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Yaws is a skin debilitating disease caused by Treponema pallidum subspecies pertenue with most cases reported in children. World Health Organization (WHO) aims at total eradication of this disease through mass treatment of suspected cases followed by an intensive follow-up program. However, effective diagnosis is pivotal in the successful implementation of this control program. Recombinase polymerase amplification (RPA), an isothermal nucleic acid amplification technique offers a wider range of differentiation of pathogens including those isolated from chronic skin ulcers with similar characteristics such as Haemophilus ducreyi (H. ducreyi). We have developed a RPA assay for the simultaneous detection of Treponema pallidum (T. pallidum) and H. ducreyi (TPHD-RPA). The assay demonstrated no cross-reaction with other pathogens and enable detection of T. pallidum and H. ducreyi within 15 min at 42 ◦C. The RPA assay was validated with 49 clinical samples from individuals confirmed to have yaws by serological tests. Comparing the developed assay with commercial multiplex real-time PCR, the assay demonstrated 94% and 95% sensitivity for T. pallidum and H. ducreyi, respectively and 100% specificity. This simple novel TPHD-RPA assay enables the rapid detection of both T. pallidum and H. ducreyi in yaws-like lesions. This test could support the yaws eradication efforts by ensuring reliable diagnosis, to enable monitoring of program success and planning of follow-up interventions at the community level.

Accurate diagnosis of urogenital schistosomiasis is vital for surveillance/control programs as well as achieving the WHO 2012–2020 road map for the total eradication of schistosomiasis. Recombinase polymerase amplification (RPA) has emerged as a rapid and simple molecular tool adaptable for fewer resources with diagnostic accuracy similar to polymerase chain reaction (PCR). This rapid molecular assay employs the use of enzymes for the amplification of nucleic acid taget at a constant temperature. The aim of this study was to validate a real-time RPA assay targeting the Dra 1 repittitive sequence of Schistosoma (S.) haematobium and evaluate its use in urogenital schistosomiasis diagnosis. S. haematobium Dra 1 molecular DNA standard was applied to determine the assay's analytical sensitivity. DNA extracts of S. haematobium, other Schistosoma species, protozoa and bacteria species were used to determine the specificity of the RPA assay. Clinical performance of the assay was validated with a panel of 135 urine samples from volunteers of schistosomiasis endemic communities. The developed assay was evaluated with urine samples extracted by just boiling and with SpeedXtract® DNA extraction kit. A specific fragment of S. haematobium Dra 1 repetitive sequence was amplified within 15 minutes at a constant 42˚C using the developed S. haematobium RPA assay. The detection limit was 15 copies of Dra1 molecular DNA standard per reaction. There was no cross-reaction with other protozoan and bacterial species except Schistosoma species, S. mansoni and S. japonicum. Using 135 urine samples, Schistosoma RPA assay had a clinical sensitivity and specificity of 98.4% (95% CI, 91.6-100) and 100% (95% CI, 94.9-99) respectively when compared to S. haematobium Dra 1 qPCR assay. The diagnostic performance of S. haematobium real-time RPA assay was not affected by the use of crude DNA extracted samples. The S. haematobium RPA assay can serve as an alternative to PCR, especially in low resource settings.

Buruli ulcer (BU) is a necrotizing skin disease caused by Mycobacterium ulcerans. People living in remote areas in tropical Sub Saharan Africa are mostly affected. Wound care is animportant component of BU management; this often needs to be extended for months afterthe initial antibiotic treatment. BU is reported in the literature as being painless, howeverclinical observations revealed that some patients experienced pain during wound care.This was the first study on pain intensity during and after wound care in BU patients andfactors associated with pain. In Ghana and Benin, 52 BU patients above 5 years of ageand their relatives were included between December 2012 and May 2014. Information onpain intensity during and after wound care was obtained during two consecutive weeksusing the Wong-Baker Pain Scale. Median pain intensity during wound care was in thelower range (Mdn= 2, CV = 1), but severe pain (score>6) was reported in nearly 30% ofthe patients. Nevertheless, only one patient received pain medication. Pain declined overtime to low scores 2 hours after treatment. Factors associated with higher self-reportedpain scores were; male gender, fear prior to treatment, pain during the night prior to treat-ment, and pain caused by cleaning the wound. The general idea that BU is painless is incorrect for the wound care procedure. This procedural pain deserves attention and appropriate intervention.

Bacterial components and cytokines induce IL-7 receptor (IL-7Rα) expression in monocytes. Aberrant low IL-7Rα expression of monocytes has been identified as a feature of tuberculosis immunopathology. Here, we investigated the mechanisms underlying IL-7Rα regulation of monocytes and tuberculosis serum effects on IL-7Rα expression.

Serum samples from tuberculosis patients and healthy controls, cytokine candidates, and mycobacterial components were analyzed for in vitro effects on IL-7Rα expression of primary monocytes, monocyte-derived macrophages (MDM), and monocyte cell lines. IL-7Rα regulation during culture and the role of FoxO1 were characterized.

In vitro activation-induced IL-7Rα expression in human monocytes and serum samples from tuberculosis patients boosted IL-7Rα expression. Although pathognomonic tuberculosis cytokines were not associated with serum effects, we identified cytokines (i.e., GM-CSF, IL-1β, TNF-α, IFN-γ) that induced IL-7Rα expression in monocytes and/or MDM comparable to mycobacterial components. Blocking of cytokine subsets (i.e., IL-1β/TNF-α in monocytes, GM-CSF in MDM) largely diminished IL-7Rα expression induced by mycobacterial components. Finally, we showed that in vitro-induced IL-7Rα expression was transient and dependent on constitutive FoxO1 expression in primary monocytes and monocyte cell lines.

This study demonstrated the crucial roles of cytokines and constitutive FoxO1 expression for transient IL-7Rα expression in monocytes.

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 <0.05 deemed to be statistically significant.

RESULTS: We found that neurological sequelae persisted in former patients at least 15 y after treatment. Depression (p<0.001) and anxiety (p=0.001) were

significantly higher in former patients with neurologic sequelae. The mean quality-of-life (QoL) scores were significantly lower for patients than in

controls in the physical, emotional and mental health domains.

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.

Background: Sub-Saharan Africa is endemic for intestinal parasites and distinguished for the largest burden of HIV cases. Blastocystis sp. is one of the most common protists infecting humans but its role in human disease is still controversial. Aim of this study was to investigate the prevalence of Blastocystis sp. in HIV positive and negative adults in Ghana and its association with immune status and other risk factors.

Methods: 122 HIV positive outpatients and 70 HIV negative blood donors from the Komfo Anokye Teaching Hospital in Kumasi, Ghana, were included in the present study. Demographic, clinical and laboratory data were collected and HIV positive patients distinguished for CD4+ T cell count <200 cells/μl (n = 54) and >200 cells/μl (n = 68). A Blastocystis's phylogenetic analysis was performed to determine sample subtype (ST).

Results: The prevalence of Blastocystis sp. in adult HIV positive individuals was lower than in HIV negative persons (6.6% vs. 20.0%, p = 0.008) and Blastocystis sp. ST1 was the most prevalent strain. Within HIV positive participants, the prevalence of Blastocystis sp. was lower in those individuals with CD4+ T cell count <200 cells/μl than in patients with higher CD4+ T cell count (1.9% vs. 10.3%, p = 0.076). Multiple regression analysis revealed that Blastocystis sp. was inversely associated with an obese Body Mass Index (BMI) in HIV negative persons (p = 0.040). Presence of Blastocystis sp. was correlated with higher CD4+ T cell count in HIV positive participants (p = 0.049).

Conclusion: It is largely reported that people living with HIV (PLHIV) in Africa are affected from parasite infections and that co-infections may adversely impact on their immune status, accelerating progress to AIDS and worsening gastrointestinal manifestations. Differently, in this study Blastocystis sp. was associated with a better immune status jointly with a healthy body weight while it seems to be reduced with the progression of HIV infection. This data agree with recent suggestions that Blastocystis sp. can represent a component of the healthy gut microbiota.

Background

Mansonellosis was first reported in Ghana by Awadzi in the 1990s. Co-infections of Mansonella perstans have also been reported in a small cohort of patients with Buruli ulcer and their contacts. However, no study has assessed the exact prevalence of the disease in a larger study population. This study therefore aimed to find out the prevalence of M. perstans infection in some districts in Ghana and to determine the diversity of Culicoides that could be potential vectors for transmission.

Methods

From each participant screened in the Asante Akim North (Ashanti Region), Sene West and Atebubu Amantin (Brong Ahafo Region) districts, a total of 70 μl of finger prick blood was collected for assessment of M. perstans microfilariae. Centre for Disease Control (CDC) light traps as well as the Human Landing Catch (HLC) method were used to assess the species diversity of Culicoides present in the study communities.

Results

From 2,247 participants, an overall prevalence of 32% was recorded although up to 75% prevalence was demonstrated in some of the communities. Culicoides inornatipennis was the only species of Culicoides caught with the HLC method. By contrast, C. imicola (47%), C. neavei (25%) and C. schultzei (15%) were caught by the CDC light trap method. A wide diversity of other Culicoides spp. was also identified but correlation was only found between the prevalence of C. inornatipennis and M. perstans during the dry season.

Conclusions

Here we demonstrate for the first time that M. perstans is highly prevalent in three districts in Ghana. We found a wide spectrum of Culicoides spp. Culicoides inornatipennis was the most anthropophilic and is therefore likely to be the species responsible for transmission of infection but formal proof has yet to be obtained.

Background. Helicobacter pylori coinfection in human immunodeficiency virus (HIV) patients has been associated with higher CD4+ cell counts and lower HIV-1 viral loads, with the underlying mechanisms being unknown. The objective of this study was to investigate the impact of H. pylori infection on markers of T-cell activation in HIV-positive and HIV-negative individuals.

Methods. In a cross-sectional, observational study, HIV patients (n = 457) and HIV-negative blood donors (n = 79) presenting to an HIV clinic in Ghana were enrolled. Data on clinical and sociodemographic parameters, CD4+/CD8+ T-cell counts, and HIV-1 viral load were recorded. Helicobacter pylori status was tested using a stool antigen test. Cell surface and intracellular markers related to T-cell immune activation and turnover were quantified by flow cytometry and compared according to HIV and H. pylori status.

Results. Helicobacter pylori infection was associated with decreased markers of CD4+ T-cell activation (HLA-DR+CD38+CD4+; 22.55% vs 32.70%; P = .002), cell proliferation (Ki67; 15.10% vs 26.80%; P = .016), and immune exhaustion (PD-1; 32.45% vs 40.00%; P = .005) in 243 antiretroviral therapy (ART)–naive patients, but not in 214 patients on ART. In HIV-negative individuals, H. pylori infection was associated with decreased frequencies of activated CD4+ and CD8+ T cells (6.31% vs 10.40%; P = .014 and 18.70% vs 34.85%, P = .006, respectively).

Conclusions. Our findings suggest that H. pylori coinfection effectuates a systemic immune modulatory effect with decreased T-cell activation in HIV-positive, ART-naive patients but also in HIV-negative individuals. This finding might, in part, explain the observed association of H. pylori infection with favorable parameters of HIV disease progression.

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.

Background

Buruliulcer(BU),caused by Mycobacterium ulcerans, is a neglected tropical disease frequently leading to permanent disabilities.The ulcers are treated with rifampicin and streptomycin,wound care and,if necessary surgical intervention. Professionals have exclusively shaped there search agenda concerning management and control, while patients’perspective on priorities and preferences have not explicitly been explored or addressed.

Methodology/Principalfindings

To get insight into patient perception of the management and control of Buruli ulcera mixed methods research design was applied with a questionnaire and focus group discussions among former BU patients.Data collection was obtained in collaboration with a local team of native speakers in Ghana. A questionnaire was completed by 60 former patients and four focus group discussions were conducted with eight participants per group. Former patients positively evaluated both the effectiveness of the treatment and the financial contribution received for the travel costs to the hospitals. Pain experienced  during treatment procedures,in particular wound care and the streptomycin injections,and the side-effects of the treatment were negatively evaluated. Former patients considered the development of preventive measures and knowledge on the transmission as priorities. Additionally,former patients asked for improved accessibility of health services,counselling and economic support.

Conclusions

These findings can be used to improve clinical management and to guide the international research agenda.

Following the detection of the first imported case of COVID-19 in the northern sector of Ghana, we molecularly charac-terized 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.

Background

Buruli ulcer is a disease of the skin and soft tissues caused by infection with a slow growing pathogen, Mycobacterium ulcerans. A vaccine for this disease is not available but M. ulcerans possesses a giant plasmid pMUM001 that harbours the polyketide synthase (PKS) genes encoding a multi-enzyme complex needed for the production of its unique lipid toxin called mycolactone, which is central to the pathogenesis of Buruli ulcer. We have studied the immunogenicity of enzymatic domains in humans with M. ulcerans disease, their contacts, as well as non-endemic areas controls.

Methods

Between March 2013 and August 2015, heparinized whole blood was obtained from patients confirmed with Buruli ulcer. The blood samples were diluted 1 in 10 in Roswell Park Memorial Institute (RPMI) medium and incubated for 5 days with recombinant mycolactone PKS domains and mycolyltransferase antigen 85A (Ag85A). Blood samples were obtained before and at completion of antibiotic treatment for 8 weeks and again 8 weeks after completion of treatment. Supernatants were assayed for interferon-γ (IFN-γ) and interleukin-5 (IL-5) by enzyme-linked immunosorbent assay. Responses were compared with those of contacts and non-endemic controls.

Results

More than 80% of patients and contacts from endemic areas produced IFN-γ in response to all the antigens except acyl carrier protein type 3 (ACP3) to which only 47% of active Buruli ulcer cases and 71% of contacts responded. The highest proportion of responders in cases and contacts was to load module ketosynthase domain (Ksalt) (100%) and enoylreductase (100%). Lower IL-5 responses were induced in a smaller proportion of patients ranging from 54% after ketoreductase type B stimulation to only 21% with ketosynthase type C (KS C). Among endemic area contacts, the, highest proportion was 73% responding to KS C and the lowest was 40% responding to acyltransferase with acetate specificity type 2. Contacts of Buruli ulcer patients produced significantly higher IFN-γ and IL-5 responses compared with those of patients to PKS domain antigens and to mycolyltransferase Ag85A of M. ulcerans. There was low or no response to all the antigens in non-endemic areas controls. IFN-γ and IL-5 responses of patients improved after treatment when compared to baseline results.

Discussion

The major response to PKS antigen stimulation was IFN-γ and the strongest responses were observed in healthy contacts of patients living in areas endemic for Buruli ulcer. Patients elicited lower responses than healthy contacts, possibly due to the immunosuppressive effect of mycolactone, but the responses were enhanced after antibiotic treatment. A vaccine made up of the most immunogenic PKS domains combined with the mycolyltransferase Ag85A warrants further investigation.

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.

Intoduction

Buruli ulcer (BU) is the third most frequent mycobacterial disease in immunocompetent per-sons after tuberculosis and leprosy. During the last decade, eight weeks of antimicrobialtreatment has become the standard of care. This treatment may be accompanied by transient clinical deterioration, known as paradoxical reaction. We investigate the incidence andthe risks factors associated with paradoxical reaction in BU.

Methods

The lesion size of participants was assessed by careful palpation and recorded by serialacetate sheet tracings. For every time point, surface area was compared with the previousassessment. All patients received antimicrobial treatment for 8 weeks. Serum concentrationof 25-hydroxyvitamin D, the primary indicator of vitamin D status, was determined in duplexfor blood samples at baseline by a radioimmunoassay. We genotyped four polymorphismsin theSLC11A1gene, previously associated with susceptibility to BU. For testing the associ-ation of genetic variants with paradoxical responses, we used a binary logistic regressionanalysis with the occurrence of a paradoxical response as the dependent variable.

Results

Paradoxical reaction occurred in 22% of the patients; the reaction was significantly associ-ated with trunk localization (p = .039 byΧ2), larger lesions (p = .021 byΧ2) and genetic factors. The polymorphisms 3’UTR TGTG ins/ins (OR 7.19, p<.001) had a higher risk fordeveloping paradoxical reaction compared to ins/del or del/del polymorphisms.

Conclusions

Paradoxical reactions are common in BU. They are associated with trunk localization, largerlesions and polymorphisms in theSLC11A1 gene.

Isothermal amplification techniques such as recombinase polymerase amplification (RPA) and loop-mediated isothermal amplification (LAMP) for diagnosing Buruli ulcer, a necrotic skin disease caused by Mycobacterium ulcerans, have renewed hope for the molecular diagnosis of clinically suspected Buruli ulcer cases in endemic districts. If these techniques are applied at district-level hospitals or clinics, they will help facilitate early case detection with prompt treatment, thereby reducing disability and associated costs of disease management. The accuracy as well as the application of these molecular techniques at point of need is dependent on simple and fast DNA extraction. We have modified and tested a rapid extraction protocol for use with an already developed recombinase polymerase amplification assay. The entire procedure from "sample in, extraction and DNA amplification" was conducted in a mobile suitcase laboratory within 40 min. The DNA extraction procedure was performed within 15 min, with only two manipulation/pipetting steps needed. The diagnostic sensitivity and specificity of this extraction protocol together with M. ulcerans RPA in comparison with standard DNA extraction with real-time PCR was 87% (n = 26) and 100% (n = 13), respectively. We have established a simple, fast and efficient protocol for the extraction and detection of M. ulcerans DNA in clinical samples that is adaptable to field conditions.

Immune-based diagnosis of Buruli ulcer disease (BUD) in children is difficult due to cross-reactivity between mycobacteria. We found that T-cell IFNγ/TNFα responses against Mycobacterium (M.) ulcerans and M. tuberculosis (PPD_Mulc, PPD_Mtub) were different between children with BUD (n = 27) and TB (n = 20) but only ratios (PPD_Mtub/PPD_Mulc) discriminated the study groups efficiently.

Background. Sub-Saharan Africa (SSA) has one of the highest global hepatitis C virus (HCV) prevalence estimates. However, reports that suggest high rates of serologic false positives and low levels of viremia have led to uncertainty regarding the burden of active infection in this region. Additionally, little is known about the predominant transmission risk factors in SSA.

Methods. We prospectively recalled 363 past blood donors (180 who were rapid screen assay [RSA] positive and 183 who were RSA negative at time of donation) to identify the level of active infection and risk factors for infection at a teaching hospital in Kumasi, Ghana. Participants had repeat blood testing and were administered a questionnaire on risk factors.

Results. The frequency of HCV active infection ranged from 74.4% to 88% depending on the criteria used to define serologically positive cases. Individuals with active disease had biochemical evidence of liver inflammation and median viral loads of 5.7 log copies/mL. Individuals from the northern and upper regions of Ghana had greater risks of infection compared with participants from other areas. Additional risk factors included traditional circumcision, home birth, tribal scarring, and hepatitis B virus coinfection.

Conclusions. Viremic infection was common among serologically confirmed cases. Attention to testing algorithms is needed in order to define the true HCV burden in SSA. These data also suggest that several transmission modes are likely contributing to the current HCV epidemic in Ghana and that the distribution of these practices may result in substantial regional variation in prevalence.

We investigated the contributions of thymidine analogue (TA) and tenofovir disoproxil fumarate (TDF) anti-retroviral therapy on renal mitochondrial toxicity in Ghanaian PWH. Similar levels of renal biochemical and mitochondrial dysfunction were seen, and there was no increased risk in PWH who had sequenced from TA to TDF. However, mild renal impairment was associated with mitochondrial DNA damage in TDF but not TA-treated PWH. These data support the continued use of TDF in resource limited settings.

Background: Ghana is among the high-burden countries for malaria infections and recently reported a notable increase in malaria cases. While asymptomatic parasitaemia is increasingly recognized as a hurdle for malaria elimination, studies on asymptomatic malaria are scarce, and usually focus on children and on non-falciparum species. The present study aims to assess the prevalence of asymptomatic Plasmodium falciparum and non-falciparum infections in Ghanaian adults in the Ashanti region during the high transmission season. Methods: Asymptomatic adult residents from five villages in the Ashanti Region, Ghana, were screened for Plasmodium species by rapid diagnostic test (RDT) and polymerase chain reaction (PCR) during the rainy season. Samples tested positive were subtyped using species-specific real-time PCR. For all Plasmodium ovale infections additional sub-species identification was performed. Results: Molecular prevalence of asymptomatic Plasmodium infection was 284/391 (73%); only 126 (32%) infections were detected by RDT. While 266 (68%) participants were infected with Plasmodium falciparum, 33 (8%) were infected with Plasmodium malariae and 34 (9%) with P. ovale. The sub-species P. ovale curtisi and P. ovale wallikeri were identified to similar proportions. Non-falciparum infections usually presented as mixed infections with P. falciparum. Conclusions: Most adult residents in the Ghanaian forest zone are asymptomatic Plasmodium carriers. The high Plasmodium prevalence not detected by RDT in adults highlights that malaria eradication efforts must target all members of the population. Beneath Plasmodium falciparum, screening and treatment must also include infections with P. malariae, P. o. curtisi and P. o. wallikeri.

Background: In high-income countries, mortality related to hospitalized patients with the Coronavirus disease 2019 (COVID-19) is approximately 4-5%. However, data on COVID-19 admissions from sub-Saharan Africa are scanty.
Objective: To describe the clinical profile and determinants of outcomes of patients with confirmed COVID-19 admitted at a hospital in Ghana.
Methods: A prospective study involving 25 patients with real time polymerase chain reaction confirmed COVID-19 admitted to the treatment centre of the University Hospital, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana from 1st June to 27th July, 2020. They were managed and followed up for outcomes. Data were analysed descriptively, and predictors of mortality assessed using a multivariate logistic regression modelling.
Results: The mean age of the patients was 59.3 ± 20.6 years, and 14 (56%) were males. The main symptoms at presentation were breathlessness (68%) followed by fever (56%). The cases were categorized as mild (6), moderate (6), severe (10) and critical (3). Hypertension was the commonest comorbidity present in 72% of patients. Medications used in patient management included dexamethasone (68%), azithromycin (96%), and hydroxychloroquine (4%). Five of 25 cases died (Case fatality ratio 20%). Increasing age and high systolic blood pressure were associated with mortality.
Conclusion: Case fatality in this sample of hospitalized COVID-19 patients was high. Thorough clinical assessment, severity stratification, aggressive management of underlying co-morbidities and standardized protocols incountry might improve outcomes.

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.

OCCUPATIONAL APPLICATIONS

Results of a survey of drivers working for two bus

companies in Norway suggest that 20% of drivers sometimes use a mobile phone

while driving, even though it is not permitted. Sociotechnical analysis of the

system surrounding drivers at one of the companies elicited ways in which social

and technical factors combined to support mobile phone use by bus drivers. These

factors were arranged under four themes: increased societal dependence on

technology; developments in bus driver culture; the need for bus drivers to

resolve conflicting goals; and a lack of belief in adverse consequences of using

mobile phone while driving. Our findings (i) support claims that driver-centered

analyses of mobile phone use or other traffic safety challenges are an

insufficient basis for the development of measures and should be supplemented by

sociotechnical analyses; and (ii) can inspire the design of more comprehensive

measures to help reduce mobile phone use and road safety risks.

Plain Language Summary: Background: Sociotechnical measures could supplement

traditional risk management measures and further reduce risks of collisions

involving heavy vehicles. Such measures can be identified using methods rooted

in sociotechnical systems theory, which considers that people work in systems

comprising multiple social and technical elements that interact to create

emergent properties and conditions that influence valued system outcomes.

Purpose: To investigate the potential of sociotechnical measures in helping to

reduce road risks, we identified how social and technical factors combine to

influence mobile phone use by bus drivers working at a company in Norway.

Method: A survey of ∼600 drivers was completed, followed by focus group

interviews with managers and drivers and one-on-one or group interviews with

drivers. The interviews were structured using a sociotechnical analysis

framework. Results: Twenty percent of drivers reported using their phone while

operating a bus, even though such use was against company guidelines. Almost all

drivers took their phone with them when they drove, and 40% of those who said

they never used their phone while driving could still hear incoming calls and

messages. Analysis from nine interviews with 26 drivers suggested that phone use

by drivers operating buses is supported by interacting sociotechnical factors

due to an increased societal dependence on technology, developments in bus

driver culture, a need for bus drivers to resolve conflicting goals at work, and

a lack of consequences for drivers using mobile phone use while driving.

Conclusions: Limited consideration of the sociotechnical ecosystems surrounding

bus drivers can contribute to their mobile phone use and thereby to potential

problems of attention and awareness while driving. Sociotechnical approaches

should be developed using participative design to reduce phone use while

driving, especially to promote openness and information sharing and support bus

drivers in the field as they strive to resolve conflicting goals.

BACKGROUND: Buruli ulcer disease (BUD) caused by Mycobacterium (M.) ulcerans is characterized by necrotic skin lesions. As for other mycobacterial infections,

e.g., tuberculosis, the immune response is important for host protection. B-cells may play a role in antimycobacterial immunity but studies characterizing

the B-cell repertoire and memory generation in BUD and during the course of treatment are scarce.

METHODS: We investigated the adaptive immune cell repertoire in children with BUD and healthy matched controls by flow cytometry. Analyses prior to treatment,

also in a study group of patients with tuberculosis, as well as three time points during BUD treatment (i.e., week 8, 16, and 32) were performed. In

addition, BUD disease severity as well as treatment response were analysed for association with B-cell repertoire differences.

RESULTS: Children with BUD had comparable total B- and T-cell proportions but differed largely in B-cell subsets. Memory B-cell (B mem) proportions were

higher in children with BUD whereas regulatory B-cell (B reg) proportions were lower as compared to healthy controls and tuberculosis patients. Lower naïve (B

naïve) and higher transitional B-cell (B trans) proportions characterized children with BUD in comparison with tuberculosis patients. Under treatment, B

mem proportions decreased significantly whereas proportions of B reg and B naive increased concomitantly in children with BUD. Also, we found significant

correlation between lesion size and B mem as well as B reg. However, we did not detect associations between treatment efficacy and B-cell proportions.

CONCLUSIONS: These results suggest a role of B-cell subsets in the immune response against M. ulcerans. Furthermore, changes in B-cell subset proportions

may be used as markers for treatment monitoring in BUD.

Background:HIV remains a significant public health dilemma in West and Central Africa. HIV-related morbidity and mortality are unjustly high, yet little is known about the spectrum of complicating comorbidities in HIV-positivepatients who are admitted to hospitals in these regions.

Methods:This study involved a retrospective chart review to determine the common comorbidities and mortalityrate of HIV-infected patients admitted over a six month period to the internal medicine service at the Komfo AnokyeTeaching Hospital (KATH), a tertiary care center in Ghana. Patients admitted with a known or new HIV diagnosis fromJanuary to July 2016 were included. Data were collected regarding the number of new versus known cases admitted,the most common presenting complaints, final admitting diagnoses, and causes of mortality in these patients.

Results:During the six-month study period, 250 HIV-positive patients were admitted to KATH, and 245 of theseindividuals had valid survival time recorded. Of these patients, 145/245 (59.2%) were female. Median age of patientsincluded in the study was 42 years old (IQR 35–51). The mortality rate for HIV patients admitted to the hospital was 35.5% (87 patients). One hundred and forty-five (59.4%) patients had a known history of HIV documented in their patientcharts, while the remaining patients were newly diagnosed with HIV during their inpatient stay. Pulmonary tuberculosispredominated among diagnostic findings, with 40.4% of HIV-infected patients diagnosed with the condition whileadmitted. Patients presenting with neurological symptoms on admission were 2.14 (95% CI: 1.27–3.61) times more likely to die than those without neurological symptoms (p=.004).

Conclusions:Over 40% of HIV-positive patients admitted to KATH were newly diagnosed with HIV at admission. While pulmonary tuberculosis was the most common comorbidity, patients presenting with neurological symptoms were at higher risk of death. This study suggests that enhanced outpatient screening is needed for early diagnosis and prompt HAART initiation, as well as increased access to diagnostic modalities and treatment for HIV-positive patients with neurological symptoms.

Introduction

Buruli ulcer(BU) caused by Mycobacterium ulcerans is effectively treated with rifampicin and streptomycin for 8 weeks but some lesions take several months to heal. We have shown previously that some slowly healing lesions contain mycolactone suggesting continuing infection after antibiotic therapy. Now we have determined how rapidly combined M.ulcerans16SrRNA reverse transcriptase/ IS2404qPCRassay(16SrRNA) became negative during antibiotic treatment and investigated its influence on healing.

Methods

Fine needle aspirates and swab samples were obtained for culture, acid fast bacilli(AFB) and detection of M.ulcerans 16SrRNA and IS2404 by qPCR(16SrRNA) from patients with IS2404PCR confirmed BU at baseline,during antibiotic and after treatment. Patients were followed up at 2 weekly intervals to determine the rate of healing.The Kaplan-Meier survival analysis was used to analyse the time to clearance of M.ulcerans16SrRNA and the influence of persistent M ulcerans16SrRNA on time to healing.The Mann Whitney test was used to compare the bacillary load at baseline in patients with or without viable organisms at week 4, andto analyse rate of healing at week 4 in relation to detection of viable organisms.

Results

Out of 129 patients,16SrRNA was detected in 65%of lesions at baseline.The M.ulcerans16SrRNA remained positive in 78% of patients with unhealed lesions at 4 weeks,52%at 8weeks,23%at 12weeksand10%at week16.The median time to clearance of M.ulcerans 16SrRNA was 12weeks. BU lesions with positive16SrRNA after antibiotic treatment had significantly higher bacterial load at baseline, longer healing time and lower healing rate at week 4 compared with those in which16SrRNA was not detected at baseline or had become undetectable by week 4.

Conclusions

Current antibiotic therapy for BU is highly successful in most patients but it may be possible to abbreviate treatment to 4 weeks in patients witha low initial bacterial load.On the other hand persistent infection contributes to slow healing in patients with a high bacterial load at baseline,some of whom may need antibiotic treatment extended beyond 8 weeks.Bacterial load was estimated from a single sample taken at baseline. A better estimate could be made by taking multiple samples or biopsies but this was not ethically acceptable.

INTRODUCTION: Coronavirus disease-19 (COVID-19), which started in late December,
2019, has spread to affect 216 countries and territories around the world.
Globally, the number of cases of SARS-CoV-2 infection has been growing
exponentially. There is pressure on countries to flatten the curves and break
transmission. Most countries are practicing partial or total lockdown,
vaccination, massive education on hygiene, social distancing, isolation of
cases, quarantine of exposed and various screening approaches such as
temperature and symptom-based screening to break the transmission. Some studies
outside Africa have found the screening for fever using non-contact thermometers
to lack good sensitivity for detecting SARS-CoV-2 infection. The aim of this
study was to determine the usefulness of clinical symptoms in accurately
predicting a final diagnosis of COVID-19 disease in the Ghanaian setting.
METHOD: The study analysed screening and test data of COVID-19 suspected,
probable and contacts for the months of March to August 2020. A total of 1,986
participants presenting to Tamale Teaching hospital were included in the study.
Logistic regression and receiver operator characteristics (ROC) analysis were
carried out.
RESULTS: Overall SARS-CoV-2 positivity rate was 16.8%. Those with symptoms had
significantly higher positivity rate (21.6%) compared with asymptomatic (17.0%)
[chi-squared 15.5, p-value, <0.001]. Patients that were positive for SARS-CoV-2
were 5.9 [3.9-8.8] times more likely to have loss of sense of smell and 5.9
[3.8-9.3] times more likely to having loss of sense of taste. Using history of
fever as a screening tool correctly picked up only 14.8% of all true positives
of SARS-CoV-2 infection and failed to pick up 86.2% of positive cases. Using
cough alone would detect 22.4% and miss 87.6%. Non-contact thermometer used
alone, as a screening tool for COVID-19 at a cut-off of 37.8 would only pick
4.8% of positive SARS-CoV-2 infected patients.
CONCLUSION: The use of fever alone or other symptoms individually [or in
combination] as a screening tool for SARS-CoV-2 infection is not worthwhile
based on ROC analysis. Use of temperature check as a COVID-19 screening tool to
allow people into public space irrespective of the temperature cut-off is of
little benefit in diagnosing infected persons. We recommend the use of facemask,
hand hygiene, social distancing as effective means of preventing infection.

There is a heavy burden of liver disease in West Africa. While the role of hepatitis B virus (HBV) infection is well recognized, less is known about the contributing role of liver steatosis and how the two interact in the context of human immunodeficiency virus (HIV) infection. Adults with HIV in Ghana underwent FibroScan measurements to determine prevalence of liver steatosis (expressed as controlled attenuation parameter [CAP]) and fibrosis (expressed as liver stiffness [LS]). We explored contributing factors in linear regression models, including demographics, lifestyle characteristics, medical history, HIV and HBV status, and measurements of metabolic syndrome. Among 329 adults (72.3% women; median age, 47 years), 322 (97.9%) were on antiretroviral therapy (median duration, 8.9 years). CD4 counts were preserved (median, 619 cells/mm³); plasma HIV RNA was fully suppressed in 162 (50.3%) of the treated participants. Cigarette smoking, excessive alcohol consumption, and use of traditional or herbal remedies were uncommon (6.1%, 1.8%, 3.3%, respectively). Largely undiagnosed metabolic syndrome was detected in 87 (26.4%) participants. We obtained readings indicative of ≥S2 steatosis and ≥F2 fibrosis in 43 (13.1%) and 55 (16.7%) participants, respectively. Higher CAP values were associated with metabolic syndrome and longer prior stavudine exposure. Higher LS values were associated with male sex, higher HIV RNA, and higher CAP values. Relative to people without HBV, those with HBV (n = 90) had a similar prevalence of ≥S2 steatosis but a higher prevalence of ≥F2 fibrosis (36.7% vs. 9.2%, p < 0.0001) and concomitant ≥S2 steatosis and ≥F2 fibrosis (9.1% vs. 1.3%, p < 0.001). Conclusion: Both HBV and liver steatosis pose a threat to long-term liver health among people with HIV in West Africa. Urgently required interventions include improving HIV suppression and diagnosing and managing determinants of the metabolic syndrome.

IFN-γ release assays (IGRAs) have suboptimal sensitivity for detection of Mycobacterium tuberculosis (Mtb) infection and cannot discriminate between tuberculosis (TB) patients and healthy -potentially Mtb infected- contacts (HCs). In a case-control study, we determined T-cell phenotypes of IGRAs in TB patients (n = 20) and HCs (n = 20) from Ghana. CD27 expression of T-cells was significantly lower in TB patients as compared to HCs independent from Mtb-specificity. CD27 expression discriminated both study groups - including TB patients with low or indeterminate IGRA results - effectively. We conclude that CD27 is a promising biomarker for diagnosis of TB patients with inconclusive IGRA results.

Background

Hepatitis E virus (HEV) is a major cause of human hepatitis worldwide. Zoonotic genotypes of the virus have been found in diverse animal species with pigs playing a major role. Putative risk of zoonotic infection from livestock particularly swine in Sub-Saharan Africa including Ghana is poorly understood due to scarcity of available data, especially HEV sequence information.

Methods

Serum samples were collected from cattle, sheep, goats and pigs from Kumasi in the Ashanti region of Ghana. Samples were subjected to nested RT-PCR screening and quantification of HEV RNA-positive samples using real-time RT-PCR and the World Health Organization International Standard for HEV. Testing of all pig samples for antibodies was done by ELISA. Sanger sequencing and genotyping was performed and one representative complete genome was generated to facilitate genome-wide comparison to other available African HEV sequences by phylogenetic analysis.

Results

A total of 420 samples were available from cattle (n = 105), goats (n = 124), pigs (n = 89) and sheep (n = 102). HEV Viral RNA was detected only in pig samples (10.1%). The antibody detection rate in pigs was 77.5%, with positive samples from all sampling sites. Average viral load was 1 × 10⁵ (range 1.02 × 10³ to 3.17 × 10⁵) International Units per mL of serum with no statistically significant differences between age groups (≤ 6 month, > 6 months) by a T-test comparison of means (t = 1.4272, df = 7, p = 0.1966). Sequences obtained in this study form a monophyletic group within HEV genotype 3. Sequences from Cameroon, Ghana, Burkina Faso and Madagascar were found to share a most recent common ancestor; however this was not the case for other African HEV sequences.

Conclusion

HEV genotype 3 is highly endemic in pigs in Ghana and likely poses a zoonotic risk to people exposed to pigs. HEV genotype 3 in Ghana shares a common origin with other virus strains from Sub-Saharan Africa.

Background: This prospective pilot study explored same-day point-of-care viral load testing in a setting in Ghana that has yet to implement virological monitoring of antiretroviral therapy (ART). Methods: Consecutive patients accessing outpatient care while on ART underwent HIV-1 RNA quantification by Xpert. Those with viraemia at the first measurement (T0) received immediate adherence counselling and were reassessed 8 weeks later (T1). Predictors of virological status were determined by logistic regression analysis. Drug resistance-associated mutations (RAMs) were detected by Sanger sequencing. Findings: At T0, participants had received treatment for a median of 8·9 years; 297/333 (89·2%) were on NNRTI-based ART. The viral load was ≥40 copies/mL in 164/333 (49·2%) patients and ≥1000 copies/mL in 71/333 (21·3%). In the latter group, 50/65 (76·9%) and 55/65 (84·6%) harboured NRTI and NNRTI RAMs, respectively, and 27/65 (41·5%) had ≥1 tenofovir RAM. Among 150/164 (91·5%) viraemic patients that reattended at T1, 32/150 (21·3%) showed resuppression <40 copies/mL, comprising 1/65 (1·5%) subjects with T0 viral load ≥1000 copies/mL and 31/85 (36·5%) subjects with lower levels. A T0 viral load ≥1000 copies/mL and detection of RAMs predicted ongoing T1 viraemia independently of self-reported adherence levels. Among participants with T0 viral load ≥1000 copies/mL, 23/65 (35·4%) showed resuppression <1000 copies/mL; the response was more likely among those with higher adherence levels and no RAMs. Interpretation: Same-day point-of-care viral load testing was feasible and revealed poor virological control and suboptimal resuppression rates despite adherence counselling. Controlled studies should determine optimal triaging modalities for same-day versus deferred viral load testing. Funding: University of Liverpool, South Tees Infectious Diseases Research Fund

Highlights Type 1 diabetes onset age in Kumasi/Ghana has a peak at around 17 to 20 years, whereas the peak is at 11 to 12 years in North Rhine-Westphalia, Germany. Higher proportions of females were found in the type 1 diabetes cohort from Ghana, and males were more frequent in the German cohort.

Background:The only available vaccine that could be potentially beneficial against mycobacterial diseases contains liveattenuated bovine tuberculosis bacillus (Mycobacterium bovis) also called Bacillus Calmette-Gue ́rin (BCG). Even though the BCGvaccine is still widely used, results on its effectiveness in preventing mycobacterial diseases are partially contradictory, especiallyregarding Buruli Ulcer Disease (BUD). The aim of this case-control study is to evaluate the possible protective effect of BCGvaccination on BUD.

Methodology:The present study was performed in three different countries and sites where BUD is endemic: in theDemocratic Republic of the Congo, Ghana, and Togo from 2010 through 2013. The large study population was comprised of401 cases with laboratory confirmed BUD and 826 controls, mostly family members or neighbors.

Principal Findings:After stratification by the three countries, two sexes and four age groups, no significant correlation wasfound between the presence of BCG scar and BUD status of individuals. Multivariate analysis has shown that theindependent variables country (p= 0.31), sex (p= 0.24), age (p= 0.96), and presence of a BCG scar (p= 0.07) did notsignificantly influence the development of BUD category I or category II/III. Furthermore, the status of BCG vaccination wasalso not significantly related to duration of BUD or time to healing of lesions.

Conclusions:In our study, we did not observe significant evidence of a protective effect of routine BCG vaccination on the risk ofdeveloping either BUD or severe forms of BUD. Since accurate data on BCG strains used in these three countries were notavailable, no final conclusion can be drawn on the effectiveness of BCG strain in protecting against BUD. As has been suggestedfor tuberculosis and leprosy, well-designed prospective studies on different existing BCG vaccine strains are needed also for BUD.

Objective: Approximately 70% of all hepatitis C (HCV) infections develop chronic disease. Active or exacerbated chronic hepatitis C infection subsequently progress to liver disease. The role of T-cells secretions in achieving viral clearance is still not well understood. Thus, the current study was set to determine the relationship between the T cell cytokine profiles, biochemical parameters and persistent HCV infection or spontaneous recovery. Results: Twenty-five percent (41/163) of the anti-HCV positive participants had recovered from HCV and had significantly higher concentration of IL-10 compared to those with active HCV infection (P < 0.012). Other circulating cytokines measured; IL-2, IFN gamma, TNF alpha, IL-5 and IL-17 were similar in both groups. Participants with active HCV infection had significantly higher aspartate transaminase (AST) (35 units) and alanine transaminase (46 units) compared to those in the recovered state (P < 0.001). Thus, serum levels of IL10 could be explored in larger prospective cohort study as a predictive marker of recovering from an active HCV infection.

BU is distributed mainly in West Africa, but cases are also found in other parts of the world. We may be underestimating its true disease burden, due to the limited awareness of this disease. More awareness and more understanding of BU will surely contribute in enhancing our fight against this skin NTD.

Background

The declaration of COVID-19 as a pandemic on March 11 2020, by the World Health Organisation prompted the need for a sustained and a rapid international response. In a swift response, the Government of Ghana, in partnership with Zipline company, launched the use of Unmanned Automated Vehicles (UAV) to transport suspected samples from selected districts to two foremost testing centres in the country. Here, we present the experiences of employing this technology and its impact on the transport time to the second largest testing centre, the Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR) in Kumasi, Ghana.

Methods

Swab samples collected from suspected COVID-19 patients were transported to the Zipline office by health workers. Information on the samples were sent to laboratory personnel located at KCCR through a WhatsApp platform to get them ready to receive the suspected COVID-19 samples while Zipline repackaged samples and transported them via drone. Time of take-off was reported as well as time of drop-off.

Results

A total of 2537 COVID-19 suspected samples were received via drone transport from 10 districts between April 2020 to June 2021 in 440 deliveries. Ejura-Sekyedumase District Health Directorate delivered the highest number of samples (765; 30%). The farthest district to use the drone was Pru East, located 270 km away from KCCR in Kumasi and 173 km to the Zipline office in Mampong. Here, significantly, it took on the average 39 minutes for drones to deliver samples compared to 117 minutes spent in transporting samples by road (p<0.001).

Conclusion

The use of drones for sample transport during the COVID-19 pandemic significantly reduced the travel time taken for samples to be transported by road to the testing site. This has enhanced innovative measures to fight the pandemic using technology.

There is a heavy burden of liver disease in West Africa. While the role of

hepatitis B virus (HBV) infection is well recognized, less is known about the

contributing role of liver steatosis and how the two interact in the context of

human immunodeficiency virus (HIV) infection. Adults with HIV in Ghana underwent

FibroScan measurements to determine prevalence of liver steatosis (expressed as

controlled attenuation parameter [CAP]) and fibrosis (expressed as liver

stiffness [LS]). We explored contributing factors in linear regression models,

including demographics, lifestyle characteristics, medical history, HIV and HBV

status, and measurements of metabolic syndrome. Among 329 adults (72.3% women;

median age, 47 years), 322 (97.9%) were on antiretroviral therapy (median

duration, 8.9 years). CD4 counts were preserved (median, 619 cells/mm3 ); plasma

HIV RNA was fully suppressed in 162 (50.3%) of the treated participants.

Cigarette smoking, excessive alcohol consumption, and use of traditional or

herbal remedies were uncommon (6.1%, 1.8%, 3.3%, respectively). Largely

undiagnosed metabolic syndrome was detected in 87 (26.4%) participants. We

obtained readings indicative of ≥S2 steatosis and ≥F2 fibrosis in 43 (13.1%) and

55 (16.7%) participants, respectively. Higher CAP values were associated with

metabolic syndrome and longer prior stavudine exposure. Higher LS values were

associated with male sex, higher HIV RNA, and higher CAP values. Relative to

people without HBV, those with HBV (n = 90) had a similar prevalence of ≥S2

steatosis but a higher prevalence of ≥F2 fibrosis (36.7% vs. 9.2%, p < 0.0001)

and concomitant ≥S2 steatosis and ≥F2 fibrosis (9.1% vs. 1.3%, p < 0.001).

Conclusion: Both HBV and liver steatosis pose a threat to long-term liver health

among people with HIV in West Africa. Urgently required interventions include

improving HIV suppression and diagnosing and managing determinants of the

metabolic syndrome.

PURPOSE: Human tuberculosis is characterized by immunopathology that affects

T-cell phenotype and functions. Previous studies found impaired T-cell response

to phytohemagglutinin (PHA) in patients with acute tuberculosis. However, the

influence of disease severity, affected T-cell subsets, and underlying

mechanisms remain elusive.

METHODS: Here we investigated PHA-induced and antigen-specific T-cell effector

cytokines in tuberculosis patients (n = 55) as well as in healthy asymptomatic

contacts (n = 32) from Ghana. Effects of Mycobacterium (M.) tuberculosis sputum

burden and treatment response were analyzed and compared during follow-up.

Finally, cytokine characteristics of the aberrant plasma milieu in tuberculosis

were analyzed as a potential cause for impaired PHA response.

RESULTS: PHA-induced IFN-γ expression was significantly lower in sputum-positive

tuberculosis patients as compared to both, contacts and paucibacillary cases,

and efficiently discriminated the study groups. T-cell responses to PHA

increased significantly early during treatment and this was more pronounced in

tuberculosis patients with rapid treatment response. Analysis of alternative

cytokines revealed distinct patterns and IL-22, as well as IL-10, showed

comparable expression to IFN-γ in response to PHA. Finally, we found that high

IL-6 plasma levels were strongly associated with impaired IFN-γ and IL-22

response to PHA.

CONCLUSION: We conclude that impaired T-cell response to PHA stimulation in

acute tuberculosis patients (i) was potentially caused by the aberrant plasma

milieu, (ii) affected differentially polarized T-cell subsets, (iii) normalized

early during treatment. This study shed light on the mechanisms of impaired

T-cell functions in tuberculosis and yielded promising biomarker candidates for

diagnosis and monitoring of treatment response.

BACKGROUND: Scabies commonly affects poor populations in low-middle-income

countries. The WHO has advocated for country-driven and country-owned control

strategies. Knowledge of context specific issues will be important for design

and implementation of scabies control interventions. We aimed to assess beliefs,

attitudes and practices towards scabies in central Ghana.

METHODOLOGY/PRINCIPAL FINDINGS: Data was collected via semi-structured

questionnaires for people who had active scabies or scabies in the past year and

people who never had scabies in the past. The questionnaire covered several

domains: knowledge about the causes and risk factors; perceptions towards

stigmatisation and consequences of scabies in daily life; and treatment

practices. Out of 128 participants, 67 were in the (former) scabies group and

had a mean age of 32.3 ± 15.6 years. Overall scabies group participants less

often indicated a factor to predispose to scabies than community controls; only

'family/friends contacts' was more often mentioned in the scabies group. Scabies

causation was attributed to poor hygiene, traditional beliefs, heredity and

drinking water. Individuals with scabies delay care seeking (median time from

symptom onset to visiting the health centre was 21 [14 - 30] days) and this

delay is enhanced by their beliefs (like witchcraft and curses) and a perception

of limited disease severity. Compared to past scabies participants in the

dermatology clinic, participants with past scabies in the community tended to

have a longer delay (median [IQR] 30 [14-48.8] vs 14 [9.5-30] days, p = 0.002).

Scabies was associated with health consequences, stigma, and loss of

productivity.

CONCLUSION/SIGNIFICANCE: Early diagnosis and effective treatment of scabies can

lead to persons less frequently associating scabies with witchcraft and/ or

curses. There is the need to enhance health education to promote early care

seeking, enhance knowledge of communities on impact and dispel negative

perceptions about scabies in Ghana.

BACKGROUND: Extended-spectrum beta-lactamase (ESBL)-producing Klebsiella

pneumoniae (ESBL-KP) and Escherichia coli (ESBL-EC) present a high burden in

both communities and healthcare sectors, leading to difficult-to-treat

infections. Data on intestinal carriage of ESBL-KP and ESBL-EC in children is

scarce, especially in sub-Saharan African countries. We provide data on faecal

carriage, phenotypic resistance patterns, and gene variation of ESBL-EC and

ESBL-KP among children in the Agogo region of Ghana.

METHODS: From July to December 2019, fresh stool samples were collected within

24 h from children < 5 years with and without diarrhoea attending the study

hospital. The samples were screened for ESBL-EC and ESBL-KP on ESBL agar and

confirmed using double-disk synergy testing. Bacterial identification and an

antibiotic susceptibility profile were performed using the Vitek 2 compact

system (bioMérieux, Inc.). ESBL genes, blaSHV, blaCTX-M, and blaTEM were

identified by PCR and further sequencing.

RESULTS: Of the 435 children recruited, stool carriage of ESBL-EC and ESBL-KP

was 40.9% (n/N = 178/435) with no significant difference in prevalence between

children with diarrhoea and non-diarrhoea. No association between ESBL carriage

and the age of the children was found. All isolates were resistant to ampicillin

and susceptible to meropenem and imipenem. Both ESBL-EC and ESBL-KP isolates

showed over 70% resistance to tetracycline and sulfamethoxazole-trimethoprim.

Multidrug resistance was observed in over 70% in both ESBL-EC and ESBL-KP

isolates. The blaCTX-M-15 was the most prevalent ESBL gene detected.

blaCTX-M-27, blaCTX-M-14, and blaCTX-M-14b were found in non-diarrhoea stools of

children, whereas blaCTX-M-28 was found in both the diarrhoea and non-diarrhoea

patient groups.

CONCLUSIONS: The carriage of ESBL-EC and ESBL-KP among children with and without

diarrhoea in the Agogo community with a high prevalence of blaCTX-M-15 is

noteworthy, highlighting the importance of both the population as a possible

reservoir. This study reports for the first time the ESBL gene blaCTX-M-28 among

the studied populations in Ghana.

Buruli ulcer (BU) is one of the 17 neglected tropical diseases for which the World Health Organizationhas adopted resolutions to improve treatment. BU was previously described as a relatively painless condition; however,recent research has indicated that some patients experience substantial pain. The objective of this study was to explorepatients’experiences of pain and their expectations for its treatment. Semistructured interviews were conducted in aBU-endemic region of Ghana. Interviews were held with former BU patients (N= 20) and community controls (N=19).Former patients were asked about BU-related pain and their expectations for its treatment. The interviews wereconducted in October 2014, and were audiotaped, translated and transcribed into English, and then qualitatively ana-lyzed. Of the 20 former BU patients interviewed, 19 (95%) reported experiencing pain, with patients reporting pain asa consequence of the ulcer and wound management. Some participants expressed pain through crying, whereas othersdid not openly express pain, sometimes because they feared the repercussions of doing so. Patients wanted to receivepain relief; however, many were unable to name a medication. Nonpharmaceutical options were cited as being an alter-native. Many BU patients experience pain; however, former patients and community members alike appear to havea limited knowledge about available pain relief. A low-cost alternative to medication may be the use of non-pharmaceutical means for pain relief. Routine pain assessment may reduce patients’fear and unwillingness to express pain. Awareness of such issues will be valuable when implementing a BU pain relief guideline.

Background: A dose of 30 mg/kg of azithromycin is recommended for treatment of yaws, a disease targeted for global
eradication. Treatment with 20 mg/kg of azithromycin is recommended for the elimination of trachoma as a public
health problem. In some settings, these diseases are co-endemic. We aimed to determine the efficacy of 20 mg/kg of
azithromycin compared with 30 mg/kg azithromycin for the treatment of active and latent yaws.
 

Methods: We did a non-inferiority, open-label, randomised controlled trial in children aged 6–15 years who were
recruited from schools in Ghana and schools and the community in Papua New Guinea. Participants were enrolled
based on the presence of a clinical lesion that was consistent with infectious primary or secondary yaws and a positive
rapid diagnostic test for treponemal and non-treponemal antibodies. Participants were randomly assigned (1:1) to
receive either standard-dose (30 mg/kg) or low-dose (20 mg/kg) azithromycin by a computer-generated random
number sequence. Health-care workers assessing clinical outcomes in the field were not blinded to the patient’s
treatment, but investigators involved in statistical or laboratory analyses and the participants were blinded to treatment
group. We followed up participants at 4 weeks and 6 months. The primary outcome was cure at 6 months, defined as
lesion healing at 4 weeks in patients with active yaws and at least a four-fold decrease in rapid plasma reagin titre
from baseline to 6 months in patients with active and latent yaws. Active yaws was defined as a skin lesion that was
positive for Treponema pallidum ssp pertenue in PCR testing. We used a non-inferiority margin of 10%. This trial was
registered with ClinicalTrials.gov, number NCT02344628.
 

Findings: Between June 12, 2015, and July 2, 2016, 583 (65·1%) of 895 children screened were enrolled; 292 patients were
assigned a low dose of azithromycin and 291 patients were assigned a standard dose of azithromycin. 191 participants had
active yaws and 392 had presumed latent yaws. Complete follow-up to 6 months was available for 157 (82·2%) of
191 patients with active yaws. In cases of active yaws, cure was achieved in 61 (80·3%) of 76 patients in the low-dose group
and in 68 (84·0%) of 81 patients in the standard-dose group (difference 3·7%; 95% CI −8·4 to 15·7%; this result did not
meet the non-inferiority criterion). There were no serious adverse events reported in response to treatment in either
group. The most commonly reported adverse event at 4 weeks was gastrointestinal upset, with eight (2·7%) participants
in each group reporting this symptom.
 

Interpretation: In this study, low-dose azithromycin did not meet the prespecified non-inferiority margin compared
with standard-dose azithromycin in achieving clinical and serological cure in PCR-confirmed active yaws. Only a
single participant (with presumed latent yaws) had definitive serological failure. This work suggests that 20 mg/kg of
azithromycin is probably effective against yaws, but further data are needed.

Background:Previous studies have reported that presence and severity of Buruli ulcer (BU) may reflect theunderlying immunosuppression in HIV infected individuals by causing increased incidence of multiple, larger andulcerated lesions. We report cases of BU-HIV coinfection and the accompanying programmatic challengesencountered in central Ghana.

Methods:Patients with PCR confirmed BU in central Ghana who were HIV positive were identified and their BU01forms were retrieved and reviewed in further detail. A combined 16S rRNA reverse transcriptase / IS2404 qPCR assaywas used to assess theMycobacterium  ulceransload. The characteristics of coinfected patients (BU+HIV+) werecompared with a group of matched controls.

Results:The prevalence of HIV in this BU cohort was 2.4% (compared to national HIV prevalence of 1.7%). Eight of9BU+HIV+patients had a single lesion and ulcers were the most common lesion type. The lesions presented werepredominantly category II (5/9) followed by category I lesions. The median (IQR) time to healing was 14 (8–28)weeks in the BU+HIV+compared to 28 (12–33) weeks in the control BU+HIV−group (p= 0.360). Only one BU+HIV+developed a paradoxical reaction at week 16 but the lesion healed completely at week 20. The median bacterialload (16SrRNA) of BU+HIV+patients was 750 copies /ml (95% CI 0–398,000) versus 500 copies/ml (95% CI 0–126,855,500) in BU+HIV−group. Similarly, the median count using the IS2404 assay was 500 copies/ml (95% CI 0–500) forBU+HIV+patients versus 500 copies/ml (95% CI 500–31,000) for BU+HIV−patients. BU+HIV−patients mounted asignificantly higher interferon-γresponse compared to the BU+HIV+co-infected patients with respective median(range) responses of [1687(81.11–4399) pg/ml] versus [137.5(4.436–1406) pg/ml,p= 0.03]. There were challengeswith the integration of HIV and BU care in this cohort.

Conclusion:The prevalence of HIV in the BU+ infected population was not significantly increased when comparedto the prevalence of HIV in the general population. There was no clear relationship between BU lesion severity andHIV viral load or CD4 counts. Efforts should be made to encourage the integration of care of patients with BU-HIVcoinfection.

Investment in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

sequencing in Africa over the past year has led to a major increase in the

number of sequences that have been generated and used to track the pandemic on

the continent, a number that now exceeds 100,000 genomes. Our results show an

increase in the number of African countries that are able to sequence

domestically and highlight that local sequencing enables faster turnaround times

and more-regular routine surveillance. Despite limitations of low testing

proportions, findings from this genomic surveillance study underscore the

heterogeneous nature of the pandemic and illuminate the distinct dispersal

dynamics of variants of concern-particularly Alpha, Beta, Delta, and Omicron-on

the continent. Sustained investment for diagnostics and genomic surveillance in

Africa is needed as the virus continues to evolve while the continent faces many

emerging and reemerging infectious disease threats. These investments are

crucial for pandemic preparedness and response and will serve the health of the

continent well into the 21st century.

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 high-level 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.

Determination of previous SARS-COV-2 infection is hampered by the absence of a

standardized test. The marker used to assess previous exposure is IgG antibody

to the nucleocapsid (IgG anti-N), although it is known to wane quickly from

peripheral blood. The accuracies of seven antibody tests (virus neutralization

test, IgG anti-N, IgG anti-spike [anti-S], IgG anti-receptor binding domain

[anti-RBD], IgG anti-N + anti-RBD, IgG anti-N + anti-S, and IgG anti-S +

anti-RBD), either singly or in combination, were evaluated on 502 cryopreserved

serum samples collected before the COVID-19 vaccination rollout in Kumasi,

Ghana. The accuracy of each index test was measured using a composite reference

standard based on a combination of neutralization test and IgG anti-N antibody

tests. According to the composite reference, 262 participants were previously

exposed; the most sensitive test was the virus neutralization test, with 95.4%

sensitivity (95% CI: 93.6-97.3), followed by 79.0% for IgG anti-N + anti-S (95%

CI: 76.3-83.3). The most specific tests were virus neutralization and IgG

anti-N, both with 100% specificity. Viral neutralization and IgG anti-N + anti-S

were the overall most accurate tests, with specificity/sensitivity of 100/95.2%

and 79.0/92.1%, respectively. Our findings indicate that IgG anti-N alone is an

inadequate marker of prior exposure to SARS COV-2 in this population. Virus

neutralization assay appears to be the most accurate assay in discerning prior

infection. A combination of IgG anti-N and IgG anti-S is also accurate and

suited for assessment of SARS COV-2 exposure in low-resource settings.

The past 2 years, during which waves of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants swept the globe, have starkly highlighted health disparities across nations. Tegally et al. show how the coordinated efforts of talented African scientists have in a short time made great contributions to pandemic surveillance and data gathering. Their efforts and initiatives have provided early warning that has likely benefited wealthier countries more than their own. Genomic surveillance identified the emergence of the highly transmissible Beta and Omicron variants and now the appearance of Omicron sublineages in Africa. However, it is imperative that technology transfer for diagnostics and vaccines, as well the logistic wherewithal to produce and deploy them, match the data-gathering effort. —CA

BACKGROUND: Coagulopathy is common in acute symptomatic Plasmodium falciparum

malaria, and the degree of coagulation abnormality correlates with parasitemia

and disease severity. Chronic asymptomatic malaria has been associated with

increased morbidity. However, the role of coagulation activation in

asymptomatic, semi-immune individuals remains unclear. This study investigates

the potential effect of asymptomatic P falciparum infection on coagulation

activation in semi-immune Ghanaian adults.

METHODS: Blood from asymptomatic Ghanaian adults with P falciparum blood stage

infection detectable by polymerase chain reaction (PCR) or by both PCR and rapid

diagnostic test and from noninfected individuals, was investigated. Markers of

coagulation activation including global coagulation tests, D-dimer, antithrombin

III, fibrinogen, and von Willebrand factor antigen were tested. Furthermore,

blood count, inflammation markers, and liver and kidney function tests were

assessed.

RESULTS: Acquired coagulopathy was not found in asymptomatic P falciparum

infection. Asymptomatic malaria was associated with significantly lower platelet

counts. Systemic inflammation markers and liver and kidney function tests were

not altered compared to noninfected controls.

CONCLUSIONS: There is no laboratory evidence for acquired coagulopathy in adults

with asymptomatic P falciparum malaria in highly endemic regions. Lack of

laboratory evidence for systemic inflammation and liver and kidney dysfunction

indicates that asymptomatic malaria may not be associated with significant

morbidity.

Campylobacter species are one of the leading causes of gastroenteritis in

humans. This review reports on the prevalence and antibiotic resistance data of

Campylobacter spp. isolated from humans and food-producing animals in West

Africa. A systematic search was carried out in five databases for original

articles published between January 2000 and July 2021. Among 791 studies found,

38 original articles from seven (41%) out of the 17 countries in West Africa met

the inclusion criteria. For studies conducted in food-producing animals, the

overall pooled prevalence of Campylobacter spp. was 34% (95% CI: 25-45). The MDR

prevalence was 59% (95% CI: 29-84) and half (50%, 13/26) of the animal studies

had samples collected from the market. The human studies recorded a lower pooled

prevalence of Campylobacter spp. (10%, 95% CI: 6-17), but a considerably higher

rate of MDR prevalence (91%; 95% CI: 67-98). The majority (85%, 11/13) of the

human studies took place in a hospital. Campylobacter jejuni and Campylobacter

coli were the most common species isolated from both animals and humans. Our

findings suggest that Campylobacter spp. is highly prevalent in West Africa.

Therefore, improved farm hygiene and 'One Health' surveillance systems are

needed to reduce transmission.

Introduction Until recently lamivudine was the only available agent to treat hepatitis B in the context of HIV infection in sub‐Saharan Africa. Tenofovir is gradually becoming available although access remains far from universal. Long‐term outcomes of introducing tenofovir as part of antiretroviral therapy (ART) in subjects previously extensively exposed to lamivudine as the sole HBV‐active agent in the region are unknown. Methods We report from a prospective cohort of HIV/HBV co‐infected adults attending for HIV care in Kumasi, Ghana, where HBsAg prevalence is 14%. HBsAg‐positive subjects were invited to attend for transient elastography (TE) and blood sampling before the introduction of tenofovir (TO) as part of ART, and within 1 year (T1) and 4 years (T2) of starting tenofovir. Adherence and alcohol consumption were determined by a questionnaire‐based interview. Results Overall 178 patients underwent evaluation at T0/T1, of whom 98 (55%) also attended for assessment at T2. Remaining patients were lost to follow up (50; 28%); had died (10; 6%); declined to attend (17; 10%); or were excluded due to pregnancy (2; 1 %) or invalid TE (1; 1 %). Of the 98 subjects, 94 had started tenofovir‐based ART and had received tenofovir for median 4 years (IQR 3.8, 4.1), while continuing previous lamivudine (Table 1). By multivariable linear regression, female gender, no history of alcohol excess, and higher HBV DNA level, higher liver stiffness, and lower platelet count at T0/T1 were significant predictors of decreasing liver stiffness between TO/1 and T2. No treatment‐emergent resistance mutations in HBV polymerase were observed by Sanger sequencing among subjects with HBV DNA>100 lU/ml at T2; one subject showed M204V+V173L+L180M at both TO and T2. Conclusions This is the first report of the long‐term impact on liver stiffness and virologic parameters of introducing tenofovir as part of ART in extensively lamivudine exposed HIV/HBV co‐infected patients in sub‐Saharan Africa. Significant reductions in liver stiffness and improved HBV control were observed at four years.

BACKGROUND: Doxycycline is used for treatment of Mansonella perstans infection.

Immune modulatory effects of both M. perstans and doxycycline have been

described but long-term implications on host immune response are not defined.

Here we determined multiple immune parameters of M. perstans-infected

individuals before and after doxycycline treatment to characterize doxycycline

effects on host T-cell immunity.

METHODS: Immune characterization of doxycycline-treated M. perstans-infected

individuals was performed as part of an open-label randomized clinical trial.

Immune cell population phenotyping by flow cytometry and functional in vitro

T-cell assays were performed at baseline, 6 months, and "long term" (18-24

months) after treatment start. Treatment efficacy, based on peripheral blood

microfilaria (mf) burden, was correlated with immune parameters and effects on

immune response against concomitant Mycobacterium tuberculosis infection were

determined.

RESULTS: Immune population phenotyping indicated changes in functional T-cell

responses after doxycycline treatment. Constitutive and superantigen-induced

T-cell activation and polarization towards T-helper type (TH) 1 phenotype at

baseline declined after doxycycline treatment, whereas low proportions of TH17

and TH1* cells at baseline increased significantly at follow-up. In accordance,

long-term decline in antigen-specific TH1 responses against concomitant M.

tuberculosis infection was seen. Notably, only TH17 and TH1* changes after 6

months and TH17 at baseline were negatively correlated with M. perstans

microfilaria burden or reduction, whereas long-term changes were not associated

with treatment efficacy.

CONCLUSIONS: We found long-term immune modulatory effects of doxycycline

treatment leading to decreased constitutive T-cell activation, polarization

towards TH17/TH1*, and impaired immune response against concomitant M.

tuberculosis infection.

Objectives: The study assessed markers of renal health in HIV/HBV co-infected patients receiving TDF-containing antiretroviral therapy in Ghana.Methods: Urinary protein-to-creatinine ratio (uPCR) and albumin-to-protein ratio (uAPR) were measured cross-sectionally after a median of four years of TDF. At this time, alongside extensive laboratory testing, patients underwent evaluation of liver stiffness and blood pressure. The estimated glomerular filtration rate (eGFR) was measured longitudinally before and during TDF therapy.

Results: Among 101 participants (66% women, median age 44 years, median CD4 count 572 cells/mm3) 21% and 17% had detectable HIV-1 RNA and HBV DNA, respectively. Overall 35% showed hypertension, 6% diabetes, 7% liver stiffness indicative of cirrhosis, and 18% urinary excretion of Schistosoma antigen.
Tubular proteinuria occurred in 16% of patients and was independently predicted by female gender and hypertension. The eGFR declined by median 1.8 ml/min/year during TDF exposure (IQR −4.4, −0.0); more pronounced declines (≥ 5 ml/min/year) occurred in 22% of patients and were associated with receiving ritonavir-boosted lopinavir rather than efavirenz. HBV DNA, HBeAg, transaminases, and liver stiffness were not predictive of renal function abnormalities.

Conclusions: The findings mandate improved diagnosis and management of hypertension and suggest targeted laboratory monitoring of patients receiving TDF alongside a booster in sub-Saharan Africa.

BACKGROUND: Mycobacterium (M.) tuberculosis-caused immunopathology is

characterized by aberrant expression of plasma cytokines in human tuberculosis.

Disease severity and long-term anti-mycobacterial treatment are potentially

influenced by immunopathology and normalization of plasma cytokine levels during

therapy may indicate treatment efficacy and recovery.

STUDY DESIGN AND METHODS: In this study, we analyzed the concentrations of

selected plasma cytokines (i.e., IL-6, IP-10, IL-10, IL-22, IFNγ, GM-CSF, IL-8)

and M. tuberculosis sputum burden in patients with tuberculosis (n = 76).

Cytokine levels were compared to healthy contacts (n = 40) and changes under

treatment were monitored (i.e., 6 and 16 weeks after treatment start). According

to differences in M. tuberculosis sputum burden and conversion, tuberculosis

patients were classified as paucibacillary as well as 'rapid' or 'slow'

treatment responders. A subgroup of tuberculosis patients had fatal disease

courses.

RESULTS: Six of seven cytokines were significantly higher in tuberculosis

patients as compared to contacts and four of these (i.e., IL-6, IP-10, IL-10,

and IL-22) were detectable in the majority of tuberculosis patients. IL-6 showed

the strongest discriminating capacity for tuberculosis disease and in

combination with IL-10 concentrations efficiently classified paucibacillary

tuberculosis cases as well as those with fatal disease outcome. In addition,

IL-6 and IP-10 levels decreased significantly after 6 weeks of treatment and

analyses of subgroups with differential treatment response showed delayed

decline of IL-6 levels in slow treatment responders.

CONCLUSIONS: Combinations of different plasma cytokine (namely, IL-6, IL-10, and

IP-10) efficiently classified tuberculosis patients with differential

mycobacterial burden and especially IL-6 qualified as a biomarker candidate for

early treatment response.

Buruliulcerdisease(BUD),causedbyMycobacterium(M.)ulcerans,is the third most common mycobacterial disease after tuberculosis and leprosy. BUD causes necrotic skin lesions and is a significant problem for health care in the affected countries. As for other mycobacterial infections,T cell mediated immune responses are important for protection and recovery during treatment, but detailed studies investigating these immune responses in BUD patients are scarce. In this study,we aimed to characterise M.ulcerans-specific CD4+T cell responses in BUD patients and to analyse specific cytokine-producingT cells in the context of disease severity and progression.

Methodology/Principalfindings: For this case-control study,whole blood samples of BUDpatients (N= 36,1.5–17yearsof age) and healthy contacts(N= 22,3–15yearsof age) were stimulated with antigen prepared from M.ulcerans and CD4+T cells were analysed for the expression of TNFα, IFNγ and CD40L by flow cytometry.Theproportionsandprofileof cytokine producing CD4+T cells was compared between the two study groups and correlated with disease progression and severity. Proportions of cytokine double positive IFNγ+TNFα+,TNFα+CD40L+,IFNγ+CD40L+(p = 0.014,p = 0.010,p = 0.002,respectively) and triple positive IFNγ+TNFα+CD40L+(p = 0.010) producing CD4+T cell subsets were increased in BUD patients. In addition,TNFα+CD40L-IFNγ-CD4+T cells differed between patients and controls (p =0.034). TNFα+CD40L-IFNγ-CD4+T cells were correlated with lesion size (p = 0.010) and proportion were higher in ‘slow’healers compared to ‘fasthealers’ (p = 0.030)

Conclusions: We were able to identify M.ulcerans-specific CD4+T cell subsets with specific cytokine profiles. In particulara CD4+T cell subset, producingTNFα but not IFNγ and CD40L,showed association with lesion size and healing progress. Further studies are required to investigate, if the identified CD4+T cell subset has the potential to be used as biomarker for diagnosis,severity and/or progression of disease.

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

OBJECTIVES: The global prevalence of intestinal extended-spectrum

β-lactamase-producing Enterobacterales (ESBL-PE) is approximately 17% in

communities, with significant variations among regions. This longitudinal study

aimed to assess the impact of antibiotic intake on the incidence of intestinal

ESBL-PE in Ghanaian pharmacy customers outside of hospitals.

METHODS: Screening for ESBL-PE was performed in four independent pharmacies in

Kumasi, Ghana, using rectal swabs and an ESBL-PE-selective medium. Pharmacy

customers purchasing antibiotics were recruited, and those buying non-antibiotic

drugs served as controls. Participants who were negative for ESBL-PE provided

follow-up swabs for up to 28 days.

RESULTS: At baseline, 302 (75%) of 404 participants were colonized with ESBL-PE.

Sixty-three participants who were negative for ESBL-PE at baseline received

per-protocol follow-up, including 28 individuals who took antibiotics and 35

controls. The cumulative proportions of ESBL-PE in the antibiotics and control

groups were 71% (20/28) and 54% (19/35) at the first follow-up (p 0.258), 86%

(24/28) and 80% (28/35) at the second follow-up (p 0.741) and 86% (24/28) and

94% (33/35) at the third follow-up (p 0.393), respectively.

DISCUSSION: The rate of intestinal ESBL-PE carriage among pharmacy customers

outside of hospitals was higher than expected at baseline and further increased

during the 28 days of follow-up, irrespective of antibiotic intake. This

alarming finding needs to be considered in the antibiotic treatment of

outpatients and emphasizes the urgent need for improved prevention strategies,

development of new antibiotic drugs and potential future elimination strategies.

Further longitudinal studies on ESBL-PE in African communities, also outside of

pharmacy settings, are required.

Monocyte-derived macrophages contribute centrally to immune protection in

Mycobacterium tuberculosis infection and changes in monocyte phenotype

characterize immunopathology in tuberculosis patients. Recent studies

highlighted an important role of the plasma milieu in tuberculosis

immunopathology. Here, we investigated monocyte pathology in patients with acute

tuberculosis and determined tuberculosis plasma milieu effects on phenotype as

well as cytokine signalling of reference monocytes. Patients with tuberculosis

(n = 37) and asymptomatic contacts (controls n = 35) were recruited as part of a

hospital-based study in the Ashanti region of Ghana. Multiplex flow cytometry

phenotyping of monocyte immunopathology was performed and effects of individual

blood plasma samples on reference monocytes prior to and during treatment were

characterized. Concomitantly, cell signalling pathways were analysed to

elucidate underlying mechanisms of plasma effects on monocytes. Multiplex flow

cytometry visualization characterized changes in monocyte subpopulations and

detected higher expression of CD40, CD64 and PD-L1 in monocytes from

tuberculosis patients as compared to controls. Aberrant expression normalized

during anti-mycobacterial treatment and also CD33 expression decreased markedly.

Notably, higher CD33, CD40 and CD64 expression was induced in reference

monocytes when cultured in the presence of plasma samples from tuberculosis

patients as compared to controls. STAT signalling pathways were affected by the

aberrant plasma milieu and higher levels of STAT3 and STAT5 phosphorylation was

found in tuberculosis plasma-treated reference monocytes. Importantly, high

pSTAT3 levels were associated with high CD33 expression and pSTAT5 correlated

with CD40 as well as CD64 expression. These results suggested plasma milieu

effects with potential implications on monocyte phenotype and function in acute

tuberculosis.

Objectives

To assess associations between polymorphisms within genes encoding proximal tubule transporters implicated in tenofovir renal clearance and kidney tubular dysfunction (KTD), chronic kidney disease (CKD) and individual biochemical parameters.

Patients and methods

The study included a cohort of HIV-positive Ghanaians receiving regimens containing tenofovir disoproxil fumarate (n = 66) for at least 6 months prior to study enrolment. SNPs in ABCC10, ABCC2 and ABCC4 were selected for analysis based on previous published associations. All SNPs were genotyped by real-time PCR allelic discrimination. Creatinine clearance (CL_CR), serum and urine creatinine concentrations and biochemical measures of KTD were assessed. Statistical significance was determined through univariate linear or binary logistical regression (P ≤ 0.05).

Results

None of the SNPs evaluated was associated with CKD or KTD. A trend between body weight and higher incidence of CKD (P = 0.012, OR = 0.9) was observed. ABCC10 2843T>C (rs2125739) was significantly associated with lower log₁₀ baseline creatinine (P = 0.001, β= −0.4), higher baseline CL_CR (P = 0.008, β = 65.2) and lower CL_CR after 1 year (P = 0.024, β= −26.6).

Conclusions

This study demonstrates an association of ABCC10 rs2125739 with indicators of declining renal function and builds on current knowledge of this interaction within a Ghanaian cohort.

Buruli ulcer (BU) is a disabling and stigmatising neglected tropicaldisease(NTD).Its distribution and burden are unknown because of under diagnosis and under reporting. It is caused by Mycobacterium ulcerans, an environmental pathogen whose environmental niche and transmission routes are not fully understood.Themaincontrolstrategyis activesurveillanceto promote early treatment and thus limit morbidity, but these activities are mostly restricted to well-known endemic areas. A betterunderstanding of environmental suitability for the bacterium and disease could inform targeted surveillance, and advance understanding of the ecology and burden of BU.We used previously compiled point-level datasets of BU and M.ulcerans occurrence,evidence for BU occurrence with in national and sub-national areas, and a suite of relevant environmental covariates in a distribution modelling framework. We fitted relationships between BU and M.ulcerans occurrence and environmental predictors by applying regression and machine learning based algorithms, combined in an ensemble model to characterise the optimal ecological niche for the disease and bacterium across Africa at a resolution of 5km x 5km.Proximity to water bodies was the strongest predictor of suitability for BU, followed potential evapotranspiration. The strongest predictors of suitability for M.ulcerans were deforestation and potential evapotranspiration. We identified patchy foci of suitability throughout West and Central Africa,including areas with no previous evidence of the disease. Predicted suitability for M.ulcerans was wider but overlapping with that of BU.The estimated population living in areas predicted suitable for the bacterium and disease was 46.1million.These maps could be used to inform burden estimations and case searches which would generate a more complete understanding of the spatial distribution of BU in Africa,and may guide control programmes to identify cases beyond the well known endemic areas.

BACKGROUND: Community Based Surveillance Volunteers (CBSVs) have been

instrumental in the management of Neglected Tropical Diseases (NTDs) but a

concern that their services in scale up programmes may be affected due to high

attrition rates has been widely acknowledged. We explored the roles and capacity

needs of existing CBSVs to inform for a successful integrated NTD management

programme in Ghana and similar contexts.

METHODS: We conducted qualitative interviews with 50 CBSVs, 21 Community Nurses,

4 Disease control officers, 7 skin NTD researchers, 2 skin NTD patients and a

Director of District Health Services in Central Ghana. Interviews were digitally

recorded, transcribed and coded prior to translation and thematic analysis.

RESULTS: The roles of CBSVs in NTD management were shown to have an impact on

disease identification, surveillance, health seeking behaviours and status of

CBSVs. Lack of motivation, inadequate structures for engagement of CBSVs within

the health system and delayed management of reported cases were identified as

gaps that hinder effective delivery of CBSV roles. Provision of incentives as

recognition for the unpaid services rendered by CBSVs was seen as a major factor

to reduce the rate of CBSV attrition in this scale up programme. Other factors

included the formulation of policies by government to guide CBSV engagement,

regular training of CBSV in NTD management as well as provision of resources and

logistics.

CONCLUSION: Measures including continuous training, institution of rewards and

incentivization are important for ensuring the sustainability of CBSVs in the

provision of skin NTD services in Ghana.

BACKGROUND: Since the release of the first global hepatitis elimination targets

in 2016, and until the COVID-19 pandemic started in early 2020, many countries

and territories were making progress toward hepatitis C virus (HCV) elimination.

This study aims to evaluate HCV burden in 2020, and forecast HCV burden by 2030

given current trends.

METHODS: This analysis includes a literature review, Delphi process, and

mathematical modelling to estimate HCV prevalence (viraemic infection, defined

as HCV RNA-positive cases) and the cascade of care among people of all ages (age

≥0 years from birth) for the period between Jan 1, 2015, and Dec 31, 2030.

Epidemiological data were collected from published sources and grey literature

(including government reports and personal communications) and were validated

among country and territory experts. A Markov model was used to forecast disease

burden and cascade of care from 1950 to 2050 for countries and territories with

data. Model outcomes were extracted from 2015 to 2030 to calculate

population-weighted regional averages, which were used for countries or

territories without data. Regional and global estimates of HCV prevalence,

cascade of care, and disease burden were calculated based on 235 countries and

territories.

FINDINGS: Models were built for 110 countries or territories: 83 were approved

by local experts and 27 were based on published data alone. Using data from

these models, plus population-weighted regional averages for countries and

territories without models (n=125), we estimated a global prevalence of viraemic

HCV infection of 0·7% (95% UI 0·7-0·9), corresponding to 56·8 million (95% UI

55·2-67·8) infections, on Jan 1, 2020. This number represents a decrease of 6·8

million viraemic infections from a 2015 (beginning of year) prevalence estimate

of 63·6 million (61·8-75·8) infections (0·9% [0·8-1·0] prevalence). By the end

of 2020, an estimated 12·9 million (12·5-15·4) people were living with a

diagnosed viraemic infection. In 2020, an estimated 641 000 (623 000-765 000)

patients initiated treatment.

INTERPRETATION: At the beginning of 2020, there were an estimated 56·8 million

viraemic HCV infections globally. Although this number represents a decrease

from 2015, our forecasts suggest we are not currently on track to achieve global

elimination targets by 2030. As countries recover from COVID-19, these findings

can help refocus efforts aimed at HCV elimination.

BACKGROUND: Neglected tropical diseases (NTDs) affect over 1.5 billion people

worldwide, the majority of them belonging to impoverished populations in low-

and middle-income countries (LMICs). Skin NTDs are a subgroup of NTDs that

manifest primarily as skin lesions. The diagnosis and treatment of skin NTDs

entail considerable resources, including trained personnel and financial

backing. Many interventions are being launched and evaluated, particularly

mobile health (mHealth) interventions, such as Skin NTDs App, a training and

decision support tool offered by the World Health Organization (WHO) for

frontline health workers (FHWs). As most digital health guidelines prioritize

the thorough evaluation of mHealth interventions, it is essential to conduct a

rigorous and validated assessment of Skin NTDs App.

OBJECTIVE: We aim to assess the quality of version 3 of Skin NTDs App, developed

for the WHO by Universal Doctor and Netherlands Leprosy Relief as a training and

decision support tool for FHWs.

METHODS: A cross-sectional study will be conducted in 2 LMICs: Ghana and Kenya.

We will use snowball sampling recruitment to select 48 participants from the

target population of all FHWs dealing with skin NTDs. The sample group of FHWs

will be asked to download and use Skin NTDs App for at least 5 days before

answering a web-based survey containing demographic variables and the user

Mobile App Rating Scale (uMARS) questionnaire. A semistructured interview will

then be conducted. Quantitative and qualitative data will be analyzed using SPSS

(version 25; SPSS Inc), with statistical significance for all tests set at a 95%

CI and P≤.05 considered significant. Data derived from the semistructured

interviews will be clustered in themes and coded to enable analysis of various

dimensions using ATLAS.ti.

RESULTS: The estimated completion date of the study is in the third quarter of

2022. The results are expected to show that Skin NTDs App version 3 has a good

reported user experience, as assessed using the uMARS scale. No differences are

expected to be found, except for those related to experience in dermatology and

the use of mobile technology that could influence the final score.

Semistructured interviews are expected to complete the results obtained on the

uMARS scale. Moreover, they will be the previous step before assessing other

aspects of the app, such as its efficiency and how it should be disseminated or

implemented.

CONCLUSIONS: This study is the first step in a qualitative and quantitative

assessment of Skin NTDs App as a training and support tool for FHWs diagnosing

and managing skin NTDs. Our results will serve to improve future versions of the

App.

: Buruli ulcer caused by Mycobacterium ulcerans is a neglected tropical disease characterized by extensive ulceration involving predominantly the upper and lower limbs of patients. The disease is common in rural tropical communities in West and Central Africa, where access to proper health care is limited. Pathogenesis of the characteristic painless ulcers is linked to the elaboration by M. ulcerans of a lipid toxin called mycolactone that has potent cytopathic, immunosuppressive, and analgesic effects on a host of cells in cutaneous tissues. Mycolactone is known to profoundly inhibit secretion of a plethora of proteins that are essential for wound healing. Even though a combination antibacterial therapy of streptomycin and rifampicin for 8 weeks is effective for treatment, it relies on good and appropriate wound management to prevent secondary bacterial infections and improve healing. Evidence-based interventions for wound care in Buruli ulcer disease are often lacking and have relied on expert advice and recommendations. Surgical interventions are limited to debridement of necrotic tissue and grafting of extensive ulcers, usually after antibiotic therapy. Patients’ rehabilitation is an important component of care to reduce disabilities associated with the disease and proper integration into the community after treatment.

Background: Despite appropriate prevention and control measures, tuberculosis (TB) remains a significant contributor to maternal morbidity and mortality. Diagnosis of the disease in pregnancy is usually challenging, as the symptoms may be attributed to the pregnancy. Little is known about the true burden of the disease and its associated risk factors among pregnant women. This study sought to assess the prevalence of TB among pregnant women and associated sociodemographic characteristics in Ghana.

Methods: The study used nationally representative data gathered from the national TB project in 2013. A total of 1747 pregnant women were sampled from 56 randomly selected diagnostic health centers across the ten regions of Ghana. TB was confirmed with Ziehl-Neelsen staining technique using morning sputum samples from pregnant women who reported coughing for more than 2 weeks. We assessed how the observed TB prevalence differed by some sociodemographic characteristics and other factors. We further examined the regional spatial distribution of pregnant women with TB in the country.

Results: Up to 11.2% of the pregnant women had a history of cough during pregnancy. Eighteen (1.1%) cases of TB were confirmed among the pregnant women during the 2-year period, with the Eastern region of the country recording the highest (n = 13, 72%), followed by Volta region ( n = 2, 11.1%). No cases were recorded in five regions. The geographical region of residence was the only determinant of TB in pregnancy significantly associated with TB (P = 0.001).

Conclusion: Although the burden of TB was found to be low, appropriate control measures have to be put in place to detect the disease during the early stages of pregnancy to safeguard the health of the expectant mother and the unborn child.

To assess associations between polymorphisms within genes encoding proximal tubule transporters implicated in tenofovir renal clearance and kidney tubular dysfunction (KTD), chronic kidney disease (CKD) and individual biochemical parameters. Patients and methods: The study included a cohort of HIV-positive Ghanaians receiving regimens containing tenofovir disoproxil fumarate (n = 66) for at least 6 months prior to study enrolment. SNPs in ABCC10, ABCC2 and ABCC4 were selected for analysis based on previous published associations. All SNPs were genotyped by real-time PCR allelic discrimination. Creatinine clearance (CLCR), serum and urine creatinine concentrations and biochemical measures of KTD were assessed. Statistical significance was determined through univariate linear or binary logistical regression (P ≤ 0.05). Results: None of the SNPs evaluated was associated with CKD or KTD. A trend between body weight and higher incidence of CKD (P = 0.012, OR = 0.9) was observed. ABCC10 2843T>C (rs2125739) was significantly associated with lower log10 baseline creatinine (P = 0.001, β= -0.4), higher baseline CLCR (P = 0.008, β = 65.2) and lower CLCR after 1 year (P = 0.024, β= -26.6). Conclusions: This study demonstrates an association of ABCC10 rs2125739 with indicators of declining renal function and builds on current knowledge of this interaction within a Ghanaian cohort.

To maximise the likelihood of success, global health programmes need repeated, honest appraisal of their own weaknesses, with research undertaken to address any identified gaps. There is still much to be learned to optimise work against neglected tropical diseases. To facilitate that learning, a comprehensive research and development plan is required. Here, we discuss how such a plan might be developed.

Mycobacterium (M.) bovis BCG vaccination is recommended for healthy babies after

birth in several countries with a high prevalence of tuberculosis, including

Ghana. Previous studies showed that BCG vaccination prevents individuals from

developing severe clinical manifestations of tuberculosis, but BCG vaccination

effects on the induction of IFN-γ after M. tuberculosis infection have hardly

been investigated. Here, we performed IFN-γ-based T-cell assays (i.e., IFN-γ

Release Assay, IGRA; T-cell activation and maturation marker assay, TAM-TB) in

children who had contact with index tuberculosis patients (contacts). These

contacts were classified as either being BCG vaccinated at birth (n = 77) or

non-BCG-vaccinated (n = 17) and were followed up at three timepoints for a

period of one year to determine immune conversion after M. tuberculosis exposure

and potential infection. At baseline and month 3, BCG-vaccinated contacts had

significantly lower IFN-γ levels after stimulation with M. tuberculosis-specific

proteins as compared to non-BCG-vaccinated contacts. This resulted in decreased

proportions of positive IGRA results (BCG-vaccinated: 60% at baseline, 57% at

month 3; non-BCG-vaccinated: 77% and 88%, respectively) at month 3. However,

until month 12, immune conversion in BCG-vaccinated contacts led to balanced

proportions in IGRA responders and IFN-γ expression between the study groups.

TAM-TB assay analyses confirmed higher proportions of IFN-γ-positive T-cells in

non-BCG-vaccinated contacts. Low proportions of CD38-positive M.

tuberculosis-specific T-cells were only detected in non-BCG-vaccinated contacts

at baseline. These results suggest that BCG vaccination causes delayed immune

conversion as well as differences in the phenotype of M. tuberculosis-specific

T-cells in BCG-vaccinated contacts of tuberculosis patients. These differences

are immune biomarker candidates for protection against the development of severe

clinical tuberculosis manifestations.

MacCallum and coworkers described Buruli ulcer (BU) as an infectious disease caused by Mycobacterium ulcerans in Victoria, Australia. They first considered the skin lesions in their patients to be caused by tuberculosis or leprosy, when they observed numerous acid-fast bacilli in the biopsy specimens [1]. The typical duration of illness was between 1 and 2 years; treatment was essentially surgical. With the advent of chemotherapy for tuberculosis [2–4], and later for leprosy, doctors made individual attempts to treat the lesions with anti-tuberculosis and anti-leprosy drugs. The anecdotal evidence suggested poor or no response to chemotherapy with rifampicin monotherapy [5], despite the fact that in vitro susceptibility of 33 strains of M. ulcerans was as good as for M. tuberculosis [6]. A randomized clinical trial by the British Medical Research Council in Buruli county (now called Nakasongola; Uganda) failed to show any benefit from clofazimine, a drug then first marketed for leprosy [7]. A small-sized trial with cotrimoxazole (18 participants; 12 evaluable) was inconclusive [8]. A small-sized randomized study in Côte d’Ivoire compared a combination of dapsone and rifampicin with placebo; the follow-up was limited; the ulcer size decreased slightly faster in the intervention group but the baseline characteristics of both groups differed, and the study did not allow to draw any firm conclusions about the effectiveness of these drugs [9]. By the turn of the millennium, the discrepancy between in vitro efficacy of rifampicin [6] or clarithromycin [10] and lack of clinical response prompted to stressing the need for well-designed and well-powered drug trials, but in the meantime, to also improve early detection and surgical treatment [11].

Background. Antiretroviral treatment (ART) programs in sub-Saharan Africa have for many years included lamivudine as the sole hepatitis B virus (HBV) inhibitor. Long-term outcomes and the effects of introducing tenofovir as part of ART in these populations have not been characterized.

Methods. The study comprised a cross-sectional analysis of 106 human immunodeficiency virus (HIV)/HBV–coinfected subjects maintained on lamivudine, as well as a prospective analysis of 76 lamivudine-experienced subjects who introduced tenofovir. Patients underwent assessment of liver fibrosis by transient elastography (TE) and testing to characterize HIV type 1 (HIV-1) and HBV replication.

Results. After a median of 45 months of lamivudine treatment, HIV-1 RNA and HBV DNA were detectable in 35 of 106 (33.0%) and 54 of 106 (50.9%) subjects, respectively, with corresponding drug resistance rates of 17 of 106 (16.0%) and 31 of 106 (29.2%), respectively. Median TE values were 5.7 kPa (interquartile range, 4.7–7.2 kPa) and independently associated with HBV DNA load, aspartate aminotransferase levels, and platelet counts; 13 of 106 (12.3%) subjects had TE measurements >9.4 kPa. Twelve months after the first assessment, and a median of 7.8 months after introducing tenofovir, HBV DNA levels declined by a mean of 1.5 log₁₀ IU/mL (P < .001). TE values changed by a mean of −0.2 kPa (P = .097), and declined significantly in subjects who had pretenofovir HBV DNA levels >2000 IU/mL (mean, −0.8 kPa; P = .048) or TE values >7.6 kPa (mean, −1.2 kPa; P = .021). HIV-1 RNA detection rates remained unchanged.

Conclusions. A proportion of HIV/HBV-coinfected patients on long-term lamivudine-containing ART had poor HIV and HBV suppression, drug resistance, and TE values indicative of advanced liver fibrosis. Tenofovir improved HBV control and reduced liver stiffness in subjects with high HBV DNA load and TE values.

Background

Global cases of COVID-19 continue to rise, causing havoc to several economies. So far, Ghana has recorded 48,643 confirmed cases with 320 associated deaths. Although summaries of data are usually provided by the Ministry of Health, detailed epidemiological profile of cases are limited. This study sought to describe the socio-demographic features, pattern of COVID-19 spread and the viral load dynamics among subjects residing in northern, middle and part of the southern belt of Ghana.

Methods

This was a cross-sectional retrospective study that reviewed records of samples collected from February to July, 2020. Respiratory specimens such as sputum, deep-cough saliva and nasopharyngeal swabs were collected from suspected COVID-19 subjects in 12 regions of Ghana for laboratory analysis and confirmation by real-time reverse transcription polymerase chain reaction (RT-PCR).

Results

A total of 72,434 samples were collected during the review period, with majority of the sampled individuals being females (37,464; 51.9%). The prevalence of SARS-CoV-2 identified in the study population was 13.2% [95%CI: 12.9, 13.4). Males were mostly infected (4,897; 51.5%) compared to females. Individuals between the ages 21–30 years recorded the highest number of infections (3,144, 33.4%). Symptomatic subjects had higher viral loads (1479.7 copies/μl; IQR = 40.6–178919) than asymptomatic subjects (49.9; IQR = 5.5–3641.6). There was significant association between gender or age and infection with SARS-CoV-2 (p<0.05). Among all the suspected clinical presentations, anosmia was the strongest predictor of SARS-CoV-2 infection (Adj. OR (95%CI): 24.39 (20.18, 29.49). We observed an average reproductive number of 1.36 with a minimum of 1.28 and maximum of 1.43. The virus trajectory shows a gradual reduction of the virus reproductive number.

Conclusion

This study has described the epidemiological profile of COVID-19 cases in northern, middle and part of the southern belt of Ghana, with males and younger individuals at greater risk of contracting the disease. Health professionals should be conscious of individuals presenting with anosmia since this was seen as the strongest predictor of virus infection.

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Infection of subcutaneous tissue with Mycobacterium ulcerans can lead to chronic skin ulceration known as Buruli ulcer. The pathogenesis of this neglected tropical disease is dependent on a lipid-like toxin, mycolactone, which diffuses through tissue away from the infecting organisms. Since its identification in 1999, this molecule has been intensely studied to elucidate its cytotoxic and immunosuppressive properties. Two recent major advances identifying the underlying molecular targets for mycolactone have been described. First, it can target scaffolding proteins (such as Wiskott Aldrich Syndrome Protein), which control actin dynamics in adherent cells and therefore lead to detachment and cell death by anoikis. Second, it prevents the co-translational translocation (and therefore production) of many proteins that pass through the endoplasmic reticulum for secretion or placement in cell membranes. These pleiotropic effects underpin the range of cell-specific functional defects in immune and other cells that contact mycolactone during infection. The dose and duration of mycolactone exposure for these different cells explains tissue necrosis and the paucity of immune cells in the ulcers. This review discusses recent advances in the field, revisits older findings in this context and highlights current developments in structure-function studies as well as methodology that make mycolactone a promising diagnostic biomarker.

Treating Mansonella perstans is challenged by the low efficacy of registered antihelminthics. Wolbachia endobacteria provide an alternative treatment target because depletion results in amicrofilaremia in filarial infections with Wuchereria bancrofti and Onchocerca volvulus infections. This open-label, randomized study sought to confirm that i) Wolbachia are present in M. perstans in Ghana and ii) doxycycline treatment will deplete Wolbachia and cause a slow, sustained decline in microfilariae (MF). Two hundred and two Ghanaians with M. perstans infection were randomized into early (immediate) and delayed (6 months deferred) treatment groups, given doxycycline 200 mg/day for 6 weeks, and monitored for MF and Wolbachia levels at baseline, 4, 12, and 24 months after the study onset (= time of randomization and start of treatment for the early group). Per protocol analysis revealed that the median MF/mL in the early group declined from 138 at baseline to 64 at month 4 and further to 0 at month 12. In the delayed group, MF load did not change from a baseline median of 97 to 102 at month 4 but declined to 42 at month 12, that is, 6 months after receiving treatment, trailing the early group as expected. By month 24, both treatment groups had reached a median MF level of 0. After treatment, Wolbachia were depleted from MF by ≥ 1-log drop compared with baseline levels. We conclude that M. perstans in Ghana harbor Wolbachia that are effectively depleted by doxycycline with subsequent reduction in MF loads, most likely because of interruption of fertility of adult worms.

Objectives

The global prevalence of intestinal extended-spectrum β-lactamase–producing Enterobacterales (ESBL-PE) is approximately 17% in communities, with significant variations among regions. This longitudinal study aimed to assess the impact of antibiotic intake on the incidence of intestinal ESBL-PE in Ghanaian pharmacy customers outside of hospitals.

Methods

Screening for ESBL-PE was performed in four independent pharmacies in Kumasi, Ghana, using rectal swabs and an ESBL-PE–selective medium. Pharmacy customers purchasing antibiotics were recruited, and those buying non-antibiotic drugs served as controls. Participants who were negative for ESBL-PE provided follow-up swabs for up to 28 days.

Results

At baseline, 302 (75%) of 404 participants were colonized with ESBL-PE. Sixty-three participants who were negative for ESBL-PE at baseline received per-protocol follow-up, including 28 individuals who took antibiotics and 35 controls. The cumulative proportions of ESBL-PE in the antibiotics and control groups were 71% (20/28) and 54% (19/35) at the first follow-up (p 0.258), 86% (24/28) and 80% (28/35) at the second follow-up (p 0.741) and 86% (24/28) and 94% (33/35) at the third follow-up (p 0.393), respectively.

Discussion

The rate of intestinal ESBL-PE carriage among pharmacy customers outside of hospitals was higher than expected at baseline and further increased during the 28 days of follow-up, irrespective of antibiotic intake. This alarming finding needs to be considered in the antibiotic treatment of outpatients and emphasizes the urgent need for improved prevention strategies, development of new antibiotic drugs and potential future elimination strategies. Further longitudinal studies on ESBL-PE in African communities, also outside of pharmacy settings, are required.

BACKGROUND: Encephalitis is a serious disease of the brain characterized by

prodromal and specific neurological symptoms. HIV infections offer opportunistic

viruses, such as Varicella-zoster virus (VZV), the chance to cause encephalitis

in patients. There is a lack of information on the genetic diversity of VZV in

Ghana and other parts of Africa which requires sequencing and characterization

studies to address. The active evolution of HIV-1 in West Africa also requires

continuous surveillance for the emergence of new genetic forms.

CASE PRESENTATION: VZV was detected in the CSF sample of an 11-year-old patient

presenting with symptoms of encephalitis by real-time PCR diagnostics. To

identify possible unknown aetiological pathogens, next-generation sequencing was

performed, and revealed an HIV-1 co-infection. Alignments of concatenated HIV-1

genome fragments in the gag, pol, vif, env and nef regions and a near-complete

VZV genome were analyzed by Bayesian inference, and phylogenetic trees were

generated. The VZV sequence belongs to clade 5 and the HIV-1 sequence is a

member of the CRF02_AG predominant circulating recombinant form in Ghana.

CONCLUSIONS: Diagnostic tests for CSF HIV would be useful where possible in

patients presenting with encephalitis due to VZV and other opportunistic viruses

in Kumasi to shed light on the role of HIV in encephalitis cases in Ghana. This

report reaffirms the role of the CRF02_AG circulating recombinant form in HIV

infections in Ghana and also gives a preliminary genetic characterization of VZV

in Kumasi, Ghana.

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: HCV RNA screening of large sample repositories provides data on HCV epidemic patterns that mayhelp guide control policies. In resource-limited settings, shipment of frozen samples to molecular laboratory facilities and testing of individual samples may be prohibitively expensive.

Objective: Our aim was to detect and sequence HCV RNA in a large HIV-positive cohort from Kumasi, Ghana,using pooled and individual dried plasma spots (DPS) produced from samples stored at −80 °C.

Study design: In the validation phase, replicate DPS were prepared with six dilutions (500–10,000 IU/ml) of the 4th International Standard for HCV and tested in three independent experiments. In the testing phase, DPS prepared with plasma samples from 875 HIV-positive subjects were pooled for screening, followed by testing of
individual DPS of positive pools. Input from individual DPS was two 6 mm punches; pools comprised two punches from each of five DPS. Genotypes were determined by Sanger sequencing of HCV core and NS5B.

Results: With the dilution series, sensitivity of HCV RNA detection was ≥2500 IU/ml. Replicate DPS gave intra-assay and inter-assay coefficients of variation ≤1.4%. With the stored samples, HCV RNA was detected in 5/175 DPS pools and in one DPS from each positive pool, yielding a HCV RNA prevalence of 5/875 (0.57%; 95% confidence interval 0.07-1.07%). The five samples were sequenced as HCV genotypes 2l and 2r.

Discussion: DPS allowed reproducible HCV RNA detection, and pooling effectively contained the cost and labour
of screening a previously untested, low-prevalence cohort. DPS were also suitable for HCV sequencing.

Background: Antibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic.

Methods: A retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders.

Results: A total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5-124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly.

Conclusion: The decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU.

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.

Immunopathology in human tuberculosis affects T-cell phenotype and functions.
Previous studies identified impaired T-cell sensitivity to Interleukin (IL)-7
accompanied by lower IL-7 receptor α-chain (IL-7Rα) expression in patients with
acute tuberculosis. In the present study, we characterized affected T-cell
subsets and determined the influence of tuberculosis disease severity and
treatment response. Tuberculosis patients (n = 89) as well as age- and
gender-matched asymptomatic contacts (controls, n = 47) were recruited in Ghana.
Mycobacterium (M.) tuberculosis sputum burden was monitored prior to and during
treatment. Blood samples from all patients and controls were analyzed for IL-7Rα
expression and T-cell markers by multi-colour flow cytometry. CD4+ and CD8+
T-cells of tuberculosis patients showed generally lower IL-7Rα expression as
compared to controls. Concomitantly, tuberculosis patients had higher
proportions of naïve and lower proportions of memory CD4+ T-cells. Notably, a
subset of CD27 positive central memory T-cells (Tcm), which lacked IL-7Rα
expression was enriched in tuberculosis patients as compared to controls. M.
tuberculosis sputum burden was not associated with differences in IL-7Rα
expression. Treatment duration and response showed no clear effects although
IL-7Rα expression patterns were highly variable. These results suggested
generally impaired generation of memory CD4+ T-cells and enrichment of a Tcm
subset without IL-7Rα expression in patients with tuberculosis.

In the post-polio eradication era, increasing attention is given to non-polio enteroviruses. Most of the data about enteroviruses in sub-Saharan Africa are related to acute flaccid paralysis surveillance and target the pediatric population. This study aimed to investigate the presence of enterovirus in PLHIV (people living with HIV) and HIV-negative individuals in Ghana. Stool samples from HIV-positive individuals (n = 250) and healthy blood donors (n = 102) attending the Komfo Anokye Teaching Hospital in Kumasi, Ghana, were screened by real-time PCR for enterovirus. Molecular typing of the VP1 region was performed. Enterovirus-positive samples were tested for norovirus, adenovirus, rotavirus, sapovirus, and cosaviruses. Twenty-six out of 250 HIV-positive subjects (10.4%) and 14 out of 102 HIV-negative individuals (13.7%) were detected enterovirus-positive, not showing a significant different infection rate between the two groups. HIV-negative individuals were infected with Enterovirus C strains only. HIV-positive participants were detected positive for species Enterovirus A, Enterovirus B, and Enterovirus C. Co-infections with other viral enteric pathogens were almost exclusively detected among HIV-positive participants. Overall, the present study provides the first data about enteroviruses within HIV-positive and HIV-negative adults living in Ghana.

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<0.001), oedematous (OR 4.23; 95% CI 1.43-12.5; p = 0.009) and category II lesions (OR 2.26; 95% CI 1.14-4.48; p = 0.02) were strongly associated with the occurrence of PR. The median time to complete healing (28 vs 13 weeks, p <0.001) was significantly longer in the PR group.

Conclusions: Buruli ulcer patients who develop PR are characterized by high bacterial load in lesion samples taken at baseline and a higher rate of positive M. ulcerans culture. Occurrence of a PR was associated with delayed healing.

Objective/Background: Drug-resistant strains of tuberculosis (TB) represent a major threat to global TB control. In low- and middle-income countries, resource constraints make it difficult to identify and monitor cases of resistance using drug susceptibility testing and culture. Molecular assays such as the GeneXpert Mycobacterium tuberculosis/rifampicin may prove to be a cost-effective solution to this problem in these settings. The objective of this study is to evaluate the use of GeneXpert in the diagnosis of pulmonary TB since it was introduced into two tertiary hospitals in Ghana in 2013.

Methods: A 2-year retrospective audit of clinical cases involving patients who presentedwith clinically suspected TB or documented TB not improving on standard therapy and had samples sent for GeneXpert testing.Results: GeneXpert identified 169 cases of TB, including 17 cases of rifampicin-resistant TB. Of the seven cases with final culture and drug susceptibility testing results, six demonstrated further drug resistance and five of these were multidrug-resistant TB.

Conclusion: These findings call for a scale-up of TB control in Ghana and provide evidence that the expansion of GeneXpert may be an optimal means to improve case finding and guide treatment of drug-resistant TB in this setting.

IFN-γ release assays [e.g., QuantiFERON (QFT)] are widely used for diagnosis of Mycobacterium tuberculosis (Mtb) infection. T-cell responses against QFT antigens ESAT6 and CFP10 are highly Mtb specific but previous studies indicated suboptimal assay sensitivity. Especially for potentially infected healthy contacts (HCs) of tuberculosis patients, alternative antigen usage and more sensitive tests may contribute to improved detection of latent Mtb infection. In a pilot case-control study of tuberculosis patients (n = 22) and HCs (n = 20) from Ghana, we performed multifaceted in vitro assays to identify optimal assay conditions. This included a two-hit stimulation assay, which is based on initial and second re-stimulation with the same antigen on d6 and intracellular IFN-γ analysis, to compare T-cell responses against ESAT6/CFP10 (E6/C10) and selected latency antigens (i.e. Rv2628, Rv1733, Rv2031, Rv3407) of Mtb. Considerable subgroups of tuberculosis patients (64%) and HCs (75%) had negative or indeterminate QFT results partially accompanied by moderate PHA induced responses and high IFN-γ background values. Intracellular IFN-γ analysis of E6/C10 specific CD4+ T-cell subpopulations and evaluation of responder frequencies had only moderate effects on assay sensitivity. However, two-hit in vitro stimulation significantly enhanced E6/C10 specific IFN-γ positive T-cell proportions especially in QFT non-responders, and in both study groups. Mtb latency antigen-specific T cells against Rv1733 and Rv2628 were especially detected in HCs after two-hit stimulation and T-cell responses against Rv2628 were highly capable to discriminate tuberculosis patients and HCs. Two-hit in vitro stimulation may improve moderate sensitivity of short term IFN-γ based assays, like QFT, to detect Mtb infection. Latency stage-specific antigens added significantly to detection of Mtb infection in HCs and tuberculosis patients with negative QFT test results.

Introduction: Pharmacological treatment of Buruli ulcer (Mycobacterium ulcerans infection; BU) is highly effective, as shown in two randomized trials in Africa. Areas covered: We review BU drug treatment–in vitro, in vivo and clinical trials (PubMed: ‘(Buruli OR (Mycobacterium AND ulcerans)) AND (treatment OR therapy).’ We also highlight the pathogenesis of M. ulcerans infection that is dominated by mycolactone, a secreted exotoxin, that causes skin and soft tissue necrosis, and impaired immune response and tissue repair. Healing is slow, due to the delayed wash-out of mycolactone. An array of repurposed tuberculosis and leprosy drugs appears effective in vitro and in animal models. In clinical trials and observational studies, only rifamycins (notably, rifampicin), macrolides (notably, clarithromycin), aminoglycosides (notably, streptomycin) and fluoroquinolones (notably, moxifloxacin, and ciprofloxacin) have been tested. Expert opinion: A combination of rifampicin and clarithromycin is highly effective but lesions still take a long time to heal. Novel drugs like telacebec have the potential to reduce treatment duration but this drug may remain unaffordable in low-resourced settings. Research should address ulcer treatment in general; essays to measure mycolactone over time hold promise to use as a readout for studies to compare drug treatment schedules for larger lesions of Buruli ulcer.

BACKGROUND: Buruli ulcer (BU) can lead to disfiguring ulcers and permanent

disability. The 2030 World Health Organization (WHO) road map for Neglected

Tropical Diseases (NTDs) calls for major scaling up in diagnosis and management

to eliminate disability due to the disease. Current treatment for BU is with

daily oral rifampicin (10mg/kg dose) and clarithromycin (15mg/kg dose) for eight

weeks, combined with standard gauze wound dressings. Dialkylcarbamoyl chloride

(DACC)-coated dressings have been shown to irreversibly bind bacteria on wound

surfaces resulting in their removal when dressings are changed. This trial aims

to determine whether combining a high-dose oral rifampicin regimen with DACC

dressings can improve the rate of wound healing relative to standard-dose oral

rifampicin combined with DACC dressings.

METHODS: This is an individual, multi-centre Phase 3 randomised controlled

trial, which will be conducted in three clinical sites in Ghana. The primary

outcome measure will be the mean time to clearance of viable mycobacteria. Cost

and health-related quality of life data will be collected, and a

cost-effectiveness analysis will be performed.

DISCUSSION: The findings from this trial could lead to a change in how BU is

treated. A shorter but more efficacious regimen would lead to improved treatment

outcomes and potentially substantial financial and economic savings.

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 high-level 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.

The COVID-19 pandemic is one of the fastest evolving pandemics in recent history. As such, the SARS-CoV-2 viral evolution needs to be continuously tracked. This study sequenced 1123 SARS-CoV-2 genomes from patient isolates (121 from arriving travellers and 1002 from communities) to track the molecular evolution and spatio-temporal dynamics of the SARS-CoV-2 variants in Ghana. The data show that initial local transmission was dominated by B.1.1 lineage, but the second wave was overwhelmingly driven by the Alpha variant. Subsequently, an unheralded variant under monitoring, B.1.1.318, dominated transmission from April to June 2021 before being displaced by Delta variants, which were introduced into community transmission in May 2021. Mutational analysis indicated that variants that took hold in Ghana harboured transmission enhancing and immune escape spike substitutions. The observed rapid viral evolution demonstrates the potential for emergence of novel variants with greater mutational fitness as observed in other parts of the world.

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 decentra-lise 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 regres-sion 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.

The gold standard for detection of Mycobacterium ulcerans is PCR due to its high

accuracy in confirmation of suspected cases. But the available PCR assays are

designed for standard size thermocyclers which are immobile and suited for

reference laboratories often located long distances from endemic communities.

This makes it a challenge to obtain immediate results for patient management. We

validated and evaluated a dried reagent-based PCR assay adapted for a handheld,

battery-operated, portable thermocycler with the potential to extend diagnostics

to endemic communities with limited infrastructure. The diagnostic accuracy of

the assay following a multi-center evaluation by three Buruli ulcer reference

laboratories with over 300 clinical samples showed sensitivity and specificity

of 100-97% and 100-94%, respectively using centralized IS2404 quantitative PCR

platform as a reference standard. This assay coupled with a field-friendly

extraction method fulfill almost all the target product profiles of Buruli ulcer

for decentralized testing at the district, health center and community levels; a

key critical action for achieving the NTD Road Map 2030 target for Buruli ulcer.

Bacterial components and cytokines induce IL-7 receptor (IL-7Rα) expression in

monocytes. Aberrant low IL-7Rα expression of monocytes has been identified as a

feature of tuberculosis immunopathology. Here, we investigated the mechanisms

underlying IL-7Rα regulation of monocytes and tuberculosis serum effects on

IL-7Rα expression. Serum samples from tuberculosis patients and healthy

controls, cytokine candidates, and mycobacterial components were analyzed for in

vitro effects on IL-7Rα expression of primary monocytes, monocyte-derived

macrophages (MDM), and monocyte cell lines. IL-7Rα regulation during culture and

the role of FoxO1 were characterized. In vitro activation-induced IL-7Rα

expression in human monocytes and serum samples from tuberculosis patients

boosted IL-7Rα expression. Although pathognomonic tuberculosis cytokines were

not associated with serum effects, we identified cytokines (i.e., GM-CSF, IL-1β,

TNF-α, IFN-γ) that induced IL-7Rα expression in monocytes and/or MDM comparable

to mycobacterial components. Blocking of cytokine subsets (i.e., IL-1β/TNF-α in

monocytes, GM-CSF in MDM) largely diminished IL-7Rα expression induced by

mycobacterial components. Finally, we showed that in vitro-induced IL-7Rα

expression was transient and dependent on constitutive FoxO1 expression in

primary monocytes and monocyte cell lines. This study demonstrated the crucial

roles of cytokines and constitutive FoxO1 expression for transient IL-7Rα

expression in monocytes.

Scabies is a parasitic disease of the skin that disproportionately affects disadvantaged populations. The disease causes considerable morbidity and leads to severe bacterial infection and immune-mediated disease. Scientific advances from the past 5 years suggest that scabies is amenable to population-level control, particularly through mass drug administration. In recognition of these issues, WHO added scabies to the list of neglected tropical diseases in 2017. To develop a global control programme, key operational research questions must now be addressed. Standardised approaches to diagnosis and methods for mapping are required to further understand the burden of disease. The safety of treatments for young children, including with ivermectin and moxidectin, should be investigated. Studies are needed to inform optimum implementation of mass treatment, including the threshold for intervention, target, dosing, and frequency. Frameworks for surveillance, monitoring, and evaluation of control strategies are also necessary.

The COVID-19 pandemic is one of the fastest evolving pandemics in recent

history. As such, the SARS-CoV-2 viral evolution needs to be continuously

tracked. This study sequenced 1123 SARS-CoV-2 genomes from patient isolates (121

from arriving travellers and 1002 from communities) to track the molecular

evolution and spatio-temporal dynamics of the SARS-CoV-2 variants in Ghana. The

data show that initial local transmission was dominated by B.1.1 lineage, but

the second wave was overwhelmingly driven by the Alpha variant. Subsequently, an

unheralded variant under monitoring, B.1.1.318, dominated transmission from

April to June 2021 before being displaced by Delta variants, which were

introduced into community transmission in May 2021. Mutational analysis

indicated that variants that took hold in Ghana harboured transmission enhancing

and immune escape spike substitutions. The observed rapid viral evolution

demonstrates the potential for emergence of novel variants with greater

mutational fitness as observed in other parts of the world.

Background: The 69th World Health Assembly approved the Global Health Sector Strategy to eliminate hepatitis C virus (HCV) infection by 2030, which can become a reality with the recent launch of direct acting antiviral therapies. Reliable disease burden estimates are required for national strategies. This analysis estimates the global prevalence of viraemic HCV at the end of 2015, an update of—and expansion on—the 2014 analysis, which reported 80 million (95% CI 64–103) viraemic infections in 2013.

Methods: We developed country-level disease burden models following a systematic review of HCV prevalence (number of studies, n=6754) and genotype (n=11 342) studies published af ter 2013. A Delphi process was used to gain country expert consensus and validate inputs. Published estimates alone were used for countries where expert panel meetings could not be scheduled. Global prevalence was estimated using regional averages for countries without data.

Findings: Models were built for 100 countries, 59 of which were approved by country experts, with the remaining 41 estimated using published data alone. The remaining countries had insufficient data to create a model. The global prevalence of viraemic HCV is estimated to be 1·0% (95% uncertainty interval 0·8–1·1) in 2015, corresponding to 71·1 million (62·5–79·4) viraemic infections. Genotypes 1 and 3 were the most common cause of infections (44% and 25%, respectively).

Interpretation: The global estimate of viraemic infections is lower than previous estimates, largely due to more recent (lower) prevalence estimates in Africa. A dditionally, increased mortality due to liver-related causes and an ageing population may have contributed to a reduction in infections.

Background: Access to an accurate diagnostic test for Buruli ulcer (BU) is a research priority according to the World Health Organization. Nucleic acid amplification of insertion sequence IS2404 by polymerase chain reaction (PCR) is the most sensitive and specific method to detect Mycobacterium ulcerans (M. ulcerans), the causative agent of BU. However, PCR is not always available in endemic communities in Africa due to its cost and technological sophistication. Isothermal DNA amplification systems such as the recombinase polymerase amplification (RPA) have emerged as a molecular diagnostic tool with similar accuracy to PCR but having the advantage of amplifying a template DNA at a constant lower temperature in a shorter time. The aim of this study was to develop RPA for the detection of M. ulcerans and evaluate its use in Buruli ulcer disease.

Methodology and principal findings: A specific fragment of IS2404 of M. ulcerans was amplified within 15 minutes at a constant 42°C using RPA method. The detection limit was 45 copies of IS2404 molecular DNA standard per reaction. The assay was highly specific as all 7 strains of M. ulcerans tested were detected, and no cross reactivity was observed to other mycobacteria or clinically relevant bacteria species. The clinical performance of the M. ulcerans (Mu-RPA) assay was evaluated using DNA extracted from fine needle aspirates or swabs taken from 67 patients in whom BU was suspected and 12 patients with clinically confirmed non-BU lesions. All results were compared to a highly sensitive real-time PCR. The clinical specificity of the Mu-RPA assay was 100% (95% CI, 84-100), whiles the sensitivity was 88% (95% CI, 77-95).

Conclusion: The Mu-RPA assay represents an alternative to PCR, especially in areas with limited infrastructure.

BACKGROUND: The declaration of COVID-19 as a pandemic on March 11 2020, by the

World Health Organisation prompted the need for a sustained and a rapid

international response. In a swift response, the Government of Ghana, in

partnership with Zipline company, launched the use of Unmanned Automated

Vehicles (UAV) to transport suspected samples from selected districts to two

foremost testing centres in the country. Here, we present the experiences of

employing this technology and its impact on the transport time to the second

largest testing centre, the Kumasi Centre for Collaborative Research in Tropical

Medicine (KCCR) in Kumasi, Ghana.

METHODS: Swab samples collected from suspected COVID-19 patients were

transported to the Zipline office by health workers. Information on the samples

were sent to laboratory personnel located at KCCR through a WhatsApp platform to

get them ready to receive the suspected COVID-19 samples while Zipline

repackaged samples and transported them via drone. Time of take-off was reported

as well as time of drop-off.

RESULTS: A total of 2537 COVID-19 suspected samples were received via drone

transport from 10 districts between April 2020 to June 2021 in 440 deliveries.

Ejura-Sekyedumase District Health Directorate delivered the highest number of

samples (765; 30%). The farthest district to use the drone was Pru East, located

270 km away from KCCR in Kumasi and 173 km to the Zipline office in Mampong.

Here, significantly, it took on the average 39 minutes for drones to deliver

samples compared to 117 minutes spent in transporting samples by road (p<0.001).

CONCLUSION: The use of drones for sample transport during the COVID-19 pandemic

significantly reduced the travel time taken for samples to be transported by

road to the testing site. This has enhanced innovative measures to fight the

pandemic using technology.

Buruli ulcer (BU) is an infectious skin disease that occurs mainly in West and Central Africa. It can lead to severe disability and stigma because of scarring and contractures. Effective treatment with antibiotics is available, but patients often report to the hospital too late to prevent surgery and the disabling consequences of the disease. In a highly endemic district in Ghana, intensified public health efforts, mainly revolving around training and motivating community-based surveillance volunteers (CBSVs), were implemented. As a result, 70% of cases were reported in the earliest—World Health Organization category I—stage of the disease, potentially minimizing the need for surgery. CBSVs referred more cases in total and more cases in the early stages of the disease than any other source. CBSVs are an important resource in the early detection of BU.

The city is not just a context for friendships or a problem to be solved through them; it can be a cat-alyst for these relationships, sparking and strengthening connections between individuals and groups.Shared experiences of and curiosity in cities – expressed through practices that include revisitingfamiliar places and exploring others for the first time – can draw people together in beneficial ways.These principles underpin a health and wellbeingagenda, pioneered in Liverpool, which encouragespeople to ‘take notice’ and ‘connect’ – two of five ‘ways to wellbeing’ promoted through theLiverpool Decade of Health and Wellbeing. This paper focusses upon one particular set of schemesand relationships which brings all this into focus: befriending schemes designed to support people with dementia, which engage with objects and placesas catalysts for connection. These observationsshed a broader light upon the meanings and uses of friendship, with particular reference to cities.

Background: Hepatitis D virus (also known as hepatitis delta virus) can establish a persistent infection in people with chronic hepatitis B, leading to accelerated progression of liver disease. In sub-Saharan Africa, where HBsAg prevalence is higher than 8%, hepatitis D virus might represent an important additive cause of chronic liver disease. We aimed to establish the prevalence of hepatitis D virus among HBsAg-positive populations in sub-Saharan Africa.

Methods: We systematically reviewed studies of hepatitis D virus prevalence among HBsAg-positive populations in sub-Saharan Africa. We searched PubMed, Embase, and Scopus for papers published between Jan 1, 1995, and Aug 30, 2016, in which patient selection criteria and geographical setting were described. Search strings included sub-Saharan Africa, the countries therein, and permutations of hepatitis D virus. Cohort data were also added from HIV-positive populations in Malawi and Ghana. Populations undergoing assessment in liver disease clinics and those sampled from other populations (defined as general populations) were analysed. We did a meta-analysis with a DerSimonian-Laird random-effects model to calculate a pooled estimate of hepatitis D virus seroprevalence.

Findings: Of 374 studies identified by our search, 30 were included in our study, only eight of which included detection of hepatitis D virus RNA among anti-hepatitis D virus seropositive participants. In west Africa, the pooled seroprevalence of hepatitis D virus was 7·33% (95% CI 3·55–12·20) in general populations and 9·57% (2·31–20·43)
in liver-disease populations. In central Africa, seroprevalence was 25·64% (12·09–42·00) in general populations and 37·77% (12·13–67·54) in liver-disease populations. In east and southern Africa, seroprevalence was 0·05% (0·00–1·78) in general populations. The odds ratio for anti-hepatitis D virus detection among HBsAg-positive patients
with liver fibrosis or hepatocellular carcinoma was 5·24 (95% CI 2·74–10·01; p<0·0001) relative to asymptomatic controls.

Interpretation: Findings suggest localised clusters of hepatitis D virus endemicity across sub-Saharan Africa. Epidemiological data are needed from southern and east Africa, and from patients with established liver disease. Further studies should aim to define the reliability of hepatitis D virus testing methods, identify risk factors for
transmission, and characterise the natural history of the infection in the region.

Objectives: IFNγ-release assays (IGRAs) used for diagnosis of Mycobacterium (M.) tuberculosis infection have limited sensitivity. Alternative cytokines and M. tuberculosis latency-associated antigens may improve immune-based tests. Methods: Multiplex cytokine analyses was done in culture supernatants after 6-day in vitro restimulation with M. tuberculosis IGRA and latency-associated antigens (i.e. Rv2628, Rv1733) in tuberculosis patients (n = 22) and asymptomatic contacts (AC)s (n = 20) from Ghana. Results: Four cytokines (i.e. IFNγ, IP-10, IL-22 and IL-6) were significantly increased after IGRA-antigen specific restimulation. IFNγ, IP-10, and IL-22 correlated positively and showed no differences between the study groups whereas IGRA-antigen induced IL-6 was significantly higher in tuberculosis patients. Using adjusted IGRA criteria, IL-6 showed the highest sensitivity for detection of tuberculosis patients (91%) and ACs (85%) as compared to IFNγ, IP-10, and IL-22. Rv2628 and Rv1733 restimulation induced significantly higher IFNγ, IP-10, and IL-22 concentrations in ACs. Combined antigen/cytokine analyses identified study group specific patterns and a combination of Rv2628/Rv1733 induced IFNγ with IGRA-antigen induced IL-6 was optimal for classification of tuberculosis patients and ACs (AUC: 0.92, p<0.0001). Conclusions: We demonstrate the potency of alternative cytokines, especially IL-6, and latency-associated antigens Rv1733/Rv2628 to improve detection of M. tuberculosis infection and to classify tuberculosis patients and healthy contacts.

Buruli ulcer is one of the 20 neglected tropical diseases in the world. This necrotizing hypodermitis is a chronic debilitating disease caused by an environmental Mycobacterium ulcerans. At least 33 countries with tropical, subtropical and temperate climates have reported Buruli ulcer in African countries, South America and Western Pacific regions. Majority of cases are spread across West and Central Africa. The mode of transmission is unclear, hindering the implementation of adequate prevention for the population. Currently, early diagnosis and treatment are crucial to minimizing morbidity, costs and preventing long-term disability. Biological confirmation of clinical diagnosis of Buruli ulcer is essential before starting chemotherapy. Indeed, differential diagnosis are numerous and Buruli ulcer has varying clinical presentations. Up to now, the gold standard biological confirmation is the quantitative PCR, targeting the insertion sequence IS2404 of M. ulcerans performed on cutaneous samples. Due to the low PCR confirmation rate in endemic African countries (under 30% in 2018) for numerous identified reasons within this article, 11 laboratories decided to combine their efforts to create the network “BU-LABNET” in 2019. The first step of the network was to harmonize the procedures and ship specific reagents to each laboratory. With this system in place, implementation of these procedures for testing and follow-up was easy and the laboratories were able to carry out their first quality control with a very high success rate. It is now time to integrate other neglected tropical diseases to this platform, such as yaws or leprosy.

HIV coinfection with HCV has been poorly studied in sub-Saharan Africa, and the reliability of available seroprevalence estimates remains uncertain. The study aim was to determine HCV RNA prevalence in HIV-infected subjects receiving care in Kumasi, Ghana, and relate the findings to HCV antibody detection. From a population of 1520 HIV-infected adults, all HBsAg-positive subjects (n = 236) and a random subset of HBsAg-negative subject (n = 172) were screened for HCV RNA using pooled plasma; positive samples were genotyped by core and NS5B sequencing. HCV antibodies were detected by three commercial screening assays and confirmed by the line immunoassay. HCV RNA was detected in 4/408 subjects (1.0%, 95% confidence interval 0.0–1.9%), comprising 3/236 (1.3%; 0.0–2.8%) HBsAg-positive and 1/172 (0.6%; 0.0–1.8%) HBsAg-negative subjects. HCV RNA-positive subjects showed reactivity in all three antibody screening assays. Among HCV RNA-negative subjects, 5/67 (7.5%), 5/67 (7.5%) and 19/67 (28.4%) showed antibody reactivity by each screening assay, respectively, including two (3.0%) with reactivity by all three assays. Only one sample (1.5%) had confirmed antibody reactivity by line immunoassay indicating past HCV infection. HCV-positive subjects (three males, two females) were aged 30–46 years, by questionnaire-based interview reported surgical procedures and blood transfusion as risk factors for infection. HCV genotypes were 2 (subtypes 2j, 2l, 2k/unassigned) and 1 (subtype unassigned). Without further testing, HCV antibody screening assays variably overestimated HCV prevalence among HIV-infected subjects in Ghana. These findings inform the interpretation of previous seroprevalence estimates based upon screening assays alone.

Aspergillomas are often misdiagnosed as tuberculosis (TB) in developing countries where the prevalence of TB is high, hemoptysis is often equated with TB, and most patients are diagnosed clinically. This report describes the case of a patient being treated for smear-negative TB who presented with hemoptysis and was found to have an aspergilloma.

Real-world data on vaccine-elicited neutralising antibody responses for two-dose

AZD1222 in African populations are limited. We assessed baseline SARS-CoV-2

seroprevalence and levels of protective neutralizing antibodies prior to

vaccination rollout using binding antibodies analysis coupled with pseudotyped

virus neutralisation assays in two cohorts from West Africa: Nigerian healthcare

workers (n = 140) and a Ghanaian community cohort (n = 527) pre and post

vaccination. We found 44 and 28% of pre-vaccination participants showed IgG

anti-N positivity, increasing to 59 and 39% respectively with anti-receptor

binding domain (RBD) IgG-specific antibodies. Previous IgG anti-N positivity

significantly increased post two-dose neutralizing antibody titres in both

populations. Serological evidence of breakthrough infection was observed in 8/49

(16%). Neutralising antibodies were observed to wane in both populations,

especially in anti-N negative participants with an observed waning rate of 20%

highlighting the need for a combination of additional markers to characterise

previous infection. We conclude that AZD1222 is immunogenic in two independent

West African cohorts with high background seroprevalence and incidence of

breakthrough infection in 2021. Waning titres post second dose indicates the

need for booster dosing after AZD1222 in the African setting despite hybrid

immunity from previous infection.

Background: Buruli Ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans. Former BU patients may experience participation restrictions due to physical limitations, stigmatization and other social factors. A scale that measures participation restrictions among children, who represent almost half of the affected population, has not been developed yet. Here, we present the development of a scale that measures participation restrictions in former BU paediatric patients, the psychometric properties of this scale and the scales' results.

Methods: Items were selected and a scale was developed based on interviews with health care workers and former BU patients in and around the BU treatment centre in Lalo, Benin. Construct validity was tested using six a priori formulated hypotheses. Former BU patients under 15 years of age who received treatment in one of the BU treatment centres in Ghana and Benin between 2007-2012 were interviewed.

Results: A feasible 16-item scale that measures the concept of participation among children under 15 years of age was developed. In total, 109 (Ghana) and 90 (Benin) former BU patients were interviewed between 2012-2017. Five construct validity hypotheses were confirmed of which 2 hypotheses related to associations with existing questionnaires were statistically significant (p<0.05). In Ghana 77% of the former patients had a Paediatric Participation (PP) scale score of 0 compared to 22% in Benin. More severe lesions related to BU were seen in Benin. Most of the reported participation problems were related to sports, mainly in playing games with others, going to the playfield and doing sports at school.

Conclusion: The preliminary results of the PP-scale validation are promising but further validation is needed. The developed PP-scale may be valid for use in patients with more severe BU lesions. This is the first research to confirm that former BU patients under 15-year face participation restrictions in important aspects of their lives.

Functional interleukin-7 receptor α-chain (IL-7Rα) genetic variants, which affect alternative splicing and expression of the soluble IL-7Rα, are associated with susceptibility to autoimmunity. We previously described aberrant IL-7Rα expression and impaired IL-7-mediated T-cell functions in tuberculosis patients. In the present study, we investigated a possible role of IL7RA gene variants. Six exonic IL7RA polymorphisms were genotyped and two minor alleles were found at lower frequencies in tuberculosis patients as compared to healthy contacts from Ghana (rs11567764, p = 0.002; rs1494558, p = 0.01). The rs11567764 polymorphism tags an IL7RA haplotype exclusively found in African populations and was predicted to affect splicing of exon 5. Reduced mRNA expression of the Δexon_5-6 variant was found in T-cells from carriers of the protective rs11567764 allele. Although we were not able to demonstrate the causative effect of rs11567764, our findings suggested functional implications of genetic variants on IL-7Rα splicing and with potential impact on T-cell protection against tuberculosis.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets—“WHO Targets” (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening