In 2003 Ghana's government passed the National Health Insurance Act. The result was the institution of the National Healthcare Scheme, which allows for nationwide health coverage, replacing the country's "cash and carry" system. The old system had prevented a large portion of the population from being able to afford even routine healthcare. The current system instituted with the National Healthcare Act has resulted in a huge flux of patients seeking medical care. The higher percentage of patients going to healthcare providers is allowing doctors to treat more of the communicable diseases that were left undiagnosed and untreated previously. Under the new healthcare system the citizens of Ghana pay income-based contributions toward the system. The system in return provides care for many illnesses including diarrhea infectious diseases. One of the huge problems currently facing the Ghana Healthcare system is the enormous caseload being placed on the limited number of physicians. The World Health Organization report that there is a 0.15 to 10,000 ratio of physicians to the population currently in Ghana. Although the healthcare is universal, there are portions of the population in rural areas that may have difficulty accessing healthcare. These populations could be at a more severe risk for communicable diseases related to diarrhea.
Methods Background: Dr. Richard Guerrant's lab developed a diagnostic lactofferin assay to determine whether diarrhea is inflamatory or noninflamatory by examination of fecal leukocytes. The presence of leukocytes (as evaluated by the presence of lactofferin) is an indication that the diarrhea was inflammatory and likely caused by Salmonella, Shigella, Campylobacter jejuni, or Clostridium difficile. Being able to distinguish an inflammatory disease from a noninflamatory diarrhea can be crucial to determining the level of medical care a patient requires for diarrhea.
Dr. William Petri's lab developed a diagnostic assay to test for the presence of Entamoeba hisolytica in stool samples of patients presenting with diarrhea. The tests allow for an estimate of Amebiasis in people presenting with diarrhea. The high specificity and sensitivity of the test allows an accurate assessment of the prevalence of Amebiasis, as distinct from other protozoan infections, which was not possible before. The diagnostic test that Dr. Petri's lab has developed has been shown to detect the presence of E. histolytica in 90% of cases, as opposed to the old methods of detection in stool that only detected 25-60%.
Rationale: Our project is a study of various aspects of gastrointestinal infectious diseases within select populations in Ghana using surveys and diagnostic tests. The two locations where we will be volunteering with doctors are the Manna Mission Hospital located in Teshie Nungua/Accra and the Volta River Authority Hospital located in Akosombo. The Manna Mission Hospital just outside of the capitol of Ghana has a more urban albeit indigent population seeking care, where the Volta River Authority Hospital about 90 miles from Accra deals with a more rural population with more limited access to care. In addition, the Volta River Authority Hospital operates a hospital ship which provides medical care for populations in very remote and even more rural areas along the Volta River. Dr. Moses Woode helped to educate us about the lifestyle in Ghana and the effects of various infectious diseases. He gave us advice about what should be included in our survey, which we will hand out to all of the Ghanain patients we encounter in the Manna Mission Hospital and Volta River Authority Hospital. Dr. Eric Houpt aided in the editing of our survey into one that assesses all of the areas pertaining to doing a study on gastrointestinal infectious diseases. The survey presents the definition of diarrhea and subsequently asks for details about the patient's health history of diarrhea as well as lifestyle, sanitation, and socioeconomic questions. With the recommendation of Dr. Woode, the survey also addresses the effect of the recently implemented National Health Care System on the availability and delivery of health care in the two different populations that we will be studying in Ghana.
In addition to the surveys of the general population seeking medical care at the two facilities we will also be focusing diagnostically on the young patients presenting with diarrhea. We will be analyzing the stool for the presence of blood (fecal occult-blood test), white blood cells, and Entamoeba histolytica infection. The information gained from these stool samples will allow us to document whether the patients diarrhea involves an inflammatory response (detected with the lactoferrin test developed by Dr. Richard Guerrant's lab by the presence of white blood cells in the stool), which may suggest a severe cause of diarrhea that could necessitate more aggressive treatment then rehydration alone. The test for E. histolytica developed by Dr. William Petri's lab will assess the prevalence of Amebiasis among children presenting with diarrhea in the studied populations. In addition to these diagnostic tests we will also be analyzing the samples for the presence of Cryptosporidium and Giardia to further characterize the protozoan infections causing diarrhea in the patients.
The diagnostic tests and the surveys that we will utilize in Ghana are aimed to assess the prevalence and types of the infectious gastrointestinal diseases in the two populations (those treated at the Manna Mission Hospital versus those whose sole access to medical care is through the tent hospitals we will set up from the Volta River Authority Hospital, as well as the Hospital itself). In addition to the surveys given to patients, we will be talking to doctors with whom we will be volunteering with in the hospitals. While interviewing the doctors we hope to get another perspective on the prevalence of gastrointestinal infectious disease in the populations that they treat. We also hope to utilize the interviews with doctors to gain their perspective on how the new National Health Care system is affecting the country in general; specifically the diagnosis, treatment and prevention of infectious diseases.
Hypothesis: We hypothesize that urban populations will have greater access to healthcare as well as sanitary water and food than rural populations. We also hypothesize that rural populations will present cases of diarrhea caused by different infectious agents than those in the urban population.
Methodology: We will be traveling to Ghana from June 12, 2007 through August 1, 2007. During this time we will be visiting two hospitals to conduct our research. The surveys will be administered to all Ghanain patients that are encountered in either the Manna Mission Hospital or the Volta River Authority Hospital. Our supervisors at these two facilities will be Dr. Seth Ablorh, President of the Manna Mission Hospital and Dr. John Mills, the Director of the VRA Hospital. The two hospitals grant us exposure to two very different populations. The surveys ask questions pertaining to risk factors for diarrhea-related infectious diseases as well as a past medical history involving diarrhea. The survey, attached at the end of the proposal, defines diarrhea and then elicits the patient's sanitation conditions, socioeconomic standing, diarrhea history, and thoughts on the National Healthcare Scheme.
In addition to the surveys we will also be taking stool samples from children presenting with diarrhea in both the Manna Mission Hospital and Volta River Authority Hospital using two-milliliter cryogenic vials. Using Cryptosporidium, Giardia, and fecal occult-blood test, the lactoferrin assay developed by Dr. Richard Guerrant's lab, and the E. histolytica assay developed by Dr. William Petri's lab, we will be able to classify the varying causes of diarrhea into different categories. The classification of diarrhea the diseases by these assays will allow for an assessment of the prevalence of the various causes of diarrhea in the populations. In addition to our diagnostic techniques in Ghana we will be freezing aliquots of our samples to bring back to UVa when we return to confirmation by other methods including PCR and for PCR for enteroaggregative Escherichia coli, a pathogen also studied by Dr. Guerrant as a cause of diarrhea in both industrialized and developing nations.
We will be working with Dr. Guerrant and Dr. Petri to write a protocol to submit for HSR approval. Dr. Woode is also contacting Dr. Mercy Newman and Dr. Ayeh-Kumi, who are both in the Department of Microbiology at the University of Ghana Medical School in Korle Bu/Accra, on our behalf. We plan to consult with both Dr. Newman (who worked with Dr. Guerrant in developing the lactoferrin assay) and Dr. Ayeh-Kumi (who worked with Dr. Petri in developing the E. histolyticaI assay) are knowledgeable about the diagnostic tests we will be utilizing.
Expected Outcomes: We will be working with two separate populations in Ghana, which could provide helpful information about the relative frequencies of the disease in the urban and more secluded rural settings. With information about the distribution, the surveys and diagnostic tests will help to evaluate the efficiency of the Healthcare system's ability to provide nationwide healthcare. The ultimate results of the lactoferrin and E. histolytica assays will be correlated to presence of blood in the stool and the survey results about the population's diarrhea frequency, sanitation, and socioeconomics. Our expected outcome is that the rural areas will have a lower level of access to health care and sanitary living conditions, resulting in a higher incidence of the diarrhea-related infectious diseases as it relates to diarrhea.
Survey for the Population of Ghana
Date:
Area of Country:
Patient Information
Age:
Sex: M F
Gastrointestinal Health History:
Definition of Diarrhea: Three or more liquid stools in 24 hours, for three days.
How many times have you experienced diarrhea in the past year? ________ DAYS
How long did it last? Less than 2 weeks Greater than 2 weeks
While sick, were you vomiting as well? Y N
Did you experience any fever, headaches, stomach aches, or nausea? (please circle)
How many times have you experienced this sickness in your life? ________ TIMES
Did you seek any treatment for this sickness? Y N
Where did you seek treatment? ______________________________________________
If yes, what were you diagnosed with? ________________________________________
What steps were taken to treat your sickness? ___________________________________
What medications were you given? ___________________________________________
Where do you think diarrhea comes from? _____________________________________
What do you think are the causes of diarrhea? __________________________________
Sanitation:
Where do you obtain drinking water? _________________________________________
Do you boil your water before using it? _______________________________________
Do you wash food items prior to preparing or eating them? Y N
Where do you obtain water to wash your food items? ____________________________
Do you have regular access to a latrine? Y N
How far from your home is the latrine? ________________________________________
Socioeconomic:
What village do you live in? ________________________________________________
How many people live in your household? __________ PEOPLE
What is the highest level of education among household members? _________________
National Health Insurance:
Have you personally benefited from the new health system? Y N
Would you seek medical care more often because of the health system? Y N
Have you noticed any change the quality of availability of heathcare? Y N
Do you have more access to vaccines with the National Healthcare System? Y N
Please include any other comments you have about the new healthcare system________________________________________________________________________________________________________________________________________________________________________________________________________________________