Juergen May

Mobile Phone-Based mHealth Approaches for Public Health Surveillance in Sub-Saharan Africa: A Systematic Review

Whereas mobile phone-based surveillance has the potential to provide real-time validated data for disease clustering and prompt respond and investigation, little evidence is available on current practice in sub-Sahara Africa. The objective of this review was to examine mobile phone-based mHealth interventions for Public Health surveillance in the region. We conducted electronic search in MEDLINE, EMBASE, IEE Xplore, African Index Medicus (AIM), BioMed Central, PubMed Central (PMC), the Public Library of Science (PLoS) and IRIS for publications used in the review. In all, a total of nine studies were included which focused on infectious disease surveillance of malaria (n = 3), tuberculosis (n = 1) and influenza-like illnesses (n = 1) as well as on non-infectious disease surveillance of child malnutrition (n = 2), maternal health (n = 1) and routine surveillance of various diseases and symptoms (n = 1). Our review revealed that mobile phone-based surveillance projects in the sub-Saharan African countries are on small scale, fragmented and not well documented. We conclude by advocating for a strong drive for more research in the applied field as well as a better reporting of lessons learned in order to create an epistemic community to help build a more evidence-based field of practice in mHealth surveillance in the region.

A randomized trial on effectiveness of artemether-lumefantrine versus artesunate plus amodiaquine for unsupervised treatment of uncomplicated Plasmodium falciparum malaria in Ghanaian children

BackgroundNumerous trials have demonstrated high efficacy and safety of artemisinin-based combination therapy (ACT) under supervised treatment. In contrast, effectiveness studies comparing different types of ACT applied unsupervised are scarce. The aim of this study was to compare effectiveness, tolerability and acceptance of artesunate plus amodiaquine (ASAQ) against that of artemether-lumefantrine (AL) in Ghanaian children with uncomplicated Plasmodium falciparum malaria.MethodsA randomized open-label trial was conducted at two district hospitals in the Ashanti region, Ghana, an area of intense malaria transmission. A total of 246 children under five years of age were randomly assigned to either ASAQ (Arsucam®) or AL (Coartem®). Study participants received their first weight-adjusted dose under supervision. After the parent/guardian was advised of times and mode of administration the respective three-day treatment course was completed unobserved at home. Follow-up visits were performed on days 3, 7, 14 and 28 to evaluate clinical and parasitological outcomes, adverse events, and haematological recovery. Length polymorphisms of variable regions of msp1 and msp2 were determined to differentiate recrudescences from reinfections. Acceptance levels of both treatment regimens were assessed by means of standardized interviews.ResultsAdequate clinical and parasitological responses after AL and ASAQ treatment were similar (88.3% and 91.7%, respectively). Interestingly, more late clinical failures until day 28 occurred in AL-treated children than in those who received ASAQ (17.5% and 7.3%, respectively; Hazard Ratio 2.41, 95% CI 1.00–5.79, p < 0.05).Haematological recovery and drug tolerability were not found to be significantly different in both study arms. The acceptance of treatment with ASAQ was higher than that with AL (rank-scores 10.6 and 10.3, respectively; p < 0.05).ConclusionUnobserved AL and ASAQ treatment showed high adequate clinical and parasitological responses, though AL was inferior in preventing late clinical failures.

Assessing the relationship between socioeconomic conditions and urban environmental quality in Accra, Ghana.

The influence of socioeconomic status (SES) on health inequalities is widely known, but there is still poor understanding of the precise relationship between area-based socioeconomic conditions and neighborhood environmental quality. This study aimed to investigate the socioeconomic conditions which predict urban neighbourhood environmental quality. The results showed wide variation in levels of association between the socioeconomic variables and environmental conditions, with strong evidence of a real difference in environmental quality across the five socioeconomic classes with respect to total waste generation (p < 0.001), waste collection rate (p < 0.001), sewer disposal rate (p < 0.001), non-sewer disposal (p < 0.003), the proportion of households using public toilets (p = 0.005). Socioeconomic conditions are therefore important drivers of change in environmental quality and urban environmental interventions aimed at infectious disease prevention and control if they should be effective could benefit from simultaneous implementation with other social interventions.

Malaria incidence and efficacy of intermittent preventive treatment in infants (IPTi).

BackgroundIntermittent preventive antimalarial treatment in infants (IPTi) is currently evaluated as a malaria control strategy. Among the factors influencing the extent of protection that is provided by IPTi are the transmission intensity, seasonality, drug resistance patterns, and the schedule of IPTi administrations. The aim of this study was to determine how far the protective efficacy of IPTi depends on spatio-temporal variations of the prevailing incidence of malaria.MethodsOne thousand seventy infants were enrolled in a registered controlled trial on the efficacy of IPTi with sulphadoxine-pyrimethamine (SP) in the Ashanti Region, Ghana, West Africa (ClinicalTrial.gov: NCT00206739). Stratification for the village of residence and the month of birth of study participants demonstrated that the malaria incidence was dependent on spatial (range of incidence rates in different villages 0.6–2.0 episodes/year) and temporal (range of incidence rates in children of different birth months 0.8–1.2 episodes/year) factors. The range of spatio-temporal variation allowed ecological analyses of the correlation between malaria incidence rates, anti-Plasmodium falciparum lysate IgG antibody levels and protective efficacies provided by IPTi.ResultsProtective efficacy of the first SP administration was positively correlated with malaria incidences in children living in a distinct village or born in a distinct month (R2 0.48, p < 0.04 and R2 0.63, p < 0.003, respectively). Corresponding trends were seen after the second and third study drug administration. Accordingly, IgG levels against parasite lysate increased with malaria incidence. This correlation was stronger in children who received IPTi, indicating an effect modification of the intervention.ConclusionThe spatial and temporal variations of malaria incidences in a geographically and meteorologically homogeneous study area exemplify the need for close monitoring of local incidence rates in all types of intervention studies. The increase of the protective efficacy of IPTi with malaria incidences may be relevant for IPTi implementation strategies and, possibly, for other malaria control measures.

Neighborhood Urban Environmental Quality Conditions Are Likely to Drive Malaria and Diarrhea Mortality in Accra, Ghana

Background. Urbanization is a process which alters the structure and function of urban environments. The alteration in the quality of urban environmental conditions has significant implications for health. This applies both to the ecology of insect vectors that may transmit diseases and the burden of disease. Study Objectives. To investigate the relationship between malaria and infectious diarrhea mortality and spatially varied neighborhood environmental quality conditions in a low-income economy. Design. A one time point spatial analysis of cluster-level environmental conditions and mortality data using principal component analysis (PCA), one-way analysis of variance (ANOVA) and generalized linear models (GLMs). Methods. Environmental variables were extracted from the Ghana Census 2000 database while mortality data were obtained from the Ghana Births and Deaths Registry in Accra over the period 1998–2002. Results. Whereas there was a strong evidence of a difference in relative mortality of malaria across urban environmental zones of differing neighborhood environmental conditions, no such evidence of mortality differentials was observed for diarrhea. In addition, whereas bivariate analyses showed a weak to strong evidence of association between the environmental variables and malaria mortality, no evidence of association was found between diarrhea mortality and environmental variables. Conclusion. We conclude that environmental management initiatives intended for infectious disease control might substantially reduce the risk of urban malaria mortality and to a less extent that for urban diarrhea mortality in rapidly urbanizing areas in a low-income setting.

Mapping Urban Malaria and Diarrhea Mortality in Accra, Ghana: Evidence of Vulnerabilities and Implications for Urban Health Policy

Historic increase in urban population numbers in the face of shrinking urban economies and declining social services has meant that a large proportion of the urban population lives in precarious urban conditions, which provide the grounds for high urban health risks in low income countries. This study aims to identify, investigate, and contrast the spatial patterns of vulnerability and risk of two major causes of mortality, viz malaria and diarrhea mortalities, in order to optimize resource allocation for effective urban environmental management and improvement in urban health. A spatial cluster analysis of the observed urban malaria and diarrhea mortalities for the whole city of Accra was conducted. We obtained routinely reported mortality data for the period 1998–2002 from the Ghana Vital Registration System (VRS), computed the fraction of deaths due to malaria and diarrhea at the census cluster level, and analyzed and visualized the data with Geographic Information System (GIS, ArcMap 9.3.1). Regions of identified hotspots, cold spots, and excess mortalities were observed to be associated with some socioeconomic and neighborhood urban environmental conditions, suggesting uneven distribution of risk factors for both urban malaria and diarrhea in areas of rapid urban transformation. Case–control and/or longitudinal studies seeking to understand the individual level factors which mediate socioenvironmental conditions in explaining the observed excess urban mortalities and to establish the full range of risk factors might benefit from initial vulnerability mapping and excess risk analysis using geostatistical approaches. This is key to evidence-based urban health policy reforms in rapidly urbanizing areas in low income economies.

Endothelial Protein C Receptor Gene Variants Not Associated with Severe Malaria in Ghanaian Children

Background Two recent reports have identified the Endothelial Protein C Receptor (EPCR) as a key molecule implicated in severe malaria pathology. First, it was shown that EPCR in the human microvasculature mediates sequestration of Plasmodium falciparum-infected erythrocytes. Second, microvascular thrombosis, one of the major processes causing cerebral malaria, was linked to a reduction in EPCR expression in cerebral endothelial layers. It was speculated that genetic variation affecting EPCR functionality could influence susceptibility to severe malaria phenotypes, rendering PROCR, the gene encoding EPCR, a promising candidate for an association study. Methods Here, we performed an association study including high-resolution variant discovery of rare and frequent genetic variants in the PROCR gene. The study group, which previously has proven to be a valuable tool for studying the genetics of malaria, comprised 1,905 severe malaria cases aged 1–156 months and 1,866 apparently healthy children aged 2–161 months from the Ashanti Region in Ghana, West Africa, where malaria is highly endemic. Association of genetic variation with severe malaria phenotypes was examined on the basis of single variants, reconstructed haplotypes, and rare variant analyses. Results A total of 41 genetic variants were detected in regulatory and coding regions of PROCR, 17 of which were previously unknown genetic variants. In association tests, none of the single variants, haplotypes or rare variants showed evidence for an association with severe malaria, cerebral malaria, or severe malaria anemia. Conclusion Here we present the first analysis of genetic variation in the PROCR gene in the context of severe malaria in African subjects and show that genetic variation in the PROCR gene in our study population does not influence susceptibility to major severe malaria phenotypes.

Lack of Association of CD55 Receptor Genetic Variants and Severe Malaria in Ghanaian Children

In a recent report, the cellular receptor CD55 was identified as a molecule essential for the invasion of human erythrocytes by Plasmodium falciparum, the causal agent of the most severe form of malaria. As this invasion process represents a critical step during infection with the parasite, it was hypothesized that genetic variants in the gene could affect severe malaria (SM) susceptibility. We performed high-resolution variant discovery of rare and common genetic variants in the human CD55 gene. Association testing of these variants in over 1700 SM cases and unaffected control individuals from the malaria-endemic Ashanti Region in Ghana, West Africa, were performed on the basis of single variants, combined rare variant analyses, and reconstructed haplotypes. A total of 26 genetic variants were detected in coding and regulatory regions of CD55. Five variants were previously unknown. None of the single variants, rare variants, or haplotypes showed evidence for association with SM or P. falciparum density. Here, we present the first comprehensive analysis of variation in the CD55 gene in the context of SM and show that genetic variants present in a Ghanaian study group appear not to influence susceptibility to the disease.

A study of autopsy procedures in Ghana: Implications for the use of autopsy data in epidemiological analyses

The study of cause of death certification remains a largely neglected field in many developing countries, including Ghana. Yet, mortality information is crucial for establishing mortality patterns over time and for estimating mortality attributed to specific causes. In Ghana, autopsies remain the appropriate option for determining the cause of deaths occurring in homes and those occurring within 48 hours after admission into health facilities. Although these organ-based autopsies may generate convincing results and are considered the gold standard tools for ascertainments of causes of death, procedural and practical constraints could limit the extent to which autopsy results can be accepted and/or trusted. The objective of our study was to identify and characterise the procedural and practical constraints as well as to assess their potential effects on autopsy outcomes in Ghana. We interviewed 10 Ghanaian pathologists and collected and evaluated procedural manuals and operational procedures for the conduct of autopsies. A characterisation of the operational constraints and the Delphi analysis of their potential influence on the quality of mortality data led to a quantification of the validity threats as moderate (average expert panel score = 1) in the generality of the autopsy operations in Ghana. On the basis of the impressions of the expert panel, it was concluded that mortality data generated from autopsies in urban settings in Ghana were of sufficiently high quality to guarantee valid use in health analysis.

A review of the structure and function of vital registration system in Ghana: towards improvement in mortality data quality for health policy analysis

Vital registration systems (VRS) are important in the collection of routine data on indicators of development. These are particularly useful if they are properly built to address weaknesses in the system leading to poor data quality. For instance, routine data on health events (e.g. morbidity, mortality etc.) are crucial for rapid assessment of disease burden and mortality trends in the population. They are also useful in the identification of vulnerable groups in populations. Despite their usefulness, VRS in many developing countries including Ghana are poorly structured raising questions about the quality of the output data from these systems. The present study aimed at assessing and documenting the structure and function of the VRS in Ghana, as well as at identifying the structural features that potentially compromise the reliability and validity of the output data from the Ghanaian VRS. To perform this study, collection and review of policy and legal documents establishing the VRS, documentation and evaluation of component structures of the system, assessment of procedural protocols guiding data collection processes and in-depth interviews with staff at the Ghana Births and Deaths Registry were performed. The assessment of the structure of the Ghana VRS, policy documents setting it up and the operational procedures reveals important lapses (e.g. presence of outmoded practices, imperfections in Births and Deaths Registry Act, 1965, Act 301 and imperfect system design) in the system that could compromise validity and reliability of the data generated from the VRS in Ghana.