Prevalence of refractive error and other eye diseases in schoolchildren in the Greater Accra region of Ghana.

PURPOSE: To determine the prevalence of refractive error and other eye diseases in schoolchildren in the Greater Accra region of Ghana. METHODS: Research assistants tested visual acuity (VA) using a Snellen chart in students randomly selected from 24 schools (i.e., 8 metropolitan, 8 urban, and 8 rural). An ophthalmologist examined students with VA of 6/12 or worse in either eye and students with other eye problems. RESULTS: Nine hundred fifty-seven students aged 6 to 22 years were screened: 67 had myopia with VA of 6/12 or worse in the better eye, 3 were unilaterally blind (2 from squint or amblyopia, 1 from a hypoplastic disk), and 4 had unilateral low vision from macular scars. Other eye diseases observed were congenital glaucoma (1), vernal conjunctivitis (2), and infective conjunctivitis (6). The prevalence of refractive error reducing vision to at least 6/12 was 7.0%. The prevalence of squint and amblyopia was 0.2%. CONCLUSION: The most common eye defect in the students was refractive error. Squint and amblyopia were rare.

Alternate eye care services in a ghanaian district.

OBJECTIVE: To determine eye care services sought outside the regular hospital system and their providers. STUDY SETTING: Akwapim South district METHOD: Questionnaire survey and in depth interviews. RESULTS: We recruited 1,537 persons with a previous history of eye disease and alternate service providers (21 chemical shop attendants and 55 herbalists). There was no significant difference between patronage of the regular and the alternative providers (p value 0.78). Most of the herbalists were trained by relations; parents (29/55) and grandparents (10/55). Two thirds had some formal education and 96% practiced part-time. Over 75% claimed they treated cataracts, eye injuries, and "kooko" and 28% also treated red eyes. Chemical shop attendants were all literates, sold only antibiotic eye drops, and 64% practiced full time. CONCLUSIONS: Herbalists and chemical sellers provided substantive eye care along the regular hospital services but some of their practices may be harmful.

Evaluation of risk factors for advanced glaucoma in Ghanaian patients.

PURPOSE: This study was to determine factors associated with individuals presenting late with advanced glaucomatous optic nerve damage. METHODS: A case-control study recruiting 123 patients with early features of primary open angle glaucoma (control) and 93 patients with advanced glaucoma (cases) was carried out for risk-factor analysis. Exposures of interest included those already established as major risk factors for glaucoma. These were initial intraocular pressure (IOP), age, and family history. In addition, occupation, ethnic origin, history of diagnosis of diabetes mellitus, hypertension, sickle cell disease, and previous eye examination were of interest. RESULTS: Univariate analysis showed that initial IOP>31 mmHg, age of > 60 years, absence of family history of glaucoma, occupational grouping, ethnicity, and male sex were associated with advanced glaucoma at presentation. Adjusted odds ratio or by multiple logistic regression model showed that initial IOP>31 mmHg in a patient was more likely to present with advanced glaucoma (OR 2.66, 95% confidence interval (CI) 1.45, 4.91; P-value 0.0017) than lower pressures. Patients aged 60-69 years (OR 2.53, 95% CI 1.01, 6.31; P-value 0.0473) and 70-90 years (OR 5.16, 95% CI 1.97, 13.51; P-value 0.0008) were more likely to present with advanced glaucoma than younger ones CONCLUSIONS: Subjects with initial IOP>31 mmHg were nearly three times more likely to present with advanced glaucoma than those with IOP<32 mmHg. Subjects over the age of 60 years were more than two times likely to present with advanced glaucoma than younger subjects.

Prevalence of glaucoma in an African population.

PURPOSE: To determine the prevalence of primary open-angle glaucoma (POAG) in a Ghanaian population aged 30 years and above and to describe any ethnic variations in glaucoma prevalence in this population. METHOD: A cross-sectional prevalence survey for POAG was carried out on residents of 30 years and above in the Akwapim-South district of Ghana. The principal investigator examined all glaucoma suspects and those diagnosed as glaucoma in the initial screening to determine all definite cases of POAG. All cases had intraocular pressure measurements. Glaucoma cases and suspects and some normal subjects had fundus biomicroscopy with 78 D Volk lens, and Humphrey FDT N-30 visual fields plotted. RESULTS: A total of 1843 people aged 30 years were screened from the population. The standardized age-specific prevalence was 7.7% (30 years and above) and 8.5% (40 years and above). The best-fit trend line for prevalence/age relationship was exponential. No gender or ethnic difference in prevalence was found. CONCLUSIONS: The prevalence of POAG in this population is high and comparable to those in black populations in Barbados and St. Lucia

Prevalence of children with disabilities in central region, Ghana.

A cross sectional survey was conducted in Central Region, Ghana to determine the prevalence of children with disabilities. Forty-seven (1.8%) out of a total of 2,556 children under fifteen years of age had disabilities. About a third, had difficulty with movement of which post poliomyelitis infection disability formed the majority. Twelve children (25.5%) had difficulty with hearing and speech (deaf and dumb). Three children were reported as having epilepsy and 2 others had mental retardation. There was no case of total blindness, however, two children complained of poor vision and three others had a squint. Other disabilities identified, included one child each with kyphosis (hunch back), hydrocephalus (very large head) and extensive facial scars from burns. Disability was more common among children who had not been immunized or who did not have immunization card at the time of interview. The prevalence of disability was higher among female children in the rural community and in children with no formal education. Prevalence of disability increased with age. The prevalence of disability was 14.4 per 1,000 for children (1-5) years, 16.6 per 1000 for children (6-9) years and 3.7 per 1,000 for (10-15) years age group. Younger children had better immunization status and lower disability rates. Thirty percent of the children with disability said they were experiencing discrimination especially among the female children. This study has demonstrated that there is a need to intensify the preventive efforts at reducing the problem of childhood disability and to increase public support to the disabled children by avoiding discrimination and encouraging education and training of the disabled children.

An assessment of the safety of street foods in the Ga district, of Ghana; implications for the spread of zoonoses.

Street food refers to food and beverages prepared and sold by vendors in streets and other public places for immediate consumption. In Ghana street foods are sold at small eating places popularly known as 'chop bars'. Food safety studies were conducted on the premises of 160 'chop bars' in the Ga District of Ghana in July 1998. Only three (1.8%) of the proprietors met all the requirements (based on a five-point checklist) for basic hygiene. Twenty-four (15%) out of the 160 proprietors had access to potable water while the other 136 (85%) proprietors purchased water from vendors and six used pond water. These two latter sources of water were of poor microbiological quality (as shown by faecal coliform values which ranged from 1.0x10(2)-1.9x10(5) cfu/ml). One hundred and five proprietors (65.6%) did not obtain their meat supply from an approved source. Factors influencing the purchase of meat from an approved source included the proximity of a chop bar to a slaughter facility, the conduct of meat inspection personnel and affordable user fees.

Implementation of the Bamako Initiative: strategies in Benin and Guinea.

Two West African countries, Benin and Guinea, have been reorganizing their peripheral health systems since 1986, with the goal of improving access to primary health care (PHC). A comprehensive approach evolve, based on improving effectiveness, optimizing efficiency, ensuring financial variability and promoting equity. These strategies were launched as the Bamako Initiative by the World Health Organization's Regional Assembly in 1987. This is the first in a series of five articles on the Bamako Initiative in Benin and Guinea. The strategies implemented in these two countries are discussed. Subsequent articles discuss the improved health indicators, impact on service costs efficiency, and community empowerment through local cost recovery and equity implications. The health center is the basis for a revitalized primary care system. From here, an integrated minimum health care package is readily accessible to meet basic community health needs. Through the Bamako Initiative program, drugs and other essential resources are always available, regular contract between the community health service providers and communities has increased, and the quality of care has improved while also becoming more efficient. Community health resources are managed locally through joint microplanning and monitoring, involving health personnel and village committees. Community ownership, fostered by local budgeting and decision making, is an essential pillar for the success of the system.

Serum polio antibodies in unimmunized preschool children in a rural village in Ghana: before active immunization programme.

The finding of the neutralizing antibodies against poliovirus in unimmunized preschool children confirms the endemicity of the disease in the rural community. The predominant polio antibody types were types 1 and 2. In children under 4 months of age, 82% were seropositive to type 1, 91% to polio type 2 and 55% to polio type 3; evidence of maternal transplacental antibodies. There were fewer seropositives in the age group 4-9 months, 28%, 44% and 12% to the types 1, 2 and 3, respectively. However, the percentages of seropositives to all three types increased for the rest of the age groups, indicating possible contact with the wild poliovirus in early infancy. Community spread of the virus is also supported by the intrafamilial clustering of the seropositives.

Clinical and serological reactions after immunization of children in Ghana, West Africa, with the Japanese acellular pertussis vaccine.

A sero-epidemiological survey of pertussis and a field trial with acellular pertussis vaccine was carried out in children in a rural village in Ghana, West Africa. ELISA antibody assays in 109 children aged three months to three years disclosed the rapid disappearance of transplacental maternal antibody in early infancy and the accumulation of seronegative children under three years of age. One hundred and ten children aged three months to three years were immunized with the newly developed acellular pertussis vaccine; 32 were immunized twice and 77 were immunized three times. Serological responses after immunization were measured in both groups. There were no severe adverse reactions attributable to vaccine injections among the children studied.

Immunization glossary.

PIP: This immunization glossary defines the following terms: antibody; maternal antibodies; antigen; antitoxin; booster dose; control of a disease; droplet infection; endemic; epidemic; eradication of a disease; gamma globulin; immunity; active immunity; passive immunity; herd immunity; incidence; jet injector; prevalence; seroconversion; toxoid; live attenuated vaccines; whole inactivated vaccines; inactivated bacterial toxins/toxoid vaccines; and vaccine efficacy. Antibodies are special proteins in the blood which inhibit the organisms or toxins causing the disease. Those antibodies which inhibit the action of toxins are called antitoxins. The sites of maximum antibody formation are the lymph nodes and spleen. Immunity is the state of resistance of the body to agents foreign to it. Active immunity is acquired by contracting an infection or by administration of vaccines either singly or in suitable combination. The person who contracts the infection or is immunized makes his/her own antibodies which remain in the body for a long time. This is the most desirable form of immunity. In the case of passive immunity, ready-made antibodies are acquired by infection or injection. Live vaccines contain live bacteria or viruses. These organisms are treated in the laboratory to minimize their harmful effects while retaining their ability to stimulate the production of protective antibodies. Vaccine stability can be improved by freeze-drying, a process in which the vaccine is reduced to a powder by freezing and removing water vapor under vacuum. Dead or killed vaccines are made from killed bacteria or viruses. Examples of inactivated bacterial toxins/toxoid vaccines are the diptheria and tetanus toxoids. Vaccine efficacy is a measure of the degree to which a vaccine protects the members of the community in which it is used.^ieng

The challenge of poliomyelitis in tropical Africa.

Recent surveys of lameness attributable to poliomyelitis in several African countries have revealed rates of residual paralysis of two to 11 per 1,000 children, a prevalence implying annual incidence rates for poliomyelitis of 10-55 cases per 100,000 population. Factors responsible for this high incidence are the unsanitary conditions present in many African communities, especially rural and periurban areas. Whereas poliomyelitis is endemic in Africa and paralysis occurs early in childhood, the apprehension and alarm that is evident in the developed world is almost absent in Africa. Hence, the administrative and economic resources for massive programs of poliomyelitis vaccination are lacking. Lameness prevalence rates of 2.6 per 1,000 children in certain areas of Africa illustrate that the programs of immunization against poliomyelitis should be intensified.

The control of measles in tropical Africa: a review of past and present efforts.

Measles in tropical Africa is endemic and cyclical, with a high incidence that usually peaks during the dry seasons. Measles may be a contributing factor in 10% of all deaths among African children. Several problems have hindered measles immunization programs in Africa; these include difficulties in maintaining the cold chain, poor epidemiologic surveillance, and the logistical problems involved in reaching a population that is 80% rural. The United States Agency for International Development and the World Health Organization both have programs that are helping to increase immunization coverage and to solve the problems just mentioned. Many countries have begun to train their own personnel to administer immunization programs. However, because of limited staff and equipment, a high birth rate, and an uncertain social situation, no firm predictions can be made concerning the permanent control of measles in tropical Africa.

PIP: Control of measles in tropical Africa has been attempted since 1966 in 2 large programs; recent evaluation studies have pinpointed obstacles specific to this area. Measles epidemics occur cyclically with annual peaks in dry season, killing 3-5% of children, contributing to 10% of childhood mortality, or more in malnourished populations. The 1st large control effort was the 20-country program begun in 1966. This effort eradicated measles in The Gambia, but measles recurred to previous levels within months in other areas. The Expanded Programme on Immunization initiated by WHO in 1978 also included operational research, technical assistance, cooperation with other groups such as USAID, and development of permanent national programs. Cooperative research has shown that the optimum age of immunization is 9 months, and that health centers are more efficient at immunization, but mobile teams are more cost-effective as coverage approaches 100%. 53 evaluation surveys have been done in 17 African countries on measles immunization programs. Some of the obstacles found were: rural population, underdevelopment of infrastructure, and exposure of unprotected infants contributing to the spread of measles. Measles surveillance is so poor that less than 10% of expected cases are reported. People are apathetic or unaware of the importance of immunization against this universal childhood disease. Vaccine quality is a serious problem, both from the lack of an adequate cold chain, and lack of facilities for testing vaccine. The future impact of measles control from the viewpoint of population growth and health of children offers many fine points for discussion.

The maternal and child health services in Ghana (their origins and future).

PIP: Before 1920, Ghana did not have any organized modern maternal and child health (MCH) services. Since then, substantial developments have taken place in all aspects of life in Ghana. Hospitals and maternity centers were established, and a campaign against maternal and infant mortality was initiated. The infant mortality rate fell from 360 in 1915 to the current country average of 121. However, the decline is not attributed solely or even mainly to MCH services, which has many weaknesses and problems relating to distribution of services, personnel development, and coordination with related agencies. In the north of Ghana, infant mortality rate is estimated at 234/1000 while in the south, the urban city of Accra has an estimated 85/1000. Trained midwives deliver only about 25% of babies; this is probably a valid measure of the outreach of services. Accra, accounting for only 10% of the population of Ghana, appears to utilize 30% of the health services: 1/3 of all deliveries and of all immunizations take place in Accra, and 28% of all public health nurses but only 15% of the community health nurses are in Accra. Another problem of MCH is the lack of amenities in the rural areas, such as safe water supplies, electricity, or educational facilities for children. It appears that the only hope of servicing these areas is by the use of lesser trained persons. Large numbers of local persons should be given training. Another alternative is to make better use of already exisiting MCH personnel by giving them resources to do their jobs effectively and enabling them to work more closely with their local communities. Ghana's MCH services have done well in urban areas. A major task now is to improve the quality of life in the rural and disadvantaged areas.^ieng

Comparison of methods for estimating the frequency of paralytic poliomyelitis in developing countries.

Standard reporting systems have proved to be unreliable in estimating the frequency of paralytic poliomyelitis in many developing countries. The effectiveness of three survey methods for estimating the prevalence of lameness attributable to poliomyelitis were compared in the Danfa Health Project district of rural Ghana. Lameness was studied because it is easily identified by inexpensive survey techniques. A postal survey of school headteachers was the least costly and most accurate method, giving a prevalence of lameness attributable to poliomyelitis of 7.2 per 1000 schoolchildren. This method is recommended for countries with an extensive network of primary schools. Medical examinations in a village health survey yielded a prevalence of 4.6 per 1000 children aged 6-15 years. This method was relatively expensive but could be justified if the survey was multipurpose. A question added to the annual district census showed a prevalence of 2.2 per 1000 children, a rate still many times higher than estimates from national statistics. The inclusion of such a question in a census or other national survey entails little additional cost and with more careful questioning results should improve. Repeated surveys can be used to assess the success of poliomyelitis vaccination programmes.

An evaluation of male contraceptive acceptance in rural Ghana.

To evaluate the effect of male contraceptive acceptance on fertility, the Danfa Family Planning Project in rural Ghana studied a sample of its male family planning acceptors. The findings show that half of the survey respondents accepted foam for use by their partners and half accepted the condom. The continuation rate (69 percent at 12 months) and use-effectiveness rate (80 percent at 12 months) reported by men were higher than those reported by women program acceptors. It is felt that men can play a significant role in affecting fertility through their influence on a couple's choosing to use contraception and as a result of their motivation to obtain contraception and see that it is used. It is urged that increasing emphasis be placed on providing family planning services for men in African programs.

PIP: Report of a follow-up survey of male family planning acceptors in the Danfa program. A sample of 100 men from each of 3 project areas (representing 47% of all male acceptors as of July 1974) was obtained, with 227 acceptors ultimately interviewed. A sample of female acceptors was also interviewed, using a similar questionnaire. 84% of the males were between ages 20-44. The mean age for the sampled females was 29. 19% of the males and 5% of the females reported ever using contraception before accepting it from the program. 80% of males were literate and 39% of females, the importance of literacy for males further underscored by the fact that while only 36% of their spouses were literate, the female respondents claimed 72% of their spouses to be literate. Controlling for other factors, religion was also important, with Christians most likely to accept family planning. 70% of male acceptors were married at the time of acceptance and 25% of those unmarried at time of acceptance were married by the time of the interview. 76% had at least one living child. 55% of the married men and 44% of the unmarried men claimed to have only one sexual partner. 78% of married men claimed to have discussed family planning with their wives. 66% reported that they used the accepted method only with their wives, 20% only with the other partner, and 12% with both partners. The most common reason given for acceptance was the health of their children. 52% of the male acceptors had first learned about family planning from the project health staff and 24% through mass media. 64% of the male respondents reported having tried to persuade another to accept family planning, compared with 40% of the females. Half of the men had chosen the condom, and half contraceptive foam for their partners. 16% of foam and 6% of condom acceptors had never used the methods. The large number of foam acceptors and users indicates the important role of males in acceptance of family planning. Self reporting indicated 81% of acceptors used their methods correctly. Continuation rates were higher for the male acceptors surveyed than for the women, which may be a reflection of their extra- and pre-marital relations. Among those not continuing, the major reasons were the desire for a child (28%) and inability to get supplies (18%). Accidental pregnancies were fewer among the partners of the male respondents than among women in the project in general, and the extended use-effectiveness was greater. These again may reflect the extra-marital and pre-marital sexual activities.