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Following the detection of the first imported case of COVID-19 in the northern sector of Ghana, we molecularly characterized and phylogenetically analysed sequences, including three complete genome sequences, of severe acute respiratory syndrome coronavirus 2 obtained from nine patients in Ghana. We performed high-throughput sequencing on nine samples that were found to have a high concentration of viral RNA. We also assessed the potential impact that long-distance transport of samples to testing centres may have on sequencing results. Here, two samples that were similar in terms of viral RNA concentration but were transported from sites that are over 400 km apart were analyzed. All sequences were compared to previous sequences from Ghana and representative sequences from regions where our patients had previously travelled. Three complete genome sequences and another nearly complete genome sequence with 95.6% coverage were obtained. Sequences with coverage in excess of 80% were found to belong to three lineages, namely A, B.1 and B.2. Our sequences clustered in two different clades, with the majority falling within a clade composed of sequences from sub-Saharan Africa. Less RNA fragmentation was seen in sample KATH23, which was collected 9 km from the testing site, than in sample TTH6, which was collected and transported over a distance of 400 km to the testing site. The clustering of several sequences from sub-Saharan Africa suggests regional circulation of the viruses in the subregion. Importantly, there may be a need to decentralize testing sites and build more capacity across Africa to boost the sequencing output of the subregion. Supplementary Information The online version contains supplementary material available at 10.1007/s00705-021-04986-3.

Background There is a dearth of data on scabies from Ghana. In September 2019, local health authorities in the East Mamprusi district of northern Ghana received reports of scabies from many parts of the district. Due to on-going reports of more cases, an assessment team visited the communities to assess the effect of the earlier individual treatment on the outbreak. The assessment team furthermore aimed to contribute to the data on scabies burden in Ghana and to demonstrate the use of the International Alliance for the Control of Scabies (IACS) diagnostic tool in a field survey in a resource limited setting. Methodology/Principal findings This was a cross sectional study. Demographic information and medical history was collected on all participants using a REDCap questionnaire. A standardised skin examination of exposed regions of the body was performed on all participants. Scabies was diagnosed based on the criteria of the International Alliance for the Control of Scabies (IACS). Participants were mostly female (61.5%) and had a median age of 18.8 years (IQR 13–25). Two hundred out of 283 (71%) of participants had scabies with most (47%) presenting with moderate disease. Impetigo was found in 22% of participants with scabies and 10.8% of those without scabies [RR 2.27 (95% CI 1.21–4.27)]. 119 participants who received scabies treatment in the past months still had clinical evidence of the disease. 97% of participants reported a recent scabies contact. Scabies was commoner in participants ≤16 years compared to those >16 years [RR 3.06 (95% CI 1.73–5.45)]. Conclusion/Significance The prevalence of scabies was extremely high. The lack of a systematic approach to scabies treatment led to recurrence and ongoing community spread. The IACS criteria was useful in this outbreak assessment in Ghana. Alternative strategies such as Mass drug administration may be required to contain outbreaks early in such settings., Author summary Scabies, recently categorised as a Neglected Tropical Disease by the WHO is caused by infestation with Sarcoptes scabiei and is characterised by intense pruritus and rash that typically involves the genitalia and the web spaces of the fingers and toes. It has a large global burden and is associated with significant morbidity and socio-economic burden. Secondary bacterial infections following scabies can lead to significant complications including chronic kidney disease from glomerulonephritis and possibly rheumatic heart disease. An outbreak of scabies was reported in Ghana’s East Mamprusi district in September 2019. Despite earlier treatment of individual cases, scabies prevalence was 71%. About 19% of participants had impetigo which was mostly mild in severity. Absence of a systematic approach to treat scabies led to recurrence and ongoing community spread. The recently published IACS criteria for diagnosing scabies proved useful in this outbreak assessment in Ghana. Alternative strategies such as Mass drug administration may be required to contain outbreaks in such settings.

BACKGROUND: Buruli ulcer is a neglected tropical disease caused by Mycobacterium ulcerans infection that damages the skin and subcutis. It is most prevalent in western and central Africa and Australia. Standard antimicrobial treatment with oral rifampicin 10 mg/kg plus intramuscular streptomycin 15 mg/kg once daily for 8 weeks (RS8) is highly effective, but streptomycin injections are painful and potentially harmful. We aimed to compare the efficacy and tolerability of fully oral rifampicin 10 mg/kg plus clarithromycin 15 mg/kg extended release once daily for 8 weeks (RC8) with that of RS8 for treatment of early Buruli ulcer lesions.METHODS: We did an open-label, non-inferiority, randomised (1:1 with blocks of six), multicentre, phase 3 clinical trial comparing fully oral RC8 with RS8 in patients with early, limited Buruli ulcer lesions. There were four trial sites in hospitals in Ghana (Agogo, Tepa, Nkawie, Dunkwa) and one in Benin (Pobè). Participants were included if they were aged 5 years or older and had typical Buruli ulcer with no more than one lesion (caterories I and II) no larger than 10 cm in diameter. The trial was open label, and neither the investigators who took measurements of the lesions nor the attending doctors were masked to treatment assignment. The primary clinical endpoint was lesion healing (ie, full epithelialisation or stable scar) without recurrence at 52 weeks after start of antimicrobial therapy. The primary endpoint and safety were assessed in the intention-to-treat population. A sample size of 332 participants was calculated to detect inferiority of RC8 by a margin of 12%. This study was registered with ClinicalTrials.gov, NCT01659437.FINDINGS: Between Jan 1, 2013, and Dec 31, 2017, participants were recruited to the trial. We stopped recruitment after 310 participants. Median age of participants was 14 years (IQR 10-29) and 153 (52%) were female. 297 patients had PCR-confirmed Buruli ulcer; 151 (51%) were assigned to RS8 treatment, and 146 (49%) received oral RC8 treatment. In the RS8 group, lesions healed in 144 (95%, 95% CI 91 to 98) of 151 patients, whereas lesions healed in 140 (96%, 91 to 99) of 146 patients in the RC8 group. The difference in proportion, -0·5% (-5·2 to 4·2), was not significantly greater than zero (p=0·59), showing that RC8 treatment is non-inferior to RS8 treatment for lesion healing at 52 weeks. Treatment-related adverse events were recorded in 20 (13%) patients receiving RS8 and in nine (7%) patients receiving RC8. Most adverse events were grade 1-2, but one (1%) patient receiving RS8 developed serious ototoxicity and ended treatment after 6 weeks. No patients needed surgical resection. Four patients (two in each study group) had skin grafts.INTERPRETATION: Fully oral RC8 regimen was non-inferior to RS8 for treatment of early, limited Buruli ulcer and was associated with fewer adverse events. Therefore, we propose that fully oral RC8 should be the preferred therapy for early, limited lesions of Buruli ulcer.FUNDING: WHO with additional support from MAP International, American Leprosy Missions, Fondation Raoul Follereau France, Buruli ulcer Groningen Foundation, Sanofi-Pasteur, and BuruliVac.

Background Rabies, caused by a lyssavirus, is a viral zoonosis that affects people in many parts of the world, especially those in low income countries. Contact with domestic animals, especially dogs, is the main source of human infections. Humans may present with the disease only after a long period of exposure. Nearly half of rabies cases occur in children Case presentation The patient, an 11-year-old junior high school Ghanaian student from the Obuasi Municipality in Ghana, presented with aggressive behavior, which rapidly progressed to confusion and loss of consciousness within a day of onset. Her parents reported that the patient had experienced a bite from a stray dog on her right leg 5 years prior to presentation, for which no antirabies prophylaxis was given. The patient died within minutes of arrival in hospital (within 24 hours of symptom onset). Real-time polymerase chain reaction testing of cerebrospinal fluid obtained after her death confirmed the diagnosis of rabies. Subsequent phylogenetic analysis showed the virus to belong to the Africa 2 lineage of rabies viruses, which is one of the predominant circulating lineages in Ghana. Conclusion The incubation period of rabies is highly variable so patients may only present with symptoms long after the exposure incident. Appropriate molecular testing tools, when available as part of rabies control programmes, are vital in confirming cases of rabies.

Background: Adults with diabetes mellitus (DM) in malaria-endemic areas might be more susceptible to Plasmodium infection than healthy individuals. Herein, we aimed at verifying the hypothesis that increased fasting blood glucose (FBG) promotes parasite growth as reflected by increased parasite density. Methods: Seven adults without DM were recruited in rural Ghana to determine the relationships between FBG and malaria parasite load. Socio-economic data were recorded in questionnaire-based interviews. Over a period of 6 weeks, we measured FBG and Plasmodium spc. infection in peripheral blood samples photometrically and by polymerase chain reaction (PCR)-assays, respectively. Daily physical activity and weather data were documented via smartphone recording. For the complex natural systems of homeostatic glucose control and Plasmodium spc. lifecycle, empirical dynamic modelling was applied. Results: At baseline, four men and three women (median age, 33 years; interquartile range, 30-48) showed a median FBG of 5.5 (5.1-6.0 mmol/L); one participant had an asymptomatic Plasmodium spc. infection (parasite density: 240 /µL). In this participant, convergent cross mapping (CCM) for 34 consecutive days, showed that FBG was causally affected by parasite density (p 0.05). Additionally, daily ambient temperature affected parasite density (pConclusion: In this study population living in a malaria-endemic area, we successfully piloted time series analyses for the relationships between FBG and Plasmodium spc. density. Longer observation periods and larger samples are required to confirm these findings and determine the direction of causality.

Background The extent to which neuropsychiatric sequelae affects the mental health status and quality of life of former gambiense human African trypanosomiasis (gHAT) patients is not known. Methods We assessed anxiety, depression and health-related quality of life (HRQoL) in 93 patients and their age- and sex-matched controls using the Hospital Anxiety and Depression Scale, Becks Depression Inventory and the 36-item Short Form Health Survey in structured interviews in the Vanga health zone in the Democratic Republic of Congo. Data were analysed using Stata version 14.0. The degree of association between neurologic sequelae and mental distress was evaluated using the Student's t-test and χ2 or Fisher's exact tests, where appropriate, with a p-value Results We found that neurological sequelae persisted in former patients at least 15 y after treatment. Depression (p Conclusions The presence of neurological sequelae leads to mental distress and a diminished QoL in former gHAT patients. Minimising neurologic sequelae and incorporating psychosocial interventions should be essential management goals for gHAT.

The Coronavirus disease 2019 (COVID-19) outbreak in Ghana is part of an ongoing pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). The first two cases of COVID-19 were confirmed in Ghana on 12th March 2020. COVID-19 was consequently declared a Public Health Emergency of National Concern, triggering several response actions, including enhanced surveillance, case detection, case management and contact tracing, closure of borders, suspension of international flights, ban on social gatherings and closure of schools. Preparedness and response plans were activated for implementation at the national, regional, district and community levels. Ghana's Strategic approaches were to limit and stop the importation of cases;detect and contain cases early;expand infrastructure, logistics and capacity to provide quality healthcare for the sick;minimise disruption to social and economic life and increase the domestic capacity of all sectors to deal with existing and future shocks. The health sector strategic frame focused on testing, treatment, and tracking. As of 31st December 2020, a total of 535,168 cases, including 335 deaths (CFR: 0.61%), have been confirmed with 53,928 recoveries and 905 active cases. All the regions have reported cases, with Greater Accra reporting the highest number. The response actions in Ghana have seen highlevel political commitment, appropriate and timely decisions, and a careful balance of public health interventions with economic and socio-cultural dynamics. Efforts are ongoing to intensify non-pharmaceutical interventions, sustain the gains made so far and introduce COVID-19 vaccines to reduce the public health burden of the disease in Ghana. © 2021 Ghana Medical Association. All Rights Reserved.

Background Buruli ulcer disease (BUD) is a necrotic skin neglected tropical disease (NTD) that has both a mental and physical health impact on affected individuals. Although there is increasing evidence suggesting a strong association between neglected tropical diseases (NTDs) and mental illness, there is a relative lack of information on BUD’s impact on the mental health and quality of life (QoL) of affected individuals in Ghana. This study is to assess the impact of BUD on mental health and quality of life of patients with active and past BUD infection, and their caregivers. Methods We conducted a case control study in 3 BUD endemic districts in Ghana between August and November 2019. Face-to-face structured questionnaire-based interviews were conducted on BUD patients with active and past infection, as well as caregivers of BUD patients using WHO Quality of Life scale, WHO Disability Assessment Schedule, Self-Reporting Questionnaire, Buruli Ulcer Functional Limitation Score and Hospital Anxiety and Depression Scale data tools. Descriptive statistics were used to summarize the characteristics of the study participants. Participant groups were compared using student t test and chi-square (χ2) or Fisher’s exact tests. Mean quality of life scores are reported with their respective 95% confidence intervals. Data was analysed using STATA statistical software. Results Our results show that BUD patients with active and past infection, along with their caregivers, face significant levels of distress and mental health sequelae compared to controls. Depression (P = 0.003) was more common in participants with active (27%) and past BU infection (17%), compared to controls (0%). Anxiety was found in 42% (11/26) and 20% (6/29) of participants with active and past BUD infection compared to 14% (5/36) of controls. Quality of life was also significantly diminished in active BUD infection, compared to controls. In the physical health domain, mean QoL scores were 54 ± 11.1 and 56 ± 11.0 (95% CI: 49.5‒58.5 and 52.2‒59.7) respectively for participants with active infection and controls. Similarly in the psychological domain, scores were lower for active infection than controls [57.1 ± 15.2 (95% CI: 50.9‒63.2) vs 64.7 ± 11.6 (95% CI: 60.8‒68.6)]. Participants with past infection had high QoL scores in both physical [61.3 ± 13.5 (95% CI: 56.1‒66.5)] and psychological health domains [68.4 ± 14.6 (95% CI: 62.7‒74.0)]. Conclusions BUD is associated with significant mental health distress and reduced quality of life in affected persons and their caregivers in Ghana. There is a need for integration of psychosocial interventions in the management of the disease. Graphic abstract

Background Buruli ulcer caused by Mycobacterium ulcerans is endemic in parts of West Africa and is most prevalent among the 5–15 years age group; Buruli ulcer is uncommon among neonates. The mode of transmission and incubation period of Buruli ulcer are unknown. We report two cases of confirmed Buruli ulcer in human immunodeficiency virus-unexposed, vaginally delivered term neonates in Ghana. Case presentation Patient 1: Two weeks after hospital delivery, a baby born to natives of the Ashanti ethnic group of Ghana was noticed by her mother to have a papule with associated edema on the right anterior chest wall and neck that later ulcerated. There was no restriction of neck movements. The diagnosis of Buruli ulcer was confirmed on the basis of a swab sample that had a positive polymerase chain reaction result for the IS2404 repeat sequence of M. ulcerans. Patient 2: This patient, from the Ashanti ethnic group in Ghana, had the mother noticing a swelling in the baby’s left gluteal region 4 days after birth. The lesion progressively increased in size to involve almost the entire left gluteal region. Around the same time, the mother noticed a second, smaller lesion on the forehead and left side of neck. The diagnosis of Buruli ulcer was confirmed by polymerase chain reaction when the child was aged 4 weeks. Both patients 1 and 2 were treated with oral rifampicin and clarithromycin at recommended doses for 8 weeks in addition to appropriate daily wound dressing, leading to complete healing. Our report details two cases of polymerase chain reaction-confirmed Buruli ulcer in children whose lesions appeared at ages 14 and 4 days, respectively. The mode of transmission of M. ulcerans infection is unknown, so the incubation period is difficult to estimate and is probably dependent on the infective dose and the age of exposure. In our study, lesions appeared 4 days after birth in patient 2. Unless the infection was acquired in utero, this would be the shortest incubation period ever recorded. Conclusions Buruli ulcer should be included in the differential diagnosis of neonates who present with characteristic lesions. The incubation period of Buruli ulcer in neonates is probably shorter than is reported for adults.

We aimed to assess the relationship between bone scintigraphy findings and prostate-specific antigen (PSA) and Gleason score in a group of treatment naïve West Africans with prostate cancer. The age, PSA, and Gleason scores of 363 patients with prostate cancer were collected. Patients were risk stratified using the D'Amico criteria. Logistic regression was performed to assess the relationship between bone scan results and PSA and Gleason score. Receiver operating characteristics (ROC) analysis was used to determine the diagnostic reliability of the bone scan findings. Ninety of the 96 patients with metastases had high risk, and only 6 had low-to-intermediate risk disease (P = 0.0001). PSA (odds ratio [OR] 2.4 [95% confidence interval [CI] 1.5–3.8], P = 0.001) and GS (OR 2.2 [95% CI 1.5–3.1], P = 0.001) were independently predictive of the presence of metastases. ROC analysis revealed that PSA predicted the presence of metastases with an area under the curve of 0.72, and using a cut-off value of ≥20 predicted metastases with a sensitivity of 86.5% and specificity of 41.2%. A Gleason score of ≥7 had an 89.6% sensitivity and 34.8% specificity for bone metastases. Using a Gleason cutoff of ≥8, the sensitivity and specificity for predicting bone metastases were 54.2% and 71.5%, respectively. The area under the Gleason score ROC curve was 0.68. PSA and Gleason score are independent predictors of the presence of bone metastases in West Africans with prostate cancer.

Scabies is a Neglected Tropical Disease, transmitted from person to person contact and indirectly through fomites. Though preventable, the burden and infection rate of scabies remain a menace with inadequate attention given to it in Ghana. This report presents an outcome of active disease surveillance and response measures undertaken by the District Health Management Team on the fight against the spread of scabies through case search, treatment, awareness creation, and advocacy campaigns. Students and teachers from 29 schools within the Sub District and 21,173 people in 8 communities were targeted for screening and treatment. In all, a mass drug administration was carried on 2,575 students and teachers, and 2,467 infected patients representing 11.58% from the 8 communities were treated using ivermectin 15% and 25% benzyl benzoate emulsion and Sulphur ointment. Response to the outbreak was hampered by inadequate resources and personnel resulting in low geographical and treatment coverage. Also, intensifying public education and health staff capacity building on case search and control is needed and therefore, the District Health Management Team calls for support from stakeholders in managing the situation.

Summary Across the globe, the outbreak of the COVID-19 pandemic is causing distress with governments doing everything in their power to contain the spread of the novel coronavirus (SARS-CoV-2) to prevent morbidity and mortality. Actions are being implemented to keep health care systems from being overstretched and to curb the outbreak. Any policy responses aimed at slowing down the spread of the virus and mitigating its immediate effects on health care systems require a firm basis of information about the absolute number of currently infected people, growth rates, and locations/hotspots of infections. The only way to obtain this base of information is by conducting numerous tests in a targeted way. Currently, in Ghana, there is a centralized testing approach, that takes 4–5 days for samples to be shipped and tested at central reference laboratories with results communicated to the district, regional and national stakeholders. This delay in diagnosis increases the risk of ongoing transmission in communities and vulnerable institutions. We have validated, evaluated and deployed an innovative diagnostic tool on a mobile laboratory platform to accelerate the COVID-19 testing. A preliminary result of 74 samples from COVID-19 suspected cases has a positivity rate of 12% with a turn-around time of fewer than 3 hours from sample taking to reporting of results, significantly reducing the waiting time from days to hours, enabling expedient response by the health system for contact tracing to reduce transmission and additionally improving case management. Funding Test kits were provided by AngloGold Ashanti Obuasi Mine (AngloGold Ashanti Health Foundation). The American Leprosy Mission donated the PCR machine, and the mobile laboratory van was funded by the Embassy of the Kingdom of the Netherlands (EKN). AAS, YAA was supported by (PANDORA-ID-NET RIA2016E-1609) and ROP supported by EDCTP Senior Fellowship (TMA2016SF), both funded by the European and Developing Countries Clinical Trials Partnership (EDCTP2) programme which is supported under Horizon 2020, the European Union.

Background: Influenza viruses are known to be responsible for a number of respiratory disease outbreaks worldwide. While there exists documented information on influenza which allows for effective strategic preparedness activities in industrialized countries, the same cannot be said of developing and underdeveloped countries. It therefore behoves on developing countries to document information on circulating strains of influenza. Such information will enable prioritization of prevention and more targeted preparedness strategies. In this paper, we report on three different outbreaks of Influenza A among Ghanaian students in December 2017, May 2019 and December 2019 in the Ashanti region of Ghana.Methods: Throat or nasal samples were collected from all students who presented with signs and symptoms of flu with flocked swabs, stored in RNAlater and transported to the laboratories of Kumasi Centre for Collaborative Research (KCCR) at ambient temperature. Following viral RNA extraction, detection of viral nucleic acid of both influenza A and its subtypes including H1N1 and H3N2 was done by real-time reverse transcription Polymerase Chain Reaction (RT-PCR).Results: A total of 112 samples were taken. An overall Influenza A prevalence of 51.8% (95% CI = 42.1-61.3) was recorded during the three outbreak time points. Of these, 11 (19.0%) were confirmed to be H1N1 (pdm09) and 47 (81.0%) were H3N2 strains. All the 11 H1N1 (pdm09) were identified during the first outbreak. The H3N2 strains were identified during the second and third outbreaks in May 2019 and December 2019 respectively. Our results show that influenza A virus activity was higher during the months of November and December compared to May. Age, contact with infected subjects, temperature, fever within the last 24 hours and headaches showed significant variations (p-value Conclusion: Our study provides epidemiological information to better understand the incidence and burden of influenza to allow for prioritisation of prevention and control strategies. Such information would aid in controlling and preparing for future influenza epidemics.

In regions lacking genomic data, analysis of sequences from the early stages of an outbreak can provide important insights into the diversity of pathogens present. Following the detection of the first imported case of COVID-19 in the Northern sector of Ghana on 13th March 2020, we have now molecularly characterized and phylogenetically analysed sequences including three (3) complete genomes of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) isolated from nine (9) patients observed in Ghana. Eight (8) of these patients reported with a recent history of foreign travel and one (1) with no history of foreign travel. We performed high throughput sequencing for 9 samples following the determination of high concentration of viral RNA. In addition, we estimated the potential impact that long distance transportation of samples to testing centres may have on sequencing outcomes. Here, two samples that were closest in terms of viral RNA concentration but transported from sites which are over 400km apart were assessed. All sequences were compared to previous sequences from Ghana and representative sequences from regions where our patients had previously travelled. Complete genomes were obtained for three (3) sequences and with another near complete genome with a coverage of 95.6%. Sequences with coverage in excess of 80% were found to belong to three lineages namely A, B.1 and B.2. Our sequences clustered in two different clades with the majority falling within a clade composed of sequences from sub-Saharan Africa. Less RNA fragmentation was seen in sample KATH23 which was collected 9km compared with sample TTH6 which was collected and transported over a distance of 400km to the testing site. The clustering of several sequences from sub-Saharan Africa suggests regional circulation of the viruses in the subregion. Importantly, there may be the need to decentralize testing sites and build more capacity across Africa to boost the sequencing output of the subregion.

In sub-Saharan Africa, vitamin A deficiency constitutes a severe health problem despite various supplementation and food fortification programs. Given that the intake of preformed vitamin A from animal products remains low in these countries, an efficient metabolization of plant-based provitamin A carotenoids is essential. Previously, adolescents in rural Ghana have shown high total plasma carotenoid concentrations, while 36% had a vitamin A deficiency (defined as plasma retinol &lt, 0.7 &micro, mol/L). Hence, the aim of this cross-sectional study was to identify the relationships between variants in the &beta, carotene 15,15&rsquo, oxygenase (BCO1) gene and plasma carotenoid concentrations among 189 15-year-old girls and boys in rural Ghana. BCO1 rs6564851, rs7500996, rs10048138 and PKD1L2 rs6420424, and rs8044334 were typed, and carotenoid concentrations were compared among the different genotypes. G allele carriers of rs6564851 (53%) showed higher plasma carotenoid concentrations than T allele carriers (median (interquartile range): 3.07 (2.17&ndash, 4.02) vs. 2.59 (2.21&ndash, 3.50) &micro, mol/L, p-value = 0.0424). This was not explained by differences in socio-demographic or dietary factors. In contrast, no differences in plasma retinol concentrations were observed between these genotypes. Pending verification in independent populations, the low conversion efficiency of provitamin A carotenoids among rs6564851 G allele carriers may undermine existing fortification and supplementation programs to improve the vitamin A status in sub-Saharan Africa.

Background Buruli ulcer is a chronic ulcerating skin condition, with the highest burden found in Central and West Africa where it disproportionately affects the most vulnerable populations. Treatment is demanding, comprising eight-weeks of daily antibiotics, regular wound care and possible surgical intervention. Treatment completion is key to optimising outcomes, however the degree of and barriers to this are not well understood. Recent change from injectable treatment (SR8) to oral treatment (CR8) has made it feasible to further decentralise care, potentially improving treatment access and completion. However, the impact of this and of other demographic and clinical influences on treatment completion must be explored first to ensure appropriate models of care are developed. Methodology/Principal findings A retrospective clinical notes review and secondary data analysis of records from patients diagnosed between 1 January 2006–31 December 2018 at four district hospital clinics in the Ashanti and Central Regions, Ghana. Univariable analyses and multivariable logistic regression were performed to assess the association between explanatory variables and treatment completion. There were 931 patient episodes across the four clinics with overall treatment completion of 84.4%. CR8 was associated with higher treatment completion compared to SR8 (OR 4.1, P = 0.001). There was no statistically significant association found between distance from patient residence to clinic and treatment completion. Conclusions/Significance Improved treatment completion with CR8 supports its use as first line therapy and may enable decentralisation to fully community-based care. We did not find an association between distance to care and treatment completion, though analyses were limited by data availability. However, we did find evidence that distance to care continues to be associated with more severe forms of disease, which may reflect the higher costs of accessing care and lower awareness of the condition the further a patient lives. Decentralised care must therefore also continue to support community engagement and active outreach to identify cases early., Author summary Buruli ulcer (BU) is a chronic ulcerating tropical skin disease known to particularly affect vulnerable populations. Without early detection and effective treatment it can lead to disfigurement, disability and stigma. In order to improve outcomes, we need to understand what factors prevent patients from accessing and completing treatment, however these factors are often not well understood. Factors considered to potentially affect treatment completion include access to care and type of treatment. In this study we analysed data available from clinical records of patients treated in Ghana to identify whether type of treatment and common patient characteristics were associated with treatment completion. We found that treatment completion was higher in patients who took a newly introduced oral treatment compared to those who took the traditional injectable treatment. We did not find a difference in treatment completion between patients living close to the clinic and those living further away, however we found that those living further were more likely to present with more advanced disease. The results from this study suggest that management for patients living far from care needs to be improved. The newly recommended oral treatment makes it feasible to provide care away from health centres and the improved treatment completion seen in this study supports its use. However, further research should be conducted to determine how fully community based care can best be provided.

Imaging in prostate cancer is important in defining the local extent of disease, nodal involvement, and identifying metastases. Bone scan is the most commonly used modality for identification of bone metastasis in prostate cancer despite its reported low sensitivity and specificity compared to magnetic resonance imaging (MRI) which is the imaging gold standard for bone metastasis. Gallium-68 prostate-specific membrane antigen positron emission tomography-computed tomography (68Ga PSMA PET-CT) imaging is a relatively new addition to the imaging modalities in prostate cancer. This is a report of a patient with high-risk prostate cancer with features consistent with skeletal metastases on MRI but negative for skeletal metastases on bone scan and 68Ga PSMA PET CT. Histology confirmed the absence of skeletal metastases.

Background We investigated the relationship between bacterial load in Buruli ulcer (BU) lesions and the development of paradoxical reaction following initiation of antibiotic treatment. Methods This was a longitudinal study involving BU patients from June 2013 to June 2017. Fine needle aspirates (FNA) and swab samples were obtained to establish the diagnosis of BU by PCR. Additional samples were obtained at baseline, during and after treatment (if the lesion had not healed) for microscopy, culture and combined 16S rRNA reverse transcriptase/ IS2404 qPCR assay. Patients were followed up at regular intervals until complete healing. Results Forty-seven of 354 patients (13%) with PCR confirmed BU had a PR, occurring between 2 and 42 (median 6) weeks after treatment initiation. The bacterial load, the proportion of patients with positive M. ulcerans culture (15/34 (44%) vs 29/119 (24%), p = 0.025) and the proportion with positive microscopy results (19/31 (61%) vs 28/90 (31%), p = 0.003) before initiation of treatment were significantly higher in the PR compared to the no PR group. Plaques (OR 5.12; 95% CI 2.26–11.61; p, Author summary Buruli ulcer is a neglected tropical skin disease caused by the third most common pathogenic mycobacterium: Mycobacterium ulcerans. Paradoxical reaction, a phenomenon observed in some patients is characterised by worsening of existing lesion(s) with attendant pain and occurrence of new lesions during or after antibiotic therapy following an initial period of clinical improvement. This significantly affects treatment outcomes. In this clinical study, tissue samples obtained from patients were subjected to 16S rRNA/ IS2404 qPCR to measure bacterial load. This was to identify a link between bacterial load in BU lesions and the development of paradoxical reactions following initiation of antibiotic treatment. We found that 13% of participants developed PR. Patients who developed PR had higher baseline bacterial load; a higher rate of positive M. ulcerans culture and persistently positive culture during antibiotic treatment. Occurrence of a paradoxical reaction was associated with delayed healing.

Background Accurate childhood cancer burden data are crucial for resource planning and health policy prioritisation. Model-based estimates are necessary because cancer surveillance data are scarce or non-existent in many countries. Although global incidence and mortality estimates are available, there are no previous analyses of the global burden of childhood cancer represented in disability-adjusted life-years (DALYs). Methods Using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 methodology, childhood (ages 0–19 years) cancer mortality was estimated by use of vital registration system data, verbal autopsy data, and population-based cancer registry incidence data, which were transformed to mortality estimates through modelled mortality-to-incidence ratios (MIRs). Childhood cancer incidence was estimated using the mortality estimates and corresponding MIRs. Prevalence estimates were calculated by using MIR to model survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated by multiplying age-specific cancer deaths by the difference between the age of death and a reference life expectancy. DALYs were calculated as the sum of YLLs and YLDs. Final point estimates are reported with 95% uncertainty intervals. Findings Globally, in 2017, there were 11·5 million (95% uncertainty interval 10·6–12·3) DALYs due to childhood cancer, 97·3% (97·3–97·3) of which were attributable to YLLs and 2·7% (2·7–2·7) of which were attributable to YLDs. Childhood cancer was the sixth leading cause of total cancer burden globally and the ninth leading cause of childhood disease burden globally. 82·2% (82·1–82·2) of global childhood cancer DALYs occurred in low, low-middle, or middle Socio-demographic Index locations, whereas 50·3% (50·3–50·3) of adult cancer DALYs occurred in these same locations. Cancers that are uncategorised in the current GBD framework comprised 26·5% (26·5–26·5) of global childhood cancer DALYs. Interpretation The GBD 2017 results call attention to the substantial burden of childhood cancer globally, which disproportionately affects populations in resource-limited settings. The use of DALY-based estimates is crucial in demonstrating that childhood cancer burden represents an important global cancer and child health concern. The work in this paper was supported by the Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities (ALSAC), and St Baldrick's Foundation

Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. The Lancet Publishing Group

Background Buruli ulcer disease (BUD) results in disabilities and deformities in the absence of early medical intervention. The extensive role of caregiving in BUD is widely acknowledged, however, associated caregiver burden is poorly understood. In this paper we assessed the burden which caregivers experience when supporting patients with BUD in Ghana. Method/ principal findings This qualitative study was conducted in 3 districts in Ghana between August and October 2019. 13 semi-structured interviews were conducted on caregivers of BUD patients in the local language of Twi. Data was translated into English, coded into broad themes, and direct content analysis approach was used to analyse results. The results show the caregivers face financial, psychological and health issues as a consequence of their caregiving role. Conclusion/ significance This study found significant caregiver burden on family members. It also highlighted the psychological burden caregivers experience and the limited knowledge of the disease within endemic communities. Further research is needed to quantify the caregiver burden of BUD at different economic levels in order to better understand the impact of possible caregiver interventions on patient outcomes., Author summary Buruli ulcer disease (BUD) is a stigmatizing skin condition caused by the bacteria, Mycobacterium ulcerans. The disease results in permanent functional limitations in the absence of early medical intervention. The disabling BUD conditions, financial constraints and frequent hospital visits support the role of caregiving for affected individuals. Caregiver burden is poorly understood although the role and need for caregiving is widely recognised in BUD. This study identified a previously unrecognized burden on the caregivers of BUD patients in 3 endemic districts in Ghana. Specifically, we identified significant financial and psychological pressure on affected families in meeting healthcare related costs and physical care while also providing for their own and other family members’ needs. We also highlight the emotional burden experienced by caregivers, their reduced work productivity, the barriers caregivers face in accessing healthcare with BUD patients and the limited support available for caregivers. Our study highlights the serious social consequences of BUD in Ghana. Further quantitative research within different economic regions affected by BUD is warranted to better understand the caregiver burden of BUD.

Global spread of infectious disease threatens the well-being of human, domestic, and wildlife health. A proper understanding of global distribution of these diseases is an important part of disease management and policy making. However, data are subject to complexities by heterogeneity across host classes. The use of frequentist methods in biostatistics and epidemiology is common and is therefore extensively utilized in answering varied research questions. In this paper, we applied the hierarchical Bayesian approach to study the spatial distribution of tuberculosis in Kenya. The focus was to identify best fitting model for modeling TB relative risk in Kenya. The Markov Chain Monte Carlo (MCMC) method via WinBUGS and R packages was used for simulations. The Deviance Information Criterion (DIC) proposed by [1] was used for models comparison and selection. Among the models considered, unstructured heterogeneity model perfumes better in terms of modeling and mapping TB RR in Kenya. Variation in TB risk is observed among Kenya counties and clustering among counties with high TB Relative Risk (RR). HIV prevalence is identified as the dominant determinant of TB. We find clustering and heterogeneity of risk among high rate counties. Although the approaches are less than ideal, we hope that our formulations provide a useful stepping stone in the development of spatial methodology for the statistical analysis of risk from TB in Kenya.

Thyrotoxicosis as a clinical entity has varied aetiologies. Accurate distinction of the underlying aetiology is important to guide therapy. Clinical findings are not always accurate in identifying the underlying aetiology. There is considerable overlap between the various aetiologies when using serum T3/T4 ratio. Although ultrasound is widely available and has reasonable sensitivity, it is operator dependent and misses many cases of early Grave's disease. 99mTc scintigraphy is a simple and accurate modality for assessing the functional status of the thyroid gland and delineating the aetiology of thyrotoxicosis. This paper seeks to inform on the use of thyroid scintigraphy in the management of benign thyroid disorders. Funding: None Keywords: Scintigraphy, thyroid gland, functional imaging, Grave’s disease, Ghana

Background Data from population-based cancer registries (PBCRs) are a useful resource for estimating the incidence of cancers. PBCR data is useful in the planning and implementation of cancer prevention and control strategies. Ghana’s plan for control of non-communicable diseases recognises the need for good quality data to facilitate the attainment of set goals. Methods We reviewed data from the Kumasi Cancer Registry for the year 2015. Data collected included clinical and demographic information, laboratory reports and source of case information. Data was entered into the Canreg-5 software. Data was initially analysed using Canreg-5 to estimate the incidence and age standardised rates (ASR) for various tumours. Data was also exported to Microsoft Excel for further analysis using Epi Info version 7.1.4. Microsoft Excel was used to generate charts and graphs. Aggregated data for the years 2013 and 2014 were also analysed for trends in cancer incidence and ASR. Results A total of 736 cancer cases were recorded among the residents of Kumasi for the year 2015. Females accounted for 62.4% of all cases. The overall incidence of cancer in Kumasi for 2015 was 46.1 per 100,000. The mean age of all cases was 51.3 years (with a range of 1 to 99 years). The incidence among female residents was estimated at 54.1 per 100,000 compared with 37.1 per 100,000 in males. Among females, breast and cervical cancers recorded the highest incidences of 16.1 per 100,000 and 13.7 per 100,000 respectively. Among males, prostate cancer had the highest incidence of 10.5 per 100,000. Breast, cervical and liver cancers were the commonest in both sexes accounting for 19.7, 14.7 and 11.4% of cases respectively. Conclusion There has been significant improvement in data quality and coverage since the inception of our PBCR in 2012. PBCRs are feasible; therefore there is the need for more such registries to improve data on cancers in Ghana. Consistent with other evidence, we found breast cancer as the commonest female cancer in Ghana.