ministry of healthof meningitis, ghana introduced h. influenzae serogroup b vaccine in 2002 and...

Bacterial Meningitis Laboratory Testing at Tamale Laboratory, Ghana, 2016–2017

Risk Factors for Delayed Vaccine Uptake among Children Accessing Services in an Urban Immunisation Clinic in Ghana

Summary of Weekly Epidemiological Data for Week 14, 2018

VOLUME 3

WEEK 14

8 April 2018

MINISTRY OF HEALTH

Ghana Weekly Epidemiological Report Vol. 3 Week 14 8 April 2018

The Ghana Weekly Epidemiological Report is a publication of the Ghana Health Service

and the Ministry of Health, Ghana

© Ghana Health Service 2018

ISSN - 2579-0439


Acknowledgement

This publication has been made possible with technical and financial support from the

Bloomberg Data for Health Initiative, the CDC Foundation and the World Health Organisation.

Ghana Weekly Epidemiological Report Vol. 3 Week. 14 8 April 2018 1

Content

Acknowledgement ......................................................................................................................... ii

Editorial .......................................................................................................................................... 2

Bacterial Meningitis Laboratory Testing at Tamale Laboratory, Ghana, 2016–2017. ................... 3

Risk Factors for Delayed Vaccine Uptake among Children Accessing Services in an Urban

Immunisation Clinic in Ghana ........................................................................................................ 6

Summary of Weekly Epidemiological Data for Week 14, 2018 .................................................. 14


Editorial

In this edition we present a report on bacterial pathogens that caused meningitis in the three northern regions of Ghana during the

2015-2016 epidemic as analyzed by the National Laboratory for Meningitis in Tamale. A detailed report of the epidemic was

published in the MMWR (August 4, 2017 /Vol.66/ No.30) and reproduced later in the GWER (August, 2017 / Vol. 02 / No. 33).

Acute bacterial meningitis if not diagnosed and treated early is fatal. The three northern regions of Ghana fall in the Meningitis belt,

which reports high cases of meningitis every year during the period December to April. Among 286 cerebrospinal fluid specimens

tested during the 2015-2016 epidemic, 133 were positive, including 83 for N. meningitidis and 44 for S. pneumoniae.

Neisseria meningitidis serotype A Meningitis (MenA) vaccine was introduced in a mass vaccination campaign as a control measure

for the meningitis epidemic in 2012. The MenA vaccine was later incorporated into the national immunization program in 2016.

Prior to 2012, N meningitidis was the predominant cause of acute bacterial meningitis. The results of this study present the scientific

evidence of the effectiveness of the (MenA) vaccine in preventing meningitis caused by N meningitidis serotype A. The analysis

showed that N meningitidis serotype A was not among the pathogens that caused the meningitis epidemic

The results of this study highlight the importance of laboratory surveillance in monitoring the pathogens that cause meningitis. It

also offers undisputed evidence of the effectiveness of the MenA vaccine in suppressing acute bacterial meningitis caused by N

meningitidis serotype A. Ghana’s National Immunization program deserves commendation for the great work it continues to do, and

the government should be proud of it’s achievement. The government should continue to support the Immunization program and

also guarantee that the laboratories that support this program with their surveillance activities are equally supported. The expansion

of the capacity of the National Laboratory for Meningitis in Tamale to include Polymerase Chain Reaction (PCR) is a welcome

development, without which this work and the evidence it has presented would not have been possible.

Bacterial Meningitis Laboratory Testing at Tamale Laboratory, Ghana, 2016–2017.


Bacterial Meningitis Laboratory Testing at Tamale Laboratory, Ghana,

2016–2017

Introduction Bacterial meningitis, caused primarily by Neisseria

meningitidis, Streptococcus pneumoniae, and Haemophilus

influenzae, is a serious illness that can lead to death within

hours even with appropriate antibiotic treatment. The

northern part of Ghana falls in the meningitis belt of Africa

and experiences bacterial meningitis outbreaks during the dry

season (December–April) of each year. To reduce the burden

of meningitis, Ghana introduced H. influenzae serogroup b

vaccine in 2002 and 13-valent pneumococcal conjugate

vaccine in 2012 [1,2]. A vaccine for N. meningitidis

serogroup A (MenA), previously the most common serogroup

in the meningitis belt, was introduced through a mass

vaccination campaign in 2012 and incorporated into the

routine immunization program in 2016 [1]. However, Ghana

continues to experience bacterial meningitis outbreaks

including outbreaks of S. pneumoniae (Brong-Ahafo Region)

and N. meningitidis serogroup W (Upper West Region) in

2015 [1]. Laboratory confirmation of cases is critical to

identify causal pathogens and identify potential vaccination

failures. Moreover, regular review and analysis of meningitis

laboratory results are essential to monitor the epidemiology of

meningitis in Ghana, evaluate the population impact of the

bacterial meningitis vaccination program, and inform

potential interventions. Tamale Laboratory in Tamale,

Northern Region, is the National Laboratory for Meningitis in

Ghana. Polymerase Chain Reaction (PCR) capacity for

testing of bacterial meningitis pathogens was established at

Tamale laboratory in 2012 through a collaboration with the

United States Centers for Disease Control and Prevention.

This capacity was strengthened in 2016–2017 with the

implementation of a direct real-time PCR assay for reduced

specimen processing, an external quality assurance program,

and refresher training for laboratory staff. Currently,

specimens are sent to Tamale Laboratory primarily from

Brong-Ahafo, Northern, Upper West, and Upper East

Regions. While enhanced meningitis surveillance is

conducted in each of Ghana’s ten regions, these four regions,

which contain approximately a quarter of Ghana’s population

and experience the greatest burden of meningitis, also perform

case-based meningitis surveillance with the goal of collecting

and testing cerebrospinal fluid specimens from every

suspected meningitis case.

Laboratory Results In 2016, results were available for 721 specimens tested by

PCR at Tamale Laboratory [Table 1]. Of these, 282

specimens (39%) tested positive for a bacterial meningitis

pathogen. N. meningitidis serogroup W was the most

common pathogen and was detected in 173 of 282 (61%)

positive specimens; S. pneumoniae was the second most

common pathogen and was detected in 105 specimens (37%).

During January–October 2017, 530 specimens were tested

and 241 (45%) were positive for a bacterial meningitis

pathogen [Table 2]. S. pneumoniae was detected in 124

(51%) of the positive specimens; N. meningitidis serogroup W

was detected in 107 (44%). Cases for 2017 are expected to

increase once results from November–December are

available. Notably, N. meningitidis serogroup A was not

detected in any specimens tested in either 2016 or January–

October, 2017.

Table 1. Bacterial Meningitis PCR Results by causal pathogen and region, Tamale Laboratory, 2016.

Region

N. meningitidis

S. pneumoniae H. influenzae

>1

pathogen* Negative Total

C W X Unknown B Non-B Unknown

Ashanti 0 0 0 0 0 0 0 0 0 0 0

Brong-Ahafo 0 3 0 0 6 0 0 0 0 149 158

Greater Accra 0 0 0 0 0 0 0 0 0 1 1

Central 0 0 0 0 0 0 0 0 0 0 0

Eastern 0 0 0 0 0 0 0 0 0 0 0

Northern 1 83 0 1 39 0 0 1 4 82 211

Western 0 0 0 0 0 0 0 0 0 0 0

Upper East 0 24 1 0 17 0 1 0 1 59 103

Upper West 1 58 0 0 34 0 0 3 4 148 248

Volta 0 0 0 0 0 0 0 0 0 0 0

Total 2 168 1 1 96 0 1 4 9 439 721

Numbers indicate CSF specimens with a positive result for the indicated pathogen.

*3 specimens were positive for both S. pneumoniae and H. influenzae and 6 specimens were positive for both N. meningitidis

and S. pneumoniae



Table 2. Bacterial Meningitis PCR Results by causal pathogen and region, Tamale Laboratory, January–October, 2017.

Region

N. meningitidis S. pneumoniae H. influenzae <1 pathogen Negative Total

C W X Unknown B Non-B Unknown

Ashanti 2 0 0 0 0 0 0 0 0 3 5

Brong-Ahafo 0 3 0 0 9 0 0 0 0 8 20

Greater Accra 0 0 0 0 0 0 0 0 0 0 0

Central 0 0 0 0 0 0 0 0 0 0 0

Eastern 0 0 0 0 0 0 0 0 0 0 0

Northern 0 71 0 0 39 2 0 0 0 90 202

Western 0 0 0 0 0 0 0 0 0 0 0

Upper East 0 20 0 0 11 1 0 0 0 31 63

Upper West 0 13 0 0 65 4 0 0 0 157 240

Volta 0 0 0 0 0 0 0 0 0 0 0

Total 2 107 0 0 124 7 0 0 0 289 530

Numbers indicate CSF specimens with a positive result for the indicated pathogen

N. meningitidis serogroup W was the most common pathogen

detected in the Northern and Upper East Regions in both 2016

and 2017. The Upper West Region experienced an N.

meningitidis serogroup W outbreak in 2016 that resulted in a

reactive vaccination campaign with meningococcal

polysaccharide ACW vaccine [1]. In 2017, however, S.

pneumoniae was the dominant pathogen detected in the Upper

West Region, accounting for 79% of specimens positive for a

bacterial meningitis pathogen [Table 2]. In Brong-Ahafo, S.

pneumoniae was the most common pathogen detected in both

2016 and 2017. Few specimens were received from other

regions. However, in 2017 five specimens were submitted

from cases associated with a meningitis outbreak at the

Kumasi Academy School in Ashanti Region in the southern

part of Ghana [Table 2]. Two of these specimens were

positive for N. meningitidis serogroup C, implicating this

pathogen as the cause of the outbreak. Results from Tamale

Laboratory demonstrate that multiple pathogens contribute to

meningitis cases and outbreaks in Ghana. The absence of N.

meningitidis serogroup A among specimens tested is exciting

and highlights the impact of meningitis A conjugate vaccine

implementation in Ghana; however, S. pneumoniae and N.

meningitidis serogroup W remain significant causes of

disease. Furthermore, N. meningitidis serogroup C was

detected in Ghana in 2017; this serogroup has recently caused

large outbreaks in Niger and Nigeria [3,4].

Conclusion and Recommendations As Ghana enters the 2017–18 meningitis season, it will be

essential to ensure rapid transport of CSF specimens to

Tamale Laboratory and regular analysis of the laboratory

results to monitor the epidemiologic situation in each region

under surveillance. The results from Tamale demonstrate the

importance of laboratory surveillance as a key component of

a functional public health system capable of detecting and

identifying public health threats. Ghana has built an integrated

laboratory system for surveillance and diagnosis of infectious

diseases, but concerted efforts are still needed to achieve

efficient, reliable and sustainable laboratory surveillance.

Through coordination and integration of efforts across

multiple sectors, the Global Health Security Agenda provides

a framework to help countries accelerate towards international

public health standards and protect their populations and the

global community against public health threats. As part of the

Global Health Security Agenda, Ghana Health Service and its

partners will continue to invest in Ghana’s laboratory

strengthening efforts.

Authors/Contributors 1. Lucy McNamara PhD MS - Division of Bacterial

Diseases, National Center for Immunization and

Respiratory Diseases, CDC, Atlanta, United States

2. Abass Abdul-Karim MPhil -Tamale Public Health

Laboratory, Tamale, N/R- Ghana

3. Jeni Vuong MS, - Division of Bacterial Diseases,

National Center for Immunization and Respiratory

Diseases, CDC, Atlanta, United States

4. Chastity Walker DrPH, -Division of Global Health

Protection, Center for Global Health, CDC, Atlanta,

United States

5. Catherine Bozio PhD MPH - Division of Bacterial



6. Velusamy Srinivasan PhD -Division of Bacterial



7. Franklin Asiedu-Bekoe MD FGCP - Ghana Health

Service, Accra, Ghana

The findings and conclusions in this report are those of the

authors/contributors and do not necessarily represent the

official position of the Centers for Disease Control and

Prevention.

References [1] Aku FY, Lessa FC, Asiedu-Bekoe F, et al.. Meningitis

Outbreak Caused by Vaccine-Preventable Bacterial

Pathogens — Northern Ghana, 2016. MMWR

2017;66(30):806-10.



[2] Renner LA, Newman MJ, Ahadzie L, Antwi-Agyei KO,

Eshetu M. Introduction of Haemophilus influenzae

type B conjugate vaccine into routine immunization

in Ghana and its impact on bacterial meningitis in

children younger than give years. Ped Infect Dis J

2007;26(4):356-8.

[3] Nnadi C, Oladejo J, Yennan S, et al.. Large Outbreak of

Neisseria meningitidis Serogroup C – Nigeria,

December 2016–June 2017. MMWR

2017;66(49):1352-6.

[4] Sidikou F, Zaneidou M, Alkassoum I, et al.. Emergence

of epidemic Neisseria meningitidis serogroup C in

Niger, 2015: an analysis of national surveillance

data. Lancet ID 2016;16(11):1288-94.



Risk Factors for Delayed Vaccine Uptake among Children Accessing

Services in an Urban Immunisation Clinic in Ghana

Dennis Odai Laryea1*, Joshua Arthur2, Benedicta Bonsu3, Nicholas Karikari Mensah2, Titilayo Ifeoluwa Dare-Olipede4, Fred

Kwame Awittor2

1. Disease Control Department, Public Health Division, Ghana Health Service, Accra, Ghana 2. Public Health Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana 3. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 4. Ridge Hospital, Accra, Ghana

*Correspondence: [email protected]

ABSTRACT

Introduction: Immunization against vaccine-preventable illnesses has resulted in a significant reduction in under-5 mortality.

Childhood vaccination is a cost-effective intervention in healthcare. Maintaining this success requires adherence to the

immunisation schedule. There are few studies on factors contributing to delayed vaccination in West Africa and very little done

in Ghana. This study sought to identify factors associated with delayed vaccine uptake in an urban immunization clinic in

Kumasi, Ghana.

Methods: Data were obtained from unmatched case control study of children under 5 years of age accessing immunisation

services at the Komfo Anokye Teaching Hospital (KATH) Maternal and Child Health (MCH) Clinic. A case was defined as a

child receiving any vaccine more than 4 weeks after the due date based on Ghana’s Expanded Programme on Immunisation

Schedule. Univariate analysis was conducted on all variables comparing cases and controls. A trend analysis was done using

categorical ordinal variables. Logistic regression analysis included variables with statistical significance on bivariate analysis.

Results: A total of 81 cases (children who received one or more vaccines 4 weeks post-vaccination scheduled date) and 162

controls (children who received all scheduled vaccines within 4 weeks of scheduled dates) were included in this study. A total

of 109 vaccines were received late among the 81cases with the third dose of pentavalent vaccine being the most commonly

delayed. Marital status, employment status, and means of transport were analysed using bivariate models but none were

statistically significant. Maternal educational attainment was statistically significant. Babies unwell after delivery recorded were

8 times more likely to have received a vaccine late than those well after delivery. After adjusting for other significant variables,

the adjusted odds ratio was 8.6 (95% CI, 2.6-28.7). Lower maternal education was associated with higher odds of delayed

vaccination uptake compared with higher maternal education. [AOR=1.4, 95% CI, 1.2-1.8].

Conclusion: Mothers with no or little education should have more intense sessions during antenatal clinic visits with clear and

simple instructions on immunisation schedules. Education of public health staff on the guidelines for the vaccination of sick

children is recommended. In addition to guidelines for the vaccination of sick children, there should be clear guidelines on how

to vaccinate new-borns who are unwell after delivery.

Key words: Delayed immunization, Ghana, childhood immunization, vaccine timeliness

INTRODUCTION One of the most significant public health achievements in

the past century is the decline in vaccine-preventable

illnesses. Childhood vaccination has greatly reduced

mortality caused by vaccine-preventable illnesses. It has

been identified as one of the most cost effective

interventions in healthcare delivery [1,2]. International

agencies such as the UNICEF and the World Health

Organisation (WHO) help provide immunisation services

worldwide with an estimated 35 billion dollars spent on

immunisation between 2006 and 2015 [3]. An estimated 2

to 3 million premature deaths are averted annually through

immunisation activities [4]. Country-specific immunisation

programmes are based on public health needs and the

availability of resources. Childhood vaccination in Ghana

under the Expanded Programme on Immunisation (EPI)

became fully operational nationwide in 1985 [5] from an

initial six vaccines to the current 12. The current schedule

for the EPI in Ghana recommends a total of 4 doses of oral

polio vaccine given at birth, 6, 10 and 14 weeks of age; a

dose of baccile Calmette-Guerin (BCG) at birth; 3 doses

each of diphtheria, pertussis, tetanus, Haemophilus

influenzae type B, hepatitis B (DPT/HiB/HepB) and

pneumococcal vaccine (PCV) at 6, 10 and 14 weeks of age;

rotavirus vaccine at 6 and 10 weeks of age; a dose each of

yellow fever and measles-rubella vaccines at 9 months of

age and a second dose measles vaccine at 18 months of age.

The prevalence of a vaccine-preventable disease and the

risk of disease [6] coupled with the ability of the infant to

elicit an appropriate immune response are some of the

factors used to determine the timing of vaccine

administration. Despite the successes achieved through

childhood vaccination, vaccine preventable illnesses still

occur. Delayed vaccine uptake is a challenge and perfect

adherence to the immunisation schedule has been found to

be uncommon [7]. In the United States for example, more

than a third of children are estimated to be under-vaccinated

for more than 6 months in their first 24 months of life and a

mailto:[email protected]



further 25% receive at least four vaccines late [8]. Factors

identified to contribute to delayed vaccine uptake include

cultural factors, poor supervision of health workers and

poor programme planning and monitoring [6]. Some factors

related to individuals or the community at large [9,10] have

also been identified and these include immunisation

services offered on outreach basis [6], hospital-based

immunisation services [11], and maternal education [12].

The timely uptake of the BCG vaccine in particular has been

associated with hospital birth [13]. In Ghana, delayed

vaccine uptake for specific vaccines has been found to range

between 2.7% for the first dose of the oral polio vaccine to

16.5% for the measles vaccine [14]. Although these are

lower compared with ranges between 13% for the first dose

diphtheria pertussis tetanus (DPT) vaccine and 63.8% for

third dose hepatitis B vaccine in Nigeria [15], delayed

vaccination is a health risk for children. Factors contributing

to delayed vaccine uptake have not been well explored in

Ghana. The present study set out to identify factors

associated with delayed vaccine uptake among children

accessing immunisation services at an urban immunisation

clinic in Kumasi, Ghana.

METHODS

This was an unmatched case control study with the

population being children less than 5 years of age. The study

was conducted at the Komfo Anokye Teaching Hospital

(KATH) Maternal and Child Health (MCH) Clinic in

Kumasi, Ghana. The MCH clinic runs child immunisation

services as per Ghana’s EPI schedule on all week days

except holidays and weekends. A sample size of 243 was

estimated using Epi Info statistical package Version 7.1.4.

This was based on a ratio of 1 case to 2 controls, a power of

80%, a least extreme odds ratio to be detected of 3, and a

hypothetical proportion of controls with exposure of being

10.0% and the proportion of cases with exposure being

25.0%. Subjects for the study were all children accessing

vaccination services at the KATH MCH Clinic.

Consecutive cases of delayed vaccine uptake among

attendants of the KATH MCH clinic were identified and

included in the study over a 6-month period (April to

October 2016). Cases were identified as all children for

whom at least one vaccine in the immunisation schedule

was received more than 4 weeks after due date. Controls

were selected by simple random sampling among children

who had received all their vaccines on or within 4 weeks of

their scheduled date. Data were collected using a structured

questionnaire administered by two trained research

assistants. The interviewees were mothers/guardians of

children selected for inclusion in the study. Participation

was voluntary and a refusal to participate had no effect on

the services provided. Respondents were also at liberty to

discontinue with their participation in the study at any time.

Data analysis was conducted using Epi Info Version 7.1.4.

Univariate analysis was conducted for all variables

collected. Bivariate analysis involved the estimation of odds

ratio for categorical variables comparing cases and controls.

Chi-squared tests for trend were estimated for categorical

ordinal variables. Multivariate analysis involved logistic

regression for the statistically significant variables

identified on univariate and bivariate analysis.

RESULTS A total of 81 children for whom one or more vaccines was

received more than 4 weeks after the due date were

identified and included in this study. One hundred and sixty

(162) other children who received all scheduled vaccines

within 4 weeks of due date were also identified and included

in the study. The basic demographic information on cases

and controls is shown in Table 1.

Table1: Maternal and Child Health Characteristics for Cases and Controls Variable Cases Controls p-value

Frequency % Frequency %

Mother’s educational

attainment

None 5 6.2 3 1.8 <0.001

Primary 13 16.0 5 3.1

Junior High/Middle School 29 35.8 58 35.8

Secondary 18 22.2 41 25.3

Post-Secondary/Tertiary 16 19.8 55 34.0

Mother’s occupational

status

Employed 69 85.2 145 89.5 0.33

Unemployed 12 14.8 17 10.5

Marital status of

mother

Single 8 9.9 6 4.3 0.05

Married 73 90.1 156 95.7

Place of residence Kumasi 67 82.7 125 77.2 0.32.

Outside Kumasi 14 17.3 37 22.8

Age group of children

in months

Less than 12 months 53 65.4 96 52.3 0.33

12- 23 months 20 24.7 47 29.0

24- 59 months 8 9.9 19 11.7

Sex of baby Male 34 42.0 80 49.4 0.27

Female 47 58.0 82 50.6

Means of transport Private 8 9.9 10 6.2 0.30

Public 73 90.1 152 93.8

Time to clinic < 1 hour 56 69.1 116 71.6 0.63

≥ 1 hour 25 30.9 46 28.4



Table 2: Vaccines received late among children in Kumasi

VACCINE Frequency Percent

Pentavalent 3 27 24.8

Measles/Yellow Fever 23 21.1

BCG 22 20.2



Oral Polio Vaccine 2 1.8

Measles 2 1 0.9

Total 109 100.0

Table 3: Results of bivariate analysis for delayed vaccine uptake among children in Kumasi, Ghana

Parameter Odds Ratio 95%CI p-value

Baby unwell after delivery 7.72 2.71 - 21.98 <0.001

Marital status (single) 2.84 0.95 - 8.51 0.05

Employment status (employed) 0.67 0.30 - 1.49 0.32

Means of transport 1.67 0.63 - 4.40 0.30

Place of delivery (KATH) 0.67 0.39 - 1.18 0.17

Mode of delivery (caesarean section) 1.91 1.08 - 3.38 0.02

Mother not admitted after delivery 0.40 0.23 - 0.69 <0.001

Table 4: Results of Logistic Regression for Statistically significant variables obtained during bivariate analysis

Term Odds Ratio 95% CI P-Value

Mother not admitted after delivery 0.4 0.16 - 1.02 0.0542

Mode of delivery 0.89 0.34 - 2.34 0.81

Maternal Education 1.42 1.14 - 1.76 <0.001

Baby unwell after delivery 8.59 2.57 - 28.68 <0.001

Marital status of mother (single) 2.73 0.81 - 9.22 0.105

CONSTANT * * 0.008

Maternal characteristics, antenatal care and delivery

history The mean age for mothers of cases was 29.8 years compared

with 30.4 years for controls. Similarly, when the maternal

ages were categorised into two groups (‘less than 30 years

of age’ and ‘30 years or more’, there was no statistically

significant difference between cases and controls (p=0.32).

Most mothers (88.1%) were employed at the time of the

study. The marital status of most women was ‘married’

(94.2%) with the remainder being single mothers. Almost

all mothers (99.6%) accessed ANC services during the

pregnancy. The mean (SD) number of ANC sessions during

pregnancy was 6.3 (±1.55) with a range of 2 to 9 ANC

visits. Among mothers of children with delayed vaccine

uptake, the mean (SD) frequency of ANC visits was 6.0

(±1.90) and a range of 2 to 9 visits. Mothers of children who

received vaccines on time recorded a mean frequency of

ANC visits of 6.4 (±1.33) with a range of 3 to 9. Overall, 99

(40.7%) children were delivered in KATH. Six (2.5%) were

delivered at home with private health facilities and other

government hospitals accounting for 43.6% and 13.2%

respectively. Most babies were well after delivery (91.4%).

The mode of delivery was spontaneous vaginal delivery for

69.8% of children with the others delivered by caesarean

section. Following delivery, 98 (40.3%) mothers were

admitted for a minimum of 24 hours post-delivery. Most

children reached the clinic within an hour from the

originating point (69.1% and 71.6% for cases and controls

respectively).



Number and type of vaccines received late

Among the 81 cases of delayed vaccine uptake, 62 (76.5%)

received one vaccine later than 4 weeks of the scheduled

date. Thirteen (16.1%) received 2 vaccines later than

scheduled dates with 4 (4.9%), 1 (1.2%) and 1 (1.2%)

receiving 3, 4 and 5 vaccines later than scheduled dates

respectively. A total of 109 vaccines were received late

among the 81 cases. The third dose of the pentavalent

vaccine was the most common vaccine received later

(24.8%) with the measles/yellow fever (21.1%) vaccines

and the BCG (20.2%) vaccine being the other vaccines

commonly received late [Table 2].

Bivariate analysis

Among the 99 babies delivered in KATH, 28.3% were

cases. For controls, 43.8% were delivered in KATH.

Among babies who were unwell after delivery, 76.2% were

cases. Of the 21 babies who were unwell after delivery, 16

were cases. Among controls, only 3.1% of babies were

admitted after delivery. A total of 96 mothers were admitted

after delivery. Maternal admission after delivery was

reported among 54.3% of cases compared with 32.1% of

controls. Children delivered by caesarean section were

more likely to receive vaccines late compared with those

delivered vaginally (OR 1.9; 95% CI 1.1- 3.4). Children

born to mothers who were admitted after delivery were less

likely to receive vaccines on time compared with children

whose mothers spent less than 24 hours in the facility

following delivery (OR 0.40; 95%CI 0.23- 0.69). Results of

other bivariate variables analysed are shown in Table 3.

Multivariate analysis

Logistic regression included variables found to demonstrate

statistical significance on bivariate analysis (status of baby

after delivery, marital status of mother, mode of delivery,

mother admitted after delivery and mothers educational

level). The status of the baby after delivery (AOR=8.6; 2.6-

28.7) and maternal education (AOR 1.4; 95% CI 1.1- 1.8)

were found to be significant predictors of timely vaccine

administration. Maternal admission after delivery was only

weakly associated with delayed vaccine uptake, after

adjustment for other variables. There was no statistically

significant association between the timeliness of vaccine

receipt and the marital status of the mother or the mode of

delivery [Table 4].

DISCUSSION This study on risk factors for delayed vaccination builds on

existing evidence on vaccine timeliness. Our study

identified several factors associated with delayed

vaccination in a clinic in an urban setting in Ghana. We

attempt some explanation for some findings and make

recommendations for improving vaccine timeliness in

Ghana.

Receiving recommended childhood vaccines at the

appropriate age for a defined geographic area helps prevent

vaccine-preventable diseases. Recent evidence suggests

that public health gains achieved through the institution of

vaccination programmes may be under threat in some parts

of the world [16,17]. Increases in populations susceptible to

vaccine-preventable illnesses may result from parental

refusal to have their children vaccinated [18] or from

parental delay in vaccinating children associated with

vaccine refusal [19]. Evidence suggesting intentional delay

by some parents [20] with some delay attributed to concerns

about the number of vaccines administered to children and

parental concern about vaccine safety [21] are indicative of

the challenges to gains made by routine vaccination

programmes worldwide. Although compulsory vaccination

has been identified as a potential tool for reducing the

incidence of vaccine-preventable illnesses from some of the

factors highlighted, its effectiveness has not been

completely proven [22]. For Ghana as a country, there is

currently no evidence of parental refusal of vaccination in

Ghana hence children are more likely to miss vaccination

due to factors other than parental rejection of vaccination.

We discuss our findings in relation to maternal, infant/child

and delivery factors. Maternal education and baby’s status

after delivery were the most likely factors to be associated

with the timelines of vaccine administration. In the United

States, Kim et al., [23] associated series completion rates

with low maternal education. Thus, even if children were to

complete the series, the corresponding vaccines would have

been received later than scheduled.

Our findings suggest that women with lower levels of

education were more likely to have their children receiving

their vaccines late overall. This is consistent with findings

in other studies. In rural Tanzania for example, low

maternal education also has been associated with delayed

receipt of measles-containing vaccines [24]. Higher

maternal education has also been associated with timely

vaccination of children by day 7 [25]. Again in the US,

Bobo et al., [26] identified maternal education and birth

order as the only consistent predictors of delayed

vaccination. Maternal education has also been associated

with vaccine timeliness in eastern China [27], Uganda [28],

Malawi [29], Nigeria [30] and Kenya [31]. Explaining the

basis for delayed vaccination among lower-level educated

mothers cannot be determined by this study. Other studies

have not attempted to explain the observed association. We

surmise that in Ghana, there could be issues related to

literacy because the child health record booklet that shows

dates for vaccination is in English. Ghana has a high level

of illiteracy among adult females [32], with an estimated

35% of females above 15 years of age considered illiterate.

It is worth noting however, that in rural Ghana, Ansong et

al., found lower levels of maternal education strongly

associated with adherence to timely vaccine uptake [33].

Similarly, higher maternal education was associated with

delayed receipt of some category of vaccines in Greece [34].

These contradictory findings suggest that there may be

context-specific issues or other confounding factors at play

that may be influencing the effect of maternal education on

the timeliness of childhood vaccinations. Our study was in

an urban area and may explain the difference in the role of

maternal education compared with that by Ansong et al.,

[33]. The role of outreach immunisation services, which are

a regular feature of rural immunisation services in Ghana,

may be contributory to the observed trend. Women with low

literacy rates are more likely to be home and so may receive

vaccines on outreach basis better compared with literate

women who are likely to be working in the formal sector.

Maternal age was not associated with delayed vaccine

uptake in our study. Our comparison of mean maternal ages

of mothers whose children received vaccines on time and

those who did not found no statistically significant



difference in the mean ages. Again, comparing women less

than 30 years of age with those 30 years of age or older, we

found no association between delayed vaccination and age.

Some studies have examined the association between

maternal age and vaccination, but these have largely

focused on vaccine coverage and whether vaccines were up-

to-date [23,35–38]. Speir et al., [35] found maternal age

strongly associated with completeness of vaccination

whereas Kim et al., found that up-to-date vaccination of

children did not increase significantly with maternal age

beyond 26 years. Lower maternal age in particular has been

associated with increased likelihood of lower vaccination

coverage [37]. Older mothers aged 35-45 years have been

found to be more likely to adhere to vaccination compared

with younger mothers [38]. The likelihood of older women

having had more children and therefore being more likely

to appreciate the importance of vaccination has been

suggested as a possible reason for the completeness of

vaccine uptake among children born to older women [39].

Clearly other factors may be influencing the effect of

maternal age on vaccine uptake and timeliness. Hospital

birth has been associated with increased likelihood of full

vaccination [38]. Even though an earlier study had

demonstrated an association between hospital birth and

timely receipt of BCG vaccines [14], children born in

private hospitals and clinics accounted for a the majority of

those receiving the BCG vaccines late in this study. Regular

routine vaccination services are not available in most

private facilities and may explain this observation. In public

health facilities, there were still children who did not receive

their vaccines on time although routine vaccination is

available in such facilities. Systemic failures from failure of

vaccinators to provide the services at the sites where babies

are admitted for observation after delivery or reluctance on

the part of vaccinators to waste some doses of vaccines may

underlie this finding. A vial of BCG is to be administered to

10 children. Where vaccinators anticipate a smaller number

of babies, they may defer opening a vial and hence

vaccination. Failure of mothers to return subsequently may

contribute to delayed vaccination. Culturally, this is

significant as well, as mothers following delivery in Ghana

are expected to keep their babies indoors for varying

durations depending on the particular culture [40]. Another

interesting finding is the association between delayed BCG

vaccination and the likelihood of incomplete vaccination

rates [41]. Children born to mothers who were admitted

after delivery were more likely to receive vaccines later

compared with children whose mothers were not admitted.

The strength of this association was found to be weak in our

study. The observed association may particularly be true for

the first few vaccines as mothers may be unable to move out

of the admission ward to the point of vaccine administration

particularly in places where mobile immunisation services

are not available. This may further be worsened by hospitals

without any immunisation point which is commonplace in

most private health facilities in Ghana. Mobile vaccination

teams can be useful in reducing the incidence of delayed

vaccination among women who are admitted for various

reasons after delivery. Even though admission of mothers

after delivery may be due to surgery, the mode of delivery

was not significantly associated with the risk of delayed

vaccination. Mothers may have been admitted for other

reasons other than a caesarean section. Such admissions

may have been for a longer duration and may have

contributed to delayed vaccination.

Children who were unwell after delivery were less likely to

receive the recommended vaccines on time compared with

those who were well after delivery. Among the reasons for

admission identified in this study were birth asphyxia,

prematurity, low birth weight and congenital

malformations. There are clear guidelines on vaccinating

children who are unwell particularly for febrile illness [42],

but no guidelines specifically address newborns. However,

the contraindications exclude the causes of admission found

among children in this study. There is likely to be

implementation gaps in the guidelines for immunisation in

Ghana. Maternal reluctance to vaccinate sick children has

been documented with resultant delays or non-vaccination

of such children [43]. Health worker attitudes towards

vaccination of sick infants may also be at play in this

observation as about 50% of healthcare staff have been

found to wrongly restrict vaccination based on the health

status of the child [44]. In general, even though poor infant

health is not an absolute contraindication for receiving due

vaccinations, many parents and health workers have poor

attitudes towards encouraging vaccination for such cases

and this may explain the association [21,45]. As was found

in this study, other studies have consistently associated

maternal educational level with better childhood outcomes,

of which vaccine uptake can be considered a reliable proxy

[21]. Scott et al., [46] suggest that delayed vaccination may

also be associated with a knock-on effect from earlier

vaccines that were received late as well. It has also been

associated with vaccines that require multiple doses with

successive doses more likely to be received later [38].

In our study, we found the third dose pentavalent vaccine

was the most common vaccine received late and is

consistent with findings by Chidiebere et al., in Nigeria

[38]. Based on the proportions received late reported by our

study, the principle of the knock-on effect may not be

entirely applicable in our case as there were more children

receiving the third dose pentavalent vaccine later than the

second and the first doses. In this study, 27 children

received the third dose pentavalent vaccine late compared

with 18 and 16 for the second and the first dose pentavalent

vaccines respectively. This suggests that other factors are at

play rather than just the knock-on effect of the initial delay

in receiving the first dose(s) in the series.

CONCLUSION AND RECOMMENDATIONS

The maternal and baby-associated factors associated with

delayed vaccine uptake in this study offer opportunities for

preventing these delays. Public health staff involved in child

vaccination must be educated on the guidelines for the

vaccination of sick children. Public health staff should

intensify education for at-risk mothers during antenatal

clinic attendance to ensure compliance with the

immunisation schedule. Mobile vaccination within health

facilities is recommended to ensure eligible children receive

vaccines on time.

LIST OF ABBREVIATIONS

ANC Antenatal Care

AOR Adjusted Odds Ratio

BCG baccile Calmette-Guerin

CI Confidence Interval

DPT Diphtheria, Pertussis, Tetanus

EPI Expanded Programme on



Immunisation

Hep B Hepatitis B

Hib Haemophilus Influenzae type B

KATH Komfo Anokye Teaching

Hospital

MCH Maternal and Child Health

OR Odds Ratio

PCV Pneumococcal vaccine

SD Standard Deviation

WHO World Health Organisation

ETHICAL CONSIDERATION Ethical approval for the study was obtained from the

Kwame Nkrumah University of Science and Technology

and the Komfo Anokye Teaching Hospital Committee of

Human Research, Publication and Ethics.

DECLARATION OF INTEREST

The authors declare that they have no competing interests

ACKNOWLEDGEMENTS

The authors acknowledge the support of staff of the KATH

MCH clinic. We wish to also acknowledge the participants

who were instrumental in ensuring the success of this

study.

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Summary of Weekly Epidemiological Data, Week 14


Summary of Weekly Epidemiological Data for Week 14, 2018

Summary of Total Weekly Cases & Deaths The total all-cause weekly notifiable disease morbidity for

the week (as per IDSR Weekly Summary Reporting Form)

was 1,659 with six deaths attributable to meningitis (2),

maternal deaths (3) and human rabies (1). Acute watery

diarrhoea in persons aged >5 years was the highest

proportion of cases reported and contributed 63.6% of the

notifiable diseases case load during Week 14 (See Annex 1,

summary of reported cases/deaths) compared to 62% in

Week 13.

Timeliness and Completeness of Reporting The total number of expected reports based on the District

Health Information Management System (DHIMS) for the

Week was 5,849, out of which 5,725 (97.9%) and 5,796

(99.1%) representing timeliness and completeness of

reporting respectively. Eastern and Upper East regions both

recorded 100% for timeliness and completeness of

reporting. Five regions (Brong-Ahafo, Northern, Upper

West, Volta and Western) all reported timeliness above

99% [Table 1].

Table 1: Timeliness and Completeness of Reporting from Regions Based on DHIMS reporting, Ghana, Week 14, 2018

Region

Expected

Number of

Reports

Actual Reports

Received % Completeness

Reports on

Time

% Report on

Time

Ashanti 569 564 99.1 562 98.8

Brong-Ahafo 685 682 99.6 682 99.6

Central 499 467 93.6 431 86.4

Eastern 836 836 100 836 100

Greater Accra 378 371 98.1 343 90.7

Northern 646 642 99.4 640 99.1

Upper East 449 449 100 449 100

Upper West 357 355 99.4 354 99.2

Volta 626 626 100 625 99.8

Western 804 804 100 803 99.9

Ghana 5,849 5,796 99.1 5,725 97.9

Regional Performance Based on Reporting During Week 14, overall performance of the regions ranged

from 55.2% (Central) to 92.4% (Brong-Ahafo) [Table 2].

The expected percentage for districts reporting suspected

measles or yellow fever as at Week 14 was 21.5%. All

regions achieved the target for both Measles and yellow

fever surveillance except Central and Northern regions

which failed to achieve for yellow fever surveillance.

Table 2: Ranking of Regional Performance, Week 14, 2018

Region

Timeli-

ness (%)

Week

14

A

Complete-

ness (%)

Week

14

B

AFP Measles YF Average

Score %

(A+B+C+

D+E)/5

Cum.

AFP

Cases

Week 14

Annualized

Non-Polio

AFP Rate

AFP

Score

(%)

C

%

District

reporting

D

%

District

reporting

E

Position

Brong-Ahafo 99.6 99.6 15 2.9 100 96.3 66.7 92.4 1st

Western 99.9 100 20 2.9 100 86.4 68.2 90.9 2nd

Eastern 100 100 11 2.6 100 92.3 46.2 87.7 3rd

Greater Accra 90.7 98.1 16 2.3 100 81.3 37.5 81.5 4th

Upper East 100 100 3 1.5 74 53.8 61.5 77.9 5th

Volta 99.8 100 5 1.4 68 60.0 48.0 75.2 6th

Upper West 99.2 99.4 5 5.3 100 45.5 27.3 74.3 7th

Ashanti 98.8 99.1 9 1.0 52 63.3 36.7 70.0 8th

Northern 99.1 99.4 9 1.7 86 26.9 15.4 65.4 9th

Central 86.4 93.6 5 0.9 46 30.0 20.0 55.2 10th

Ghana 97.9 99.1 98 1.9 99 65.3 43.1 80.9

Highlights:

Nandom and Nabdam hit epidemic and alert threshold for meningitis respectively

Three maternal deaths recorded in three districts

Nine cases each recorded for confirmed A (H1N1) pdm09 and Flu B YAM



MENINGITIS In Week 14, a total of 26 cases of meningitis were recorded

with two deaths [Table 3]. Nandom District in the Upper

West Region hit the epidemic threshold recording an attack

rate of 15 cases per 100,000 population. Nabdam District in

the Upper East Region crossed the alert threshold recording

an attack rate of 5.4. All cases were tested with Neisseria

meningitidis and Streptococcus pneumoniae isolated for

one case each. [Table 4]

.

.

Table 4: Meningitis cases confirmed cases by latex, Gram stain and culture/PCR*, Week 14, 2018

Districts Cases CSF CSF positive Confirmed Deaths Causative Organism

Jaman North 1 1 1 1 1 Gram positive Diplococci

Bolgatanga 1 1 1 1 0 Neisseria meningitidis

Builsa North 1 1 1 1 1 Streptococcus pneumoniae

Jirapa 2 2 1 1 0 Gram negative Diplococci

* Polymerase chain reaction result

CUMULATIVE MENINGITIS CASES IN REGIONS,

WEEK 1-14, 2018

As at the end of Week 14, a total 638 cases and 50 deaths

(overall CFR=7.8%) have been recorded in all regions.

Upper West has the highest number of suspected cases

reported with 287 and 19 deaths representing a CFR of

6.6%. Central region recorded one suspected case with no

death which was the least recorded by a region. Northern

region recorded 12 deaths out of the total of 108 cases with

CFR=11.7% [Table 6]. Lumbar Puncture was done for 632

(99.1%) out of the 638 cases and 93 had positive laboratory

results from the CSF. There details are Gram negative

diplococci – 10, Gram positive diplococci – 8, Haemophilus

influenzae – 1, Neisseria meningitidis W – 29, Neisseria

meningitidis B – 1 and Streptococcus pneumoniae – 49

[Table 7].

Table 3: Meningitis cases and deaths by region, Ghana, Week 14, 2018

Region Cases Cerebrospinal Fluid (CSF)

Lab Test Positive

Deaths

CFR

(%)

District in

Alert

District in

Epidemic

Ashanti 0 0 0 - 0 0

Brong-Ahafo 1 1 1 100.0 0 0

Central 0 0 0 - 0 0

Eastern 0 0 0 - 0 0

Greater Accra 1 0 0 - 0 0

Northern 2 0 0 - 0 0

Upper East† 5 2 1 20.0 1 0

Upper West† 16 1 0 - 0 1

Volta 1 0 0 - 0 0

Western 0 0 0 - 0 0

Total (Ghana) 26 4 2 7.7 1 1

† [Attack rate per 100,000 population]: Nandom: 8 cases [AR=15.2], Nabdam: 2 cases [AR=5.4]

Table 6: Cumulative meningitis cases and deaths by Regions, Ghana, Week 1-14, 2018

Region Cases Deaths CFR*

Number of District in

Alert, Week 1-14

Number of District in

Epidemic, Week 1-14 (%)

Ashanti 4 1 25.0 0 0

Brong-Ahafo 88 10 11.4 3 0

Central 1 0 0.0 0 0

Eastern 18 1 5.5 0 0

Greater Accra 12 0 0.0 0 0

Northern 103 12 11.7 2 1

Upper East 108 7 6.5 4 0

Upper West 287 19 6.6 6 4

Volta 12 0 0.0 1 0

Western 5 0 0.0 0 0

Ghana 638 50 7.8 16 5

*Case Fatality Rate



INFLUENZA-LIKE ILLNESS

A total of 343 cases with no deaths were reported through the

IDSR weekly reporting system. [Table 8]. A total of 137

samples were sent to Noguchi Memorial Institute for Medical

Research (NMIMR), of which 18 were confirmed with

detailed results as follows: A (H1N1) pdm09 – 9 and Flu B

YAM – 9. Cumulatively, 1,169 have been tested and 219

confirmed. The cumulative confirmed cases are A (H1N1) –

138 (63.0%) pdm09 and A (H3N2) – 2(0.9%), Flu B YAM –

77(35.2%) and Flu B VIC– 2(0.9%)

Table 8: Reported Influenza-like illness cases by Region and

District, Ghana, Week 14, 2018

Region Districts Cases Deaths

Ashanti

Adansi South 3 0

Bekwai 9 0

Ejisu-Juaben 105 0

Central Asikuma-Odoben-Brakwa 12 0

Greater

Accra

Accra 26 0

Ashaiman 3 0

Ga East 36 0

Ga West 15 0

La-Dade-Kotopon 5 0

Ledzokuku-Krowor 2 0

Ningo-Prampram 3 0

Shai Osudoku 40 0

Tema 73 0

Upper East Bolgatanga 5 0

Volta Ketu South 6 0

Total 343 0

MEASLES

During Week 14, a total of 46 suspected cases of Measles were

reported from 28 districts in seven regions [Table 10]. All samples

were sent to the National Public Health Reference Laboratory

(NPHRL) for investigation and none was confirmed as a case of

Measles.

Table 9: Reported Suspected Measles cases by Region and

District, Ghana, Week 14, 2018


Ashanti

Afigya-Kwabre 1 0

Amansie Central 1 0

Atwima-Nwabiagya 1 0

Offinso North 1 0

Sekyere Central 1 0

Sekyere East 1 0

Brong-Ahafo

Banda 1 0

Berekum 1 0

Asunafo North 3 0

Nkoranza North 7 0

Nkoranza South 1 0

Eastern

Fanteakwa 1 0

New Juaben 1 0

Greater Accra

Accra 1 0

Ashaiman 1 0

Ga South 1 0

Ledzokuku-Krowor 2 0

Upper East Binduri 1 0

Volta

Krachi East 3 0

South Tongu 1 0

Western

Aowin 1 0

Bodi 2 0

Bia West 2 0

Ellembelle 2 0

Juabeso 3 0

Mpohor 1 0

Nkwanta South 2 0

Wassa-Amenfi East 2 0

Total 46 0

Table 7: Regional distribution of meningitis pathogens, Ghana, Week 1-14, 2018

Region Cases LP* CSF

Positive GND+ GPD^

Haemophilus Neisseria

meningitidis

W

Neisseria

meningitidis

B

Streptococcus

pneumoniae influenzae

Ashanti 4 4 0 0 0 0 0 0 0

Brong-

Ahafo 88 87 24 1 1 0 4 0 18

Central 1 1 0 0 0 0 0 0 0

Eastern 18 18 1 1 0 0 0 0 0

Greater

Accra 12 12 0 0 0 0 0 0 0

Northern 103 103 40 1 1 0 17 1 20

Upper East 108 108 8 0 0 1 4 0 3

Upper West 287 287 25 7 6 0 4 0 8

Volta 12 8 0 0 0 0 0 0 0

Western 5 4 0 0 0 0 0 0 0

Grand

Total 638 632 98 10 8 1 29 1 49

*Lumbar Puncture, +Gram negative diplococci, ^Gram positive diplococci



ACUTE FLACCID PARALYSIS (SUSPECTED

POLIOMYELITIS)

A total of 11 cases of acute flaccid paralysis (AFP) were

reported by 10 districts in six regions [Table 11]. All the stool

specimens tested at the Noguchi Memorial Institute for Medical

research (Polio Laboratory) Laboratory were negative for wild

polio virus.

Table 11: Suspected Poliomyelitis cases and deaths by Region

and District, Ghana, Week 14, 2018


Brong-Ahafo Nkoranza North 1 0

Sene West 1 0

Eastern Fanteakwa 1 0

Nsawam Adoagyiri 1 0

Greater Accra Ga South 1 0

Upper West Jirapa 1 0

Volta Krachi East 1 0

Western

Bibiani-Anhwiaso-Bekwai 1 0

Juabeso 1 0

Nkwanta South 2 0

Total 11 0

YELLOW FEVER

During the week, 33 suspected cases of yellow fever were reported in 21 districts in seven regions. [Table 12]. All cases tested

negative for yellow fever IgM at the National Public Health and Reference Laboratory, Korle-Bu, Accra

Table 12: Laboratory investigation of suspected yellow fever cases, Ghana, Week 14, 2018

Region District Suspected Samples

Taken

Lab Confirmed

Deaths Presumptive Positive Negative

Ashanti Asante Mampong 1 1 0 1 0

Brong-Ahafo

Asunafo North 1 1 0 1 0

Dormaa West 1 1 0 1 0

Jaman South 1 1 0 1 0

Nkoranza North 5 5 0 5 0

Tain 1 1 0 1 0

Eastern

East Akim 1 1 0 1 0

Kwaebibirem 1 1 0 1 0

Greater Accra

Ga South 1 1 0 1 0

Ga West 1 1 0 1 0

Northern Zabzugu 4 4 0 4 0

Upper East

Bawku 1 1 0 1 0

Builsa 1 1 0 1 0

Garu-Tempane 1 1 0 1 0

Volta

Krachi East 3 3 0 3 0

South Tongu 2 2 0 2 0

Western

Bodi 1 1 0 1 0

Ellembelle 1 1 0 1 0

Sefwi-Akotombra 2 2 0 2 0

Tarkwa-Nsuem 2 2 0 2 0

Wassa-Amenfi East 1 1 0 1 0

Total 33 65 0 65 0

CHOLERA

In Week 14, there was no case of cholera reported.

MATERNAL DEATHS

During the week, there were three maternal deaths reported

by three districts in two regions [Table 9]

Table 11: Maternal deaths by Region and District, Ghana,

Week 14, 2018

Region Districts Deaths

Upper East

Bolgatanga 1

Builsa 1

Upper West Wa 1

Total 3

HUMAN RABIES

In Week 14, one death of Human rabies was report from

Jirapa in Upper West region



ACTION POINTS

It is recommended that all regions continue to strengthen

surveillance on meningitis. Periodic meetings of Public

Health Emergency Management Committees should be

held even in the absence of health emergencies to be

apprised of disease trends.

A lumbar puncture should be done, and cerebrospinal

fluid tested with Gram stain and latex agglutination

for every case of meningitis; samples should be

inoculated into Trans-Isolate bottles for confirmation

by culture at the respective regional laboratories. The

Brong-Ahafo, Northern, Upper East and Upper West

regions should ensure that frozen CSF samples in

cryotubes are dispatched to the Tamale Zonal Public

Health Laboratory (PHL) for Polymerase Chain

Reaction (PCR) Test. Timely feedback from the

laboratory to health facilities is strongly

recommended.

Regions are to ensure that influenza sentinel sites pick

five samples from influenza-like illnesses (ILI) patients

each week and send to Noguchi for testing. For all

hospitalized ILI (i.e. Severe Acute Respiratory Illness

e.g., pneumonia), nasal and oropharyngeal swabs are to

be sent to the National Influenza Center. All SARI and

ILI patients seen by sentinel and non-sentinel sites should

be entered on the weekly summary form in the DHIMS.

Sentinel sites are encouraged to complete

epidemiological forms for FluID.

The case definitions of all priority diseases/conditions are

to be adhered by clinicians and investigation teams before

classification as a suspected or probable case.

Surveillance on viral haemorrhagic fevers should be

enhanced in regions, districts, health facilities and at the

Points of entry (ground crossings, airport and ports).

Blood samples from suspected cases should be taken,

placed in viral transport medium and sent to NMIMR for

laboratory investigations.

Regions are reminded to send copies of all Case

Based Investigation forms sent to the Reference

laboratories to the Disease Surveillance Department to

ensure prompt and accurate provision of case based

surveillance data analysis.

This report and subsequent ones should be shared with

other regional, district and other heads. You are

encouraged to disseminate to other agencies as well. A

feedback addressed to the Editor-In-Chief is also

welcome.

ANNEX 1: SUMMARY OF REPORTED CASES/ EVENTS: WEEK 13 AND 14 (WEEK ENDING 08 APRIL, 2018)

Disease/Health Event

(suspected/confirmed)

Week 13 Week 14 Cumulative to Week 14

Cases

(susp)

Deaths CFR

(%)

Cases

(susp)

Deaths CFR

(%)

Cases

(susp)

Deaths CFR

(%)

AFP (suspected polio) 6 0 0.0 11 0 0.0 98 0 -

Acute haemorrhagic

fever syndrome

1 0 0.0 0 0 - 25 0 -

Adverse events

following immunization

0 0 0.0 0 0 - 0 0 -

Anthrax 2 0 0.0 0 0 - 2 0 -

Acute watery diarrhoea

in persons aged >5 years

861 0 0.0 1,075 0 - 13,819 0 -

Cholera 0 0 0.0 0 0 - 0 0 -

Dengue fever 0 0 0.0 0 0 - 0 0 -

Diarrhoea with blood 102 0 0.0 124 0 - 1,145 0 -

Dracunculiasis (Guinea

worm)

0 0 0.0 0 0 - 1 0 -

Influenza-like illness 361 0 0.0 343 0 - 8,392 0 -

Maternal deaths - 0 - - 3 - - 22 -

Measles 31 0 0.0 46 0 - 604 0 -

Meningitis 18 1 5.6 26 2 7.7 639 50 7.8

Neonatal tetanus 0 0 0.0 0 0 - 3 0 -

Plague 0 0 0.0 0 0 - 0 0 -

Public health event of

international concern

(PHEIC)

0 0 0.0 0 0 - 0 0 -

Human rabies 0 0 0.0 1 1 100 7 7 100.0

SARS 0 0 0.0 0 0 - 0 0 -

Smallpox 0 0 0.0 0 0 - 0 0 -

Yellow fever (suspected) 17 0 0.0 33 0 - 248 0 -

NATIONAL TOTAL 1,399 1 0.1 1,659 6 0.2 24,983 79 0.2

*CFR does not include maternal deaths


18

Editorial Board

Dr. Anthony Nsiah-Asare

Dr. Badu Sarkodie

Mr. Michael Adjabeng

Mr. James Addo

Dr. Emmanuel Kofi Dzotsi

Dr. Kwame Amponsa-Achiano

Dr. David Opare

Dr. Franklin Asiedu-Bekoe

Mr. Kwame Kodom Achempem

Mr. Isaac Baffoe-Nyarko

Prof. Kwadwo Koram

Dr. Ivy Frances Osei

Dr. Ernest Kenu

Dr. Phyllis Antwi

Ms. Selina Ababio

Dr. Dennis Laryea

Dr. Sally-Ann Ohene

Dr. Chastity Walker

Editorial Team

Editor

Mr. Gideon Kwarteng Acheampong

Managing Editor

Mr. Kwame Acheampong Owusu

Editor-In-Chief

Dr. Kenneth Ofosu-Barko

ministry of healthof meningitis, ghana introduced h. influenzae serogroup b vaccine in 2002 and...

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