be particularly striking for diseases such as malaria, in which no single case definition is appropriate. We used logistic regression modeling of the relationship between parasitemia and fever in data sets from Ghanaian children to determine the fraction of fevers attributable to malaria and to model how the choice of a threshold parasitemia in the clinical case definition affects the measured efficacy of malaria vaccines. Calculated clinical attack rates varied 10-fold as a function of the threshold parasitemia. Strikingly, measured vaccine efficacies in reducing clinical malaria depended heavily on the threshold parasitemia, varying between 20% and 80% as the threshold varied between 1 and 5000 parasites/μL. We suggest that clinical case definitions of malaria that incorporate a threshold parasitemia are arbitrary and do not yield stable estimates of vaccine trial end points. [ABSTRACT FROM AUTHOR]

Objective: Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana.Design: This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis.Setting: The study was conducted in rural Kassena-Nankana Districts of Northern Ghana.Study Participants: Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community.Results: Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition.Conclusion: Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition. [ABSTRACT FROM AUTHOR]

Here, we report the first population genetic study to examine the impact of indoor residual spraying (IRS) on Plasmodium falciparum in humans. This study was conducted in an area of high seasonal malaria transmission in Bongo District, Ghana. IRS was implemented during the dry season (November–May) in three consecutive years between 2013 and 2015 to reduce transmission and attempt to bottleneck the parasite population in humans towards lower diversity with greater linkage disequilibrium. The study was done against a background of widespread use of long‐lasting insecticidal nets, typical for contemporary malaria control in West Africa. Microsatellite genotyping with 10 loci was used to construct 392 P. falciparum multilocus infection haplotypes collected from two age‐stratified cross‐sectional surveys at the end of the wet seasons pre‐ and post‐IRS. Three‐rounds of IRS, under operational conditions, led to a >90% reduction in transmission intensity and a 35.7% reduction in the P. falciparum prevalence (p <.001). Despite these declines, population genetic analysis of the infection haplotypes revealed no dramatic changes with only a slight, but significant increase in genetic diversity (He: pre‐IRS = 0.79 vs. post‐IRS = 0.81, p =.048). Reduced relatedness of the parasite population (p <.001) was observed post‐IRS, probably due to decreased opportunities for outcrossing. Spatiotemporal genetic differentiation between the pre‐ and post‐IRS surveys (D = 0.0329 [95% CI: 0.0209 – 0.0473], p =.034) was identified. These data provide a genetic explanation for the resilience of P. falciparum to short‐term IRS programmes in high‐transmission settings in sub‐Saharan Africa. [ABSTRACT FROM AUTHOR]

We measured the type-specific incidence of paediatric rotavirus diarrhoea in an area of northern Ghana. Over 1 year, diarrhoea 1717 episodes were identified, of which 677 (39%) were positive for rotavirus. Risk factors for rotavirus infection included old age, wasting, high Vesikari score and the episode occurring in the dry season. Rotavirus-positive episodes tended to be more acute, causing vomiting and greater dehydration, and were more likely to require hospitalization. The incidence was 0.089 episodes per person-year for all diarrhoea, and 0.035 for rotavirus diarrhoea. The observed incidence decreased markedly with distance from the nearest health centre, suggesting a large unobserved burden. G2P[6], G3P[4] and G9P[8] made up more than half the genotypes detected, but the remainder were diverse. There is a large burden of rotavirus diarrhoea, but the effectiveness of future vaccines could be diluted by the high polymorphism of the virus, and the difficulty of reaching remote populations. [ABSTRACT FROM AUTHOR]

Background: Pneumococcal vaccine immunizations may be responsible for alterations in serotype epidemiology within a region. This study investigated the pneumococcal carriage prevalence and the impact of the 13-valent pneumococcal conjugate vaccine (PCV-13) on circulating serotypes among healthy children in Northern Ghana.Methods: This was a cross sectional study conducted in the Kassena-Nankana districts of Northern Ghana from November to December during the dry season of 2018. Nasopharyngeal swabs collected from 193 participants were cultured per standard microbiological protocols and pneumococcal isolates were serotyped using the latex agglutination technique and the capsular Quellung reaction test. We examined for any association between the demographic characteristics of study participants and pneumococcal carriage using chi-square test and logistic regression.Results: Of the 193 participants that were enrolled the mean age was 8.6 years and 54.4% were females. The carriage rate among the participants was 32.6% (63/193), and twenty different serotypes were identified. These included both vaccine serotypes (VT), 35% (7/20) and non-vaccine serotypes (NVT), 65% (13/20). The predominant serotypes (34 and 11A), both of which were NVT, accounted for a prevalence of 12.8%. PCV-13 covered only 35% of serotypes identified whiles 40% of serotypes are covered by PPV 23.Conclusion: Post-vaccination carriage of S. pneumoniae is high and is dominated by non-vaccine serotypes. There is therefore a need for the conduct of invasive pneumococcal disease surveillance (IPD) to find out if the high non-vaccine serotype carriage translates to disease. And in addition, a review of the currently used PCV-13 vaccine in the country would be considered relevant. [ABSTRACT FROM AUTHOR]

Background: In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana.Methods and Findings: This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment.Conclusions: This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality.Trial Registration: The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993). [ABSTRACT FROM AUTHOR]

Background: Substance misuse is a global public health problem. In addition to social and economic concerns, consumption of tobacco and alcohol is associated with susceptibility to cardiovascular, respiratory, and infectious diseases, cancers, and risk of transition to substance use disorders. African data suggest regional differences in the prevalence and patterns of substance use, but a number of key questions remain. This cross-sectional population-based study of middle-aged adults aims to examine prevalence and socio-demographic correlates of substance use in four sub-Saharan African countries, in rural and urban settings.Methods: Participants aged between 40 and 60 years were recruited from six research centres as part of the Africa Wits-INDEPTH partnership for Genomic Research study. Data on patterns of tobacco and alcohol consumption was captured, and the latter further assessed using the CAGE (cut-annoyed-guilty-eye) questionnaire.Results: Data from 10,703 participants suggested that more men (68.4%) than women (33.3%) were current substance users. The prevalence of current smoking was significantly higher in men than in women (34.5% vs 2.1%, p < 0.001). Smokeless tobacco was used more by women than men (14.4% vs 5.3%, p < 0.001). Current smoking was associated with alcohol consumption in men, and smoking cessation in men was associated with being a former drinker, having higher socio-economic status, and if married or cohabiting. Current alcohol consumption was higher in men, compared to women (60.3% vs 29.3%), and highest in men from Soweto (70.8%) and women from Nanoro (59.8%). The overall prevalence of problematic alcohol consumption among men was 18.9%, and women 7.3%. Men were significantly more likely to develop problematic drinking patterns, and this was more common in those who were divorced or widowed, and in current smokers.Conclusions: Regional variation in the patterns and prevalence of substance use was observed across study sites, and in rural and urban settings. The high levels of substance use recorded in this study are of concern due to the increased risk of associated morbidities. Further longitudinal data will be valuable in determining trends in substance misuse in Africa. [ABSTRACT FROM AUTHOR]

Background: The lack of background disease incidence rates in sub-Saharan countries where the RTS,S/AS01E malaria vaccine is being implemented may hamper the assessment of vaccine safety and effectiveness. This study aimed to document baseline incidence rates of meningitis, malaria, mortality, and other health outcomes prior to vaccine introduction through the Malaria Vaccine Implementation Programme. Methods: An ongoing disease surveillance study is combining prospective cohort event monitoring and hospital-based disease surveillance in three study sites in Ghana and Kenya. An interim analysis was performed on the prospective cohort in which children were enrolled in two age-groups (the 5 to 17 months or 6 to 12 weeks age-group), capturing data in the framework of routine medical practice before the introduction of the malaria vaccine. Incidence and mortality rates were computed with 95% confidential intervals (CI) using an exact method for a Poisson variable. Results: This analysis includes 14,329 children; 7248 (50.6%) in the 6 to 12 weeks age-group and 7081 (49.4%) in the 5 to 17 months age-group. In the 5 to 17 months age-group (where the malaria vaccine was planned to be subsequently rolled out) the meningitis, malaria, severe malaria and cerebral malaria incidences were 92 (95% CI 25–236), 47,824 (95% CI 45,411–50,333), 1919 (95% CI 1461–2476) and 33 (95% CI 1–181) per 100,000 person-years, respectively. The all-cause mortality was 969 (95% CI 699–1310) per 100,000 person-years. Conclusion: Incidence estimates of multiple health outcomes are being generated to allow before-after vaccine introduction comparisons that will further characterize the benefit-risk profile of the RTS,S/AS01E vaccine. Trial registration: clinicaltrials.gov NCT02374450. [ABSTRACT FROM AUTHOR]

Background: Community participation in health care delivery will ensure service availability and accessibility and guarantee community ownership of the program. Community-based strategies such as the involvement of Community Health Volunteers (CHVs) and Community Health Management Committees (CHMCs) are likely to advance primary healthcare in general, but the criteria for selecting CHVs, CHMCs and efforts to sustain these roles are not clear 20 years after implementing the Community-based Health Planning Services program. We examined the process of selecting these cadres of community health workers and their current role within Ghana's flagship program for primary care–the Community-based Health Planning and Services program. Methods: This was an exploratory study design using qualitative methods to appraise the health system and stakeholder participation in Community-based Health Planning and Services program implementation in the Upper East region of Ghana. We conducted 51 in-depth interviews and 33 focus group discussions with health professionals and community members. Results: Community Health Volunteers and Community Health Management Committees are the representatives of the community in the routine implementation of the Community-based Health Planning and Services program. They are selected, appointed, or nominated by their communities. Some inherit the position through apprenticeship and others are recruited through advertisement. The selection is mostly initiated by the health providers and carried out by community members. Community Health Volunteers lead community mobilization efforts, support health providers in health promotion activities, manage minor illnesses, and encourage pregnant women to use maternal health services. Community Health Volunteers also translate health messages delivered by health providers to the people in their local languages. Community Health Management Committees mobilize resources for the development of Community-based Health Planning and Services program compounds. They play a mediatory role between health providers in the health compounds and the community members. Volunteers are sometimes given non-financial incentives but there are suggestions to include financial incentives. Conclusion: Community Health Volunteers and Community Health Management Committees play a critical role in primary health care. The criteria for selecting Community Health Volunteers and Community Health Management Committees vary but need to be standardized to ensure that only self-motivated individuals are selected. Thus, CHVs and CHMCs should contest for their positions and be endorsed by their community members and assigned roles by health professionals in the CHPS zones. Efforts to sustain them within the health system should include the provision of financial incentives. [ABSTRACT FROM AUTHOR]