University of Ghana http://ugspace.ug.edu.gh
UNIVERSITY OF GHANA
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH
EPIDEMIOLOGY OF LEISHMANIA INFECTION AND INSECTICIDE
TREATED BED NET USE IN THREE COMMUNITIES OF OTI REGION,
GHANA
BY
AKUFFO, RICHARD ADJEI
(10103523)
THESIS SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES,
UNIVERSITY OF GHANA IN PARTIAL FULFILMENT OF THE
REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY
DEGREE IN PUBLIC HEALTH
DEPARTMENT OF EPIDEMIOLOGY AND DISEASE CONTROL
JUNE 2020
University of Ghana http://ugspace.ug.edu.gh
University of Ghana http://ugspace.ug.edu.gh
ABSTRACT
Background: Leishmaniasis is a neglected tropical disease caused by parasites of the genus
Leishmania and is transmitted by various species of female sand flies. In Ghana, the DNA of
Leishmania parasites has been identified in skin lesions from some patients suspected to have
cutaneous leishmaniasis (CL) and also from some female sand flies sampled from the Ho
municipality of the Volta Region. Systematic reviews have demonstrated that the application of
insecticides against sand fly vectors is effective in reducing incidence of leishmaniasis.
Methods: Using a community-based cross-sectional study design, the prevalence of Leishmania
infection, insecticide treated bed (ITN) use, and the occurrence of sand flies in three
communities of the Oti region of Ghana were investigated. Awareness about CL, CL experience,
and CL related knowledge among household heads were also investigated. Results: A total of
3,440 participants from 587 households comprising 189 (32.2%), 200 (34.1%), and 198 (33.7%)
households from Ashiabre, Keri, and Sibi Hilltop respectively, participated in this study.
Leishmanin skin test (LST) results for 1091, 848, and 1132 participants from Ashiabre, Keri, and
Sibi Hilltop, indicated an overall prevalence of Leishmania infection of 41.8% and individual
community prevalence of 39.4%, 55.1%, and 34.2% respectively. An overall prevalence of
31.9% and individual community prevalence of 23.2%, 29.8%, and 36.8% for CL in Ashiabre,
Keri, and Sibi Hilltop respectively was observed. Being male (AOR=1.27; CI: 1.09, 1.49), and
living in Keri (AOR=1.83; CI: 1.43, 2.34) were associated with an increase in the odds of
exposure to Leishmania infection using LST. Being 5-15 years old (AOR=1.49; CI: 1.31, 1.98),
16-45 years old (AOR=3.31; CI: 2.44, 4.47), and >45 years old (AOR=4.85; CI: 3.29, 7.15) were
also significantly associated with increased odds of being exposed to Leishmania infection. Non-
use of ITN was not significantly associated with Leishmania infection. The proportion of all
ii
University of Ghana http://ugspace.ug.edu.gh
study households that owned at least one ITN was 97.1%. 97.4% of households in Sibi Hilltop
and 97.0% of households in both Ashiabre and Keri owned at least one ITN. Cumulatively, the
number of households having at least one ITN for every two members was 386 (65.8%) while
63.5%, 68.0%, and 65.7% of households in Ashiabre, Keri, and Sibi Hilltop owned at least one
ITN for every two household members. Of the 3639 de facto household population comprising
1116, 864, and 1179 in Ashiabre, Keri, and Sibi Hilltop, the overall population with access to
ITN was 3159 (86.8%) while 87.3%, 87.9%, and 85.6% of the household populations in
Ashiabre, Keri, and Sibi Hilltop respectively, had access to ITN. The overall household
population that slept in ITN the night before this survey was 2370 (65.1%) while in Ashiabre,
Keri, and Sibi Hilltop, it was 66.4%, 65.1%, and 64.0% respectively. Of 2181 population in
households with ITN access, 1581 (72.5%) persons slept in ITN the night before the survey.
Lack of household access to ITN (AOR=1.80; CI: 1.31, 2.47), having a family size of more than
10 members (AOR=2.53; CI: 1.20, 4.24), having more than 10 rooms for sleeping in a household
(AOR=10.18; CI: 1.28, 81.00), having 2-4 screened windows (AOR=1.49; CI: 1.00, 2.20), and
having 8-10 screened windows (AOR=3.57; CI: 1.25, 10.17) were significantly associated with
increased odds of not sleeping in ITN the night before the survey. All household heads were
aware of CL with 243 (41.4%) of them demonstrating good knowledge about it. A total of 45.3%
of household heads (57.1%, 35.0%, and 44.4% in Ashiabre, Keri, and Sibi Hilltop) indicated that
at least one member of their household had experienced CL two years prior to this study. A total
of 193 female sand flies were trapped from various locations within the study communities.
Conclusions: This study demonstrated exposure to Leishmania infection in the study
communities and confirmed CL which suggests an active cycle of transmission of Leishmania
infection. Being male, living in Keri and being five years or older were associated with
iii
University of Ghana http://ugspace.ug.edu.gh
Leishmania infection. The non-use of ITNs was not significantly associated with Leishmania
infection. Household ITN access of 65.8% and usage by 65.1% of the study population suggests
a need for strategies to improve both access to ITN and its usage. Factors associated with non-
use of ITN were Lack of household access to ITN, having a family size of more than 10
members, having more than 10 rooms for sleeping, and having 2-4 or 8-10 screened windows.
The occurrence of sand flies was confirmed and suggests a need for investigation of the sand fly
species and their possible role in Leishmania transmission. Demonstration of good knowledge
about CL by less than half of household heads calls for strategies to improve knowledge about
CL.
iv
University of Ghana http://ugspace.ug.edu.gh
DEDICATION
I dedicate this work to my wife Caroline and our children: Winifred, Raymond, and Caren
Akuffo.
v
University of Ghana http://ugspace.ug.edu.gh
ACKNOWLEDGEMENTS
This study was funded by the post graduate training scheme fellowship in implementation
science by the Special Programme for Research and Training in Tropical Diseases (WHO/TDR)
at the School of Public Health, University of Ghana, for which I am grateful. I also acknowledge
the role of the Department of Neglected Tropical Diseases of the World Health Organization
(WHO /NTD) (POC: Dr. Jose Antonio Ruiz-Postigo) for supplying the Leishmanin skin test
reagents used in this study. I appreciate the laboratory support received from the Instituto de
Salud Carlos III, Spain (Led by Dr. Javier Moreno) to facilitate the processing of the research
samples.
I am grateful to my supervisors Prof. Michael Wilson, Prof. Francis Anto, and Dr. Bismark Sarfo
for their guidance and supervision throughout the conduct of this research. I also extend my
appreciation to Mrs. Naiki Attrams, Mr. Mba Mosore, Ms. Clara Yeboah of the U.S Navy
Medical Research Unit 3 Ghana Detachment (NAMRU3-GD) and all staff of the NAMRU3-GD
for their logistical and technical support throughout this project.
I am grateful to Prof. Richard Adanu, Coordinator of the WHO/TDR project at the School of
Public Health, University of Ghana for his role in providing mentorship and guidance. My
sincere thanks go to Dr. Phyllis Darko-Gyekye and all the administrators of the WHO/TDR PhD
Fellowship for the support provided to me.
I also acknowledge the support of Prof. John Gyapong, former Pro-Vice Chancellor for
Research, and Innovation Development, University of Ghana, for his leadership and counsel
during the early phase of this research journey.
vi
University of Ghana http://ugspace.ug.edu.gh
This work may not have been completed in good time without the assistance of field workers
from the Nkwanta South and North District Health directorates. My special appreciation to Mr.
Emmanuel Agbodogli of the Nkwanta South District hospital and Dr. Laud Boateng, the
Nkwanta South District Director during the period of this study.
I am also grateful to staff of the Ghana Health Service, staff of the School of Public Health,
University of Ghana, and staff of Noguchi Memorial Institute for Medical Research, University
of Ghana, for their diverse support in making this work possible.
I am also particularly grateful to Dr. Kojo Arhinful for his mentorship and support throughout
this research journey.
To my mother, sister and other siblings, I say God bless you for being there for me always.
vii
University of Ghana http://ugspace.ug.edu.gh
TABLE OF CONTENTS
Contents Page
DECLARATION .................................................................................................................................... i
ABSTRACT ........................................................................................................................................... ii
DEDICATION ....................................................................................................................................... v
ACKNOWLEDGEMENTS.................................................................................................................. vi
TABLE OF CONTENTS ....................................................................................................................viii
LIST OF FIGURES/MAPS ................................................................................................................. xii
LIST OF ABBREVIATIONS.............................................................................................................. xv
CHAPTER 1 .......................................................................................................................................... 1
INTRODUCTION ................................................................................................................................. 1
1.1 Background .................................................................................................................................. 1
1.2 Problem Statement ...................................................................................................................... 3
1.3 Justification .................................................................................................................................. 4
1.4 Conceptual Framework of Leishmania Infection ........................................................................ 6
1.5 Research Questions ...................................................................................................................... 8
1.6 Objectives ..................................................................................................................................... 8
1.6.1 Main objective ....................................................................................................................... 8
1.6.2 Specific objectives ................................................................................................................. 8
CHAPTER TWO................................................................................................................................... 9
LITERATURE REVIEW ..................................................................................................................... 9
2.1 Overview of Leishmaniaisis ......................................................................................................... 9
2.2 Transmission of Leishmania Parasites ...................................................................................... 10
2.3 Types of Leishmaniasis .............................................................................................................. 13
2.3.1 Overview of different types of leishmaniasis ...................................................................... 13
2.3.2 Cutaneous leishmaniasis ..................................................................................................... 13
2.4 Cutaneous Leishmaniasis (CL) Research in Ghana.................................................................. 14
2.5 CL Clinical Manifestations ........................................................................................................ 17
2.6 Diagnoses of Cutaneous Leishmaniasis ..................................................................................... 18
2.6.1 Microscopy, culture and histopathology............................................................................. 18
2.6.2 Immunologic diagnostic methods ....................................................................................... 19
2.6.3 Molecular methods for CL diagnosis .................................................................................. 20
viii
University of Ghana http://ugspace.ug.edu.gh
2.7 Clinical Specimen Collection Methods for Diagnosing Cutaneous Leishmaniasis .................. 21
2.8 Treatment of Cutaneous Leishmaniais ..................................................................................... 22
2.9 Control and Prevention of CL ................................................................................................... 23
2.10 Control of CL in the context of ITN for Malaria Control ...................................................... 24
2.11 Factors Associated with Leishmania Infection ........................................................................ 28
CHAPTER THREE............................................................................................................................. 31
MATERIALS AND METHODS ......................................................................................................... 31
3.1 The Study Sites........................................................................................................................... 31
3.1.1 Nkwanta South Municipality .............................................................................................. 31
3.1.2 Nkwanta North District ...................................................................................................... 31
3.2 Study Design ........................................................................................................................... 33
3.2.1 Inclusion/exclusion criteria ................................................................................................. 33
3.2.2 Operational definitions ....................................................................................................... 34
3.3 Sample size considerations ........................................................................................................ 34
3.4 Sampling Procedure................................................................................................................... 36
3.4.1 Study site selection .............................................................................................................. 36
3.4.2 Determination of minimum household number to select per community ......................... 36
3.4.3 Selection of households for study inclusion ........................................................................ 37
3.5 Pre-Study Field Procedures ....................................................................................................... 38
3.5.1 Pre-Study training ............................................................................................................... 38
3.5.2 Community engagement ..................................................................................................... 39
3.6 Study Stages ............................................................................................................................... 43
3.6.1 Study stage 1 ........................................................................................................................ 43
3.6.2 Study stage 2 ........................................................................................................................ 45
3.6.3 Study Stage 3 ....................................................................................................................... 47
3.7 Data Management and Analysis ................................................................................................ 59
3.8 Ethical Considerations ............................................................................................................... 63
CHAPTER FOUR ............................................................................................................................... 64
RESULTS ............................................................................................................................................ 64
4.1 Socio-Demographic Information ............................................................................................... 64
4.1.1 Household characteristics ................................................................................................... 68
4.2 Leishmania Infection and Cutaneous Leishmaniasis among the Study Participants ............... 82
4.2.1 Leishmania infection assessment by Leishmanin skin test (LST) ...................................... 82
ix
University of Ghana http://ugspace.ug.edu.gh
4.2.2 Cutaneous leishmaniasis and ulcer treatment options among participants with skin ulcers
...................................................................................................................................................... 87
4.2.3 Treponemal only and DPP RDT screening among selected persons with skin ulcers ....... 95
4.3 Insecticide treated bed net ownership, access and use .............................................................. 99
4.5 Presence of Sand Flies in Study Communities ........................................................................ 118
0
4.6 Malaria and Leishmania Infection among Participants with Temperature > 38.0 C ............ 120
CHAPTER FIVE ............................................................................................................................... 121
DISCUSSION .................................................................................................................................... 121
5.1 Leishmania infection and cutaneous leishmaniasis among study participants ....................... 121
5.1.1 Leishmania infection using leishmanin skin test (LST) among study participants ......... 121
5.1.2 Cutaneous leishmaniasis among study participants with skin ulcers .............................. 124
5.1.3 Treatment of persons with cutaneous leishmaniasis ........................................................ 125
5.1.4 Need for investigation of skin ulcers which were negative for Leishmania infection ...... 126
5.2 Insecticide Treated Bed Net Ownership, Access and Use ....................................................... 128
5.2.1 Insecticide treated bed net Ownership and access ........................................................... 128
5.2.2 Insecticide treated bed net use .......................................................................................... 130
5.2.3 Factors associated with failure to use ITN ....................................................................... 133
5.2.4 Insecticide treated bed net disposal in study communities .............................................. 134
5.2.5 ITN use and Leishmania infection in study communities ................................................. 135
5.3 Cutaneous Leishmaniasis awareness, experience and knowledge .......................................... 136
5.4 Presence of sand flies within study communities .................................................................... 140
5.4.1 Need for identification of vectors and reservoirs of Leishmania infection in Volta and Oti
regions of Ghana ........................................................................................................................ 141
5.5 Fever among study participants .............................................................................................. 143
CHAPTER SIX.................................................................................................................................. 144
6.0 CONCLUSIONS AND RECOMMENDATIONS ................................................................... 144
6.1 Conclusions .............................................................................................................................. 144
6.2 Public health importance of the findings from this study ....................................................... 146
6.3 Contribution to knowledge ...................................................................................................... 147
6.4 Limitations of the study ........................................................................................................... 148
6.5 Recommendations .................................................................................................................... 148
6.5.1 Research...................................................................................................................... 148
6.5.2 Ghana Health Service ................................................................................................. 148
6.5.3 World Health Organization ....................................................................................... 149
x
University of Ghana http://ugspace.ug.edu.gh
REFERENCES .................................................................................................................................. 150
Appendix 1: ETHICAL CLEARANCE FOR THE STUDY ............................................................ 167
Appendix 2: Consent Form ............................................................................................................... 168
Appendix 3: Individual case report .................................................................................................. 172
Appendix 4: Household Questionnaire ............................................................................................. 174
xi
University of Ghana http://ugspace.ug.edu.gh
LIST OF FIGURES/MAPS
Figure 1: Conceptual framework of Leishmania infection ....................................................................... 7
Figure 2: Sand fly (Phlebotomus papatasi) feeding on human blood (Available at
https://www.google.com/search?q=sandfly+feeding+on+human+blood+papatasi&prmd=ivn&sxsrf..) ... 11
Figure 3: Illustration of life cycle of Leishmania parasite in sand fly and human (Available at
https://www.google.com/search?q=life+cycle+of+leishmania+species&tbm=isch&ved...) ..................... 12
Figure 4: Examples of localised cutaneous leishmaniasis (LCL) (Picture by Richard Akuffo) ............... 14
Figure 5:Illustration of the three communities which recorded the highest number of CL cases in the Ho
municipality during the 1999 suspected CL outbreak (Kweku et al.,2011) .............................................. 15
Figure 6: Map showing study communities ........................................................................................... 32
Figure 7: Some pre-study team training activities .................................................................................. 38
Figure 8: Some suspected CL cases observed during active CL case search .......................................... 40
Figure 9: Engagement of different segments of communities during active CL case search ................... 41
Figure 10: A cross-section of community members at a durbar to explain the study .............................. 42
Figure 11: A session of household interview ......................................................................................... 44
Figure 12: Sand fly collection using indoor aspiration and CDC light trap respectively in households ... 46
Figure 13: CDC light traps for sand fly collections at mosque, school and church compound ................ 47
Figure 14: Induration on skin 48-72 hours after LST placement and measurement ................................ 49
Figure 15:Non-invasive sampling of skin lesions .................................................................................. 50
Figure 16: DNA extraction from skin lesions sampled for PCR ............................................................. 55
Figure 17: Sample of syphilis first line test and DPP test result ............................................................. 59
Figure 18: Prevalence of Leishmania infection at various study sites and cumulatively ......................... 87
Figure 19: Examples of skin ulcers which were Leishmania positive ..................................................... 94
Figure 20: Examples of skin ulcers which were Leishmania PCR negative and were observed on persons
who were DPP RDT positive ................................................................................................................. 98
Figure 21: Summary of ITN ownership, access, and use in study communities (overall) ..................... 107
Figure 22: Bed net observed hanging in sleeping area of a household.................................................. 132
xii
University of Ghana http://ugspace.ug.edu.gh
LIST OF TABLES
Table 1: Cutaneous leishmaniasis diagnostic tests (Antonio et al., 2014; Masmoudi et al., 2013) ........... 21
Table 2: Minimum proportions of households in study communities to be sampled ............................... 36
Table 3: Household composition by the number of usual household members, educational level, and
relationship to head of household ........................................................................................................... 65
Table 4: Summary of household population distribution by sex, age, and community of residence ....... 67
Table 5: Characteristics of study households (A) ................................................................................... 70
Table 6: Characteristics of study households (B) ................................................................................... 71
Table 7: Household main source of drinking water and toilet facility..................................................... 72
Table 8: Summary of household possessions ......................................................................................... 74
Table 9: Characteristics of the household heads .................................................................................... 75
Table 10: Practices and behaviors during daily routine of study participants .......................................... 79
Table 11: Additional practices and behaviors during daily routine of study participants ......................... 80
Table 12: LST prevalence by age and sex at Ashiabre and Keri ............................................................. 84
Table 13: LST prevalence by age and sex at Sibi Hilltop and cumulatively for all study sites ................ 85
Table 14: Factors associated with LST positivity .................................................................................. 86
Table 15: Individuals with skin ulcers, ulcers sampled and result of Leishmania PCR test ..................... 90
Table 16: Skin ulcers tested for Leishmania parasite using PCR by age and sex..................................... 91
Table 17: Distribution of individuals with Leishmania positive skin ulcers by age, sex, and community of
residence ............................................................................................................................................... 92
Table 18: Treatment practices for skin lesions observed ........................................................................ 93
Table 19: Treponemal specific and DPP diagnostic test screening of some persons with skin ulcers ...... 96
Table 20: Leishmania infection in skin ulcer samples obtained from persons screened with treponemal
specific RDT ......................................................................................................................................... 96
Table 21: Leishmania infection in skin ulcer samples obtained from individuals screened using DPP
diagnostic RDT ..................................................................................................................................... 97
Table 22: Number of bed nets owned by households ........................................................................... 102
Table 23: Source, duration of ownership, and observation of bed nets owned by households ............... 103
Table 24: Methods of ITN disposal, duration of ITN use before disposal, and reason for ITN disposal . 104
Table 25: Ownership of ITNs by enrolled households in study community .......................................... 105
Table 26: Access to and use of LLINs by enrolled households in study communities .......................... 106
Table 27: Use of ITNs by members of households having a minimum of one ITN for every two members
............................................................................................................................................................ 106
Table 28: Distribution of persons who used ITN the night before the interview by sex, age group and
residence ............................................................................................................................................. 108
Table 29: Factors associated with non-use of ITN the night preceding the interview among de facto
population of households having a minimum of one ITN ..................................................................... 109
Table 30: Additional Factors associated with non-use of ITN the night preceding the interview among de
facto population of households having a minimum of one ITN ............................................................. 110
Table 31: Awareness of cutaneous leishmaniasis among household heads ........................................... 115
Table 32: Cutaneous leishmaniasis related knowledge among household heads across study communities
............................................................................................................................................................ 115
Table 33: Household head report of CL experience at personal, household and community level ......... 116
Table 34: Months of year, age groups, and occupational groups seen with CL in study communities ... 117
xiii
University of Ghana http://ugspace.ug.edu.gh
Table 35: Summary of sandflies caught in study communities by sex, place of collection, and collection
methods ............................................................................................................................................... 119
xiv
University of Ghana http://ugspace.ug.edu.gh
LIST OF ABBREVIATIONS
ACL- Active cutaneous leishmaniasis
ANC - Antenatal clinic
CL - Cutaneous leishmaniasis
DALYs - Disability adjusted life years
DCL - Diffuse cutaneous leishmaniasis
DHS – Demographic and health survey
DNA - Deoxyribonucleic acid
GHS – Ghana Health Service
ITM - Insecticide treated materials
ITN - Insecticide treated bed net
LLIN - Long lasting insecticidal net
LCL - Localized cutaneous leishmaniasis
LST – Leishmanin skin test
MCL – Muco-cutaneous leishmaniasis
MST - Montenegro skin test
NAMRU-3 - U.S Naval medical research unit three
NMCP – National Malaria Control Program
NMIMR - Noguchi memorial institute for medical research
NTDs - Neglected tropical diseases
NW - New World
OW - Old World
PCR - Polymerase Chain Reaction
PKDL - Post-kala-azar dermal leishmaniasis
TDR - Special Programme for Research and Training in Tropical Diseases
VL - Visceral leishmaniasis
WHO – World Health Organization
xv
University of Ghana http://ugspace.ug.edu.gh
CHAPTER 1
INTRODUCTION
1.1 Background
Leishmaniasis is a neglected vector borne disease caused by parasites of the genus Leishmania
and is endemic in over 98 countries with 350 million people estimated to be at risk of contracting
the disease globally (Alvar et al., 2012; Steverding, 2017).
Depending on the area of localization of the parasite in mammalian tissues, two broad categories
of leishmaniasis exist: visceral and cutaneous, with cutaneous leishmaniasis (CL) being the most
common. Globally, it is estimated that between 0.7 to 1.3 million new cases of CL are reported
every year (Alvar et al., 2012; de Vries, Reedijk, & Schallig, 2015; Savoia, 2015; Steverding,
2017).
Although ulcers due to CL are often self-healing, they could take three to six months to heal and
secondary bacterial infections cause pain and may leave permanent scarring after healing (de
Vries et al., 2015; Masmoudi et al., 2013).
Leishmaniasis is geographically classified as New World or Old World depending on the
distribution of the infecting Leishmania parasites. The New World species are usually found in
Central and South America, whereas the Old World group is found in the Middle East, Asia,
Africa, and the Mediterranean (Lysenko, 1971; Masmoudi et al., 2013; Mitropoulos et al., 2010).
1
University of Ghana http://ugspace.ug.edu.gh
Natural transmission of the Leishmania parasites to humans and other mammals occurs through
the bite of various species of infected female phlebotomine sand flies belonging to the genus
Phlebotomus in the Old World and the following genera in the New World: Lutzomyia,
Psychodopygus and Nyssomyia. Majority of the Leishmania infections in humans are
transmissible only from animals (zoonotic leishmaniasis) but some can be transmitted between
humans (anthroponotic leishmaniasis) (de Vries et al., 2015; Maia & Depaquit, 2016; Maroli et
al., 2013; Masmoudi et al., 2013; Ready, 2013).
Vector control with insecticides against the sand fly vectors of leishmaniasis is effective in
reducing the incidence of the disease (Boakye, Wilson, & Kweku, 2005; González et al., 2015;
Reyburn, Ashford, Mohsen, Hewitt, 2000; Wilson et al., 2014). In Ghana, the National Malaria
Control Programme recognizes and promotes the use of insecticide treated materials (ITM)
including long lasting insecticidal nets as one of the multiple preventive tools in the control of
the malaria vectors in Ghana with the aim of 100% household ownership of at least one
insecticide treated bed net (ITN) and 80% usage by the general population (GHS, 2015).
A localized outbreak of skin ulcers suspected to be cases of CL was first reported in Ghana from
the Ho municipality of the Volta Region. in 1999 based on the identification of Leishmania
amastigotes in some skin lesion biopsies obtained from the patients and examined using
microscopy (Kweku et al., 2011).
In 2002, the DNA of Leishmania major was detected in a suspected CL patient from the Ho area
of the Volta Region using polymerase chain reaction (PCR) (Fryauff et al., 2006).
A follow up study involving nine biopsies from five suspected CL cases in 2006 and one biopsy
from another suspected CL case in 2007 from Taviefe, a community located about 10km north of
2
University of Ghana http://ugspace.ug.edu.gh
Ho, however did not confirm L. major. Instead, uncharacterized species of Leishmania were
observed (Villinski et al., 2008).
An additional study in some other parts of the Ho municipality successfully cultured and
obtained three isolates from individuals suspected with active cutaneous leishmaniasis. Using
DNA sequencing and phylogenetic analysis, the isolates were confirmed to be part of the
Leishmania enriettii complex, a new subgenus of Leishmania parasites (Kwakye-Nuako et al.,
2015). Also, L. tropica, and L. major DNA have been identified in Sergentomyia sand flies
sampled from the Ho municipality (Nzelu et al., 2014a). Identification of L. major,
uncharacterized Leishmania species, and recently, members of the Leishmania enriettii complex
from suspected CL cases in the Ho municipality suggests a complex epidemiology of CL in the
region.
Also, study of awareness about CL as well as its related knowledge and experience among
people living in areas with reports of the disease provides data to inform the implementation and
or scale up of the use of insecticide treated bed net and possibly indoor-residual spraying to
control CL.
1.2 Problem Statement
In the year 2018, researchers at the Noguchi Memorial Institute for Medical Research who have
been involved in CL research in the Volta Region of Ghana, received reports from some disease
control officers about cases of skin ulcers which were suggestive of CL in some communities of
the Oti region which until 2019 was part of the Volta Region, and which had no previous
documentation of Leishmania infection (Naiki Puplampu-Attrams personal communication).
3
University of Ghana http://ugspace.ug.edu.gh
Although the reservoir(s) and putative vector(s) of CL in the Oti and Volta Regions are yet to be
confirmed, detection of suspected cases of the disease in the region coupled with limited data on
the magnitude and distribution of Leishmania infection in Ghana, calls for control measures to
protect the population at risk of Leishmania infection (Boakye et al., 2005; Kweku et al., 2011;
Raczniak et al., 2008).
Currently, there is no organized leishmaniasis disease control program in Ghana except during
the suspected outbreak of CL in 1999 when chemotherapeutic treatment and mass spraying with
insecticides were conducted in southern communities of the Volta Region which recorded
suspected CL cases (Boakye et al., 2005; Landau, 2008).
Furthermore, no vaccine is currently approved for leishmaniasis and there is paucity of research
evidence regarding potentially beneficial treatment options for Old World CL in particular. As a
result, measures which prevent infection by the Leishmania parasites need to be prioritized as a
disease control option (González et al., 2008; Olliaro et al., 2013).
1.3 Justification
Vector control using insecticides against sand fly vectors of CL has been proven as an effective
way of reducing incidence of the disease (González et al., 2015; Wilson et al., 2014).
The insecticide treated bed net, particularly the long-lasting insecticidal net (LLIN) has been
proven for malaria control and several countries including Ghana are currently promoting its use.
As a result, it is cost effective to prioritize its promotion in areas where ITN use has the potential
4
University of Ghana http://ugspace.ug.edu.gh
of preventing other insect borne diseases (Adjei, 2012; Baume & Franca-koh, 2011; GHS, 2015;
Wilson et al., 2014).
On account of CL specifically, systematic review suggests considerable benefits of the roll out
of ITN in areas where the CL is co-endemic with malaria, such as Ghana (Wilson et al., 2014).
Implementing proven interventions such as the insecticide treated bed net in real world settings is
often not without challenges due to varying contextual issues from one setting to another
(Peabody, Taguiwalo, Robalino, 2006).
Hence the need to evaluate the use (when the evidence based intervention has already been
introduced in a given setting) as well as context specific factors associated with the use/non-use
of such proven interventions to inform the choice of implementation strategies needed to
promote uptake and sustainability of the interventions (Proctor et al., 2013).
Investigating prevalence and distribution of Leishmania infections, presence of sand flies,
indicators related to the use of ITNs, and CL related knowledge, experience and awareness in
three communities of the Oti region of Ghana without previous documentation of Leishmania
infection provides insight into the epidemiology of Leishmania infections, provides a basis for
identifying contextual factors associated with the infections, and also provides a basis for
assessing other contextual factors which may be associated with the use or non-use of the
insecticide treated bed net (ITN) as a potential evidence based intervention for control of CL in
the region.
5
University of Ghana http://ugspace.ug.edu.gh
1.4 Conceptual Framework of Leishmania Infection
Leishmania infection in a given area is influenced by several factors. The conceptual framework
below (Figure 1) illustrates the key factors that are associated with the magnitude and
distribution of Leishmania infection in a given area.
The factors could be at the individual behavioural level that includes occupation, daily activity,
sleeping habit, use of a mosquito net, application of insecticide to the sleeping area and
frequency of the insecticide use.
Household factors are also known to play important roles in the distribution of leishmaniasis.
Some household factors include number of rooms, the number of rooms with screened windows,
dwelling wall type, dwelling roof type, dwelling ceiling type, application of insecticide to
household animals‘ sleeping area.
Furthermore, some community level factors are also known to be associated with leishmaniasis
and these include the availability of alternative treatment options, cultural beliefs and perceptions
about ITN use, perception of ITN generating heat, and the presence or absence of indoor residual
spraying activities in a given endemic area.
Knowledge factors such as knowledge of symptoms and transmission of leishmaniasis in a given
affected area are also associated with Leishmania infection and subsequently the manifestation of
the infection such as CL.
Furthermore, leishmaniasis is a vector borne disease with other vertebrate reservoirs. Thus,
vector and reservoir factors such as vector abundance, vector feeding habit and reservoir type
and habitat significantly influence Leishmania infection in a given area. As a result, roll out of
6
University of Ghana http://ugspace.ug.edu.gh
any intervention for control of leishmaniasis needs to take into consideration the multiple factors
which could be associated with it.
Figure 1: Conceptual framework of Leishmania infection
7
University of Ghana http://ugspace.ug.edu.gh
1.5 Research Questions
i. What is the prevalence of Leishmania infection in three selected communities of the Oti
region, Ghana?
ii. Which household factors are associated with Leishmania infection in three communities of the
Oti Region?
iii. Is there a relationship between ITN usage and Leishmania infection in three communities of
the Oti Region?
iv. Are there sand flies in the three study communities of the Oti region?
1.6 Objectives
1.6.1 Main objective
To investigate the epidemiology of Leishmania infection and its relationship with ITN usage in
three communities of the Oti Region, Ghana.
1.6.2 Specific objectives
i. To determine the prevalence of Leishmania infection in study communities
ii. To assess household factors associated with Leishmania infection
iii. To determine the association between ITN usage and Leishmania infection
iv. To investigate the occurrence of sand flies in the study communities
8
University of Ghana http://ugspace.ug.edu.gh
CHAPTER TWO
LITERATURE REVIEW
2.1 Overview of Leishmaniaisis
Leishmaniasis is a neglected disease caused by a heterogenous group of parasites of the genus
Leishmania and is generally considered to be a disease of the poor (Pace, 2014; Savoia, 2015).
Globally, it is present in 98 countries in Africa, America, Asia, and Europe with an 350 million
people estimated to be at risk of infection and about 14 million people directly affected (Alvar et
al., 2012; de Vries et al., 2015).
Ranked ninth in the burden of parasitic and infectious diseases globally, leishmaniasis ranks third
after malaria and African trypanosomiasis, with the greater disease burden reported among
children under 15 years (Stockdale & Newton, 2013).
Leishmaniasis is generally divided into Old World and New World forms and is often found in
remote locations with a focal distribution. The Old World group is endemic in Africa, Asia, the
Mediterranean region,and the Middle East, while the New World forms are found in areas from
Texas through South America (Lysenko, 1971; Masmoudi et al., 2013; Mitropoulos et al., 2010).
Incidence data on leishmaniasis is reported by about a third of countries affected, with the lowest
proportion of country reports coming from Africa (J Alvar et al., 2012; Desjeux, 1996). In
9
University of Ghana http://ugspace.ug.edu.gh
addition, available data suggests a geographical expansion of leishmaniasis to previously non-
endemic areas, with the emergence of new species of the parasite being observed in places such
as Ghana, and the USA (Faiman et al., 2013; Kwakye-Nuako et al., 2015; Müller et al., 2009;
Reuss et al., 2012).
A review of intervention studies on various preventive methods against human leishmaniasis has
revealed a paucity of data on human specific outcomes, and suggests a need for more studies
highlighting human leishmaniasis infection as a primary outcome compared with surrogate
markers (Picado et al., 2015; Stockdale & Newton, 2013).
2.2 Transmission of Leishmania Parasites
Transmission of the Leishmania parasite is either zoonotic (transmissible only from animals) or
anthroponotic (spread between humans) (Masmoudi et al., 2013), with the primary hosts of
human leishmaniasis being vertebrates. These include domestic cats, dogs, opossums, the crab-
eating fox,, the common black rat, goats, sheep, cattle, and equids among others (Bhattarai et al.,
2010; Kenubih et al., 2015; Quinnell & Courtenay, 2009; Truppel, et al., 2014)
Leishmaniasis is transmitted mainly by infective bite of female sand flies belonging to the genus
Lutzomyia and Phlebotomus in the New World and Old World respectively (Figure 2) (Goto &
Lindoso, 2010a; Maroli et al., 2013).
10
University of Ghana http://ugspace.ug.edu.gh
There are five sand fly genera and over 700 species of sand flies globally. Of these,
approximately 98 species belonging to the genera Phlebotomus and Lutzomyia have been
implicated as putative vectors of human leishmaniasis (Desjeux, 1996; Maroli et al., 2013).
The sand flies are about a third of mosquitoes in size and measure about 2-3mm in length. They
usually breed in organic matter and in rodent burrows (Sharma & Singh, 2008).
Sand fly categorization is often based on either their feeding or resting habit (Figure 2).
Endophagic sand flies bite indoors whilst exophagic ones bite outdoors. Also, sand flies which
rest indoors are classified as endophilic whilst those which rest outdoors are classified as
exophilic (Desjeux, 2010).
Figure 2: Sand fly (Phlebotomus papatasi) feeding on human blood (Available at
https://www.google.com/search?q=sandfly+feeding+on+human+blood+papatasi&prmd=ivn&sxsrf..)
11
University of Ghana http://ugspace.ug.edu.gh
The infective stage of the Leishmania parasite, the promastigote, is injected into the human host
during blood meal of infected female sand flies. The injected promstigotes are then transformed
into amastigotes after being phagocytized by macrophages. The amastigotes then multiply in the
infected cells and also affect different tissues and cause the clinical manifestation of the disease
depending on the Leishmania species involved(Mitropoulos et al., 2010). The life cycle of
Leishmania parasite in sand fly and human is illustrated in Figure 3 below.
Figure 3: Illustration of life cycle of Leishmania parasite in sand fly and human (Available at
https://www.google.com/search?q=life+cycle+of+leishmania+species&tbm=isch&ved...)
12
University of Ghana http://ugspace.ug.edu.gh
2.3 Types of Leishmaniasis
2.3.1 Overview of different types of leishmaniasis
Leishmaniasis occurs in three main forms; Visceral (Kala-azar), cutaneous, and muco-cutaneous
(Savoia, 2015). Visceral leishmaniasis (VL) is systemic and involves internal organs such as the
liver, spleen and bone marrow. Cutaneous leishmaniasis (CL) usually begins as painless nodules
and is usually characterized by skin ulcers which may be single or multiple. Muco-cutaneous
leishmaniasis (MCL) refers to the occurrence of cutaneous leishmaniasis with mucosal
involvement (Bailey & Lockwood, 2007).
2.3.2 Cutaneous leishmaniasis
Globally, CL is the most prevalent clinical form of leishmaniasis with 0.7-1.3 million incident
cases recorded annually (de Vries et al., 2015; Steverding, 2017).
Three forms of CL exist: diffuse cutaneous leishmaniasis (DCL), localized cutaneous
leishmaniasis (LCL), and mucocutaneous leishmaniasis (MCL). LCL results in ulcers and other
skin lesions which may result in scars. DCL on the other hand is less common and involves the
whole body. It is characterized by the multiple nodules without ulceration. In MCL which so far
has been restricted to Latin America, the disease affects the mucous membranes of the nose,
throat, and mouth after the initial skin lesion has healed. As a result, the mucosal ulcers often
cause wide spread disfiguring of the face because of the associated destructive effects on the lips,
nasal septum, and palates (Steverding, 2017). An example of localized cutaneous leishmaniasis
is illustrated in figure 4 below.
13
University of Ghana http://ugspace.ug.edu.gh
Figure 4: Examples of localised cutaneous leishmaniasis (LCL) (Picture by Richard Akuffo)
The Old World CL is mainly due to infections by L. tropica (anthroponotic cutaneous
leishmanias), L. major (zoonotic cutaneous leishmaniasis), L. aethiopica and some zymodemes
of L.infantum. (Masmoudi et al., 2013).
Although, sand flies of the genus Sergentomyia have not been confirmed as putative vectors of
CL, some studies have suggested a need for investigations into their possible involvement in
Leishmania transmission, given that Leishmania parasites have been observed in these sand flies
in various parts of the world including Ghana (Berdjane-Brouk et al., 2012; Campino et al.,
2013; Maia & Depaquit, 2016; Mutinga et al., 1994; Nzelu et al., 2014b; Parvizi & Amirkhani,
2008).
2.4 Cutaneous Leishmaniasis (CL) Research in Ghana
In 1999, a cluster of suspected cases of CL were reported in the Ho District of the Volta Region
of Ghana(Kweku et al., 2011).
14
University of Ghana http://ugspace.ug.edu.gh
Of the specific communities affected by the 1999 CL outbreak, three namely Klefe in the Ho-
Shia sub-District with a population of 3,450; Taviefe and Hlefi both in the Kpedze-Vane sub-
District with populations of 5,097 and 826 respectively, had the highest suspected infection rates
(Kweku et al., 2011).
Figure 5 below illustrates the 1999 suspected CL outbreak area in the Volta Region of Ghana.
Figure 5:Illustration of the three communities which recorded the highest number of CL cases in
the Ho municipality during the 1999 suspected CL outbreak (Kweku et al.,2011)
Sand fly vector surveillance conducted from 1997 to 2002 in Navrongo in the Upper East Region
of Ghana identified 13 species of Sergentomyia and one Phlebotomus species (P. duboscqui).
Additional sand fly surveillance in the Volta region from 2004-2005 (after the outbreak) yielded
17 species including P. duboscqui and P. rodhaini, with majority being Sergentomyia (Boakye et
al., 2005).
15
University of Ghana http://ugspace.ug.edu.gh
A study in 2002 conducted by the Noguchi Memorial Institute for Medical Research (NMIMR)
and the U.S Naval Medical Research Unit-3 (NAMRU-3), Cairo, Egypt, identified Leishmania
amastigotes in 10 of 15 biopsies of chronic cutaneous ulcers from the Ho district. Additional
needle biopsy collections from the same district in 2004-2005 were sequenced for the internal
transcribed spacer region (ITS-1), confirming the presence of L. major in Ghana (Fryauff et al.,
2006).
A field investigation conducted in January 2006 for leishmaniasis in Taviefe in the Ho
municipality which included 9 biopsies from 5 suspected CL cases revealed an uncharacterized
species of Leishmania using PCR and DNA sequencing analysis (Villinski et al., 2008). A
recent study in the Ho municipality which identified new CL foci, detected Leishmania species
(GH5) which was related to non-pathogenic Leishmania enriettii but different from other known
species (Kwakye-Nuako, 2016; Kwakye-Nuako et al., 2015).
In an effort to identify CL reservoirs, a study conducted in 2006 in the 1999 outbreak area of the
Ho municipality collected and tested tissue and sera from 33 small mammals and 44 livestock
using real time PCR for the presence of Leishmania DNA. However all the samples tested
negative to the Leismania DNA (Raczniak, et al., 2008) .
Furthermore, blood meal analysis of sand flies (all Sergentomyia species) collected in 2008 from
human dwellings in the 1999 CL outbreak areas in the Volta Region of Ghana, showed that some
16
University of Ghana http://ugspace.ug.edu.gh
of the sand flies had fed on multiple blood meal sources including chicken, human , and goat.
(Kweku et al., 2011).
Although proximity of hen houses and chickens have been identified as possible environmental
factors for transmission of leishmaniasis, other studies have also confirmed that several
physiologic characteristics of chickens do not make them suitable for sustaining Leishmania
infections (Alexander, et al., 2002).
In spite of the identified gaps in the CL knowledge in Ghana, the disease has been reported as an
important emerging disease in the Volta Region of Ghana to the extent that it had a acquired a
local name, ‗‗agbamekanu‘‘ (Kweku et al., 2011).
The detection of Leishmania. major in humans and Sergentomyia sandflies in the Ho district of
Ghana, as well as the identification of L. tropica in Sergentomyia sand flies in the same district
(Fryauff et al., 2006; Nzelu et al., 2014), emphasize the public health importance of CL in the
Volta region of Ghana.
Generally, in Ghana, like many other developing countries where leishmaniasis is a neglected
tropical disease, there is no organized CL disease control effort except during suspected
outbreaks when chemotherapeutic treatment and mass spraying with insecticides indoors is
conducted (Boakye et al., 2005; Landau, 2008).
2.5 CL Clinical Manifestations
17
University of Ghana http://ugspace.ug.edu.gh
Not all Leishmania infections are clinically symptomatic. If symptomatic however, the extent of
the manifestation varies depending on the infecting species, host genetic factors as well as the
extent of immune activation. Typically, CL usually occurs on exposed parts of the body such as
the neck, limbs and face, which may be easily accessible to sandflies (Pace, 2014).
The clinical manifestation of CL in the Old World usually starts as a painless papule which may
progress into a nodule after several weeks. Sometimes, the nodule develops a central crust
underneath resulting in an indurated ulcer. At other times, the lesions do not ulcerate and rather
remain as a smooth nodule or the surface may become hyperkeratotic (ie. a high level of keratin
on the surface of the lesion). The lesions which are usually oval or circular may become large but
are rarely larger than 10cm in diameter. Generally, in the absence of secondary infections, the
CL lesions do not often cause pain. Healing of the lesion usually self occurs over several months
and may leave a scar in the skin pigmentation in the Old World. There are several patterns of
clinical manifestation of CL in the New World which tend to be less likely to resolve without
treatment (Bailey & Lockwood, 2007; Pace, 2014)
2.6 Diagnoses of Cutaneous Leishmaniasis
2.6.1 Microscopy, culture and histopathology
In view of the high specificity, parasitological methods are considered the gold standard for CL
diagnosis. Direct identification of amastigotes in Giemsa-stained lesion smears of scrapings or
biopsies are used for microscopical diagnosis of CL (de Vries et al., 2015).
18
University of Ghana http://ugspace.ug.edu.gh
On the other hand, CL diagnosis of suspected lesions using parasite culture in tubes containing
Novy-MacNeal-Nicolle medium is difficult, time consuming, requires significant technical
expertise, and is prone to contamination. In addition, the sensitivity of culture tends to be
variable and low. Some recently developed culture technologies, namely mini and micro culture
have been observed to present an advantage of being less costly, more sensitive, and relatively
easier to use compared with the conventional culture method. An assessment of the performance
of micro-culture for CL diagnoses produced sensitivity and specificity of 98.4 % (95 % CI =
96.1–99.1 %) and 100.0 %, respectively (Boggild et al., 2008; Pagheh et al., 2014).
2.6.2 Immunologic diagnostic methods
2.6.2.1 Serological diagnosis
Although serologic tests are not widely used for CL diagnoses because of their relatively low
sensitivity due to the poor humoral response elicited by CL infection, some common serologic
tests used include enzyme-linked immunosorbent assay, indirect immunofluorescence, lateral
flow assay, indirect fluorescent antibody, western blot, and direct agglutination tests. (Goto &
Lindoso, 2010a; Kar, 1995; Masmoudi et al., 2013; Zeyrek et al., 2007).
2.6.2.2 Leishmanin Skin Test or Montenegro Skin Test
The Montenegro skin test (MST) or Leishmanin intradermal skin test (LST) can be used for CL
diagnosis especially in epidemiologic surveys because it is simple to use and it also has high
sensitivity of 86.4 % up to 100 %. The LST or MST are able to detect CL infections within 2-6
weeks of infection. (Antonio et al., 2014; Manzur & Bari, 2016; Sadeghian et al., 2013).
Administration of the LST test consists of intradermal inoculation of 0.1 ml of the antigen
(leishmania) into the anterior face of the forearm. The results of the test is read after 48 or 72
19
University of Ghana http://ugspace.ug.edu.gh
hours for delayed-type hypersensitive skin reactions, and induration(s) of size equal to or more
than 5 mm is considered positive while those less than 5mm are considered negative. The
composition of a given LST is based on the target species of CL, hence it is important to know
the composition of a given LST prior to administration (da Costa et al., 1996; Manzur & Bari,
2016; Reis et al., 2008).
There are however some aspects of the LST which could become a disadvantage if not properly
taken into consideration. Firstly, the LST requires culture facilities for the production of the LST
antigen with a possibility that different antigen preparations may impact test sensitivity. It is
therefore important that the LST source is verified prior to its use. Also, it is not possible to
differentiate between past Leishmania infections from current infections when using the LST
(Weigle et al., 1991).
2.6.3 Molecular methods for CL diagnosis
2.6.3.1 Polymerase chain reaction (PCR)
Several molecular diagnostic tests for leishmaniasis diagnosis are available, with the sequences
within the kinetoplast DNA of Leishmania genus or ribosomal DNA internal transcribed spacer 1
sequence as the main targets (Monroy-Ostria et al., 2014; Reithinger & Dujardin, 2007).
In addition to serving diagnostic and prognostic purposes, PCR allows for identification of
parasite species, and this often results in a better understanding of the epidemiology of CL
(Masmoudi et al., 2013).
20
University of Ghana http://ugspace.ug.edu.gh
Furthermore, the use of PCR overcomes the requirement for previous isolation which tend to be
a challenge in resource constrained settings. However, the molecular techniques tend to be
sophisticated and expensive, requiring specialized skills (Foulet et al., 2007; Reithinger &
Dujardin, 2007).
Furthermore, a need for a comparison of the different PCR methods for diagnosing leishmaniasis
has been identified since there are currently no universally accepted protocols and each
laboratory tends to develop and apply its own protocol (Israel Cruz et al., 2013; de Vries et al.,
2015).
Table 1 below summarizes the sensitivity and specificity of key techniques for diagnosing
cutaneous leishmaniasis.
Table 1: Cutaneous leishmaniasis diagnostic tests (Antonio et al., 2014; Masmoudi et al., 2013)
Sensitivity Specificity
Technique (%) (%)
Smear 64-80 100
Culture 40-84 100
98.8 in CL;
47.4 to 83.3
PCR in ML 100
Histopathology 68 -
Montenegro's
reaction 86.4-100 100
2.7 Clinical Specimen Collection Methods for Diagnosing Cutaneous Leishmaniasis
Most of the commonly available techniques for clinical sample collection for cutaneous
leishmaniasis diagnoses tend to be invasive and require technical expertise. Some of the invasive
21
University of Ghana http://ugspace.ug.edu.gh
methods include punch biopsies, obtaining aspirates of the ulcers, and the process of obtaining
scrapings from the surface of the skin ulcers (Adams et al., 2015; Boggild et al., 2010).
Recently however, a non-invasive sampling technique based on the use of sequential tape strips
have been identified for sampling and isolation of DNA from skin lesions of CL patients
(Taslimi et al., 2017).
2.8 Treatment of Cutaneous Leishmaniais
Several treatments options have been reported for CL, yet no single ideal therapy has so far been
recognized (Bailey & Lockwood, 2007). Some of the treatment options reported include a
combination of intra-lesional antimony and cryotherapy instead of antimony or cryotherapy
alone (Asilian et al., 2004; Hodiamont et al., 2014).
Other studies have reported heat therapy as being effective in treating CL, requiring special
equipment and skills (Aronson et al., 2010). Meanwhile, in many CL endemic communities in
West Africa including Ghana, self-medication has been widely reported as the treatment option
for many people with CL (Boakye et al., 2005; Landau, 2008).
A systematic review of CL treatment trials has revealed weaknesses in many trial methodologies
including poor dosing and reporting of most of such trials, leading to a lack of consensus on the
evidence regarding treatments for CL (Bailey & Lockwood, 2007; González et al., 2008).
Some efforts have been made to provide guidance for the design, implementation, analyses and
reporting of clinical trials seeking to identify effective treatments for (Olliaro et al., 2013).
22
University of Ghana http://ugspace.ug.edu.gh
Until then, there is a need to emphasize the implementation of proven CL control measures to
reduce the disease incidence and possibly eliminate it from endemic areas.
2.9 Control and Prevention of CL
Vector control and reservoir control are key approaches to preventing the transmission of
leishmaniasis. While a recent systematic review indicated that the use of insecticides could
reduce the number of sand fly vectors of CL and lead to reduction in incident cases (González et
al., 2015), an earlier systematic review by Wilson et al., 2014, indicated benefits of insecticide
treated bed net (ITN) roll out in particular on reducing the incidence of cutaneous leishmaniasis,
especially in areas where CL is co-endemic with malaria; such as Ghana.
The findings of the systematic reviews stated above do not imply that the use of insecticides
alone or insecticide treated materials such as the insecticide treated bed net in particular, would
automatically lead to a reduction in the incidence of CL. The World Health Organization has
recommended the adoption of the following integrated approach to accelerate efforts at
overcoming the global impact of neglected tropical diseases including CL: vector and
intermediate host control, preventive chemotherapy (where available), intensified case-detection
and case management, provision of safe water, sanitation and hygiene, veterinary public health at
the human–animal interface, and strengthening of capacity to control neglected tropical diseases
(WHO, 2012).
A scoping review of some interventions applied at the community level for control of non-
helminthic neglected tropical diseases (NTD) such as CL, trypanosomiasis, dengue, and buruli
23
University of Ghana http://ugspace.ug.edu.gh
ulcer among others, suggest insecticide spraying, insecticide treated bed nets and curtains;
community education and cleanliness campaigns; chemoprophylaxis and treatment, as having the
potential to reduce the incidence and burden of non-helminthic NTDs in particular (Das et al.,
2014).
The above illustrates the need for an integrated approach for controlling NTDs such as CL by
ensuring that the appropriate context specific strategies and interventions are applied and where
possible, maximizing the benefits of proven interventions which have the potential of controlling
multiple NTDs such as the use of insecticides and insecticide treated materials(González et al.,
2015; Hailu, 2016; Menezes et al., 2015; WHO, 2013).
Furthermore, country wide and sometimes regional efforts may be required to ensure that gains
in disease reduction in one area or region are not reversed by inaction from other regions. The
strategic framework for leishmaniasis control in the WHO European region is one of such efforts
(Ejov & Dagne, 2014).
2.10 Control of CL in the context of ITN for Malaria Control
Cutaneous leishmaniasis (CL) and malaria are important vector borne parasitic diseases (Alvar et
al., 2012; Pinna et al., 2016; WHO, 2016c). Vector control approaches are among the effective
ways of controlling vector borne diseases (Wilson et al., 2015).
24
University of Ghana http://ugspace.ug.edu.gh
Although various vector control approaches such as insecticide treated bed nets and indoor
residual spraying have been proven for controlling the mosquito vectors of malaria, ITNs are
considered as the mainstay of malaria prevention especially in sub-Saharan Africa (WHO Global
Malaria Programme, 2014a).
The World Health Organization recommends the use of ITNs particularly the long lasting
insecticidal nets which have also been shown to be cost effective (World Health Organization,
2017b).
Furthermore, vector control has been identified as a key component of many leishmaniasis
control programs and is likely to remain so until an effective vaccine is available (Claborn, 2010;
Faraj et al., 2016).
Hence it is important and cost effective to implement vector control measures that have the
potential of targeting multiple vector borne diseases, especially in resource constrained settings.
The insecticide treated bed net (particularly those with pyrethroids such as permethrin and
deltamethrin treated nets) has been shown to be efficacious against sand fly vectors of
leishmaniasis (including cutaneous leishmaniasis) such as Lutzomyia longipalpis Phlebotomus
duboscqi, Phlebotomus argentipes, Phlebotomus tobbi among others, and subsequently in
reducing the incidence of leishmaniasis (Bray & Hamilton, 2013; Gunay et al., 2014; Kayedi et
al., 2017; Mondal et al., 2016; Rowland, et al., 2015; Tayeh, Jalouk, & Al-Khiami, 1997).
25
University of Ghana http://ugspace.ug.edu.gh
Since the insecticide treated bed net is known to be an effective intervention against the vectors
of malaria, its use is even more encouraged in areas where CL is co-endemic with malaria, such
as Ghana (Binka et al., 1996; Browne et al., 2001; Wilson et al., 2014).
However, it has been observed that there is a need for sustainable implementation of ITN-based
control of CL since interruption of the ITN control measure may restore the pre-intervention
disease incidence within 1-2 years (Jalouk et al., 2007).
Over the years, a lot of investment has been made into improving access to the insecticide treated
net and more people now own and use the ITNs than a few decades ago, especially in Africa
(Escamilla et al., 2017; Liu et al., 2015; Samadoulougou et al., 2017). This investment has led to
significant gains such as the reduction in global malaria incidence and mortality by 21% and
29% respectively between 2010 and 2015 (World Health Organization, 2017b).
However, in many parts of the world especially in sub Saharan Africa, there is still low coverage
of ITN in large populations at risk (Flaxman et al., 2010). In some areas which have achieved
universal coverage of ITN (at least one ITN for every two people in 80% of households), recent
data suggests gaps in usage among different age groups. For instance, some studies observed a
higher usage among children under five (which is to be encouraged) than those between 6-14
years (which is not desirable) (Wanzira et al., 2016).
It is still important to prioritize vulnerable groups including children under 5 and pregnant
women in ITN programs. However, there is also a need to promote and evaluate the communal
benefits of wide-scale ITN use by older children and adults in order to achieve greater reductions
of the malaria burden globally and in Africa in particular (Killeen et al., 2007).
26
University of Ghana http://ugspace.ug.edu.gh
In several countries including Ghana, insecticide treated bed net campaigns have been observed
to be effective strategies for rapidly increasing insecticide treated bed net coverage (Bennett et
al., 2012; Ghana Health Service, 2017; Ntuku et al., 2017; World Health Organization, 2009).
However, in both malaria and CL control, insecticide treated bed net campaigns alone may not
be sufficient to sustain high net usage as several contextual factors may influence people‘s
decision to use of not to use the insecticide treated bed nets or particular types of it (Atkinson et
al., 2009; Jalouk et al., 2007; Larsen et al., 2010; Ngwibete & James, 2016).
As a result, several countries have attempted other strategies to complement the insecticide
treated bed net campaigns to increase ownership and usage (Grabowsky et al., 2007; Kilian et al.,
2015, 2016; May-boucher & Tenikue, 2015).
In Ghana for instance, a voucher scheme introduced in the Volta Region as a potential
sustainable delivery system for increasing ITN coverage among pregnant women attending
antenatal clinic (ANC) resulted in about 50% of such women receiving the nets ( Kweku,
Webster, Taylor, Burns, & Dedzo, 2007).
The world Health Organization has recommended effective behavior change communication
strategies as a potential for increasing use and proper maintenance of the ITNs among people at
risk, in addition to insecticide treated bed net distribution campaigns (World Health
Organization, 2017b).
In addition, community engagement including the involvement of community based volunteers
in assisting with bed net hang ups and door-to-door monitoring of bed net hang-up and use have
27
University of Ghana http://ugspace.ug.edu.gh
been recommended as effective strategies for improving insecticide treated bed net use
(Desrochers et al., 2014; Kilian et al., 2015, 2016; World Health Organization, 2009).
Implementing ITN use programs are not as straight forward because context plays a major role.
For instance, whether to use a community based point of distribution of bed nets or door to door
distribution may not be a question with the same answer in all contexts although some studies
have suggested that the community based point of distribution is more cost effective (Desrochers
et al., 2014).
2.11 Factors Associated with Leishmania Infection
Several factors are associated with the emergence and spread of leishmaniasis in various parts of
the world. These factors are broadly categorized as being associated with the host, reservoir,
vector(s), and environment within which the disease is observed. Examples of environmental
factors associated with leishmaniasis include deforestation, climate change, increase in travel to
leishmanaisis endemic regions, and the presence of known reservoirs of leishmaniasis such as
dogs. Additionally, poverty and its related factors such as poor housing have been associated
with the spread of leishmaniasis (de Araujo, et al., 2016; Oryan & Akbari, 2016).
Household level characteristics such as livestock ownership, household main source of water
supply, and household member‘s age have been shown to act as risk factors for cutaneous
leishmaniasis in other studies. Because these factors are specific to particular areas, and what
may be a risk factor in one community might not necessarily be a risk factor in another, it is
important to know the context specific factors in order to conduct assessment of household level
28
University of Ghana http://ugspace.ug.edu.gh
variation in risk of CL for the purpose of designing preventive measures (de Araujo, et al., 2016;
Reithinger et al., 2010).
Biological factors, socio-economic factors, peri-domestic factors, and human behavioral factors
are also among the identified risk factors for CL (Oryan, 2014; Pedrosa & Ximenes, 2009;
Yadon, et al., 2003). Living in houses which are close to vegetation, sleeping outside or on the
floor, and living in houses with cracked mud walls can facilitate the survival of sand fly vectors
of leishmaniasis by providing breeding sites which can lead to an increase in the vector
abundance for Leishmania parasite transmission (Oryan et al., 2014; Reithinger et al., 2010).
Living close to previous cases of leishmaniasis and lack of insecticide use are also associated
with increased risk of Leishmania infection (Reithinger et al., 2010).
A study conducted in Tunisia identified family and personal history of CL, age of participants
and whether a community was an old or emerging foci of leishmaniasis among factors associated
with Leishmania infection (Bettaieb et al., 2014).
Regardless of the factors associated with leishmaniasis in a given setting, effective and
sustainable control of the disease depends on the preventive behaviors of people affected.
Evaluation of affected peoples preventive behavior and implementation of context specific
strategies such as education using the BASNEF (Belief, Attitude, Subjective Norm, and Enabling
factors) model has proven effective in improving leishmaniasis preventive behaviors (Hazavehei,
et al., 2016; Saghafipour, et al, 2017)
There is therefore a need to evaluate potential risk factors for Leishmania infection in a given
setting in order to design appropriate control strategies.
29
University of Ghana http://ugspace.ug.edu.gh
30
University of Ghana http://ugspace.ug.edu.gh
CHAPTER THREE
MATERIALS AND METHODS
3.1 The Study Sites
This study was conducted in three communities of the Oti region (part of Volta region at time of
study initiation) of Ghana. The three communities were Ashiabre, Keri, and Sibi Hilltop.
Ashiabre is in the Tutukpene sub-district of the Nkwanta south municipality while Keri is in the
Keri sub-district of the municipality. Sibi Hilltop is in the Sibi sub-district of the Nkwanta North
district of the Region (Figure 6).
3.1.1 Nkwanta South Municipality
The population of Nkwanta South municipality is estimated to be 117,878 with males
2
constituting 49.6% of the population. Covering a land area of approximately 2733 km , the
o o
Nkwanta South municipality is located between latitudes 7 30‘ and 8 45‘ North and longitude
o o
0 10‘ and 0 45‘East (Ghana Statistical Service (GSS), 2014).
3.1.2 Nkwanta North District
The population of the Nkwanta North district was estimated to be 64,553 with males constituting
50.2% of the population. The district is located between Latitude 7°30‘N and 8°45‘N and
Longitude 0°10‘W and 045‘E. It shares boundaries with Nkwanta South municipality to the
south, Nanumba South to the north, Republic of Togo to the east, and Kpandai District to the
west (Ghana Statistical Service, 2014a). Figure 6 below shows location of the study communities
in Nkwanta South and North respectively.
31
University of Ghana http://ugspace.ug.edu.gh
Figure 6: Map showing study communities
32
University of Ghana http://ugspace.ug.edu.gh
3.2 Study Design
A cross-sectional study was conducted in three communities of the Oti Region from October to
December, 2018. A household survey was conducted. The survey assessed CL awareness, CL
experience, CL related knowledge, and whether household heads considered CL to be a problem
in their communities. It also assessed ITN ownership, access, and usage. Factors associated with
non-use of the ITN were also investigated.
Prevalence of Leishmania infection as well as household factors associated with Leishmania
infection among study participants were investigated. The occurrence of sand flies in the
following locations of each study community was also investigated: households, school, church,
and mosque. In addition, a sub-sample of study participants presenting with skin ulcers were also
tested for treponemal infection.
3.2.1 Inclusion/exclusion criteria
1. Being resident in the study community for > 12 months
2. Persons aged 2 to 65 years
3. No history of sensitivity to thiomerosal (a component of Leishmanin skin test (LST))
4. Willingness to provide written informed consent by adults or parents or guardians of children
Exclusion criteria:
Being severely ill and unable to provide answers to our questions.
33
University of Ghana http://ugspace.ug.edu.gh
3.2.2 Operational definitions
A household was defined as a person or a persons who live together in the same house and share
the same house-maintenance arrangements. The head of a particular household is generally the
person with economic and social responsibility for the household. As a result, household
relationships were defined with reference the household head (Ghana Statistical Service, 2014b).
3.3 Sample size considerations
To evaluate ownership, access and use of insecticide treated bed nets, a sample size of 475
households was obtained using the following formula and
assumptions
2 2
Where, N= sample size, Z = (1.96) for 95% confidence interval (that is α = 0.05, P = proportion
2
of household owning at least one ITN (75%) D = maximum tolerable error for the prevalence
estimate (0.05), design effect of 1.5 and a non-response rate of 10% (Biadgilign et al., 2012;
Campbell & Daniel, 1994; Fokam et al., 2017; Ghana Statistical Service, 2015).
To determine the minimum number of respondents required for questionnaire on cutaneous
related (CL) related knowledge, attitude and practices, the following assumptions were
considered: Approximately 50% of the study participants would have good knowledge,
constructive attitude or good practice towards CL [confidence interval (CI) = 95%, degree of
accuracy 5%]. As a result, a minimum sample size of 385 respondents is required (Kebede et al.,
2016).
34
University of Ghana http://ugspace.ug.edu.gh
Assuming a 0.05 seropositivity of antibodies against Leishmania spp. in the study area,
acceptable difference of 0.0175, an alpha error of 0.05, and a design effect of 1.5, a minimum
sample of 834 persons was required for LST screening (Wackwella et al., 2013).
For active case detection, assuming a current CL prevalence of 22.1% (Kone et al., 2016; Kweku
2 2 2
et al., 2011), Z = (1.96) for 95% confidence interval D = maximum 0.05, a minimum sample
size of 265 individuals is required for screening for active case detection using the formula
The representative sample for this study was based on the minimum household sample size
required to evaluate ownership, access and use of insecticide treated bed nets (475) since that
was large enough to accommodate all the other sample size considerations. As a result,
household members including the heads of households of the selected minimum of 475
households were invited.
An average household size of 4.3 for the Volta Region of Ghana was reported by the 2010 Ghana
housing and population census. For Nkwanta South municipal and Nkwanta North districts in
particular, a mean household size of 5.1 and 6.4 respectively was determined (Ghana Statistical
Service, 2014b). Hence assuming an average of 6.4 inhabitants per household, this study
estimated to enroll about 475 heads of households and a total of about 3,040 (475 *6.4)
household participants into the study.
35
University of Ghana http://ugspace.ug.edu.gh
3.4 Sampling Procedure
A multistage sampling approach was used with study community and households as the primary
and secondary sampling units respectively.
3.4.1 Study site selection
Using an active CL case search approach in the Oti region, 15 communities were visited out of
which suspected cases of cutaneous leishmaniais were observed in the following communities:
Agoufie, Keri, Gekrong, Pawa, Kechiebi, Ashiabre, Sibi Hilltop, and Obunja. The name of each
of these communities was then written on separate pieces of paper after which the papers were
folded to conceal the community name. The folded pieces of paper were placed in a container
and after shaking the container for about a minute, three papers were randomly selected as the
study communities using simple random sampling without replacement. The three selected
communities were Ashiabre, Keri and Sibi Hilltop.
3.4.2 Determination of minimum household number to select per community
To determine the minimum representative number of households to select from each study
community, a proportionate population sampling technique was applied and summarized below
in Table 2. The number of households per study community was obtained from the health
information unit of the municipal/district health directorate in which the study community was
located. The household list was compiled for the national insecticide treated bed net distribution
which occurred in the Volta region six months prior to this study initiation.
Table 2: Minimum proportions of households in study communities to be sampled
Household Household Sample Minimum
Community count proportion calculation Household
36
University of Ghana http://ugspace.ug.edu.gh
Sample
Ashiabre 945 945/2924 (945/2924)*475 154
Keri 795 795/2924 (795/2924)*475 130
Sibi Hilltop 1184 1184/2924 (1184/2924)*475 193
Total 2924
3.4.3 Selection of households for study inclusion
Assuming equal probability of finding cases of Leishmania infection as well as answering all
other study objectives, 200 households were selected from each study community for study
inclusion using a systematic sampling approach described below.
Using the sorted list of households in each study community, a sampling interval I was
determined, where I=N/n with N being the sum of individual households in the study community
(number of units forming the sample frame) and n was the households to be selected (200 for
each study community). The I was rounded to 2 decimal places.
Using Microsoft excel, the RANDBETWEEN command was used to generate a random decimal
integer R between 0 and 1 rounded up to two decimal points. The sequence of households that
were selected in each study community were R*I, R*I + I, R*I +2*I, R*I +3*I,….R*I + (n-1)*I ,
each rounded up to the next highest whole number (Demographic and Health Surveys
Methodology, 2012). With the assistance of community based volunteers, the selected
households were identified after which invitation was extended to members of the households to
participate in the study.
37
University of Ghana http://ugspace.ug.edu.gh
3.5 Pre-Study Field Procedures
3.5.1 Pre-Study training
Prior to field data collection, study team members were taken through a one-week training
session comprising in-class training, break out discussion sessions, and field testing of the study
questionnaires in the Nkwanta township. The training sessions covered all aspects of the study
procedures such as informed consent process, questionnaire administration, and sample
collection. The trainees were also taken through a simulation of all study procedures.
3.5.1
Figure 7: Some pre-study team training activities
38
University of Ghana http://ugspace.ug.edu.gh
A. In class training; B. Break out discussion sessions; C. Evaluation of field practice; D. Discussion of field
practice activities.
3.5.2 Community engagement
Prior to the commencement of study procedures, leadership (usually made up of a chief and his
elders) of each study community were visited to inform them about the study and to seek
information regarding the appropriate forms of community engagement as may apply in their
respective communities.
The following approach for community engagement was used in all study communities:
1. The chief and his elders available at the time of initial visit were informed about the study
and their permission was sought for active CL case search in the community. None of the
leadership of the 15 communities visited declined to grant permission to conduct the
active CL case search.
2. Members of visited communities were then informed through an existing community
address system about the time and purpose of the visit.
3. At schools, churches, and market places within each visited community, active CL case
search using pictures of previously confirmed CL cases from the Volta region was
conducted and also a request was made to see people who may have similar skin lesions.
(Figure 7 and 8).
39
University of Ghana http://ugspace.ug.edu.gh
Figure 8: Some suspected CL cases observed during active CL case search
40
University of Ghana http://ugspace.ug.edu.gh
Figure 9: Engagement of different segments of communities during active CL case search
4. After selecting the three study communities out of the 8 potential study communities
observed, leadership of the 3 selected communities were informed about the decision to
conduct the study in their communities and they agreed.
5. In each selected study community, a durbar was organized for the study team to interact
with a larger number of the community members in order to explain the study objectives
and also to answer any questions they may have. After this, announcement about the
study was made to the entire community using the existing community address system
(Figure 9).
41
University of Ghana http://ugspace.ug.edu.gh
Figure 10: A cross-section of community members at a durbar to explain the study
6. Throughout the interaction with both community leaders and members, information about
the study was provided.
7. To confirm validity of the household list obtained from the health information unit of the
district/municipal health directorate, opportunity was given over a three days period in
each study community for any household(s) (represented by either the household head or
any adult member of the household capable of mentioning the name of the household
head) which was missed during the household enumeration for bed net distribution, to
have their household added to the list of households obtained by going to a central
location within the community for their household to be captured. No new households
42
University of Ghana http://ugspace.ug.edu.gh
were added in the study communities. Instead, community members went to the central
location assigned to verify that their households were included in the list.
3.6 Study Stages
3.6.1 Study stage 1
3.6.1.1 Household and individual level questionnaire administration
Using interviewer administered questionnaire, household heads awareness about cutaneous
leishmaniasis (CL) using pictures of CL as well as community specific names used to refer to
CL, was assessed during this phase of the study. Cutaneous leishmaniasis related knowledge and
experience were also investigated using the questionnaire.
Data on household ownership, access to and use of insecticide treated bed nets as well as other
household factors which may be associated with Leishmania infection were obtained using the
interviewer administered questionnaire, with household heads as the respondents. In each
household, the household head was requested to provide a list of all members of the household,
his/her relationship to each member of household, as well as information on each household
member‘s educational level and other demographic characteristics (Figure 7).
43
University of Ghana http://ugspace.ug.edu.gh
Figure 11: A session of household interview
The household questionnaire also included questions on other household characteristics such as
presence of electricity, main material of the household dwelling floor, main material of the roof,
main material of the exterior wall of the household, number of rooms for sleeping, household
number of windows, number of windows with screen/net, place for cooking, main cooking fuel,
main source of drinking water and main type of toilet facility.
The household questionnaire also explored possessions of the households. Household ownership
of effects such as radio, television, telephone, and refrigerator were determined. In addition,
ownership of agricultural land and a means transportation such as bicycle, motorcycle and car
were explored. Furthermore, information on specific characteristics of household heads such as
religion, ethnicity, sex, and educational level was obtained using the household questionnaire.
44
University of Ghana http://ugspace.ug.edu.gh
Each enrolled study participant (including the household heads) responded to an additional
individual questionnaire. For children below 18 years, their parents/guardians assisted them in
the provision of response.
Information obtained from the individual level questionnaire included communities of residence
in the five years preceding the study, history of skin lesions (ulcers), number of scars on skin,
number of active skin ulcers as well as information on some practices and experiences during
daily routine. Some of the practices and experiences explored included use of mosquito
repellents, use of longs sleeves, contact with dogs, contact with goats, contact with other
domestic animals, among others.
3.6.2 Study stage 2
3.6.2.1 Sand fly sampling in study communities
In a random sample of enrolled households (approximately 10 households per study community),
sand fly collections were conducted for three consecutive nights in the sleeping area(s) of each
household using battery powered indoor aspiration method for collection of resting flies from
4am to 6am each collection night (Figure 8). On the compound of the selected households, sand
fly collections were conducted for three consecutive nights using battery powered CDC light
traps from 6pm to 6am each collection night (John W. Hock Company, Gainesville, FL).
45
University of Ghana http://ugspace.ug.edu.gh
Figure 12: Sand fly collection using indoor aspiration and CDC light trap respectively in households
Beyond the study households, sand flies were trapped outdoor using the CDC light trap at the
following locations in each study community: a church compound, compound of a mosque,
school compound from 6pm to 6am each collection night for three consecutive nights (Figure
12). Indoor aspiration was performed at the following locations within each study community:
inside church building, inside mosque, and classrooms from 4am to 6am for each collection night
for 3 consecutive nights. For each school selected, a classroom was selected from the nursery
(KG), primary, and Junior high school departments respectively for indoor sand fly trapping
using the aspiration method.
46
University of Ghana http://ugspace.ug.edu.gh
Figure 13: CDC light traps for sand fly collections at mosque, school and church compound
Sand flies collected were freeze-killed at -20º C and sorted out into labeled 1.5ml eppendorf
tubes containing silica gel for dry preservation. The tubes were secured in sealed Ziploc bags and
transported to the entomology Laboratory at Noguchi Memorial Institute for Medical Research
(NMIMR), University of Ghana, Legon-Accra. The sand flies were subsequently separated into
either male or female on the basis of morphology of their reproductive organ as was observed
under a stereomicroscope (Olympus SZ60) at the Instituto de Salud Carlos III in Spain.
3.6.3 Study Stage 3
During this phase, study participants were screened for Leishmania infection using leishmanin
skin test (LST). The participants were also checked for the presence of any active ulcers which
were subsequently sampled for testing for the presence of Leishmania infection. Furthermore, the
first five study participants presenting with active skin ulcers were screened for potential
47
University of Ghana http://ugspace.ug.edu.gh
treponemal infection which is characteristic of yaws cases, given a history of yaws cases in the
region in which the study was conducted. Details of the tests conducted on the study participants
are presented below.
3.6.3.1 Leishmanin skin test
All study participants were invited to participate in the Leishmanin skin test (LST) to establish
prevalence of Leishmania infection. The leishmanin was obtained from the Pasteur Institute of
Iran and was prepared with Leishmania major. For this study, the leishmanin used was lot
number 128, manufactured in February 2016, and expected to expire in February 2021. Details
of the LST procedure is provided below:
A 0.1 mL of LST suspension was injected intradermally into the volar aspect of each study
participant‘s left forearm using new sterile tuberculin syringes. Between 48 and 72 hours post-
LST placement, the delayed-type hypersensitivity (DTH) reaction was assessed by averaging the
greatest diameter of induration and the diameter of induration perpendicular to it, measured in
millimeters using calipers/rulers. A positive LST was defined as induration >5 mm (Figure 10).
48
University of Ghana http://ugspace.ug.edu.gh
Figure 14: Induration on skin 48-72 hours after LST placement and measurement
3.6.3.2 Sampling of suspected active cutaneous leishmaniasis (ACL) lesions (ulcers)
At the time of LST placement, each study participant was examined in order to identify any
suspected active CL lesion(s) (ACL). The location, size, and duration of each suspected skin
lesion was documented.
A suspected ACL lesion was defined clinically as any open ulcer with diameter bigger than
5mm. For each suspected active CL lesion, a non-invasive diagnostic sampling technique using
sequential tape strips with a diameter of 22 mm (D-Squame, CuDerm Corporation, Texas, USA)
was used to obtain samples for subsequent DNA isolation (Taslimi et al., 2017).
49
University of Ghana http://ugspace.ug.edu.gh
For the non-invasive skin sampling, one tape disc was placed on each suspected skin lesion after
which even pressure was applied to disc on the lesion using a plunger which was gently held on
the disc and pressed for approximately 20 seconds. The tape disc was then detached and
transferred into a sterile 1.5ml Eppendorf vial and stored at 4˚C for transportation to the
laboratory for further analysis (Figure 11). Participants received standard wound care after
sample collection.
Figure 15:Non-invasive sampling of skin lesions
50
University of Ghana http://ugspace.ug.edu.gh
3.6.3.3 DNA isolation from tape strip disc
DNA extraction was performed using SpeedTools Tissue DNA Extraction Kit (Biotools). A
summary of the DNA extraction method is provided below:
a. Sample lysis
With tape disc in 1.5 ml centrifuge tube, 25 µl of Proteinase K was pipetted (equilibrated
to room temperature) into the tube. To each sample tube containing proteinase K, 200 µl
of lysis Buffer BB3 was added. The samples were then vortexed vigorously for 10-20 s
after which they were incubated at 70°C for 10 -15 min.
b. Adjustment of DNA binding conditions:
210 µl of molecular grade ethanol (96-100%) was added to the lysed samples and then
vortexed again for 10-20 s.
c. DNA binding
The samples were placed in individual spin columns and then centrifuged for 1 min at
11,000 x g. The collection tubes containing the flow-through were discarded while the
spin columns were placed into new Collection tube.
d. Washing of silica membrane:
Two washes were performed during this stage. First, 500 µl of Buffer BBW was added to
the samples after which it was centrifuged for 1 min at 11,000 x g. The flow-through was
discarded while the spin columns were placed into new collection tubes.
Next, 600 µl of Buffer BB5 was added to the samples. This was also centrifuged for 1
min at 11,000 x g. The flow-through containing the collection tubes were discarded at
this stage.
51
University of Ghana http://ugspace.ug.edu.gh
e. Dry silica membrane
The spin columns were placed into new collection tubes and centrifuged for 1 min at
11,000 x g. Residual wash buffers was removed during this step.
f. Elute pure DNA
The spin columns were placed in new individually labelled 1.5 ml centrifuge tubes after
which 100 µl of pre-warmed elution Buffer BBE (70°C) was added. The buffer was
dispensed directly onto the silica membrane which was then incubated at room
temperature for 1 min. This was then centrifuged for 1 min at 11,000 x g. The elute now
o
contained pure DNA of the samples which was stored at -20 C until PCR amplification
was performed.
3.6.3.4 PCR amplification of Leishmania species
A nested polymerase chain reaction (Ln-PCR) approach was used to amplify DNA of
Leishmania species from the human skin lesions following an adaptation of the protocol by Cruz
et al., 2002, with the target being the small subunit ribosomal ribonucleic acid (SSU rRNA)
gene. Positive control used was Leishmania infantum (JPC strain) with distilled water as negative
control.
The following primers below were used for the PCR:
R221 (R1): 5´- GGT TCC TTT CCT GAT TTA CG - 3´
R332 (R2): 5´- GGC CGG TAA AGG CCG AAT AG - 3´
R223 (R3): 5´- TCC CAT CGC AAC CTC GGT T - 3´
R333 (R4): 5´- AAA GCG GGC GCG GTG CTG - 3
52
University of Ghana http://ugspace.ug.edu.gh
PCR MIX CONDITIONS:
A summary of the master mix used for the first PCR reaction is described below. The master mix
together with the extracted DNA from the sample constituted a total of 50 µl reaction volume :
Master mix (µl)
H2O (sterile and distilled) 30.6
Buffer (Biotools Buffer 10X, 20mM MgCl2) 5.0
dNTPmix (Biotools dNTP mix 10mM each) 1.0
R1 (15 pmol/ µl working solution) 1.0
R2 (15 pmol/ µl working solution) 1.0
Tth (Biotools Tth DNA polymerase 1U/ µl) 1.4
DNA template 10.0
The following thermocycler program was applied:
30 cycles
94ºC 94ºC 60ºC 72ºC 72ºC 4ºC
5min 30sec 30sec 30sec 5min infinite
Second Reaction
For the second PCR reaction, 25 µl of the first PCR product was diluted in 1ml of sterile distilled
water after which 10 µl of the dilution was used as template for the second reaction. Below is a
summary of the master mix for the second reaction making a total of 25 µl reaction volume.
Master mix (µl)
H2O (sterile and distilled) 10.5
Buffer (Biotools Buffer 10X, 20mM MgCl2) 2.5
dNTPmix (Biotools dNTP mix 100mM each) 0.5
53
University of Ghana http://ugspace.ug.edu.gh
R1 (15 pmol/ µl working solution) 0.5
R2 (15 pmol/ µl working solution) 0.3
Tth (Biotools Tth DNA polymerase 1U/ µl ) 0.7
DNA template 10.0
The following thermocycler program was applied for the second reaction:
30 cycles
94ºC 94ºC 65ºC 72ºC 72ºC 4ºC
5min 30sec 30sec 30sec 5min infinite
This nested PCR assay described above amplifies all Leishmania species and is therefore useful
as a first step in confirming the presence of Leishmania DNA to inform the next steps of species
characterization which was not performed as part of this study (Figure 12).
54
University of Ghana http://ugspace.ug.edu.gh
Figure 16: DNA extraction from skin lesions sampled for PCR
Agarose gel electrophoresis
The products obtained from the PCR amplification were loaded onto 2% agarose gels containing
5 ng/µl of ethidium bromide and Tris-acetate (TAE) buffer which was then electrophoresed for
45 minutes at 75 – 100 V. The DNA bands obtained were subsequently viewed under ultraviolet
trans-illuminator and photographed.
3.6.3.5 Malaria test
For each study participant screened using the LST, axillary body temperature was checked.
0
Persons with temperature greater or equal to 38.0 C were tested for malaria using malaria rapid
55
University of Ghana http://ugspace.ug.edu.gh
test kit given that this study was conducted in an area considered to be malaria endemic and for
which the ITN was targeted.
3.6.3.6 Screening for treponemal infection among persons with skin ulcers
The first five study participants presenting with skin ulcers in each study community were also
screened for treponemal infection as potential cases of Yaws using a two stage screening
process. Additional numbers of study participants presenting with skin ulcers were randomly
selected and screened as potential cases of Yaws.
The first stage of the suspected Yaws case screening comprised a treponemal only test using a
rapid test kit (Syphilis 3.0) manufactured by standard diagnostics, inc, and obtained from the
Ghana national Yaws control program of the Ghana Health Service. The Syphilis 3.0 is a one
step, rapid test for the detection of syphilis antibodies to Treponema pallidum (TP). The
following procedure was followed for the treponemal only testing:
1. Alcohol swab was used to clean the area to be lanced (for this study, the middle finger of
the left hand was selected) after which a sterile lancet finger prick was done.
2. Using a capillary tube, 20 µl blood sample was drawn.
3. The 20 µl of drawn blood was added into a round sample well after which 4 drops of
assay diluent provided with the test kit was added into the sample well.
4. Test result was within 5-20 minutes after adding the assay diluent. The test was
considered negative only if one line was observed at the part of the result window of the
test kit labelled ―C‖. The result was considered positive if two lines were observed at the
result window at the parts labeled ―C‖ and ―T‖.
56
University of Ghana http://ugspace.ug.edu.gh
Participants with negative test result at the end of the first stage were not tested further.
However, participants who test positive at the first stage were tested at the second stage using the
Dual Path Platform (DPP) Syphilis Screen and Confirm assay manufactured by Chembio
Diagnostic Systems, Inc, and obtained from the national Yaws control program of the Ghana
Health Service.
The DPP Syphilis screen and confirm assay is a qualitative test for the detection of antibodies
against both non-treponemal and Treponema pallidum antigens in venous whole blood, human
finger stick whole blood, plasma, or serum specimens. The following procedure was used for the
second stage of screening:
1. The thumb of the left hand of the person being tested was cleaned with alcohol swab after
which a finger prick was done using a sterile lancet. The first blood drop was wiped off
using a sterile gauze.
2. The second drop of blood was collected with a microsafe tube held in a horizontal
position at the punctured site. Capillary action drew the blood sample to the black fill line
on the tube.
3. The blood was then transferred to the center of the round Sample + Buffer well 1 of the
test kit.
4. The running buffer bottle (red cap) was inverted and held vertically over the Sample +
Buffer well 1 after which 2 drops of the running buffer were added into the center of the
round Sample + Buffer well 1.
5. There was a waiting time of 5 minutes after the 2 drops of running buffer was added to
center of the sample + buffer well 1. The blue and green colored lines at the rectangular
window of the DPP test kit was expected to disappear by the end of the 5 minutes waiting
57
University of Ghana http://ugspace.ug.edu.gh
time. If the lines did not disappear after 5 minutes, the test device was discarded and the
procedure was repeated.
6. Once the blue and green coloured lines at the rectangular window of the DPP test device
disappeared, the running buffer bottle (red cap) was inverted and held vertically over
buffer well 2. Five drops of the buffer was then added to Buffer well number 2.
7. The result was read 15 minutes after adding the buffer to well 2.
8. Test was interpreted as non-reactive if one pink/purple line was visible at the control
(―C‖) area with no line in the Test 1 or Test 2 areas.
The test was considered reactive treponemal and non-treponemal if 3 pink/purple lines,
one in the Test 1 area, one in the control area, and one in the Test 2 area were observed.
The DPP test result was interpreted as reactive treponemal nonreactive non-treponemal if two
pink/purple lines, one in Test 1 area and another in control area was observed. If two lines, one
in Test 2 area, and another in the control area was observed, the test result was classified as
reactive non treponemal and non-reactive treponemal. The test was considered invalid if no line
was observed at control area regardless of any other lines that may be present after testing
(Figure 13). This study paid for the cost of treating all DPP positive participants using
azithromycin.
58
University of Ghana http://ugspace.ug.edu.gh
Figure 17: Sample of syphilis first line test and DPP test result
A. Negative first line syphilis test result; B. Positive first line syphilis test result; C. DPP positive
test result
3.7 Data Management and Analysis
Study data were captured using Microsoft Access software version 2013 and analyzed using
STATA software version 14. Association between nominal variables in this study was assessed
using Pearson‘s chi square test of association and Fishers exact test where cell counts below 5
were observed. Data analysis for this study was based on a 95% confidence level.
Using descriptive statistics, the following were determined:
a) Proportion of households having at least one ITN;
b) Proportion of households having at least one ITN for every two household members ;
59
University of Ghana http://ugspace.ug.edu.gh
c) Proportion of individuals with access to an ITN within the households;
d) Proportion of population reporting having slept last night under an ITN/ LLIN (by age,
and sex).
A brief explanation of key ITN indicators analysed is summarized below:
Proportion of households with at least one ITN. This indicator was used to measure household
ownership of an ITN. The numerator for this calculation was made up of all households having
least one ITN and the denominator was composed of the total of number of households.
Proportion of households having a minimum of one ITN for every two household members.
This indicator was used to measure the proportion of households that had enough access to ITN
(households having at least one ITN for every two household assuming that each ITN was used
by two household members). To calculate this, the number of ITNs belonging to he household
was divided by the number of individuals in the household. The numerator was made up of all
households that had an ITN to people ratio of 0.5 or higher, while the denominator was the total
number of households surveyed.
Proportion of individuals with access to ITN within the households. This indicator was used
to estimate the proportion of study population that could use the existing ITNs, assuming that
each ITN in a household was to be used by two people. The numerator was composed of all
household members who had access to ITN in the study households, and the denominator was
the de-facto population in the sample. Calculation of this indicator was done in two steps as
outlined below.
60
University of Ghana http://ugspace.ug.edu.gh
First, an intermediate variable ―potential ITN users‖ was calculated by multiplying the number of
ITNs in each household by two. To adjust for households with more than one bed net for every
two people, the potential ITN users were set equal to the members in that household if the
potential users were more than the number of people in the household.
Next, the indicator for individual access was calculated by dividing the potential ITN users by
the number of individuals in each household.
Proportion of households with at least one ITN for every two people among households
owning any LLIN. This indicator measures the proportion of households owning at least one
ITN which had at least one ITN for every two people.
Proportion of individuals who slept under ITNs the previous night. This indicator measured
the level of ITN use among all individuals at the time of the survey. The numerator was made up
of all individuals who slept under an ITN the night prior to the survey, while the denominator
was the total surveyed population.
Ratio of ITN use to ITN access. This indicator compared the indicator of individual ITN use to
ITN access. This ratio is helpful in inferring whether the difference between ITN use and access
could be explained as due to behavioral factors (Al-Eryani et al., 2017; Seyoum et al., 2017)
For the ITN indicators analyzed, 95% confidence intervals (two sided) were estimated per study
community and cumulatively. Binary (simple and multiple) logistic regression was used to
estimate factors associated with failure to use the ITN.
Factors evaluated in the simple binary logistic regression for association with failure to use ITN
included community of residence, participants‘ age sex, educational level, sex of household
head, age of household head, household size, main material in household roof, household
61
University of Ghana http://ugspace.ug.edu.gh
number of rooms used for sleeping, number of windows in household, number of screened
windows in household, whether household head heard any malaria message in the past 6 months,
household access to ITN, being at open field at dawn or sunset, sleeping near forest or farm
fields, sleeping in rooms or places with open windows without screen, having mosquito bites,
having bites from other insects, having contact with dogs, having contact with goats, having
contact with other domestic animals, spraying bedroom with insecticide in the last six months,
use of long sleeves, use of mosquito repellents, and sleeping in bed nets.
Factors with p value less than 0.05 in the bivariate analysis were included in the multiple logistic
regression analysis. Odd ratios for all variables included in the multiple logistic regression
analysis with outcome being failure to use ITN the night before the survey, were adjusted for all
covariates included in the model as well as for clustering at the household level using the vce
(cluster clustvar) command in Stata statistical software version 14.
In addition, prevalence of LST positivity and cutaneous leishmaniasis was described.
Furthermore, logistic regression model (simple and multiple) was used to evaluate association
between various factors and Leishmania infection as observed using the LST, in the study
communities.
The factors compared with LST positivity included community of residence, age of study
participant, sex of participant, number of scars, number of skin ulcers, family history of CL, use of
bed nets, being at open field at dawn or sunset, sleeping near forest or farm fields, and sleeping in
rooms or places with open windows without screen. Additional factors included were frequency
of mosquito bites, having bites from other insects, having contact with dogs, having contact with
goats, having contact with other domestic animals, spraying bedroom with insecticide in the last
62
University of Ghana http://ugspace.ug.edu.gh
six months, use of long sleeves, use of mosquito repellents, and household ownership of
livestock.
Factors with p value less than 0.05 in bivariate analysis were included in the multiple logistic
regression analysis. Odd ratios for all variables included in the multiple logistic regression
analysis were adjusted for all covariates included in the model as well as for clustering at the
household level using the vce (cluster clustvar) command in Stata statistical software version 14.
3.8 Ethical Considerations
Ethical approval to conduct this study was obtained from the ethics review committee of the
Ghana Health Service (GHS-ERC006/08/18). Permission was also obtained from community
leaders and household heads prior to the commencement of the study. Written informed consent
was obtained from each study participant.
63
University of Ghana http://ugspace.ug.edu.gh
CHAPTER FOUR
RESULTS
4.1 Socio-Demographic Information
A total of 587 households comprising 189 (32.2%), 200 (34.1%), and 198 (33.7%) from
Ashiabre, Keri and Sibi Hill Top respectively, were included in this study. The study households
had a total of 3718 members out of which 3,440 (92.5%) consisting of 1,194, 941, 1305 from
Ashiabre, Keri, and Sibi Hilltop respectively were enrolled in the study (Table 3).
The average household size was 6.3 with a range of 1 to 18 household members. Ashiabre and
Sibi Hilltop had an average household size of 7 while Keri had an average household size of 5
(Table 3).
In Ashiabre, 35.4% of the household members were in households with 7-9 individuals. This
was closely followed by 33.4% and 29.3% of households with 4-6 persons, and ten or more
persons respectively. In Keri, the majority (58.0%) lived in households with 4-6 persons while in
Sibi Hilltop, the majority (40.6%) lived in households with 7-9 members (Table 3).
Regarding educational level of household members, 51.5% at Ashiabre had no formal education
which was similar for Keri (54.7%) and Sibi Hilltop (51.5%) (Table 3).
The overall proportion of the household members with tertiary level education is the study area
was 0.5% and this observation with Ashiabre, Keri, and Sibi Hilltop recording 0.6%, 0.7%, and
0.1% respectively (Table 3).
The majority of all the household members (61.5%) were children of the household heads. Other
household members included sons-in-law/daughters-in-law, grandchildren, parents, parents-in-
64
University of Ghana http://ugspace.ug.edu.gh
law, brothers/sisters, brothers-in-law/sisters-in-law, uncles/aunt, nieces/nephews, other relatives,
Household Categories Study Communities
characteristics
and adopted/foster/stepchildren (Table 3).
The detailed summary of household population is presented in Table 5. Of the 3718 household
members, 1894 (50.9%) made up of 673 (50.9%), 502 (50.0%), and 719 (51.6%) of the
participants at Ashiabre, Keri and Sibi Hilltop were males. Four hundred and ninety-eight
(13.4%) of them were children under 5 years, and 2394 (64.4%) were less than 20 years old.
Table 3: Household composition by the number of usual household members, educational level,
and relationship to head of household
65
University of Ghana http://ugspace.ug.edu.gh
Ashiabre Keri Sibi Hill Top Total
n (%) n (%) n (%) n (%)
Number of
household
members 1-3 persons 26(2.0) 113 (11.3) 33 (2.4) 172 (4.6)
4-6 persons 441 (33.4) 582 (58.0) 402 (28.9) 1425 (38.3)
7-9 persons 467 (35.4) 240 (23.9) 565 (40.6) 1272 (34.2)
>=10 persons 387 (29.3) 69 (6.9) 393 (28.2) 849 (22.8)
Subtotal 1321 (100) 1004(100) 1393 (100) 3718 (100)
Mean size of households 7.0 5.0 7.0 6.3
Minimum household size 2 1 2 1
Maximum household size 18 13 16 18
Educational
Level No Formal Edu cation 648 (49.1) 549 (54.7) 718 (51.5) 1915 (51.5)
Preschool 159 (12) 75 (7.5) 139 (10) 373 (10)
Primary 370 (28) 285 (28.4) 425 (30.5) 1080 (29)
Junior High School 101 (7.6) 64 (6.4) 87 (6.2) 252 (6.8)
Senior High School 35 (2.6) 24 (2.4) 22 (1.6) 81 (2.2)
Tertiary 8 (0.6) 7 (0.7) 2 (0.1) 17 (0.5)
Relationship to
head of
household Head of household 189 (14.3) 200 (19.9) 198 (14.2) 587 (15.8)
Wife/Husband 189 (14.3) 160 (15.9) 210 (15.1) 559 (15.0)
Son/Daughter 844 (63.9) 555 (55.3) 886 (63.6) 2285 (61.5)
Son-in-law/Daughter-in-law 10 (0.8) 10 (1.0) 19 (1.4) 39 (1.0)
Grandchild 28 (2.1) 36 (3.6) 26 (1.9) 90 (2.4)
Parent 9 (0.7) 3 (0.3) 15 (1.1) 27 (0.7)
Parent-in-law 3 (0.2) 3 (0.3) 8 (0.6) 14 (0.4)
Brother/Sister 20 (1.5) 11 (1.1) 17 (1.2) 48 (1.3)
Brother-in-law/sister-in-law 3 (0.2) 2 (0.2) 2 (0.1) 7 (0.2)
Uncle/Aunt 4 (0.3) 11 (1.1) 2 (0.1) 17 (0.5)
Niece/ Nephew 14 (1.1) 4 (0.4) 3 (0.2) 21 (0.6)
Other relative 7 (0.5) 5 (0.5) 2 (0.1) 14 (0.4)
Adopted /Foster/ stepchild 1 (0.1) 4 (0.4) 5 (0.4) 10 (0.3)
Total 1 321 (100) 1004 (100) 1,393.00 3718 (100)
66
University of Ghana http://ugspace.ug.edu.gh
Table 4: Summary of household population distribution by sex, age, and community of residence
Ashiabre Keri Sibi Hill Top Total
Male Female Total Male Female Total Male Female Total Male Female Total
Age (y ears) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
<5 99 (14.7) 90 (13.9) 189(14.3) 62 (12.4) 62 (12.4) 124(12.4) 82 (11.4) 103(15.3) 185(13.3) 243(12.8) 255 (14) 498(13.4)
5-9 136(20.2) 106(16.4) 242(18.3) 121(24.1) 102(20.3) 223(22.2) 171(23.8) 125(18.5) 296(21.2) 428(22.6) 333(18.3) 761(20.5)
10-14 137(20.4) 138(21.3) 275(20.8) 102(20.3) 84 (16.7) 186(18.5) 181(25.2) 136(20.2) 317(22.8) 420(22.2) 358(19.6) 778(20.9)
15-19 90 (13.4) 60 (9.3) 150(11.4) 35 (7) 40 (8) 75 (7.5) 78 (10.8) 54 (8) 132 (9.5) 203(10.7) 154 (8.4) 357 (9.6)
20-24 28 (4.2) 32 (4.9) 60 (4.5) 14 (2.8) 28 (5.6) 42 (4.2) 25 (3.5) 23 (3.4) 48 (3.4) 67 (3.5) 83 (4.6) 150 (4)
25-29 16 (2.4) 36 (5.6) 52 (3.9) 24 (4.8) 27 (5.4) 51 (5.1) 21 (2.9) 42 (6.2) 63 (4.5) 61 (3.2) 105 (5.8) 166 (4.5)
30-34 20 (3) 42 (6.5) 62 (4.7) 20 (4) 42 (8.4) 62 (6.2) 34 (4.7) 62 (9.2) 96 (6.9) 74 (3.9) 146 (8) 220 (5.9)
35-39 39 (5.8) 46 (7.1) 85 (6.4) 31 (6.2) 34 (6.8) 65 (6.5) 28 (3.9) 44 (6.5) 72 (5.2) 98 (5.2) 124 (6.8) 222 (6)
40-44 20 (3) 42 (6.5) 62 (4.7) 27 (5.4) 37 (7.4) 64 (6.4) 33 (4.6) 43 (6.4) 76 (5.5) 80 (4.2) 122 (6.7) 202 (5.4)
45-49 32 (4.8) 26 (4) 58 (4.4) 30 (6) 24 (4.8) 54 (5.4) 22 (3.1) 23 (3.4) 45 (3.2) 84 (4.4) 73 (40) 157 (4.2)
50-54 19 (2.8) 8 (1.2) 27 (2) 22 (4.4) 9 (1.8) 31 (3.1) 19 (2.6) 7 (1) 26 (1.9) 60 (3.2) 24 (1.3) 84 (2.3)
55-59 5 (0.7) 4 (0.6) 9 (0.7) 3 (0.6) 5 (1) 8 (0.8) 6 (0.8) 8 (1.2) 14 (1) 14 (0.7) 17 (0.9) 31 (0.8)
60-64 8 (1.2) 8 (1.2) 16 (1.2) 3 (0.6) 4 (0.8) 7 (0.7) 9 (1.3) 2 (0.3) 11 (0.8) 20 (1.1) 14 (0.8) 34 (0.9)
65-69 7 (1) 0 (0) 7 (0.5) 1 (0.2) 0 (0) 1 (0.1) 2 (0.3) 1 (0.1) 3 (0.2) 10 (0.5) 1 (0.1) 11 (0.3)
70-74 5 (0.7) 2 (0.3) 7 (0.5) 4 (0.8) 1 (0.2) 5 (0.5) 2 (0.3) 0 (0) 2 (0.1) 11 (0.6) 3 (0.2) 14 (0.4)
75-79 2 (0.3) 0 (0) 2 (0.2) 2 (0.4) 1 (0.2) 3 (0.3) 4 (0.6) 0 (0) 4 (0.3) 8 (0.4) 1 (0.1) 9 (0.2)
>80 10 (1.5) 8 (1.2) 18 (1.4) 1 (0.2) 2 (0.4) 3 (0.3) 2 (0.3) 1 (0.1) 3 (0.2) 13 (0.7) 11 (0.6) 24 (0.6)
Total 673 (100) 648 (100) 1321(100) 502 (100) 502 (100) 1004 (100) 719 (100) 674 (100) 1393 (100) 1894(100) 1824(100) 3718(100)
67
University of Ghana http://ugspace.ug.edu.gh
4.1.1 Household characteristics
A total of 536 (91.3%) out of the 587 households had electricity within their households with
178 (94.2%), 185 (92.5%), and 173 (87.4%) households having electricity in Ashiabre, Keri and
Sibi Hilltop respectively (Table 6).
The main material of the household dwelling floor observed in 425 (72.4%) of the households
was cement, followed by earth/sand 96 (16.4%) and carpet 55 (9.4%) (12). In the study
communities, 81.0%, 69.5%, and 67.2% of household dwellings in Ashiabre, Keri, and Sibi
Hilltop recorded cement as the main material of the dwelling floor (Table 5).
Majority (90.8%) of the household dwelling across the study communities had metallic roofing
while the main material of the exterior wall of the household dwellings of all study communities
were cement blocks for 136 (23.2%) households, mud with cement covering for 162 (27.6%)
households, stone with mud covering for 149 (25.4%) households, and bamboo with mud
covering for 140 (23.9%) households.
In Ashiabre, 34.9% of the household dwellings had exterior wall made of stone with mud
covering while 36.0% of household dwellings in Keri had exterior walls made of bamboo with
mud covering. In Sibi Hilltop, 27.6% of the household dwellings had exterior wall made of mud
with cement covering (Table 5).
The majority of the households (71%) in the study communities used 2-5 rooms for sleeping
which ranged from 1 to 18 in Ashiabre and Keri but was 1 to 12 in Sibi Hilltop (Table 5). The
number of household windows ranged from 0 to 15 with Ashiabre having a range of 0 to 13
household windows, while Keri had a range of 1 to 15 household widows, and Sibi Hilltop
68
University of Ghana http://ugspace.ug.edu.gh
recorded a range of 0 to 12 household windows. Overall, majority (59.1%) of household
dwellings had 2 to 4 windows. This observation was consistent across the study communities as
53.4%, 57.0%, and 66.7% of household dwellings in Ashiabre, Keri, and Sibi Hilltop
respectively also recorded 2 to 4 windows (Table 7). The majority of households (71%) had
windows with no screen/nets.
The majority of the households (58%) cooked outdoors and the remaining 42% used a separate
room as kitchen distributed as follows: Keri and Sibi Hilltop 65.0% and 62.1% cooked outdoors
and 55.0% used a separate room as kitchen at Ashiabre.
Wood was the main source of fuel used for cooking in most (91.5%) of the study households
with Ashiabre, Keri, and Sibi Hilltop recording 97.9%, 85.0%, and 91.9% respectively (Table 6).
Regarding main source of drinking water and toilet facility, 51% of the households used surface
water and 84% lacked toilet facility and so used the bush/field (Table 7).
The use of surface water as main source of drinking water was particularly high among
households in Ashiabre (61.9%) and Sibi Hilltop (79.3%). In Keri however, majority (64.5%) of
the study households used public tap/standpipe as their main source of drinking water (Table 7).
69
University of Ghana http://ugspace.ug.edu.gh
Table 5: Characteristics of study households (A)
H ousing Characteristics Categories Study Communities
Ashiabre Keri Sibi Hill Top Total
n (%) n (%) n (%) n (%)
Electricity Have Electricity 178 (94.2) 185 (92.5) 1 73 (87.4) 536 (91.3)
No Electricity 11 (5.8) 15 (7.5) 25 (12.6) 51 (8.7)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Main dwelling floor material
E arth / Sand 1 2 (6.3) 44 (22.0) 4 0 (20.2) 9 6 (16.4)
Dung 1 (0.5) 2 (1.0) 3 (1.5) 6 (1.0)
Wood planks 0 (0) 1 (0.5) 1 (0.5) 2 (0.3)
Ceramic tiles 1 (0.5) 0 (0) 2 (1.0) 3 (0.5)
Cement 153 (81.0) 139 (69.5) 133 (67.2) 425 (72.4)
Carpet 22 (11.6) 14 (7) 19 (9.6) 55 (9.4)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
M ain roof material
Thatch / Palm leaf 11 (5.8) 18 (9.0) 25 (12.6) 5 4 (9.2)
Metal 178 (94.2) 182 (91.0) 173 (87.4) 533 (90.8)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Main material of exterior wall
Bamboo with mud 26 (13.8) 72 (36.0) 42 (21.2) 140 (23.9)
Stone with mud 52 (27.5) 33 (16.5) 64 (32.3) 149 (25.4)
Mud with cement 66 (34.9) 42 (21.0) 54 (27.3) 162 (27.6)
Cement blocks 45 (23.8) 53 (26.5) 38 (19.2) 136 (23.2)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
R ooms used for sleeping
1 2 0 (10.6) 2 5 (12.5) 16 (8.10 61 (10.4)
2 to 5 126 (66.7) 137 (68.5) 151 (76.3) 414 (70.5)
6 to 10 36 (19.1) 33 (16.5) 27 (13.6) 96 (16.4)
> 10 7 (3.7) 5 (2.5) 4 (2.0) 16 (2.7)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
70
University of Ghana http://ugspace.ug.edu.gh
Table 6: Characteristics of study households (B)
Housing Characteristics Categories Study Communities
Ashiabre Keri Sibi Hill Top Total
n (%) n (%) n (%) n (%)
Household number of windows
No windows 3 (1.6) 0 (0) 1 (0.5) 4 (0.7)
1 window 17 (9.0) 27 (13.5) 15 (7.6) 59 (10.1)
2 to 4 windows 101 (53.4) 114 (57.0) 132 (66.7) 347 (59.1)
5 to 7 windows 46 (24.3) 44 (22.0) 36 (18.2) 126 (21.5)
8 to 10 windows 16 (8.5) 11 (5.5) 11 (5.6) 38 (6.5)
> 10 windows 6 (3.2) 4 (2.0) 3 (1.5) 13 (2.2)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
W indows with screen/net
N o screened windows 118 (62.4) 1 40 (70.0) 1 58 (79.8) 416 (70.9)
1 screened window 17 (9.0) 13 (6.5) 9 (4.5) 39 (6.6)
2 to 4 screened windows 37 (19.6) 32 (16.0) 23 (11.6) 92 (15.7)
5 to 7 screened windows 10 (5.3) 11 (5.5) 5 (2.5) 26 (4.4)
8 to 10 screened windows 6 (3.2) 4 (2) 3 (1.5) 13 (2.2)
> 10 screened windows 1 (0.5) 0 (0) 0 (0) 1 (0.2)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Place for cooking
In a separate room used an kitchen 104 (55.0) 70 (35.0) 75 (37.9) 249 (42.4)
Outdoors 85 (45.0) 130 (65.0) 123 (62.1) 338 (57.6)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Main cooking fuel
Kerosene 0 (0) 1 8 (9.0) 5 (2.5) 23 (3.9)
Charcoal 4 (2.1) 12 (6.0) 11 (5.6) 27 (4.6)
Wood 185 (97.9) 170 (85.0) 182 (91.9) 537 (91.5)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
71
University of Ghana http://ugspace.ug.edu.gh
Table 7: Household main source of drinking water and toilet facility
Study Communities
Characteristics Categories Ashiabre Keri Sibi Hill Top Total
n (%) n (%) n (%) n (%)
Main Source of Drinking water
Improved source
Public tap / standpipe 5 0 (26.5) 129 (64.5) 18 (9.1) 1 97 (33.6)
Tube Well, Borehole 14(7.4) 43 (21.5) 2 (1) 59 (10.1)
Protected well 2 (1.1) 1 (0.5) 16 (8.1) 19 (3.2)
Non-improved source
Unprotected well 6 (3.2) 0 (0) 5 (2.5) 1 1 (1.9)
Surface water 117 (61.9) 27 (13.5) 157 (79.3) 301 (51.3)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Main toilet facility
Improved facility
Ventilated Improved Pit latrine (VIP) 13 (6.9) 5 (2.5) 5 (2.5) 2 3 (3.9)
Pit latrine with slab 24 (12.7) 19 (9.5) 4 (2) 47 (8)
Non-improved facility
Pit latrine without slab / Open pit 12 (6.3) 9 (4.5) 4 (2) 25 (4.3)
No facility, bush, field 140 (74.1) 167 (83.5) 185 (93.4) 492 (83.8)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
72
University of Ghana http://ugspace.ug.edu.gh
4.1.2 Household possessions and household head characteristics
Table 8 below shows that radios (47.2%), televisions (50.3%) and mobile telephones (80.4%)
were common durable goods owned by the study households. Mobile telephones were
particularly more common among the households and were owned by at least one person in 164
(86.8%), 134 (67.0%), and 174 (87.9%) households in Ashiabre, Keri and Sibi Hilltop
respectively. Overall, ownership of refrigerator was observed in only 6.5% of the study
households (Table 8).
Regarding ownership of means of transportation, bicycle ownership was the majority (74.8%). In
the respective communities, 88.4%, 63.0%, and 73.7% of households in Ashiabre, Keri, and Sibi
Hilltop owned at least one bicycle as a means of transportation (Table 8).
Ownership of agricultural land was observed in 72.7% of the households. In the study
communities, agricultural land was owned by 69.3%, 58.5%, and 90.4% of households in
Ashiabre, Keri, and Sibi Hilltop respectively (Table 8).
Farm animals were owned by 174 (92.1%) households in Ashiabre. In Keri and Sibi Hilltop, 126
(63.0%), and 167 (84.3%) households owned farm animals. Cumulatively, 79.6% of the study
households owned at least one farm animal (Table 8).
Table 9 summarizes key characteristics of the 587 household heads. Majority (83%) of them
were males. Most of them (73%) had no formal education. Regarding religion of the household
heads, 11.1% indicated that they did not belong to any religion while the remaining were
members of various religious groupings such as Catholics (16.5%), Protestants (9.5%),
Pentecostals (21.5%), Moslems (3.9%), Traditional/Spiritualists (30.0%).
73
University of Ghana http://ugspace.ug.edu.gh
Although the heads of households interviewed belonged to different ethnic groups, it was noted
that certain ethnic groups were more dominant in the respective study communities. In Ashiabre
for instance, 81% of the household heads interviewed belonged to the Kokomba ethnic group
while in Keri, the Achode ethnic group (62.0%) dominated. In Sibi Hilltop, it was observed that
92.9% of the household heads were members of the Kokomba ethnic group (Table 9).
Table 8: Summary of household possessions
Study Communities
Sibi Hill
Ashiabre Keri Top Total
Possession n (%) n (%) n (%) n (%)
H ousehold effects
Radio 1 00 (52.9) 8 8 (44.0) 89 (44.9) 277 (47.2)
Television 108 (57.1) 92 (46.0) 95 (48) 295 (50.3)
Mobile telephone 164 (86.8) 134 (67.0) 174 (87.9) 472 (80.4)
Non-mobile telephone 35 (18.5) 23 (11.5) 8 (4) 66 (11.2)
Refrigerator 17 (9) 6 (3.0) 15 (7.6) 38 (6.5)
Means of transport
Bicycle 167 (88.4) 126 (63.0) 146 (73.7) 439 (74.8)
Animal drawn cart 23 (12.2) 33 (16.5) 33 (16.7) 89 (15.2)
Motorcycle/scooter 95 (50.3) 57 (28.5) 76 (38.4) 228 (38.8)
Car/truck 4 (2.1) 2 (1.0) 7 (3.5) 13 (2.2)
Boat with motor 3 (1.6) 1 (0.5) 5 (2.5) 9 (1.5)
Boat without motor 3 (1.6) 2 (1.0) 0 (0) 5 (0.9)
O wnership of agricultural land 1 31 (69.3) 117 (58.5) 179 (90.4) 4 27 (72.7)
1
Ownership of farm animals 174 (92.1) 126 (63) 167 (84.3) 467 (79.6)
N umber of households 1 89 (100) 2 00 (100) 1 98 (100) 587 (100)
1 Cattle, milk cows, goat s, sheep, chic ken, ducks, o ther poultry
74
University of Ghana http://ugspace.ug.edu.gh
Table 9: Characteristics of the household heads
Household head characteristics Categories Study Communities
Ashiabre Keri Sibi Hill Top Total
n (%) n (%) n (%) n (%)
Household headship (Sex)
Male 164 (86.8) 158 (79.0) 164 (82.8) 486 (82.8)
Female 25 (13.2) 42 (21.0) 34 (17.2) 101 (17.2)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Household head Level of education
N o Formal Education 1 31 (69.3) 139 (69.5) 1 59 (80.3) 429 (73.1)
Preschool 7 (3.7) 6 (3.0) 4 (2) 17 (2.9)
Primary 14 (7.4) 22 (11.0) 8 (4) 44 (7.5)
Junior High School 21 (11.1) 15 (7.5) 16 (8.1) 52 (8.9)
Senior High School 13 (6.9) 15 (7.5) 9 (4.5) 37 (6.3)
Tertiary 3 (1.6) 3 (1.5) 2 (1.0) 8 (1.4)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
Household head religion
C atholic 1 6 (8.5) 76 (38) 5 (2.5) 97 (16.5)
Protestant (Anglican, Presbyterian,
Methodist, etc.) 14 (7.4) 10 (5.0) 32 (16.2) 56 (9.5)
Pentecostal/Charismatic 61 (32.3) 33 (16.5) 32 (16.2) 126 (21.5)
Other Christian 13 (6.9) 18 (9.0) 13 (6.6) 44 (7.5)
Moslem 13 (6.9) 5 (2.5) 5(2.5) 23 (3.9)
Traditional/Spiritualist 47 (24.9) 37 (18.5) 92 (46.5) 176 (30)
No religion 25 (13.2) 21 (10.5) 19 (9.6) 65(11.1)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
H ousehold head ethnicity
Ewe 1 (0.5) 2 (1.0) 0 (0) 3 (0.5)
Akan 1 (0.5) 12 (6.0) 0 (0) 13 (2.2)
Mole-Dagbani 1 (0.5) 1 (0.5) 2 (1.0) 4 (0.7)
Kokomba 153 (81.0) 27 (13.5) 184 (92.9) 364 (62.0)
Grusi 0 (0) 2 (1.0) 3 (1.5) 5 (0.9)
Achode 0 (0) 124 (62.0) 0 (0) 124 (21.1)
Basare 19 (10.1) 1 (0.5) 6 (3.0) 26 (4.4)
Challa 0 (0) 22 (11.0) 0 (0) 22 (3.7)
Other 14 (7.4) 9 (4.5) 3 (1.5) 26 (4.4)
Subtotal 189 (100) 200 (100) 198 (100) 587 (100)
75
University of Ghana http://ugspace.ug.edu.gh
4.1.3 Practices and behaviors during daily routine of study participants
Information regarding some specific routine practices and behaviors of study participants were obtained
and classified as often (if it occurred at least once a week), sometimes (if it occurred at least once in three
months), and never (if there had not been a previous experience).
A little over half of respondents (50.7%) had been at open field at dawn or sunset sometimes while 1323
(38.5) had been at open field at dawn or sunset often. This observation was similar in Ashiabre and Keri
where 54.9% and 55.2% of respondents indicated that they had been at open field at dawn or sunset
sometimes (Table 10).
In Sibi Hilltop however, majority of respondents (53.2%) had been at open field at dawn or sunset often
compared with 43.5% who did same sometimes. The overall proportion of people who indicated that they
never go to open field at dawn or sunset was 10.9% while 3.3%, 14.2%, and 17.1% of respondents at Sibi
Hilltop, Ashiabre, and Keri respectively indicated that they had never been open fields at dawn or sunset
(Table 10).
Regarding sleeping near forest or farm fields, 37.6% and 26.1% of respondents interviewed indicated that
they had slept near forest and farms fields sometimes or often respectively. Overall, 36.3% of study
participants interviewed never sleep near forest or farm fields. In the respective study communities, 42.5%,
38.9% and 28.6% of participants never sleep near forest or farm fields in Ashiabre, Keri, and Sibi hilltop
(Table 10).
Cumulatively, 68.4% of participants reported that they slept in rooms or places without screen either
sometimes or often. This proportion was 53.7% in Ashiabre, 71.3% in Keri, and 79.8% in Sibi Hilltop
(Table 10).
76
University of Ghana http://ugspace.ug.edu.gh
Mosquito bites was reported in 98.9% of participants with 64.1% of respondents reporting that they
experienced mosquito bites often. In the respective study communities, 68.8%, 55.7%, and 65.8% study
participants reported that they experienced mosquito bites often in Ashiabre, Keri, and Sibi Hill top
respectively (Table 10).
Apart from mosquito bites, 98.2% of participants reported that they experienced bites from other insects
with 56.0% of respondents indicating that they experienced these bites often. In the individual study
communities, 42.0%, 50.2%, and 73.1% of participants in Ashiabre, Keri, and Sibi Hilltop indicated that
they experienced bites from other insects often (Table 10). Other insects indicated by study participants to
have bitten them were ants, bees, blackflies, sand flies, tsetse flies, and some insects which were described
as small insects.
Regarding contact with dogs, 2588 (74.2%) of study participants indicated that they had contact with dogs
either often or sometimes. Specifically, 1091 (31.7%) of participants indicated that they have contact with
dogs often. In Ashiabre, 68.5% of participants had some contact with dogs with 36.8% of them having dog
contacts often. In Keri, 67.8% of participants had contact with dogs with 20.1% of participants having
contact with dogs often. In Sibi Hilltop, 86.8% of participants had some contact with dogs while 35.5% of
participants had contact with dogs often (Table 11).
Overall, 79.7% of participants had contact with goats, with 37.8% having contact with them often. In
Ashiabre, 71.5% of participants had some contact with goats while 30.4% of them had contact with them
often. In Keri, 77.2 of the respondents had some contact with goats while 30.4% of them had contact with
goats often. In Sibi Hilltop, 89.1% of the participants had some contact with goats while 44.2% of them
had contact with goats often (Table 11).
77
University of Ghana http://ugspace.ug.edu.gh
Apart from dogs and goats, 86.7% of study participants reported having contact with other domestic
animals with 50.5% of participants having contact with at least one other domestic animal often. Contact
with other domestic animals was reported among 80.7% of participants at Ashiabre with 45.0% of them
indicating that such contact occurred often (Table 11). The other domestic animals that study participants
had contact with included sheep, cattle, pigs, ducks, chicken, and other poultry such as guinea fowl and
turkey.
In Keri, 83.6% of the participants reported having some contact with other domestic animals while 42.3%
of them indicated that they had contact with other domestic animals often. In Sibi Hilltop, 61.5% of
participants had contact with other domestic animals often although as many as 2980 (94.2%) of the
participants indicated having some contact with other domestic animals (Table 11).
Concerning spraying of sleeping area with insecticides, 33.5% of participants indicated that they do, while
356 (10.3%) participants indicated that they spray their sleeping area with insecticides often. In Ashiabre,
3.9% of participants indicated that they sprayed their sleeping area with insecticides often while 12.3% and
14.8% of participants in Keri and Sibi Hilltop respectively, indicated that they used insecticides to spray
their sleeping area often (Table 11).
The use of long sleeves was mentioned by 74.8% of study participants with 367 (10.7%) participants
indicating that they use long sleeves often. In the study communities, long sleeves were used often by
10.3%, 9.2%, and 12.0% of participants in Ashiabre, Keri, and Sibi Hilltop respectively (Table 11).
Mosquito repellents such as mosquito coils were used by a total of 8.4% participants with 46 (1.3%) using
them often. In the individual study communities, 2.4%, 1.5%, and 0.2% of participants in Ashiabre, Keri,
and Sibi Hilltop used mosquito repellents often (Table 11).
78
University of Ghana http://ugspace.ug.edu.gh
Regarding sleeping in bed nets, 94.7% of study participants indicated that they slept in bed nets either
sometimes or often. However, 69.0% of them reported that they slept in the bed nets often. In Ashiabre,
62.8% of the participants slept in bed nets often, while 59.9%, and 81.1% reported that they slept in bed
nets often at Keri and Sibi Hilltop respectively (Table 11).
Table 10: Practices and behaviors during daily routine of study participants
Ashiabre Keri Sibi Hilltop Total
Characteristics
no. % no. % no. % no. %
Been at open field at dawn or sunset
Often 368 30.8 261 27.7 694 5 3.2 1,323.00 38.5
Sometimes 656 54.9 519 55.2 568 43.5 1,743.00 50.7
Never 170 14.2 161 17.1 43 3.3 374 10.9
Sle ep near forest or farm fields
Often 219 18.3 253 26.9 427 32.7 899 26.1
Sometimes 467 39.1 322 34.2 505 38.7 1,294.00 37.6
Never 508 42.5 366 38.9 373 28.6 1,247.00 36.3
Sl eep in rooms or places with open windows without screen
Often 246 20.6 259 27.5 604 46.3 1,109.00 32.2
Sometimes 395 33.1 412 43.8 437 33.5 1,244.00 36.2
Never 553 46.3 270 28.7 264 20.2 1,087.00 31.6
Ha ve mosquito bites
Often 821 68.8 524 55.7 859 65.8 2,204.00 64.1
Sometimes 358 30 398 42.3 442 33.9 1,198.00 34.8
Never 15 1.3 19 2 4 0.3 38 1.1
Ha ve bites from other insects
Often 501 42.0 472 50.2 954 73.1 1,927.00 5 6.0
Sometimes 647 54.2 454 48.2 350 26.8 1,451.00 42.2
Never 46 3.9 15 1.6 1 0.1 62 1.8
Total 1,194.00 100 941 100 1,305.00 100 3,440.00 100
79
University of Ghana http://ugspace.ug.edu.gh
Table 11: Additional practices and behaviors during daily routine of study participants
Ashiabre Keri Sibi Hilltop Total
Characteristics
No. % No. % No. % No. %
Have contact with dogs
Often 439 36.8 189 20.1 463 3 5.5 1,091.00 3 1.7
Sometimes 379 31.7 449 47.7 669 51.3 1,497.00 43.5
Never 376 31.5 303 32.2 173 13.3 852 24.8
H ave contact with goats
Often 438 36.7 286 30.4 577 4 4.2 1,301.00 37.8
Sometimes 415 34.8 440 46.8 586 44.9 1,441.00 41.9
Never 341 28.6 215 22.8 142 10.9 698 20.3
H ave contact with other domestic animals
Often 537 45.0 398 42.3 803 61.5 1,738.00 5 0.5
Sometimes 426 35.7 389 41.3 427 32.7 1,242.00 36.1
Never 231 19.3 154 16.4 75 5.7 460 13.4
S pray bedroom with insecticide in the last six months
Often 47 3.9 116 12.3 193 14.8 356 10.3
Sometimes 268 22.4 246 26.1 283 21.7 797 23.2
Never 879 73.6 579 61.5 829 63.5 2,287.00 66.5
U se long sleeves
Often 123 10.3 87 9.2 157 12 367 10.7
Sometimes 555 46.5 708 75.2 943 72.3 2,206.00 64.1
Never 516 43.2 146 15.5 205 15.7 867 25.2
U se mosquito repellents
Often 29 2.4 14 1.5 3 0.2 46 1.3
Sometimes 110 9.2 54 5.7 79 6.1 243 7.1
Never 1,055.00 88.4 873 92.8 1,223.00 93.7 3,151.00 91.6
S leep in bed nets
Often 750 62.8 564 59.9 1,059.00 8 1.1 2,373.00 6 9.0
Sometimes 366 30.7 318 33.8 199 15.2 883 25.7
Never 78 6.5 59 6.3 47 3.6 184 5.3
Total 1,194.00 100 941 100 1,305.00 100 3,440.00 100
80
University of Ghana http://ugspace.ug.edu.gh
81
University of Ghana http://ugspace.ug.edu.gh
4.2 Leishmania Infection and Cutaneous Leishmaniasis among the Study Participants
4.2.1 Leishmania infection assessment by Leishmanin skin test (LST)
Of the 3440 enrolled study participants, 3173 (92.2%) were screened using the Leishmanin skin test (LST)
procedure. Of the 3173, 3071(96.8%) comprising 1091, 848, 1132 participants from Ashiabre, Keri, and
Sibi Hilltop returned within 48 to 72 hours to complete the test. Table 13 and Table 14 summarizes the
prevalence of Leishmania infection by the LST procedure.
At Ashiabre and Keri, prevalence of 39.4% and 55.1% respectively was observed (Table 12). Prevalence
among males at Ashiabre was 43.6% and 35.6% among females in the same community. In both males and
females at Ashiabre, prevalence of Leishmania infection increased with age from 18.8% and 19.1% among
males and females under five respectively to 67.4% and 59.5% among males and females greater than 45
years respectively. Cumulatively, prevalence of Leishmania infection at Ashiabre increased from 19.0%
among children under five, to 63.8% among adults greater 45 years (Table 12).
At Keri, prevalence of Leishmania infection among males was 55.4% while a prevalence of 54.8% was
observed among females. Among both males and females at Keri, prevalence of Leishmania infection
increased with age from 24.4% and 22.2% among males and females under five respectively to 83.3% and
80.7% among males and females above 45 years respectively. Cumulatively, prevalence of Leishmania
infection at Keri increased from 23.3% among children under five to 82.1% among adults aged above 45
years (Table 12)
Table 13 summarizes prevalence of Leishmania infection at Sibi Hilltop (34.2%) as well as the cumulative
prevalence of Leishmania infection determined by the LST for all study sites (41.8%). At Sibi Hilltop,
prevalence of Leishmania infection among males was 35.1% while it was 33.3% among females.
Prevalence of infection increased from 28.8% and 30.2% among males and females under five respectively
82
University of Ghana http://ugspace.ug.edu.gh
to 47.4% and 48.0% among adult males and females above 45 years respectively. Cumulatively,
Prevalence of infection determined by LST at Sibi Hilltop increased from 29.5% among children under five
to 47.6% among adults above 45 years (Table 13)
In all the study communities, prevalence of Leishmania infection was observed to increase with age of
study participants. While a cumulative prevalence of 41.8% was observed, prevalence among age groups
was 23.3%, 47.1%, 70.0% and 82.1% among <5years, 5-15 years, 16-45 years, and >45 years respectively
(Table 13). A summary of the prevalence of Leishmania infection across the study communities and
cumulatively is presented in Figure 18 below.
LST positivity was associated with the study community, age of the study participants, and sex of the study
participants. Compared to persons in Ashiabre, participants in Keri (AOR=1.83; 95% CI: 1.43, 2.34) had
higher odds of being LST positive. Compared to children under 5 years, participants 5-15 years
(AOR=1.49; 95% CI: 1.31, 1.98), those 16-45 years (AOR=3.31; 95% CI: 2.44, 4.47), and participants
aged 45 years and above (AOR=4.85; 95% CI: 3.29, 7.15) had higher odds of being LST positive, with the
odds increasing with age. Compared to females, males (AOR=1.27; 95% CI: 1.09, 1.49) had higher odds of
being LST positive. Never using ITN or use of ITN sometimes was not significantly associated with being
LST positive when compared with those who used ITN often (Table 14).
83
University of Ghana http://ugspace.ug.edu.gh
Table 12: LST prevalence by age and sex at Ashiabre and Keri
Community Sex Age Number of household LST Prevalence P value
members screened n (%) 95% CI
< 5 years 69 13 (18.8) (11.1, 30.1)
5-15 years 280 108 (38.6) (33.0, 44.4)
<0.001
Males 16-45 years 131 78 (59.5) (50.8, 67.7)
>45 years 43 29 (67.4) 51.6, 80.1)
Subtotal 523 228 (43.6) (39.4, 47.9)
< 5 year s 68 13 (19. 1) ( 11.3, 30.5)
5-15 years 245 64 (26.1) (21.0, 32.0)
<0.001
Ashiabre Females 16-45 years 218 103 (47.3) (40.7, 53.9)
>45 years 37 22 (59.5) (42.4, 74.5)
Subtotal 568 202 (35.6) (31.7, 39.6)
< 5 year s 137 26 (19. 0) (13.2, 26.5)
5-15 years 525 172 (32.8) (28.9, 36.9)
<0.001
Total 16-45 years 349 181 (51.9) (46.6, 57.1)
>45 years 80 51 (63.8) (52.5, 73.7)
Total 1091 430 (39.4) (36.5, 42.4)
< 5 year s 41 10 (24. 4) ( 13.3, 40.4)
5-15 years 220 111 (50.5) (43.8, 57.1)
<0.001
Males 16-45 years 84 60 (71.4) (60.7, 80.2)
>45 years 36 30 (83.3) (66.6, 92.6)
Subtotal 381 211 (55.4) (50.3, 60.3)
< 5 year s 45 10 (22. 2) ( 12.1, 37.2)
5-15 years 192 83 (43.2) (36.3, 50.4)
<0.001
Keri Females 16-45 years 199 138 (69.4) (62.5, 75.4)
>45 years 31 25 (80.7) (61.9, 91.5)
Subtotal 467 256 (54.8) (50.3, 59.3)
< 5 year s 86 20 (23. 3) ( 15.4, 33.5)
5-15 years 412 194 (47.1) (42.3, 51.9)
<0.001
Total 16-45 years 283 198 (70.0) (64.3, 75.1)
>45 years 67 55 (82.1) (70.7, 89.7)
Total 848 467 (55.1) (51.7, 58.4)
84
University of Ghana http://ugspace.ug.edu.gh
Table 13: LST prevalence by age and sex at Sibi Hilltop and cumulatively for all study sites
Community Sex Age Number of household LST Prevalence P value
members screened n (%) 95% CI
< 5 years 59 17 (28.8) (18.5, 42.0)
5-15 years 346 109 (31.5) (26.8, 36.6)
0.022
Males 16-45 years 136 59 (43.4) (35.2, 51.9)
>45 years 38 18 (47.4) (31.6, 63.7)
Subtotal 579 203 (35.1) (31.3, 39.1)
< 5 years
63 19 (30.2) ( 19.9, 42.9)
5-15 years 251 65 (25.9) (20.8, 31.7)
0.002
Sibi Hilltop Females 16-45 years 214 88 (41.1) (34.7, 47.9)
>45 years 25 12 (48.0) (28.4, 68.2)
Subtotal 553 184 (33.3) (29.5, 37.3)
< 5 years 122 36 (29.5) (
22.0, 38.3)
5-15 years 597 174 (29.2) (25.6, 32.9)
<0.001
Total 16-45 years 350 147 (42.0) (36.9, 47.3)
>45 years 63 30 (47.6) (35.4, 60.2)
Total 1132 387 (34.2) (31.5, 37.0)
< 5 years 169 4 0 (23.7) ( 17.8, 30.7)
5-15 years 846 328 (38.8) (35.5, 42.1)
<0.001
Males 16-45 years 351 197 (56.1) (50.9, 61.3)
>45 years 117 77 (65.8) (56.6, 73.9)
Subtotal 1483 642 (43.3) (40.8, 45.8)
< 5 years 176 42 (23.9) (18.1, 30.8)
5-15 years 688 212 (30.8) (27.5, 34.4)
<0.001
Total Females 16-45 years 631 329 (52.1) (48.2, 56.0)
>45 years 93 59 (63.4) (53.0, 72.7)
Subtotal 1588 642 (40.4) (38.0, 42.9)
< 5 years 345 82 (23.8) (19.6, 28.6)
5-15 years 1534 540 (35.2) (32.8, 37.6)
<0.001
Total 16-45 years 982 526 (53.6) (50.4, 56.7)
>45 years 210 136 (64.8) (58.0, 71.0)
Total 3071 1284 (41.8) (40.1, 43.6)
85
University of Ghana http://ugspace.ug.edu.gh
Table 14: Factors associated with LST positivity
Number and
proportion LST Crude OR (95%
Characteristics Categories Frequency positive, n(%) CI) P value AOR (95% CI) P value
Study community
A shiabre 1091 4 30 (39.4) [Reference] [Reference]
Keri 848 467 (55.1) 1.88 (1.57, 2.26) <0.001 1.83 (1.43, 2.34) <0.001*
Sibi 1132 387 (34.2) 0.80 (0.67, 0.95) 0.011 0.65 (0.50, 0.85) 0.002
Subtotal 3071 1284 (41.8)
Person's age
< 5 years 336 86 (25.6) [Reference] [Reference]
5-15 years 1529 530 (34.7) 1.54 (1.18, 2.01) 0.001 1.49 (1.31, 1.98) 0.005*
16-45 years 993 533 (53.7) 3.37 (2.56, 4.43) <0.001 3.31 (2.44, 4.47) <0.001*
>45 years 213 135 (63.4) 5.03 (3.47, 7.29) <0.001 4.85 (3.29, 7.15) <0.001*
Subtotal 3071 1284 (41.8)
Person's sex
Female 1579 639 (40.5) [Reference] [Reference]
Male 1492 645 (43.2) 1.12 (0.97, 1.29) 0.121 1.27 (1.09, 1.49) 0.002*
Subtotal 3071 1284 (41.8)
Number of scars on skin
No scars 491 2 09 (42.6) [Reference] [Reference]
1-3 scars 680 248 (36.5) 0.77 (0.61, 0.98) 0.035 0.99 (0.76, 1.28) 0.923
4-6 scars 582 226 (38.8) 0.86 (0.67, 1.09) 0.215 1.07 (0.80, 1.42) 0.665
7-9 scars 482 193 (40.0) 0.90 (0.70, 1.16) 0.424 1.07 (0.78, 1.48) 0.674
>=10 scars 836 408 (48.8) 1.29 (1.03, 1.61) 0.028 1.28 (0.97, 1.69) 0.084
Subtotal 3071 1284 (41.8)
Family CL history
N o family history 825 341 (41.3) [ Reference] [Reference]
1-3 persons with CL history 1874 772 (41.2) 0.99 (0.84, 1.17) 0.946 1.01 (0.83, 1.23) 0.946
4-6 persons with CL history 307 139 (45.3) 1.17 (0.90, 1.53) 0.233 1.40 (0.94, 2.06) 0.094
7-9 persons with CL history 25 13 (52.0) 1.54 (0.69, 3.41) 0.29 1.39 (0.66, 2.91) 0.382
>=10 persons 40 19 (47.50) 1.28 (0.68, 2.43) 0.441 1.49 (0.84, 2.65) 0.170
Subtotal 3071 1284 (41.8)
Use of bed nets
Often 2129 887 (41.7) [Reference] [Reference]
Sometimes 677 304 (44.9) 1.14 (0.96, 1.36) 0.137 0.85 (0.68, 1.07) 0.163
Never 162 63 (38.9) 0.89 (0.64, 1.24) 0.490 0.80 (0.55, 1.15) 0.227
Subtotal 2968 1254 (42.3)
86
University of Ghana http://ugspace.ug.edu.gh
60
55.1
50
41.81
39.4
40
34.2
30
20
10
0
Ashiabre total Keri total Sibi total Overall Total
Study sites and total of study sites (Overall Total)
Figure 18: Prevalence of Leishmania infection at various study sites and cumulatively
4.2.2 Cutaneous leishmaniasis and ulcer treatment options among participants with skin ulcers
Out of 3440 persons who were physically examined for ulcers, a total of 595 skin ulcers were observed on
426 (12.4%) of them (Table 15). Of the 426 persons with skin ulcers, 73.7% were within the age group 5-
15 years followed by children under five who constituted 13.6%. The number of skin ulcers observed on
the participants ranged from 1 to 7 with those having one ulcer (47.1%) and two ulcers (27.6%) being in
the majority. Although the skin ulcers were observed on various parts of the participants‘ body, majority
occurred on the lower legs (71.3%) and feet (17.1%). In Ashiabre, Keri, and Sibi Hilltop, 65.2%, 70.1%,
and 74.3% of persons with skin ulcers had the ulcer on their lower legs respectively (Table 15).
87
LST Prevalence
University of Ghana http://ugspace.ug.edu.gh
PCR test of the 595 ulcer samples indicated that 150 (25.2%) of them were Leishmania positive (Table 15).
In the study communities, 14 (20.3%), 62 (22.1%), and 74 (30.2%) of skin ulcers tested from Ashiabre,
Keri, and Sibi Hilltop were positive for Leishmania.
Of the 595 ulcer samples tested, 365 (61.3%) were obtained from males while 90 (60.0%) of the 150
Leishmania positive samples were also obtained from males. Also, 437 (73.4%) of the ulcer samples tested
as well as 112 (74.7%) of the Leishmania positive ulcer samples were obtained from people within the age
group 5-15 years (Table 16).
The 150 Leishmania positive ulcer samples were obtained from 136 study participants of which 123
(90.4%) had single Leishmania positive skin ulcer, 12 (8.8%) had two Leishmania positive skin ulcers and
1 person had three Leishmania positive skin ulcers (Table 16). Majority of individuals with Leishmania
positive ulcers were within the age group of 5-15 years (73.5%) followed by children under five (14.0%)
and persons aged 16-45 years (10.3%). Across the study sites and among males and females respectively,
majority of persons with Leishmania positive skin ulcer(s) were within the age group 5-15 years (Table
17).
The overall prevalence of Leishmania infection (cutaneous leishmaniasis) observed among those with skin
ulcers was 31.9% (136/426) with prevalence of 23.2% (13/56), 29.8% (56/188), and 36.8% (67/182)
observed in Ashiabre, Keri and Sibi Hilltop respectively.
The average size of the skin ulcers was 10.2mm by 10.3mm with 573 (96.3%) of them reported to have
started in the year 2018, 3 (0.5%) in 1990, 1 (0.2%) in 2007, 2 (0.3%) in 2010, 3 (0.5%) in 2011, 3 (0.5%)
in 2012, 2 (0.3%) in 2015, 4 (0.7%) in 2016, and 4 (0.7%) in 2017. Among the ulcers which started in the
year 2018, 17 (3.0%) of them were mentioned as having started between January to July 2018 while 13
(2.3%), 70 (12.2%), 346 (60.4%), 127 (22.2%) of them started in August, September, October and
88
University of Ghana http://ugspace.ug.edu.gh
November of the year 2018 respectively. Examples of Leishmania positive skin ulcers observed is captured
as Figure 19.
Of the 426 individuals with skin ulcers observed, 419 (98.4%) indicated that they applied some form of
treatment. Table 18 summarizes the type of treatments that the 419 participants used for their skin ulcers.
Majority of them (67.5%) used herbs while 35.3%, and 14.2% of them used hot stone and hot water
respectively for treatment of their skin ulcers.
89
University of Ghana http://ugspace.ug.edu.gh
Table 15: Individuals with skin ulcers, ulcers sampled and result of Leishmania PCR test
Characteristic Category Ashiabre Keri Sibi Hilltop Total
n % n % n % n % P value
Age of individuals with skin ulcers
<5 years 12 2 1.4 2 2 11 .7 2 4 13 .2 5 8 13 .6
5-15 years 35 62.5 145 77.1 134 73.6 314 73.7
0.141
16-45 years 9 16.1 19 10.1 18 9.9 46 10.8
>45 years 0 0 2 1.1 6 3.3 8 1.9
Total 56 100 188 100 182 100 426 100
Sex of individu als with skin ulcers
Male 36 64.3 109 58 110 60.4 255 59.9
0.684
Female 20 35.7 79 42 72 39.6 171 40.1
Total 56 100 188 100 182 100 426 100
Number of Ski n ulcers tested
1 31 4 4.9 11 6 41 .3 13 3 54 .3 28 0 47 .1
2 28 40.6 84 29.9 52 21.2 164 27.6
3 8 11.6 46 16.4 37 15.1 91 15.3
4 0 0 30 10.7 11 4.5 41 6.9 <0.001
5 2 2.9 5 1.8 0 0 7 1.2
6 0 0 0 0 5 2 5 0.8
7 0 0 0 0 7 2.9 7 1.2
Total 69 100 281 100 245 100 595 100
Skin ulcer loca tions
Face/Head 3 4.3 5 1 .8 6 2 .4 1 4 2 .4
Upper arm 0 0 2 0.7 0 0 2 0.3
Lower arm 1 1.4 13 4.6 11 4.5 25 4.2
Palm/Back of palm 0 0 2 0.7 3 1.2 5 0.8
Chest 0 0 1 0.4 0 0 1 0.2
Back (upper part below neck)) 0 0 0 0 2 0.8 2 0.3 0.029
Stomach 2 2.9 0 0 0 0 2 0.3
Buttocks 1 1.4 0 0 2 0.8 3 0.5
Thighs 1 1.4 8 2.8 6 2.4 15 2.5
Lower legs(crus/cnemis) 45 65.2 197 70.1 182 74.3 424 71.3
Feet 16 23.2 53 18.9 33 13.5 102 17.1
Total 69 100 281 100 245 100 595 100
Leishmania pc r result
Negative 55 7 9.7 21 9 77 .9 17 1 69 .8 44 5 74 .8
0.061
Positive 14 20.3 62 22.1 74 30.2 150 25.2
Total 69 100 281 100 245 100 595 100
90
University of Ghana http://ugspace.ug.edu.gh
Table 16: Skin ulcers tested for Leishmania parasite using PCR by age and sex
Sex Age Number of skin Leishmania Positive P value
ulcers tested n (%) 95% CI
< 5 years 48 8 (16.7) (8.3, 30.5)
5-15 years 276 70 (25.4) (20.6, 30.9)
0.467
Males 16-45 years 36 10 (27.8) (15.2, 45.3)
>45 years 5 2 (40.0) (3.8, 91.9)
Subtotal 365 90 (24.7) (20.5, 29.4)
< 5 years 45 1 3 (28.9) (17.2, 44.3)
5-15 years 161 42 (26.1) (19.8, 33.5)
0.912
Females 16-45 years 19 4 (21.1) (7.3, 47.3)
>45 years 5 1 (20.0) (0.8, 88.9)
Subtotal 230 60 (26.1) (20.8, 32.2)
< 5 years 93 21 (22.6) ( 15.1, 32.4)
5-15 years 437 112 (25.6) (21.7, 29.9)
0.918
Total 16-45 years 55 14 (25.5) (15.4, 39.0)
>45 years 10 3 (30.0) 7.6, 69.0)
Total 595 150 (25.2) (21.9, 28.9)
91
University of Ghana http://ugspace.ug.edu.gh
Table 17: Distribution of individuals with Leishmania positive skin ulcers by age, sex, and community of residence
Characteristic Category Ashiabre Keri Sibi Hilltop Total
Male (%) Female (%) Male Female Male Female Male Female Total
Individuals with one Leishmania positive skin ulcer
<5 years 1 (25.0) 1 (12.5) 3 (9.4) 5 (27 .8) 4 (9 .8) 3 (15 .0) 8 (10 .4) 9 (19 .6) 17 (13 .8)
5-15 years 3 (75.0) 6 (75.0) 23 (71.9) 11 (61.1) 31 (75.6) 15 (75.0) 57 (74.0) 32 (69.6) 89 (72.4)
16-45 years 0 1 (12.5) 6 (18.8) 1 (5.6) 4 (9.8) 2 (10.0) 10 (13.0) 4 (8.7) 14 (11.4)
>45 years 0 0 0 (0) 1 (5.6) 2 (4.9) 0 2 (2.6) 1 (2.2) 3 (2.4)
Sub total 4 (100) 8 (100) 32 (100) 18 (100) 41 (100) 20 (100) 77 (100) 46 (100) 123 (100)
Individuals with two Leishmania positive skin ulcers
<5 years 0 0 0 1 (33 .3) 0 1 (25 .0) 0 2 (28 .6) 2 (16 .7)
5-15 years 1 (100) 0 3 (100) 2 (66.7) 1 (100) 3 (75.0) 5 (100) 5 (71.4) 10 (83.3)
16-45 years 0 0 0 0 0 0 0 0 0
>45 years 0 0 0 0 0 0 0 0 0
Sub total 1 (100) 0 3 (100) 3 (100) 1 (100) 4 (100) 5 (100) 7 (100) 12 (100)
Individu als with three Leishmania positive skin ulcers
<5 years 0 0 0 0 0 0 0 0 0
5-15 years 0 0 0 0 1 (100.0) 0 1 (100.0) 0 1 (100.0)
16-45 years 0 0 0 0 0 0 0 0 0
>45 years 0 0 0 0 0 0 0 0 0
Sub total 0 0 0 0 1 (100) 0 1 (100) 0 1 (100)
Individu als with Leishmania positive skin ulcer(s)
<5 years 1 (20.0) 1 (12.5) 3 (8.6) 6 (28 .6) 4 (9 .3) 4 (16 .7) 8 (9.6 ) 11 (2 0.8) 19 (14 .0)
5-15 years 4 (80.0) 6 (75.0) 26 (74.3) 13 (61.9) 33 (76.7) 18 (75.0) 63 (75.9) 37 (69.8) 100 (73.5)
16-45 years 0 1 (12.5) 6 (17.1) 1 (4.8) 4 (9.3) 2 (8.3) 10 (12.0) 4 (7.5) 14 (10.3)
>45 years 0 0 0 (0) 1 (4.8) 2 (4.7) 0 2 (2.4) 1 (1.9) 3 (2.2)
Sub total 5 (100.0) 8 (100.0) 35 (100) 21 (100) 43 (100) 24 (100) 83 (100) 53 (100) 136 (100)
92
University of Ghana http://ugspace.ug.edu.gh
Table 18: Treatment practices for skin lesions observed
Treatment Ashiabre Keri Sibi Hilltop Total
Options No. % No. % No. % No. %
Herbs 21 40.4 117 62.6 145 80.6 283 67.5
Hot stone 3 5.8 72 38.5 73 40.6 148 35.3
Dermacot 7 13.5 31 16.6 3 1.7 41 9.8
Penicillin 7 13.5 14 7.5 8 4.4 29 8.1
Amoxycillin 5 9.6 10 5.3 2 1.1 17 4.7
Hotwater 5 9.6 19 10.2 27 15 51 14.2
Other treatment 5 9.6 4 2.1 6 3.3 15 4.2
Total 52 100 187 100 180 100 419 100
93
University of Ghana http://ugspace.ug.edu.gh
Figure 19: Examples of skin ulcers which were Leishmania positive
94
University of Ghana http://ugspace.ug.edu.gh
4.2.3 Treponemal only and DPP RDT screening among selected persons with skin ulcers
A total of 46 study participants were screened using a treponemal specific rapid diagnostic test. Of the
total, 13 (28.3%) tested positive (Table 20). The 13 treponemal positive persons were further screened
using the DPP diagnostic RDT out of which 9 (69.2%) were observed to be positive (Table 19).
A total of 71 ulcer samples were obtained from the 46 people screened using the treponemal specific RDT;
18 (25.4%) from 13 persons who were RDT positive while 53 (74.6) were from 33 persons who were
negative (Table 20).
Test for Leishmania parasite in the 71 ulcers indicated that 16 (22.5%) of the ulcers were Leishmania
positive. Of the 16 ulcer samples that were Leishmania positive, 1 (6.3%) of them was obtained from a
person who was positive to the treponemal specific RDT while the remaining 15 (93.8%) Leishmania
positive ulcer samples were obtained from persons who were negative to the treponemal specific RDT
(Table 20).
Eleven (61.1%) of the 18 ulcer samples from the 13 persons who tested positive to the treponemal specific
RDT were obtained from persons who tested positive to the DPP RDT while 7 samples were from persons
who tested negative to the DPP diagnostic RDT (Table 21).
It was also noted that none of the 11 samples obtained from persons who were DPP diagnostic RDT
positive was also positive for Leishmania infection. One of the 7 samples obtained from persons who were
DPP diagnostic RDT negative was Leishmania PCR positive (Table 21).
It was also observed that 5 of the 9 persons (55.6%) who were DPP diagnostic test positive were females.
The ages and number of people per age of the 9 persons who were DPP diagnostic test positive were as
follows: 10 years (1), 12 years (1), 14 years (2), 15 years (1), 16 years (1), 17 years (1), 55 years (1), and
65 years (1).
95
University of Ghana http://ugspace.ug.edu.gh
Table 19: Treponemal specific and DPP diagnostic test screening of some persons with skin ulcers
Study communities
Characteristics Categories Ashiabre Keri Sibi Hilltop Total
No. % No. % No. % No. %
T reponemal
specific RDT* Positive 1 16.7 5 55.6 7 22.6 13 28.3
Total 6 100 9 100 31 100 46 100
DPP RDT** Positive 1 100 2 40 6 85.7 9 69.2
Total 1 100 5 100 7 100 13 100
Table 20: Leishmania infection in skin ulcer samples obtained from persons screened with treponemal
specific RDT
Treponemal Leishmania PCR test result
Study specific RDT
communities result Negative Positive Total
No. % No. % No. %
Negative 5 83.3 1 100 6 85.7
Ashiabre Positive 1 16.7 0 0 1 14.3
Total 6 100 1 100 7 100
Negati ve 6 46.2 1 50 7 46.7
Keri Positive 7 53.8 1 50 8 53.3
Total 13 100 2 100 15 100
Negati ve 27 75 13 100 40 81.6
Sibi Hilltop Positive 9 25 0 0 9 18.4
Total 36 100 13 100 49 100
N egative 38 69.1 15 93.8 53 74.6
Total Positive 17 30.9 1 6.3 18 25.4
Total 55 100 16 100 71 100
96
University of Ghana http://ugspace.ug.edu.gh
Table 21: Leishmania infection in skin ulcer samples obtained from individuals screened using DPP
diagnostic RDT
Study DPP RDT Leishmania PCR test result
communities result Negative Positive Total
No. % No. % No. %
Negative 6 85.7 1 100 7 87.5
Ashiabre Positive 1 14.3 0 0 1 12.5
Total 7 100 1 100 8 100
Negativ e 6 75 1 100 7 77.8
Keri Positive 2 25 0 0 2 22.2
Total 8 100 1 100 9 100
Negativ e 6 42.9 1 100 7 46.7
Sibi Hilltop Positive 8 57.1 0 0 8 53.3
Total 14 100 1 100 15 100
Negative 6 35.3 1 100 7 38.9
Total Positive 11 64.7 0 0 11 61.1
Total 17 100 1 100 18 100
97
University of Ghana http://ugspace.ug.edu.gh
Figure 20: Examples of skin ulcers which were Leishmania PCR negative and were observed on persons who were
DPP RDT positive
98
University of Ghana http://ugspace.ug.edu.gh
4.3 Insecticide treated bed net ownership, access and use
Bed nets owned by the households ranged from 1 to 13 with majority of them owning 3 (35.9%) bed nets
(Table 22). In the study communities, 59 (31.2%), 87 (43.5%), and 65 (32.8%) households owned 3 nets in
Ashiabre, Keri, and Sibi Hilltop respectively. Cumulatively, the study households owned 2002 bed nets
distributed as follows: 716 in Ashiabre, 542 in Keri, and 744 in Sibi Hilltop (Table 22).
Regarding cost of the bed nets, all respondents indicated that the bed nets were obtained free of charge. All
respondents also indicated that they had heard about malaria.
Most (99.6%) of the bed nets owned by the study households were obtained from the public sector sources
such as the Government hospital, health post/CHPS compound, and national ITN distribution campaigns
(Table 23). Of the bed nets owned, 1253 (62.6%) and 1973 (98.6%) were obtained within 6 months and 12
months of this study initiation respectively (Table 23).
Of the bed nets owned, 1226 (61.2%) were observed hanging, 617 (30.8%) were either not hanging or
packaged, while 159 (7.9%) of them were not observed. A similar trend was observed across the individual
study communities (Table 23).
Within a period of 12 months prior to this study, respondents indicated that in 496 (84.6) of the 587
interviewed households, at least one ITN had been disposed of using different methods. Across the study
communities, the commonest methods of bed net disposal mentioned by household heads were garbage
/refuse dump (45.2%) followed by burning (42.3%) (Table 24). Regarding duration of bed net use before
disposal, majority of the household heads (69.4%) indicated that the nets had been used for a period of 2-4
years prior to disposal. This was followed by 121 (24.4%) household heads who indicated that their bed
nets had been used for periods less than 2 years prior to disposal (Table 24).
99
University of Ghana http://ugspace.ug.edu.gh
Among the reasons for bed net disposal, 404 (81.5) household heads indicated that their nets were disposed
of because they were torn. This was followed by 55 (11.1%) respondents who indicated that their bed nets
were disposed of because they had obtained a new one (Table 24).
The proportion of households having a minimum of one ITN (this case the LLIN type) was 97.1% (95%
CI: 95.4, 98.2). In both Keri and Sibi Hilltop, 97.0% of the households had at least one ITN with 97.4% in
Ashiabre (Table 25).
Cumulatively, 386 (65.8%) households owned at least one ITN for every two household members. The
proportion of households with at least one ITN for every two household members was 63.5%, 68.0%, and
65.7% in Ashiabre, Keri, and Sibi Hilltop respectively (Table 25).
Furthermore, the overall proportion of the individuals that could be potentially covered by the existing
ITNs, if each ITN in the household could be used by two people (proportion of individuals with access to
ITN within the households) was estimated as 86.8% (95% CI: 85.7, 87.9) with similar proportions observed
in the individual study communities (87.3%, 87.9%, and 85.6% in Ashiabre, Keri, and Sibi Hilltop
respectively) (Table 26).
The overall proportion of the study participants that used ITNs the night before the interview was 65.1%
(95% CI: 63.6, 66.7). In the respective study communities, the proportions were 66.4% (95% CI: 63.7,
68.9), 65.1% (95% CI: 62.1, 68.0), and 64.0% (95% CI: 61.4, 66.5) in Ashiabre, Keri and Sibi Hilltop
respectively. The overall ratio of ITN use to ITN access observed was 0.75 (Table 26).
In addition, it was observed among households having at least one ITN for every two family members that
1,581 (72.5%) of the household members slept in an ITN the previous night, with similar proportions of
73.5%, 71.1%, and 72.6 observed for same group in Ashiabre, Keri, and Sibi Hilltop respectively (Table
27).
100
University of Ghana http://ugspace.ug.edu.gh
A summary of the distribution of persons who used the ITN the night prior to this study by age, sex, and
community of residence is presented in Table 22 below with 1197 (50.5%) of them being males. Majority
of ITN users were within the age groups of 5-15 years (42.1%) and 16-45 years (35.6%) respectively.
In Ashiabre, 439 (51.7%) of those who slept in the ITN the night before the interview were males. Majority
of ITN users in Ashiabre were within the age group 5-15 years (41.0%) followed by those within the age
group 16-45 years (Table 28).
In Keri, 310 (48.4%) of the ITN users were males with majority of ITN users (38.9%) being within the age
group 5-15 years followed by 38.3% of ITN users who were in the age group 16-45 years. In Sibi Hilltop,
448 (50.9%) of ITN users were males with majority of ITN users (45.5%) being 5-15 years old followed by
34.7% of ITN users who were 16-45 years old. Among females, majority of ITN users were 16-45 years
old (42.4%) followed by those who were 5-15 years old (36.8%). Among males, majority of ITN users
(47.3%) were 5-15 years old followed by those who were 16-45 years old (28.9%) (Table 28).
This study also observed significant associations between not sleeping under ITN the night before the
household survey and the following factors using multiple logistic regression: family size and number of
rooms used for sleeping (Table 29). Other factors associated with failure to sleep under ITN were number
of screened windows in household, and household lacking access to ITN (Table 30).
Participants from households with size of 10 or more members (AOR = 2.53; 95% CI: 1.20, 4.24) were
more likely not to use ITN than those from households with size less than 10.
Participants from households having >10 rooms for sleeping (AOR = 10.18; 95% CI: 1.28, 81.0) had
greater odds of not using ITN than those from households having <10 rooms for sleeping. In addition,
participants from households having 2-4 screened windows (AOR = 1.49; 95% CI: 1.00, 2.20), and 8-10
101
University of Ghana http://ugspace.ug.edu.gh
screened windows (AOR = 3.57; 95% CI: 1.25, 10.17) had higher likelihood of not using ITN compared
with those
no screened windows the night before this survey.
Participants from households which did not have one ITN for every two household members (AOR = 1.80;
95% CI: 1.31, 2.47) had higher odds of failing to use ITN compared with participants from households
Ashiabre Keri Sibi Hilltop Total
Number Number Number Number
Households of Households of Households of Households of
Bednet owning bednets owning bednets owning bednets owning bednets
number bednet, n(%) owned bednet, n(%) owned bednet, n(%) owned bednet, n(%) owned
0 5 (2.6) 0 6 (3.0) 0 6 (3.0) 0 17 (2.9) 0
1 4 (2.1) 4 19 (9.5) 19 10 (5.1) 10 33 (5.6) 33
2 33 (17.5) 66 53 (26.5) 106 29 (14.6) 58 115 (19.6) 230
3 59 (31.2) 177 87 (43.5) 261 65 (32.8) 195 211 (35.9) 633
which had at least one ITN for every two household members.
Table 22: Number of bed nets owned by households
102
University of Ghana http://ugspace.ug.edu.gh
4 30 (15.9) 120 23 (11.5) 92 25 (12.6) 100 78 (13.3) 312
5 28 (14.8) 140 9 (4.5) 45 27 (13.6) 135 64 (10.9) 320
6 14 (7.4) 84 2 (1.0) 12 15 (7.6) 90 31 (5.3) 186
7 9 (4.8) 63 1 (0.5) 7 14 (7.1) 98 24 (4.1) 168
8 5 (2.6) 40 0 (0) 0 6 (3.0) 48 11 (1.9) 88
9 1 (0.5) 9 0 (0) 0 0 (0) 0 1 (0.2) 9
10 0 (0) 0 0 (0) 0 1 (0.5) 10 1 (0.2) 10
13 1 (0.5) 13 0 (0) 0 0 (0) 0 1 (0.2) 13
Total 189 (100) 716 200 (100) 542 198 (100) 744 587 (100) 2002
Table 23: Source, duration of ownership, and observation of bed nets owned by households
Characteristic Category Ashiabre Keri Sibi Hilltop Total
no. % no. % no. % no. %
Source of bed net
Public Sector 713 99 .6 53 7 99 .1 74 4 10 0 199 4 99 .6
Other/Don‘t know 3 0.4 5 0.9 0 0 8 0.4
Duration of bed ne t ownership
0-6 months 430 60 .1 45 0 83 .0 37 3 50 .1 125 3 62 .6
7-12 months 279 39.0 85 15.7 356 47.8 720 36.0
Not sure 7 0.9 7 1.3 15 2.0 29 1.4
Was bed net obser ved?
Observed Hanging 409 57 .1 38 7 71 .4 43 0 57 .8 122 6 61 .2
Observed Not
Hanging or
packaged 271 37.9 108 19.9 238 32 617 30.8
Not observed 36 5.0 47 8.7 76 10.2 159 7.9
103
University of Ghana http://ugspace.ug.edu.gh
Total bed nets owned 716 100 542 100 744 100 2002 100
Characteristics Category Ashiabre Keri Sibi Hilltop Total
Table 24: Methods of ITN disposal, duration of ITN use before disposal, and reason for ITN disposal
104
University of Ghana http://ugspace.ug.edu.gh
no. % no. % no. % No. %
Method of treated n et disposal
Burned 44 30.3 88 48.9 78 45.6 210 42.3
Buried 2 1.4 12 6.7 10 5.8 24 4.8
Garbage or refuse dump 87 60.0 69 38.3 68 39.8 224 45.2
Reused for other purpose 9 6.2 8 4.4 14 8.2 31 6.3
Other 3 2.1 3 1.7 1 0.6 7 1.4
How long was tre at ed net used?
Less than 2 years 27 18.6 43 23.9 51 29.8 121 24.4
2-4 years 102 70.3 134 74.4 108 63.2 344 69.4
More than 4 years 11 7.6 2 1.1 10 5.8 23 4.6
Don‘t know 5 3.4 1 0.6 2 1.2 8 1.6
What was the pri ma ry reason for treated net disposal?
Torn 114 78.6 148 82.2 142 83 404 81.5
Could not repel mosquitoes anymore 6 4.1 17 9.4 9 5.3 32 6.5
Got a new one 22 15.2 14 7.8 19 11.1 55 11.1
Other/Don‘t Know 3 2.1 1 0.6 1 0.6 5 1.0
Households in w hic h any treated net was disposed of in the past 12 mo nths
Total 145 100 180 100 171 100 496 100
Table 25: Ownership of ITNs by enrolled households in study community
105
University of Ghana http://ugspace.ug.edu.gh
Households with at least one
Households with at least LLIN
Study Households one LLIN, n(%) for every two people
Community interviewed n(%) 95% CI n(%) 95% CI
Ashiabre 189 184 (97.4) (93.7, 98.9) 120 (63.5) (56.3, 70.1)
Keri 200 194 (97.0) (93.4, 98.7) 136 (68.0) (61.2, 74.1)
Sibi Hilltop 198 192 (97.0) (93.4, 98.6) 130 (65.7) (58.7, 72.0)
Total 587 570 (97.1) (95.4, 98.2) 386 (65.8) (61.8, 69.5)
Table 26: Access to and use of LLINs by enrolled households in study communities
Population with access to Population that slept in ITN Ratio of use
Study Household Population ITN the night prior to the study to access
Community (de facto) n(%) 95% CI n(%) 95% CI
Ashiabre 1279 1116 (87.3) (85.3, 89.0) 849(66.4) (63.7, 68.9) 0.76
Keri 983 864 (87.9) (85.7, 89.8) 640 (65.1) (62.1, 68.0) 0.74
Sibi Hilltop 1377 1179 (85.6) (83.7, 87.4) 881 (64.0) (61.4, 66.5) 0.75
Total 3639 3159 (86.8) (85.7, 87.9) 2370(65.1) (63.6, 66.7) 0.75
Table 27: Use of ITNs by members of households having a minimum of one ITN for every two members
Persons that used ITN
Study Persons in Households the night prior to the study
Community with ITN access among households with ITN access
(de facto) n(%) 95% CI
Ashiabre 736 541(73.5) (70.2, 76.6)
Keri 620 441 (71.1) (67.4, 74.6)
Sibi Hilltop 825 599 (72.6) (69.5, 75.5)
Total 2181 1581(72.5) (70.6, 74.3)
106
University of Ghana http://ugspace.ug.edu.gh
100 97.1
90 86.8
80
70 65.8 65.1
60
50
40
30
20
10
0
Percent of households Percent of households Percent of the Percent of the
with at least one ITN with at least one ITN household population household population
for every two with access to an ITN who sept under an ITN
household members within their household last night
Figure 21: Summary of ITN ownership, access, and use in study communities (overall)
107
Percent
University of Ghana http://ugspace.ug.edu.gh
Table 28: Distribution of persons who used ITN the night before the interview by sex, age group and
residence
Community Age groups Male Female Total p-value
< 5 years 65 (14.8) 65 (15.9) 130 (15.3)
5-15 years 198 (45.1) 150 (36.6) 348 (41.0)
0.002
Ashiabre 16-45 years 127 (28.9) 165 (40.2) 292 (34.4)
>45 years 49 (11.2) 30 (7.3) 79 (9.3)
Sub total 439 (100) 410 (100) 849 (100)
< 5 years 38 (12.3) 37 (11.2) 75 (11.7)
5-15 years 135 (43.5) 114 (34.5) 249 (38.9)
0.002
Keri 16-45 years 96 (31.0) 149 (45.2) 245 (38.3)
>45 years 41 (13.2) 30 (9.1) 71 (11.1)
Sub total 310 (100) 330 (100) 640 (100)
< 5 years 52 (11.6) 59 (13.6) 111 (12.6)
5-15 years 233 (52.0) 168 (38.8) 401 (45.5)
<0.001
Sibi Hilltop 16-45 years 123 (27.5) 183 (42.3) 306 (34.7)
>45 years 40 (8.9) 23 (5.3) 63 (7.2)
Sub total 448 (100) 433 (100) 881 (100)
< 5 years 155 (12.9) 161 (13.7) 316 (13.3)
5-15 years 566 (47.3) 432 (36.8) 998 (42.1)
<0.001
Total 16-45 years 346 (28.9) 497 (42.4) 843 (35.6)
>45 years 130 (10.9) 83 (7.1) 213 (9.0)
Total 1197 (100) 1173(100) 2370 (100)
108
University of Ghana http://ugspace.ug.edu.gh
Table 29: Factors associated with non-use of ITN the night preceding the interview among de facto population of households having a
minimum of one ITN
People that
did not
defacto sleep under Crude OR (95%
Characteristics Categories population ITN, n(%) CI) P value *AOR (95% CI) P value
Sex of Household head
Female 452 115 (25.4) [ Reference] [Reference]
Male 3095 1062 (34.3) 1.53 (1.22, 1.92) <0.001 1.45 (0.96, 2.20) 0.077
Household head age
< 35 years 82 0 2 40 (29.3) [ Reference] [Reference]
36-40 years 610 171 (28.0) 0.94 (0.75, 1.19) 0.610 0.98 (0.63,1.51) 0.910
41-50 years 1226 443 (36.1) 1.37 (1.13, 1.65) 0.001 1.24 (0.84,1.84) 0.275
>51 years 891 323 (36.3) 1.37 (1.12, 1.68) 0.002 1.15 (0.76, 1.73) 0.515
Family size
1-3 persons 15 7 33 (21.0) [Reference] [Reference]
4-6 persons 1380 374 (27.1) 1.40 (0.93, 2.09) 0.103 1.15 (0.81, 2.24) 0.249
7-9 persons 1203 404 (33.6) 1.90 (1.27, 2.84) 0.002 1.34 (0.83, 2.65) 0.182
>=10 persons 807 366 (45.4) 3.12 (2.07, 4.69) <0.001 2.53 (1.20, 4.24) 0.011*
Main material in household roof
Metal 323 4 1 057 (32.7) [ Reference] [Reference]
Thatch 313 120 (38.3) 1.28 (1.00, 1.63) 0.043 1.12 (0.70, 1.78) 0.643
Household socioeconomic status
Low 65 8 199 (30.2) [Reference] [Reference]
Second 735 237 (32.2) 1.10 (0.87, 1.38) 0.421 1.09 (0.65, 1.82) 0.755
Middle 758 259 (34.2) 1.20 (0.96, 1.50) 0.115 1.22 (0.70, 2.10) 0.481
Fourth 781 259 (33.2) 1.14 (0.92, 1.43) 0.236 1.15 (0.66, 2.02) 0.624
Highest 615 223 (36.3) 1.31 (1.04, 1.66) 0.023 1.39 (0.85, 2.27) 0.188
Household number of rooms for sleeping
1 room 25 9 70 (27.0) [Reference] [Reference]
2-5 rooms 2553 802 (31.4) 1.23 (0.93, 1.65) 0.146 1.30 (0.35, 4.75) 0.693
6-10 rooms 613 253 (41.3) 1.90 (1.38, 2.61) <0.001 2.29 (0.60, 8.77) 0.225
>10 rooms 122 52 (42.6) 2.01 (1.28, 3.15) 0.003 10.18 (1.28, 81.00) 0.028*
OR=Odds ratio, AOR= Adjusted odds ratio
109
University of Ghana http://ugspace.ug.edu.gh
Table 30: Additional Factors associated with non-use of ITN the night preceding the interview among de facto population of
households having a minimum of one ITN
People that did not
defacto sleep under ITN, Crude OR (95%
Characteristics Categories population n(%) CI) P value AOR (95% CI) P value
Number of window s in household
1 window 276 81 (29.4) [ Reference] [Reference]
2-4 windows 2100 662 (31.5) 1.11 (0.84, 1.46) 0.464 0.74 (0.20, 2.79) 0.656
5-7 windows 847 312 (36.8) 1.40 (1.05, 1.88) 0.024 0.66 (0.17, 2.47) 0.533
8-10 windows 231 96 (41.6) 1.71 (1.18, 2.47) 0.004 0.41 (0.09, 1.77) 0.232
>10 windows 93 26 (28.0) 0.93 (0.55, 1.57) 0.798 0.06 (0.01, 0.57) 0.015
Number of scre ened windows in household
No screened window 2476 765 (3 0.9) [ Reference] [Reference]
1 screened window 223 59 (26.5) 0.80 (0.59, 1.10) 0.169 0.76 (0.41, 1.41) 0.387
2-4 screened windows 557 208 (37.3) 1.33 (1.10, 1.61) 0.003 1.49 (1.00, 2.20) 0.047*
5-7 screened windows 190 92 (48.4) 2.10 (1.56, 2.83) <0.001 1.68 (0.85, 3.32) 0.136
8-10 screened windows 96 53 (55.2) 2.76 (1.83, 4.16) <0.001 3.57(1.25, 10.17) 0.017*
>10 screened windows 5 0 (0) 1 1
Household head heard malaria message 6 months prior to interview
Heard malaria message 3468 1141 (32.9) [Reference] [Reference]
Did not hear malaria message 79 36 (45.6) 1.71 (1.09, 2.67) 0.019 2.01 (0.87, 4.64) 0.104
Household has ITN access (one ITN for every two household members)
Has access 2181 600 (27.5) [ Reference] [Reference]
Lack access 1366 577 (42.2) 1.93 (1.67, 2.22) <0.001 1.80 (1.31, 2.47) <0.001*
Total defacto po pu lation with at least one ITN 3547 1177 (33.2)
O R: Odds ratio; A OR: Adjusted odds ratio
110
University of Ghana http://ugspace.ug.edu.gh
* Statistically associated (AOR) with an increase in not using ITNs the night prior to
the study
111
University of Ghana http://ugspace.ug.edu.gh
4.4 Cutaneous Leishmaniasis (CL) awareness, CL experience and CL related knowledge
When presented with pictures of skin lesions diagnosed as cutaneous Leishmaniasis from previous studies
on cutaneous Leishmaniasis in the Volta Region of Ghana, 91.8% of the household heads interviewed
admitted to having ever seen such lesions. Furthermore, 77.3% of them admitted to having ever heard
about cutaneous Leishmaniasis. As a result, all household heads interviewed had either ever seen lesions of
cutaneous Leishmaniasis or had heard about the disease (Table 31).
When asked about other community specific names used to describe cutaneous Leishmaniasis, either based
on pictures of CL seen or based on the name of CL known in the study community, some names appeared
dominant in some of the study communities. For instance, in Ashiabre, most household heads (82.0%)
referred to CL as ―Nato‖ while in Keri, 57% of them referred to CL as ―Doti‖. In Sibi Hilltop on the other
hand, 52% of them referred to CL as ―Mgbangba‖ with 35% of them calling it ―Nato‖. Across the study
communities, 13% of the household heads referred to CL as ―Mbuu‖ which is a Kokomba word for sore
because to those household heads, CL was just sore which took a long time to heal. When asked whether
CL was a problem in the study communities, 80% indicated that CL was a problem in their community
(Table 31).
When asked five questions regarding CL related knowledge: cause of CL, how CL is transmitted,
symptoms of CL, whether CL is preventable, and whether CL is treatable, 45% of the respondents
indicated that CL is preventable while 80% indicated that CL is treatable. All respondents knew at least one
symptom of CL. Regarding the cause of CL and how CL is transmitted, none of the household heads
interviewed was able to provide a correct answer. A household head scored ‗good knowledge about CL‘
when he/she correctly answered three or more of the five questions asked. Overall, 41% of the household
heads scored ‗good knowledge about CL‘ (Table 32).
112
University of Ghana http://ugspace.ug.edu.gh
Regarding CL experience, 48% of the household heads admitted to having previous personal history of the
disease. Furthermore, 53% of them (64% in Ashiabre, 45% in Keri and 51% in Sibi Hilltop) indicated that
they have had household members (excluding the household heads) with previous history of cutaneous
leishmaniasis (Table 33).
Regarding number of household members (including the head of household) who had previous history of
cutaneous leishmaniasis, a range of 1 to 10 was reported with 34% of the households reporting one person
with a history of CL followed by 20% of households having two people with a history of CL. In all, 419
(71.4%) households reported at least one person including the household head with a previous history of
CL (Table 33).
In the past two years preceding this study, 45.3% of household heads indicated that at least one member of
their respective households (including the household head) had experienced CL. This proportion was
57.1%, 35.0%, and 44.4% in Ashiabre, Keri, and Sibi Hilltop respectively. A range of 1 to 8 household
members were reported as having experienced CL in the past two years preceding this study initiation, in
the households with a history of at least one case of CL (Table 33).
Beyond the respective households interviewed, 69% of the household heads indicated that they knew
people in their community (outside of their households) who have had a history of cutaneous leishmaniasis
(Table 3). Household heads were also interviewed regarding the months of the year, age groups, and
occupational groups of people in their respective communities that they see with CL. According to them,
cases of CL were seen in the various months of the year but majority of them indicated the following
months across the study communities: June (16%), July (17%), August (14%), and November (15%)
(Table 34).
113
University of Ghana http://ugspace.ug.edu.gh
Regarding age groups of people seen with CL in the study communities, majority of household heads
(67%) indicated people within the age group 5-17 years. This was followed by 40.5%, 30.0%, 21.0%, and
1.9% of respondents who indicated persons <5 years, 18-35 years, 36-60 years, and persons above 60 years
respectively (Table 34). Household heads were then asked about occupational groups of people they saw
with CL and majority of them (61%) mentioned farmers whilst 47% of them mentioned children/students
(Table 34).
114
University of Ghana http://ugspace.ug.edu.gh
Table 31: Awareness of cutaneous leishmaniasis among household heads
Study communities
CL Awareness Category Ashiabre, n(%) Keri, n (%) Sibi Hilltop, n(%) Total, n(%)
Ever seen CL lesions as presented in picture 170 (89.9) 182 (91.0) 187 (94.4) 539 (91.8)
Ever heard about cutaneous leishmaniasis 153 (81.0) 156 (78.0) 145 (73.2) 454 (77.3)
Ever seen CL lesions or heard about CL 189 (100) 200 (100.0) 198 (100.0) 587 (100.0)
Names used to describe cutaneous leishmaniasis in co mmunity:
Doti 0 (0) 114 (57.0) 1 (0.5) 115 (19.6)
Kpakpai 15 (7.9) 2 (1.0) 6 (3.0) 23 (3.9)
Mbuu 22 (11.6) 4 (2.0) 49 (24.7) 75 (12.8)
Mgbangba 1 (0.5) 0 (0) 103 (52.0) 104 (17.7)
Nato 155 (82.0) 9 (4.5) 69 (34.8) 233 (39.7)
C L is a probl em in this co mmunity
1 70 (90.0) 1 58 (79.0) 141 (71.2) 469 (79.9)
Total 1 89 (100) 2 00 (100.0) 1 98 (100.0) 5 87 (100.0)
Table 32: Cutaneous leishmaniasis related knowledge among household heads across study communities
Study communities
Ashiabre, n(%) Keri, n (%) Sibi Hilltop, n(%) Total, n(%)
Know the cause of CL 0 (0) 0 (0) 0 (0) 0 (0)
Know how CL is transmitted to people 0 (0) 0 (0) 0 (0) 0 (0)
Know CL symptoms 189 (100.0) 200 (100.0) 198 (100.0) 587 (100.0)
Know that CL is preventable 93 (49.2) 90 (45.0) 82 (41.4) 265 (45.1)
Know that CL is treatable 160 (84.7) 159 (79.5) 152 (76.8) 471 (80.2)
Overall good knowledge about CL 92 (48.7) 79 (39.5) 72 (36.4) 243 (41.4)
Total 1 89 (100.0) 2 00 (100.0) 198 (100.0) 5 87 (100.0)
115
University of Ghana http://ugspace.ug.edu.gh
Table 33: Household head report of CL experience at personal, household and community level
Study communities
Ashiabre, Sibi Hilltop,
CL Experience n(%) Keri, n (%) n(%) Total, n(%)
Household head history of personal CL experience 78(41.3) 95 (47.5) 106 (53.5) 279 (47.5)
Household member (excluding household head) history of CL
experience 120(63.5) 89 (44.5) 100 (50.5) 309 (52.6)
Households with various numbers of household members (including hous ehold
head) with a history of CL experience:
1 72 (38. 10 6 9 (34.5) 56 (28.3) 1 97 (33.6)
2 22 (11.6) 56 (28.0) 39 (19.7) 117 (19.9)
3 23 (12.2) 10 (5.0) 25 (12.6) 58 (9.9)
4 13 (6.9) 3 (1.5) 13 (6.6) 29 (4.9)
5 6 (3.2) 0 (0) 4 (2.0) 10 (1.7)
>5 6 (3.2) 0 (0) 2 (1.0) 8(1.4)
Maximum 10 4 6 10
Awarene ss of people in th e community (outside pers onal
household) with a history of CL experience 149(78.8) 132 (66.0) 126 (63.6) 407 (69.3)
Any household member (including household head) with CL
experience within the past 2 years: 108(57.1) 70 (35.0) 88 (44.4) 266 (45.3)
Number of household members (including household head) with
CL experience CL within past two years:
1 55 (29.1) 35 (17.5) 3 1 (15.7) 121 (20.6)
2 20 (10.6) 23 (11.5) 26 (13.1) 69 (11.8)
3 17 (9.0) 11 (5.5) 17 (8.6) 45 (7.7)
4 9 (4.8) 1 (0.5) 8 (4.0) 18 (3.1)
5 3 (1.6) 0 (0) 4 (2.0) 7 (1.2)
>5 4 (2.1) 0 (0) 2 (1.0) 6 (1.0)
Maximum 8 4 6 8
Number of hou seholds interv iewed 189 (100) 200 (100.0) 198 (100.0) 587 (100.0)
116
University of Ghana http://ugspace.ug.edu.gh
Table 34: Months of year, age groups, and occupational groups seen with CL in study communities
Study communities
Characteristic Categories Ashiabre, n(%) Keri, n (%) Sibi Hilltop, n(%) Total, n(%)
Months of the year cases of CL are seen in this community:
January 10 (5.3) 10 (5.0) 1 3 (6.6) 3 3 (5.6)
February 2 (1.1) 3 (1.5) 5 (2.5) 10 (1.7)
March 5 (2.6) 6 (3.0) 9 (4.5) 20 (3.4)
April 5 (2.6) 3 (1.5) 7 (3.5) 15 (2.6)
May 10 (5.3) 8 (4.0) 3 (1.5) 21 (3.6)
June 22 (11.6) 41 (20.5) 33 (16.7) 96 (16.4)
July 36 (19.0) 24 (12.0) 40 (20.2) 100 (17.0)
August 30 (15.9) 25 (12.5) 26 (13.1) 81 (13.8)
September 15 (7.9) 18 (9.0) 20 (10.1) 53 (9.0)
October 24 (12.7) 9 (4.5) 5 (2.5) 38 (6.5)
November 34 (18.0) 26 (13.0) 30 (15.2) 90 (15.3)
December 32 (16.9) 7 (3.5) 12 (6.1) 51 (8.7)
All months 3 (1.6) 6 (3.0) 15 (7.6) 24 (4.1)
Age groups of people seen with CL in this community:
<5 years 6 4 (33.9) 98 (49.0) 76 (38.4) 238 (40.5)
5-17 years 135 (71.4) 124 (62.0) 136 (68.7) 395 (67.3)
18-35 years 53 (28.0) 52 (26.0) 71 (35.9) 176 (30.0)
36-60 years 32 (16.9) 43 (21.5) 50 (25.3) 125 (21.3)
>60 years 1 (0.5) 5 (2.5) 5 (2.5) 11 (1.9)
Occupational groups seen with CL in this community:
Farmers 103 (54.5) 1 19 (59.5) 1 33 (67.2) 355 (60.5)
Hunters 30 (15.9) 46 (23.0) 47 (23.7) 123 (21.0)
Traders 31 (16.4) 36 (18.0) 51 (25.8) 118 (20.1)
Children/Students 93 (49.2) 95 (47.5) 87 (43.9) 275 (46.8)
Civil Servants 5 (2.6) 13 (6.5) 16 (8.1) 34 (5.4)
Tota l respo ndents 189 (100.0) 200 (100.0) 198 (100.0) 587 (100.0)
117
University of Ghana http://ugspace.ug.edu.gh
4.5 Presence of Sand Flies in Study Communities
A total of 218 sand flies comprising of 25 males and 193 females were trapped using both the
CDC light trap and indoor aspiration methods. Sand flies were caught in all of the following
locations; household compound, household sleeping area, church compound, inside church
building, mosque compound, school compound, school KG classroom, school primary
classroom, and school Junior high class room (Table 35).
Of the 193 female sand flies, 165 were trapped using the CDC light trap while 28 were trapped
using the indoor aspiration method. Of the 165 female sand flies trapped using the CDC light
traps, 131 (79.4%) were trapped from household compounds. In addition, 7 (4.2%), 25 (15.2%),
and 2 (1.2%) were trapped from church compound, school compound, and mosque compound
respectively (Table 35).
Of the 28 female sand flies caught using indoor aspiration, 9(32.1%), 2(7.1%), 3(10.7%),
3(10.7%), and 11(39.3%) were collected from Junior High School classroom, KG classroom,
primary classroom, inside church, and household sleeping area respectively (Table 35).
118
University of Ghana http://ugspace.ug.edu.gh
Table 35: Summary of sandflies caught in study communities by sex, place of collection, and
collection methods
Sex of
Place of collection Sample collection sand No.
Study Outdoor/indoor flies of
Community collection Method Flies
Ashiabre Outdoor Household Compound CDC Light Trap Female 77
Ashiabre Outdoor Church compound CDC Light Trap Female 2
Ashiabre Outdoor School compound CDC Light Trap Female 9
Ashiabre Outdoor Household Compound CDC Light Trap Male 14
Ashiabre Indoor School Junior High Classroom Aspiration Female 9
Ashiabre Indoor School KG Classroom Aspiration Female 2
Ashiabre Indoor School Primary Classroom Aspiration Female 3
Ashiabre Indoor Inside church Aspiration Female 3
Keri Outdoor Household compound CDC Light Trap Female 50
Keri Outdoor Church compound CDC Light Trap Female 3
Keri Outdoor Mosque compound CDC Light Trap Female 2
Keri Outdoor School compound CDC Light Trap Female 8
Keri Outdoor Mosque compound CDC Light Trap Male 1
Keri Outdoor Household compound CDC Light Trap Male 7
Keri Indoor Household sleeping area* Aspiration Female 10
Keri Indoor Household sleeping area** Aspiration Female 1
Keri Indoor Household sleeping area* Aspiration Male 2
Sibi Hilltop Outdoor Household compound CDC Light Trap Female 4
Sibi Hilltop Outdoor Church compound CDC Light Trap Female 2
Sibi Hilltop Outdoor School compound CDC Light Trap Female 8
Sibi Hilltop Outdoor Household compound CDC Light Trap Male 1
Total 218
*Room without bednet
** Room with old bednet ( >6 years)
119
University of Ghana http://ugspace.ug.edu.gh
0
4.6 Malaria and Leishmania Infection among Participants with Temperature > 38.0 C
Nine (0.3%) out of the 3440 individuals screened recorded an axillary temperature greater or
o
equal to 38.0 C and were tested for malaria infection using malaria rapid test kit. All of the 9
persons reporting fever were positive.
Of the 9 persons, 4 (44.4%) were from Ashiabre while 5 (55.6%) were from Keri. Seven
(77.8%) of the 9 persons were males while two of them were females.
Of the 4 malaria positive persons from Ashiabre, one was female. The ages of the malaria
positive persons from Ashiabre were 4, 5 and 8 years with two of them being 5 years old.
Of the 5 malaria positive persons from Keri, one was female. The ages of the 5 malaria positive
persons from Keri were 2, 4, 5 and 12 years old with two of them being 4 years old. As a result
7 out of the 9 malaria positive persons were 5 years old or younger.
All persons with fever were also tested for exposure to Leishmania parasite using the LST. Of
these, two persons comprising a 4 year old male from Ashiabre and a 5 year old female from
Keri were positive to the LST test.
Three persons comprising the 4 year old male from Ashiabre who was LST positive, a 5 years
old male from Ashiabre, and a 12 years old male from Keri, had current skin ulcers among those
reporting with fever. None of the samples of the skin ulcers obtained from the persons with fever
were positive for Leishmania parasite.
120
University of Ghana http://ugspace.ug.edu.gh
CHAPTER FIVE
DISCUSSION
5.1 Leishmania infection and cutaneous leishmaniasis among study participants
Cutaneous leishmaniasis (CL) remains an important neglected tropical skin disease (Skin NTD)
of public health importance and is the commonest form of leishmaniasis, characterized by skin
lesions (mainly ulcers) which may result in scars, disability and stigma (Gabriel et al., 2019; Hay
& Asiedu, 2018; World Health Organization, 2019c, 2019b).
The control of CL requires an understanding of the disease epidemiology including knowledge
of the vectors, reservoirs and potential interventions (González et al., 2008, 2015). In the context
of this study, confirmation of exposure to Leishmania infection using the Leishmanin skin test as
well as detection of Leishmania infection in skin ulcers observed in communities without a
previous documentation of Leishmania infection, is an important step towards understanding the
epidemiology of the disease.
5.1.1 Leishmania infection using leishmanin skin test (LST) among study participants
Using the LST, an overall prevalence of 41.8% was determined for Leishmania infection, with
individual community Leishmania prevalence of 39.4%, 55.1%, and 34.2% observed in
Ashiabre, Keri, and Sibi Hill top respectively. This result therefore confirmed earlier suspicion of
Leishmania infection in the study communities upon observation of skin ulcers which fit the
clinical presentation of cutaneous leishmaniasis.
121
University of Ghana http://ugspace.ug.edu.gh
Data on LST positivity obtained from this study compares with that observed in some other
African countries such as Mali where community based studies using LST observed Leishmania
prevalence as high as 49.9% in certain communities with increase of prevalence associated with
age groups such that in a certain community (Diema), Leishmania prevalence increased from
13.8% to 88% for age groups of 2-5 years and 41-56 years respectfully (Oliveira et al., 2009).
Systematic review of some studies conducted in Mali has further observed an overall prevalence
of Leishmania infection using LST to be 22.1% while prevalence of CL among suspect cases
was determined to be 40.3% (Kone et al., 2016).
In Tunisia, a cross-sectional survey for Leishmania infection among some households using the
LST detected an overall prevalence of 57%, with age, personal or family history of cutaneous
leishmaniasis, and whether the study community was an emerging or old focus of CL identified
as determinants of Leishmania infection using the LST (Bettaieb et al., 2014)
Country wide estimates for Leishmania infection in Ghana is currently not available. Data
obtained from this study on Leishmania infection therefore augments existing data on
leishmaniasis in Ghana and Africa as a whole where a general paucity of data on leishmaniasis
exists (Jorge Alvar et al., 2012).
As has been observed in other studies, this study detected significant association between
increase in the prevalence of LST positivity and increase in age across the study communities
(Bettaieb et al., 2014; Traore et al., 2016).
The observation of a significant association between increase in LST positivity and increasing
age suggests a need to put in interventions to protect children in particular from exposure to
Leishmania infection while additional studies are carried out to understand the reasons for the
122
University of Ghana http://ugspace.ug.edu.gh
increased prevalence observed among the older segments of the study population (Bettaieb et al.,
2014; Traore et al., 2016).
Although Leishmania infection was observed in all three study communities, being a resident of
study community Keri was significantly associated with increase in the likelihood of being
exposed to the infection, while staying in Sibi Hill top was significantly associated with a less
likelihood of being exposed to the infection, compared with being a resident of Ashiabre. This
calls for more studies to better understand the characteristics of the study communities
particularly with regards to determining how long members of the study communities may have
been living with the health challenge of CL. This is important because of findings from other
studies which observed higher prevalence of Leishmania infection in communities considered to
be older/endemic foci for CL compared with those considered to be emerging foci (Oliveira et
al., 2009; Traore et al., 2016).
Furthermore, observation of a significant association between being male and increased
prevalence of Leishmania infection in the study communities calls for more studies to understand
the daily activities of males in the study communities in order to develop appropriate measures to
protect them from Leishmania infections. These findings corroborates Custodio et al., (2012)
who found that sleeping outside, being male, and increasing age were associated with LST
positivity in the highlands of northern Ethiopia.
Although in the present study, 89.2% of participants had been on open field either sometimes or
often and 63.7% of study participants slept near forest or farm fields, their proximity to these
areas being at open field or sleeping near forest was not significantly associated with LST
123
University of Ghana http://ugspace.ug.edu.gh
positivity. The factors associated with LST positivity in this study should therefore be taken into
consideration in the development of CL control strategies in the study area.
5.1.2 Cutaneous leishmaniasis among study participants with skin ulcers
This study confirmed Leishmania infection in 150 (25.2%) out of 595 ulcer biopsies tested by
PCR. This result therefore confirmed the existence of cutaneous leishmaniasis in the study
communities. The overall prevalence of cutaneous leishmaniasis among those with skin ulcers
was 31.9% (136/426) with prevalence of 23.2% (13/56), 29.8% (56/188), and 36.8% (67/182)
observed in Ashiabre, Keri and Sibi Hilltop respectively. In Mali, a systematic review reported a
prevalence of 40.3% for cutaneous leishmaniasis among suspected CL cases (Kone et al., 2016).
Majority of the persons with CL in this study (73.5%) were in the age group of 5-15 years, with
males in this age group constituting majority of those infected among persons with skin ulcers. A
study in Mali which conducted both LST for exposure to Leishmania parasites and also screened
study participants with skin lesions for CL using PCR, confirmed Leishmania infection in skin
ulcer samples from 8 persons who were all under 18 years (Traore et al., 2016).
In a study that evaluated CL in Afghanistan, the mean age of persons with the disease was 15
years with CL being significantly associated with persons‘ age, household prevalence and type of
wall of houses (Reithinger et al., 2010).
A review of CL suggest that although Leishmania infection and subsequent leishmaniasis disease
generally tends to be influenced by factors associated with the host, the parasite, as well as the
disease vectors, the prevalence of CL usually increases with age till about 15 years. It is assumed
that the prevalence of CL levels of at about 15 years because persons exposed early on in life to
124
University of Ghana http://ugspace.ug.edu.gh
Leishmania infection may have acquired some level of immunity to the infection by then
(Reithinger, et al., 2007).
Detection of increased odds of exposure to Leishmania infection using LST among children 5-15
years in this study and subsequently observing the highest prevalence of CL in this age group
suggest a need to prioritize this group in future CL control planning in the study area.
5.1.3 Treatment of persons with cutaneous leishmaniasis
An important aspect of disease control is treatment of affected people. The data on treatment of
skin lesions by study participants indicate that majority of them use herbs (67.5%) followed by
those who use hot stone (33.5%) and hot water (14.2%) respectively (Table 19).
In the case of cutaneous leishmaniasis, the first choice of treatment is pentavalent antimonials
with its attendant cost and possible adverse effects (Aronson et al., 2010; Asilian et al., 2004;
Berbert et al., 2018; Haldar et al., 2011; Hodiamont et al., 2014).
However, the evidence for what can be described as optimal treatment for CL has been described
as patchy and generally weak. There is therefore a need for the development of improved
guidelines for management of CL in addition to the conduct of more robust studies to improve
the existing body of evidence for treatment of CL (Berbert et al., 2018; Olliaro et al., 2013;
Palumbo, 2009; Uribe-Restrepo et al., 2018).
Furthermore, although efforts are ongoing to develop a vaccine against leishmaniasis, there is
currently no vaccine licensed for use against leishmaniasis ( Whyte, et al., 2017; De Luca &
Macedo, 2016).
125
University of Ghana http://ugspace.ug.edu.gh
Given the gaps in the treatment of leishmaniasis and ongoing global efforts to develop vaccines,
there is a need to develop measures in the local Ghanaian context, to protect people who are
affected by leishmaniasis while research continues to provide data on critical aspects of the
disease such as the vectors and reservoirs.
5.1.4 Need for investigation of skin ulcers which were negative for Leishmania infection
Given that not all skin ulcers observed in the study communities were infected with Leishmania
parasites, there is a need for continuous diagnoses of skin ulcers observed in the study
communities in order to identify the ulcers infected by Leishmania parasite for the appropriate
treatment to be applied (Cruz, et al., 2013; Foulet, et al., 2007; Goto & Lindoso, 2010b).
It was observed that 9 (69.2%) of 13 persons who tested positive to the treponemal only RDT
were also positive to the DPP test (Tables 26-28). Interestingly, 11 ulcers obtained from the 9
persons who tested positive to the DPP RDT were all negative to the Leishmania PCR test.
Examples of the ulcers observed on the 9 persons who were DPP RDT positive but whose ulcers
were Leishmania test negative is presented in Figure 19.
The treponemal only as well as the DPP RDT which were designed for screening for syphilis
have also been used in field studies in areas known to have cases of Yaws as a first line
screening test. This has been possible because the causative agent for Yaws, Treponema
pallidum pertenue, is a bacterium which closely resembles the causative agent of syphilis,
Treponema pallidum pallidum, with the key difference being the fact that while syphilis is a
venereal disease, Yaws is transmitted by skin-to-skin contact in warm and humid environments,
usually among children (Oriol Mitjà, Kingsley Asiedu, 2013).
126
University of Ghana http://ugspace.ug.edu.gh
Although the treponemal only test has a limitation of not being able to differentiate between past
and current treponemal infection, the DPP is able to differentiate between past and current
infection and its widespread use in areas known to be endemic with Yaws has been suggested to
improve understanding of worldwide Yaws case reporting (Marks et al., 2014, 2020).
A previous pilot study aimed at using azithromycin as treatment for Yaws in some communities
of the West Akim district of Ghana also used sero-positivity based on a point of care dual
treponemal and non-treponemal test as the primary outcome in addition to presentation with
clinically active Yaws like lesions (as secondary outcome) to select Yaws cases (Abdulai et al.,
2018).
As a result, future studies aimed at screening a larger sample of persons in the study area for
Yaws and other skin ulcer causing diseases such as buruli ulcer, incorporating more sophisticated
laboratory diagnostic approaches may help to better characterize the etiologies of the ulcers.
127
University of Ghana http://ugspace.ug.edu.gh
5.2 Insecticide Treated Bed Net Ownership, Access and Use
5.2.1 Insecticide treated bed net Ownership and access
Results from this study indicate that 570 households, representing 97.1% (95% CI: 95.4, 98.2) of
the total owned at least one ITN. Similar proportions of ITN ownership was observed across the
study communities with all the ITNs being the long lasting insecticidal net (LLIN) type. In
addition, 86.8% (95% CI: 85.7, 87.9) of the population in the enrolled study households had
access to ITN.
ITNs have been one of the main interventions for malaria control (World Health Organization,
2017a). In addition, it has been suggested that insecticide treated materials (ITMs) may be
effective in the control of other vector borne diseases including CL, in areas where CL is co-
endemic with malaria (Moosa-Kazemi, et al., 2007; WHO/Department of Communicable
Disease Prevention, 1997; Wilson et al., 2014).
Between 2016-2018, Ghana was one of a total of 8 countries that received 50% of the global
distribution of ITNs hence evaluation of ITN indicators in communities with suspected CL cases
is an implementation research which provides feedback to inform future improvements of the
intervention delivery (World Health Organization, 2019a)
Although documentation of previous studies on ITN in the study communities was not found, a
study conducted in the year 2010 in the Hohoe municipality of the Volta region of Ghana among
mothers/caregivers of children under five observed ITN ownership of 81.3% while another study
conducted in the same municipality in the year 2016 among the same target group observed ITN
ownership of 88.1% (Amedo, 2016; Nyavor, et al., 2017).
128
University of Ghana http://ugspace.ug.edu.gh
According to the 2014 Ghana demographic and health survey (DHS), 80.1% of households in the
Volta Region (made up of the current Volta and Oti Regions) owned a bed net with 75.3% of
households in the region owning bed nets of the LLIN type. In that survey, 70% of the de facto
population of the then Volta region had access to an ITN (Ghana Statistical Service, 2015).
Furthermore, the 2014 Ghana DHS also observed that 59.8% of households in the Volta region
had one bed net for every two household members with 54.0% of households in the region
having one bed net of the LLIN type for every two household members (Ghana Statistical
Service, 2015). On average, 65.8% of the households in this study had one ITN for every two
household members .
Over the years, several countries including Ghana have made significant strides in increasing the
number of households that own ITNs through the adoption of several ITN (intervention) delivery
strategies such as mass ITN distribution campaigns (Baume & Franca-koh, 2011).
The observations made regarding bed net ownership and household population with access to
ITN in this study were improvements over what was observed in the Volta region during the
2014 Ghana DHS as well as the individual studies in the Volta Region cited above. Current
regional level estimates of the Oti Region for the ITN indicators discussed above will be helpful
in comparing the observations in the study communities.
Evaluating access to ITN at both the household and individual levels is important in explaining
the ITN use observed in a given setting. The fact that a household has at least one ITN may not
mean that the household has enough ITNs such that every two household members could use one
ITN if they decide to use the ITN (access). Given that 86.8% of study population and 65.8% of
129
University of Ghana http://ugspace.ug.edu.gh
study households had access to ITN suggests a need to improve the existing strategies of
delivering ITNs to the study communities to ensure that all households have at least one ITN for
every two household members (Seyoum et al., 2017).
5.2.2 Insecticide treated bed net use
Across the study communities, an average of 65.1% of the study population used the ITN the
night prior to the interview (Figure 28). Among households having least one ITN for every two
household members (access), 72.5% of their household population used ITN the night prior to
the interview.
According to the 2014 DHS, only 36% of the household population in Ghana slept under an ITN.
In that survey, the then Volta region recorded the highest proportions of household population
using the ITN compared to other regions such that 53.7% of the household population in the
region was reported to have slept under an ITN while 64.9% of the household population in
households having at least one ITN slept under an ITN the night before the survey in the Volta
region of Ghana (Ghana Statistical Service, 2015).
As a result, while data obtained from this study indicate a need to improve household access to
ITN, it also suggests a need to put in measures to understand why some people in households
with household access to ITN still fail to use the ITN. This may call for the development of
context specific change communications strategy to promote ITN use among the general study
population (Kilian et al., 2016; Pulford et al., 2011).
130
University of Ghana http://ugspace.ug.edu.gh
As a result, universal coverage, defined as all households having at least one ITN and at least
80% of household population using the ITN was not attained in any of the study communities
(Larsen et al., 2010; Roll Back Malaria, 2009).
The fact that universal coverage of ITN was not achieved in the study communities suggests a
need to review the current ITN delivery strategies to ensure that all households in these malaria
endemic communities of Ghana attain universal coverage of ITN. This is important because of
documented benefits of community wide high coverage of ITN on reduction of malaria
morbidity and mortality as well as the anticipated benefits of this intervention against vectors of
leishmaniasis, particularly in communities with malaria and leishmaniasis co-morbidity (Kilian,
et al, 2009).
Furthermore, there may be a need to investigate what other uses the bed nets may be put to in the
study communities which may reduce the number of bed nets available for the household use.
This is because 496 (84.5%) of household heads indicated that at least one ITN had been
disposed of from their households in the past 12 months prior to this study. Among the methods
for net disposal indicated, 6.3% of household heads mentioned that they had reused the bed nets
for other purposes.
131
University of Ghana http://ugspace.ug.edu.gh
Figure 22: Bed net observed hanging in sleeping area of a household
Across the study communities, it was observed that the use of ITNs cut across the age groups
with the majority of users being in the 5-15 years group (42.1%) followed by those in the age
group of 16-45 years (35.6%). Children under 5 years accounted for 13.3% of the ITN users.
When ITN users were stratified by sex, it was observed that females of 16-45 years were the
majority of net users (42.4%) while males of 5-15 years (47.3%) were the majority net users
among the males. Regardless of sex, children under 5 constituted between 12.9%-13.7% of the
ITN users among males and females respectively .
Considering the breakdown of household population by age group, children under 5 constitute
13.4% (12.8% of males and 13.4% of females) of household population among the study
households. As a result, efforts should be made to encourage and possibly increase ITN use by
132
University of Ghana http://ugspace.ug.edu.gh
people of all age groups in the malaria endemic communities to ensure community wide benefits
from the improvements in ongoing malaria control efforts which may be of benefit to the control
of leishmaniasis, as has been observed in other countries such as India and Nepal (Maxwell et
al., 2002; Picado, et al., 2010).
5.2.3 Factors associated with failure to use ITN
This study explored associations between the non-use of ITN and the socio-demographic
variables. The lack of household access to ITN (AOR=1.80; CI: 1.31, 2.47), having family size
of more than 10 members (AOR=2.53; CI: 1.20, 4.24), having more than 10 rooms for sleeping
in a household (AOR=10.18; CI: 1.28, 81.00), having 2-4 screened windows (AOR=1.49; CI:
1.00, 2.20), and having 8-10 screened windows (AOR=3.57; CI: 1.25, 10.17) were found to be
significantly associated with non-use of ITNs.
In a cross-sectional study conducted in south west Ethiopia, household having decreased access
to ITN, and having household size of 4-6 members were significantly associated with failure to
use ITN (Seyoum et al., 2017). Another cross-sectional survey conducted in Yemen found
having three or more damaged LLINs in the house, individuals aged 16 years and above, and
living in huts to be significantly associated with failure to use ITN (Al-Eryani et al., 2017).
Given that in this study, lack of household access to ITN was significantly associated with failure
to use it, the national malaria control program should review its delivery mechanisms to ensure
that all households own an ITN and at least 80% of all households in the study communities have
a minimum of one ITN for every two members in order to achieve universal coverage (WHO
Global Malaria Programme, 2014b; World Health Organization, 2017a).
133
University of Ghana http://ugspace.ug.edu.gh
Having increased family size (>10 members) and more than two screened windows were also
observed to be associated with failure to use the ITN in this study. As a result, further studies on
sleeping arrangements, housing conditions as well as reasons for non-use of ITN by larger
families and households having at least two screened windows will help to develop strategies to
improve use of ITNs in the study communities (Seyoum et al., 2017).
Factors associated with use of ITNs therefore tend to be context specific and varied. Identifying
such factors and the people not using the ITNs presents an opportunity to both explore and
understand their reasons for non-use in order to develop and adapt implementation strategies to
encourage an increased use of the ITNs among community members (Baume & Franca-koh,
2011; Biadgilign et al., 2012; Fokam et al., 2017; Kimbi et al., 2014; Moon et al., 2016).
5.2.4 Insecticide treated bed net disposal in study communities
It was observed that various methods of net disposal were used by the 496 (84.5%) households
which disposed of at least one ITN in the 12 months preceding this study. The commonest bed
net disposal methods indicated was garbage or refuse dump, followed by burning. The mode of
disposal of the ITNs and their non-biodegradable packaging materials is of concern due to its
potential for environmental and human health harm. Efforts towards recycling these used bed
nets should be explored to reduce their potential for human and environmental harm (Ghana
Statistical Service, 2015).
In addition, majority (81.5%) of those who disposed of at least one bed net indicted that the nets
were torn. This observation was similar to what was observed in the 2014 Ghana demographic
134
University of Ghana http://ugspace.ug.edu.gh
and health survey in which 82.9% of households surveyed in Ghana indicated that their main
reason for treated bed net disposal was because the nets were torn (Ghana Statistical Service,
2015).
It was also observed in this study that 69.4% of the respondents disposed of their nets after using
them for 2-4 years while 24.4% of the respondents disposed of nets which were less than 2 years
old. While these results suggest a need to intensify campaigns about maintenance and retention
of the ITNs to ensure that they are used longer without compromising their effectiveness, these
findings also support the three-year serviceable life span recommendation of WHO for LLINs
and which has been confirmed by other studies (De Sousa et al., 2019; Hakizimana et al., 2014)
5.2.5 ITN use and Leishmania infection in study communities
The Ghana national malaria control program distributes free insecticide treated bed nets to
Ghanaian households through various channels such as free bed net distribution campaigns, and
antenatal clinics. This distribution of insecticide treated bed nets is therefore encouraged as a
preventive measure not only against vectors of malaria but against vectors of cutaneous
leishmaniasis as well (González et al., 2015; Wilson et al., 2014).
The use of insecticide treated materials has been recommended to reduce the numbers of
phlebotomine sand flies which may eventually lead to a reduction in the incidence of
leishmaniasis (González et al., 2015).
However, this study did not observe a significant association between the non-use of insecticide
treated bed net and Leishmania infection. Although systematic reviews have suggested that the
use of insecticides including ITNs can be effective against sand fly vectors and thereby result in
135
University of Ghana http://ugspace.ug.edu.gh
a reduction in the incidence of leishmaniasis, other studies have also failed to establish any
association between the ownership, use or non-use of insecticides including ITN and
leishmaniasis (Reithinger et al., 2010).
This is an a example of a case where an evidence based intervention, in this case the ITN has
been found to be effective, yet it does not appear to have the same effect in a real setting (Moosa-
Kazemi, et al., 2007; Yaghoobi et al., 2006).
5.3 Cutaneous Leishmaniasis awareness, experience and knowledge
Measuring awareness about different aspects of cutaneous leishmaniasis is helpful in planning
CL disease control programs (Sarkari et al., 2014). This study obtained information on household
heads awareness of cutaneous leishmaniasis by asking whether they had seen people with CL
(using pictures of CL lesions) or heard about CL using the context specific local name. All
household heads had either seen or heard of CL which suggests a high level of awareness of the
disease by its name and appearance. However, only some 77.3% of them were aware of the local
name(s) used to describe CL.
This suggests that although the CL or CL like lesions was familiar to most household heads as
evidenced by their response when the CL pictures were shown to them, some of them were not
familiar with the local name used to describe CL. Recognition of the picture of CL lesions
presented in itself may not necessarily indicate awareness of the CL lesion but suggests
familiarity with such skin lesions. This is because there are several skin NTDS which share
similar characteristics with CL. Some of these skin NTDs include Buruli ulcer, Yaws, leprosy,
136
University of Ghana http://ugspace.ug.edu.gh
cutaneous and muco-cutaneous ulcers, and this has resulted in a call for an integrated approach to
tackling skin NTDs (Barogui et al., 2018; Yotsu, 2018).
Previous studies on CL in the Volta Region noted that CL was commonly referred to as
‗agbamekanu‘ meaning gift from someone who has returned from a journey in the local Ewe
language (Boakye et al., 2005; Doe, et al., 2019; Kwakye-Nuako et al., 2015; Kweku et al.,
2011).
In this study, it was detected that household heads belonging to the Ewe ethnic group constituted
only 0.5% of the household heads. Majority (62%) of the household heads in this study belonged
to the Kokomba ethnic group followed by the Achode (21%) ethnic group, and others.
The diverse ethnic groups in the study communities also reflected in different local names used
to describe CL. In Ashiabre, CL was predominantly referred to as ―Nato‖ by 82% of household
heads while in Keri and Sibi Hilltop, it was mainly called ―Doti‖ and ―Mgbangba‖ by 57% and
52% respectively. Across the study communities, 12.8% of the interviewed household heads
used a local Kokomba name, ―Mbuu‖, which means sore, to describe CL. This is because to
them, the CL lesion is a sore which is difficult to treat and takes a long time to heal.
The fact that 80% of respondents admit that CL was a problem in their community may also be
of importance to future control efforts in terms of getting the buy-in of community stakeholders
such as the household heads (Kebede et al., 2016).
Any future CL control program in this study area needs to take into account the different ethnic
groups, particularly the different names used to refer to CL, in order to develop an appropriate
control measure.
137
University of Ghana http://ugspace.ug.edu.gh
Results on CL related knowledge of household heads in this study suggest a gap in the
knowledge of the causes and transmission of CL as none of the interviewees was able to
correctly indicate the cause of CL or how CL is transmitted. There is therefore a need for
increased awareness building activities about CL in the study areas in order to sensitize the
community members about key aspects of the disease such as cause, mode of transmission,
treatment and prevention (Akram et al., 2015; Ruoti et al., 2013).
A study in the Ho municipality of the Volta Region reported that community members had a
reasonable knowledge of CL but lacked sufficient knowledge of the vector (Doe et al., 2019).
Although household heads in this study exhibited high awareness about CL, 58.6% did not
demonstrate good knowledge about key aspects of the disease. As a result, innovative
approaches including direct, in-person training on CL for key stakeholders in the community
such as the household heads may also help in improving preventative practices and attitudes
towards CL (Kebede et al., 2016; Saberi et al., 2012). Future CL health education and awareness
campaign activities should also focus on the vector of the disease to promote CL preventive
behavior on the part of community members.
Regarding CL experience, the data summarized in Table 34 suggests that CL was quite common
in the study communities as 69% of the interviewed household heads knew at least one person
within their community (outside their home) who had a history of CL. Within the study
households, a history of CL was reported for at least one person in 71.4% of the households
while a history at least one person with CL in the past two years preceding the study was
reported in 45.3% of the study households. The months of June, July, August, and November
were mentioned by majority of the respondents as the months in which majority of the skin
ulcers reported as CL were observed in the study communities.
138
University of Ghana http://ugspace.ug.edu.gh
Furthermore, in descending order, cases of CL were reported in the following age groups 5-17
years, < 5 years, 18-35 years, and 36-60 years. In terms of occupational groups observed with CL
in the study communities, farmers were the majority (61%) followed by children/students (47%).
This information can be helpful for conducting follow-up investigations in the study area to
better understand the epidemiology of the reported CL by taking into account the data provided
regarding months of the year with most CL cases observed, occupational groups affected as well
as age groups of people affected by CL.
The experience of CL may lead to social and mental dimensions for the affected people
considering that the disease can be disfiguring and may also result in stigma. As a result, these
reports of CL by the household heads require the attention of the Ghana health authorities as well
as other stakeholders such as researchers to better understand and address the situation of skin
ulcers in the communities (Bilgic-Temel et al., 2019; Khatami et al., 2018).
Although this study had no way of verifying that each number of persons reported in the
respective households as having a history of CL within the past two years or earlier, actually had
CL, the reports of CL obtained from the household heads interviewed is important because there
are many NTDs that have major skin manifestations including ulceration. As a result, an
unknown proportion of the reported history of CL may or may not actually be CL (Chandler &
Fuller, 2018) .
However, what is not in doubt is the fact that the heads of households reported skin ulcers which
to their understanding fits the clinical description of CL. An integrated skin NTD study in this
area will therefore be very useful in determining what proportions of the reported skin ulcers
139
University of Ghana http://ugspace.ug.edu.gh
may not be CL and to determine which other skin NTD etiologies could be circulating in the
study area (Chandler & Fuller, 2018; World Health Organization, 2019c; Yotsu, 2018).
5.4 Presence of sand flies within study communities
Using indoor aspiration and CDC light traps, 218 sand flies (25 males and 193 females) were
trapped from various locations of the study communities where humans could be found such as
household compounds, household sleeping areas, church compounds, inside church buildings,
mosque compounds, school compounds, school KG classrooms, school primary classrooms, and
school Junior high class rooms.
It is also important to indicate that, even among the vectors of Leishmaniasis in the Old World,
some phlebotomine sand fly species have been more associated with certain species of the
Leishmania parasite which has more than twenty parasite species known to infect humans. Of
about 500 known phlebotomine sand fly species, only about 30 of them are known to transmit
Leishmania parasites (Claborn, 2010; WHO, 2016a).
There is a need to confirm the presence of sand flies in a given setting in order to proceed with
the next steps of investigating the sand fly species as well as determining whether or not the sand
flies observed are infected with Leishmania parasites. Identification of sand flies in the
communities investigated in this study presents an opportunity for the next steps of sand fly
species identification and investigation of Leishmania infection to be carried out.
It is also worth noting that, out of the sleeping areas of thirty households (10 in each community)
in which indoor aspiration was carried out, sand flies were trapped in only one household. All the
other 29 households had ITN which was obtained within the past one year. The sand flies were
140
University of Ghana http://ugspace.ug.edu.gh
trapped in two rooms in a household and these rooms had peculiarities. One of the rooms had no
bed net at all while the other room had an old bed net (more than 6 years old). All other rooms
with ITN in this study recorded no sand flies. It is therefore important for future studies to be
carried out to investigate the role of the ITN roll out in these study communities on the absence
of sand flies observed in majority of the household sleeping rooms having ITN which were
selected for indoor aspiration.
Furthermore, detection of sand flies in areas outside the household sleeping areas but with close
proximity to human activities such as the household compounds, school compounds and
classroom calls for a more integrated vector control approach to ensure a reduced contact with
the sand flies as further studies are conducted to describe species and vector competence of sand
flies in the study communities to transmit leishmaniasis (Claborn, 2010; Dostálová & Volf,
2012; WHO, 2016a).
5.4.1 Need for identification of vectors and reservoirs of Leishmania infection in Volta and
Oti regions of Ghana
Previous vector studies in Ghana have confirmed DNA of Leishmania parasites such as
Leishmania tropica and Leishmania major in sand flies belonging to the genus Sergentymyia
(Nzelu et al., 2014a). Sand flies belonging to the genus Sergentomyia have not been confirmed as
vectors of human Leishmaniasis. However, detecting species of Leishmania known to cause
human Leishmaniasis in the Volta region calls for more studies to identify the likely putative
vectors of those parasites (Maia & Depaquit, 2016).
141
University of Ghana http://ugspace.ug.edu.gh
It is also of interest to point out that several previous vector studies in Ghana aimed at
identifying phlebotomine sand flies belonging to the order Diptera in the family Psychodidae
(known vectors of leishmaniasis in the Old World) have resulted in identifying many species of
sand flies mostly belonging to the genus Sergentymyia with only two species belonging to the
genera Phlebotomus (P. duboscqi and P. rodhaini) detected in such low numbers that their
vectorial role in Ghana is currently uncertain (Boakye et al., 2005).
Dogs, fox, rodents, and humans are among the documented reservoirs for CL in west Africa
(Alemayehu & Alemayehu, 2017). The reservoir of cutaneous leishmaniasis in the Volta region
of Ghana is currently uncertain. Previous attempts at identifying the potential reservoirs of
leishmaniasis in the Volta region of Ghana were unsuccessful due to various reasons such as
difficulty in trapping animals.
In the areas of the Volta region with reported CL cases during a suspected CL outbreak in the
year 1999 in Ghana, keeping dogs was considered a taboo. As a result, although dogs have been
documented as a reservoir for CL, they have not yet been investigated for Leishmania infection
in Ghana. Goats were among the suspected reservoirs for leishmaniasis in the Volta region of
Ghana. However, previous attempts to investigate Leishmania infection in goats suspected to
have Leishmania infection did not find any such infection (Raczniak, et al., 2008).
In this current study, dogs were among the livestock owned by households and no taboos
prevented dog ownership in this study area. In this study, 75.2% of study participants had some
contact with dogs with 31.7% of participants having such contacts often. Furthermore, 79.7% of
the study participants also indicated having some contact with goats (Table 11). As a result, new
studies targeted at identifying reservoir of cutaneous leishmaniasis are needed to inform CL
142
University of Ghana http://ugspace.ug.edu.gh
control approaches in the Oti and Volta regions of Ghana (Alemayehu & Alemayehu, 2017;
Boakye et al., 2005).
Despite the gaps mentioned above which calls for more studies on the different aspects of CL in
the Volta region including the recently carved out Oti region, this study provides critical data on
the epidemiology of Leishmania infections in the Oti region including age groups previously and
currently exposed to Leishmania infection, which is important for guiding implementation of
future CL control measures.
5.5 Fever among study participants
Fever has been documented as one of the human body‘s mechanisms for responding to various
o
infections (Plaza, et al., 2016). All 9 persons reporting with axillary body temperature of 38 C or
more during this study were positive for malaria infection using malaria RDT. As a result, while
a more integrated approach for sand fly vector control approach is advocated, the continuation of
insecticide treated bed net distribution program of the Ghana Health service is encouraged to
ensure that the gains made on the malaria control front in the study area are not eroded.
143
University of Ghana http://ugspace.ug.edu.gh
CHAPTER SIX
6.0 CONCLUSIONS AND RECOMMENDATIONS
6.1 Conclusions
This study has demonstrated exposure to Leishmania infection in three communities of the Oti
region of Ghana using the LST. Prevalence of Leishmania infection observed was 39.4%, 55.1%,
and 34.2% in Ashiabre, Keri, and Sibi Hilltop respectively. Being male, living in Keri and being
five years or older were associated with an increase in the odds of exposure to Leishmania
infection using LST.
Out of 426 individuals observed with various numbers of skin ulcers in the study communities,
majority (73.7%) were within the ages of 5-15 years. Of 136 individuals with various numbers of
confirmed Leishmania positive skin ulcers, 100 (73.5%) were children within the ages of 5-15
years. The data obtained on exposure to Leishmania infection as well as actual Leishmania
positive skin ulcers in the study area suggest an active cycle of transmission of Leishmania
infection with children of the ages 5-15 years having the highest numbers of cases of cutaneous
leishmaniasis.
This study also confirmed the presence of sand flies in the study communities in areas where
people could easily be found such as household compounds, school compounds and classrooms,
as well as church and mosque compounds.
In addition, this study evaluated the following indicators of insecticide treated bed net
distribution program of the Ghana malaria control program: household ownership of at least one
ITN (97.1%), households with at least one ITN for every two household members (65.8%),
144
University of Ghana http://ugspace.ug.edu.gh
population with access to ITN (86.8%), and population that slept in ITN the night prior to this
study (65.1%). Household ITN access of 65.8% and use of ITN by 65.1% of the study population
suggests room for implementation strategies to improve both access to ITN and use of ITN in the
study communities in order to achieve universal coverage of ITN. However, no association was
observed between non-use of ITN and Leishmania infection.
This study also identified the following factors as being significantly associated with non-use of
ITN across the study communities: Lack of household access to ITN, having family size of more
than 10 members, having more than 10 rooms for sleeping in a household, having 2-4 screened
windows, and having 8-10 screened windows.
Because factors associated with using or not using ITNs tend to be context specific,
identification of these factors is an opportunity for further studies to understand reasons for non-
use in order to develop and adapt implementation strategies to encourage an increased use of the
ITNs among community members (Baume & Franca-koh, 2011; Biadgilign et al., 2012; Fokam
et al., 2017; Kimbi et al., 2014; Moon et al., 2016)
All household heads either knew a local name for CL or recognized the CL lesion as being
familiar. Thus, the household heads had high awareness of CL based on the two criteria above.
In addition, this study concluded that different local names were used to refer to CL in the
respective communities and as such any future control intervention in the study area will have to
take these different names into consideration.
Household heads confirmed that CL was common in their communities and indicated previous
and recent (within two years prior to the start of the study) cases in the respective study
communities. The reported experience of CL in the study communities suggested that cases of
145
University of Ghana http://ugspace.ug.edu.gh
CL were seen in all months of the year with majority of cases seen in the months of June, July
and November of the year.
In descending order, the following age groups were reported as having experienced CL: 5-17
years, < 5 years, 18-35 years, and 36-60 years. Farmers and children were mentioned by 61%
and 47% of household heads as occupational groups commonly seen affected by CL. Results of
PCR test confirm that majority of those with CL in the study community were within the ages 5-
15 as was reported by the household heads.
Less than half of the interviewed household heads (41.4%) demonstrated overall good
knowledge about cutaneous leishmaniasis. This calls for strategies to improve overall awareness
of the various aspects of cutaneous leishmaniasis disease in order to ensure improvements in
future interventions for disease control.
6.2 Public health importance of the findings from this study
This study has demonstrated exposure to Leishmania infection and cutaneous Leishmaniasis
(CL) in three communities of the Oti region of Ghana which had no previous documentation of
Leishmania infection. Identification of cases of cutaneous Leishmaniasis in such communities
forms a basis for future studies to investigate key aspects of the disease such as vectors and
reservoirs.
Furthermore, identification of these CL cases calls for measures to provide appropriate CL
treatment for affected people who otherwise may have been treated as having other types of
ulcers.
This study also investigated and demonstrated gaps in CL related knowledge of interviewed
household heads. This information can form a basis for future interventions such as behaviour
146
University of Ghana http://ugspace.ug.edu.gh
change communication approaches to improve community awareness about key aspects of CL
such as mode of transmission and CL preventive measures.
Documentation of key indicators of ITN in the study communities and observation of gaps in the
household access and use of ITN provides a basis for implementation strategies to improve
household access to as well as use of ITNs in the study communities.
6.3 Contribution to knowledge
This study described prevalence of exposure to Leishmania infection and also confirmed
Leishmania infection in skin ulcers obtained from three communities of the Oti region of Ghana
without a previous documentation of Leishmania infection.
Although experimental studies and systemic reviews have suggested an effect of insecticide use
on reducing the incidence of leishmaniasis, no association was observed between non-use of
ITNs and exposure to Leishmania infection in this study which was conducted in a real-world
setting.
This study confirmed the possibility of multiple aetiologies of skin ulcer in the study community
and calls for an integrated skin NTD approach.
This study further investigated and confirmed the presence of sand flies in three communities of
the Oti region which had cases of cutaneous leishmaniasis.
Although household heads demonstrated high awareness about CL, this study identified gaps in
their knowledge about CL.
147
University of Ghana http://ugspace.ug.edu.gh
6.4 Limitations of the study
This study was a community based cross-sectional study which only used quantitative
research methods. A better understanding of some aspects of the study such as reasons
for non-use of ITN could have been achieved if qualitative methods were included.
Also, a longitudinal study of both sand flies and human Leishmania infection would have
enriched the data.
6.5 Recommendations
6.5.1 Research
1. Studies to investigate species of Leishmania parasites causing human cutaneous
leishmaniasis in the study communities.
2. Research to characterize species of sand flies in the study communities.
3. Investigation of Leishmania infection in sand flies in the study communities.
4. Research to investigate reservoirs of Leishmania infection in the study communities.
5. Investigation of additional aetiologies of skin diseases (Skin NTDS) in the study area
6.5.2 Ghana Health Service
1. Identification of cases of cutaneous leishmaniasis calls for treatment of the affected
people. The Ghana Health service should therefore develop and put in place measures
to treat the affected people.
2. The service should also develop and put in place community sensitization
programmes.
148
University of Ghana http://ugspace.ug.edu.gh
6.5.3 World Health Organization
1. The assistance of WHO with the development of clinical guidelines for CL case
identification and management in Ghana.
149
University of Ghana http://ugspace.ug.edu.gh
REFERENCES
Abdulai, A. A., Agana-Nsiire, P., Biney, F., Kwakye-Maclean, C., Kyei-Faried, S., Amponsa-
Achiano, K., Simpson, S. V., Bonsu, G., Ohene, S. A., Ampofo, W. K., Adu-Sarkodie, Y.,
Addo, K. K., Chi, K. H., Danavall, D., Chen, C. Y., Pillay, A., Sanz, S., Tun, Y., Mitjà, O.,
… Ballard, R. C. (2018). Community-based mass treatment with azithromycin for the
elimination of yaws in Ghana—Results of a pilot study. PLoS Neglected Tropical Diseases,
12(3), 1–16. https://doi.org/10.1371/journal.pntd.0006303
Adams, E. R., Gomez, M. A., Scheske, L., Rios, R., Marquez, R., Cossio, A., Albertini, A.,
Schallig, H., & Saravia, N. G. (2015). Sensitive diagnosis of cutaneous leishmaniasis by
lesion swab sampling coupled to qPCR. Parasitology, 141(14), 1891–1897.
https://doi.org/10.1017/S0031182014001280.Sensitive
Adjei, J. K. (2012). Household bednet ownership and use in Ghana : Implications for malaria
control. 2(1), 15–30.
Akram, A., Khan, H. A. A., Qadir, A., & Sabir, A. M. (2015). A cross-sectional survey of
knowledge, attitude and practices related to cutaneous leishmaniasis and sand flies in
Punjab, Pakistan. PLoS ONE, 10(6), 1–8. https://doi.org/10.1371/journal.pone.0130929
Al-Eryani, S. M. A., Mahdy, M. A. K., Al-Mekhlafi, A. M., & Abdul-Ghani, R. (2017). Access
to and use of long-lasting insecticidal nets and factors associated with non-use among
communities in malaria-endemic areas of Al Hudaydah governorate in the Tihama region,
west of Yemen. Malaria Journal, 16(1), 1–10. https://doi.org/10.1186/s12936-017-1894-9
Alemayehu, B., & Alemayehu, M. (2017). Leishmaniasis: A Review on Parasite, Vector and
Reservoir Host. Health Science Journal, 11(4), 1–6. https://doi.org/10.21767/1791-
809X.1000519
Alexander, B., Lopes de Carvalho, R., McCallum, H., & Pereira, M. H. (2002). Role of the
domestic chicken (Gallus gallus) in the epidemiology of urban visceral leishmaniasis in
Brazil. Emerging Infectious Diseases, 8(12), 1480–1485.
https://doi.org/10.3201/eid0812.010485
Alvar, J, Vélez, I. D., Bern, C., Herrero, M., Desjeux, P., & Cano, J. (2012). WHO
Leishmaniasis Control Team. Leishmaniasis worldwide and global estimates of its
incidence. PLoS One, 7. https://doi.org/10.1371/journal.pone.0035671
Alvar, Jorge, Velez, D. I., Bern, C., Herrero, M., Desjeux, P., Cano, J., Jannin, J., Boer, den M.,
& Team, the W. L. C. (2012). Leishmaniasis Worldwide and Global Estimates of Its
Incidence. PLoS Neglected Tropical Diseases, 7(5), 1–12.
https://doi.org/10.1371/journal.pone.0035671
Amedo, E. K. (2016). Utilization of insecticide treated mosquito nets among caregivers of
children under five in Hohoe township of Ghana.
Antonio, L. de F., Fagundes, A., Oliveira, R. V. C., Pinto, P. G., Bedoya-Pacheco, S. J.,
Vasconcellos, Ér. de C. F. e, Valete-Rosalino, M. C., Lyra, M. R., Passos, S. R. L.,
Pimentel, M. I. F., & Schubach, A. de O. (2014). Montenegro skin test and age of skin
lesion as predictors of treatment failure in cutaneous leishmaniasis. Revista Do Instituto de
150
University of Ghana http://ugspace.ug.edu.gh
Medicina Tropical de Sao Paulo, 56(5), 375–380. https://doi.org/10.1590/S0036-
46652014000500002
Aronson, N. E., Wortmann, G. W., Byrne, W. R., Howard, R. S., Bernstein, W. B., Marovich, M.
A., Polhemus, M. E., Yoon, I. K., Hummer, K. A., Gasser, R. A., Oster, C. N., & Benson, P.
M. (2010). A randomized controlled trial of local heat therapy versus intravenous sodium
stibogluconate for the treatment of cutaneous Leishmania major infection. PLoS Neglected
Tropical Diseases, 4(3). https://doi.org/10.1371/journal.pntd.0000628
Asilian, A., Sadeghinia, A., Faghihi, G., & Momeni, A. (2004). Comparative study of the
efficacy of combined cryotherapy and intralesional meglumine antimoniate (GlucantimeR)
vs. cryotherapy and intralesional meglumine antimoniate (GlucantimeR) alone for the
treatment of cutaneous leishmaniasis. International Journal of Dermatology, 43(4), 281–
283. https://doi.org/10.1111/j.1365-4632.2004.02002.x
Atkinson, J.-A., Bobogare, A., Fitzgerald, L., Boaz, L., Appleyard, B., Toaliu, H., & Vallely, A.
(2009). A qualitative study on the acceptability and preference of three types of long-lasting
insecticide-treated bed nets in Solomon Islands: implications for malaria elimination.
Malaria Journal, 8, 119. https://doi.org/10.1186/1475-2875-8-119
Bailey, M. S., & Lockwood, D. N. J. (2007). Cutaneous leishmaniasis. Clinics in Dermatology,
25(2), 203–211. https://doi.org/10.1016/j.clindermatol.2006.05.008
Barogui, Y. T., Diez, G., Anagonou, E., Johnson, R. C., Gomido, I. C., Amoukpo, H., Bachirou,
Z. S., Houezo, J. G., Saizonou, R., Sopoh, G. E., & Kingsley, A. (2018). Integrated
approach in the control and management of skin neglected tropical diseases in Lalo, Benin.
PLoS Neglected Tropical Diseases, 12(6), 1–12.
https://doi.org/10.1371/journal.pntd.0006584
Baume, C. A., & Franca-koh, A. C. (2011). Predictors of mosquito net use in Ghana. Malaria
Journal, 10, 2–7.
Bennett, A., Smith, S. J., Yambasu, S., Jambai, A., Alemu, W., Kabano, A., & Eisele, T. P.
(2012). Household possession and use of insecticide-treated mosquito nets in sierra leone 6
months after a national mass-distribution campaign. PLoS ONE, 7(5).
https://doi.org/10.1371/journal.pone.0037927
Berbert, T. R. N., Mello, T. F. P. De, Wolf Nassif, P., Mota, C. A., Silveira, A. V., Duarte, G. C.,
Demarchi, I. G., Aristides, S. M. A., Lonardoni, M. V. C., Vieira Teixeira, J. J., & Silveira,
T. G. V. (2018). Pentavalent antimonials combined with other therapeutic alternatives for
the treatment of cutaneous and mucocutaneous leishmaniasis: A systematic review.
Dermatology Research and Practice, 2018. https://doi.org/10.1155/2018/9014726
Berdjane-Brouk, Z., Koné, A. K., Djimdé, A. A., Charrel, R. N., Ravel, C., Delaunay, P., del
Giudice, P., Diarra, A. Z., Doumbo, S., Goita, S., Thera, M. A., Depaquit, J., Marty, P.,
Doumbo, O. K., & Izri, A. (2012). First detection of Leishmania major DNA in
Sergentomyia (Spelaeomyia) darlingi from cutaneous leishmaniasis foci in Mali. PLoS
ONE, 7(1), 1–7. https://doi.org/10.1371/journal.pone.0028266
Bettaieb, J., Toumi, A., Chlif, S., Chelghaf, B., Boukthir, A., Gharbi, A., & Salah, A. Ben.
151
University of Ghana http://ugspace.ug.edu.gh
(2014). Prevalence and determinants of Leishmania major infection in emerging and old
foci in Tunisia. Parasites & Vectors, 7(386), 1–8.
Bhattarai, N. R., Van Der Auwera, G., Rijal, S., Picado, A., Speybroeck, N., Khanal, B., De
Doncker, S., Das, M. L., Ostyn, B., Davies, C., Coosemans, M., Berkvens, D., Boelaert, M.,
& Dujardin, J. C. (2010). Domestic animals and epidemiology of visceral leishmaniasis,
Nepal. Emerging Infectious Diseases, 16(2), 231–237.
https://doi.org/10.3201/eid1602.090623
Biadgilign, S., Reda, A., & Kedir, H. (2012). Determinants of ownership and utilization of
insecticide-treated bed nets for malaria control in Eastern Ethiopia. Journal of Tropical
Medicine, 2012. https://doi.org/10.1155/2012/235015
Bilgic-Temel, A., Murrell, D. F., & Uzun, S. (2019). Cutaneous leishmaniasis: A neglected
disfiguring disease for women. International Journal of Women‟s Dermatology, 5(3), 158–
165. https://doi.org/10.1016/j.ijwd.2019.01.002
Binka, F. N., Kubaje, A., Adjuik, M., Williams, L. A., Lengeler, C., Maude, G. H., & Armah, G.
E. (1996). Impact of permethrin impregnated bednets on child mortality in Kassena-
Nankana district , Ghana : a randomized controlled trial. I(2), 147–154.
Boakye, D. A., Wilson, M., & Kweku, M. (2005). A review of leishmaniasis in west Africa.
Ghana Medical Journal, 39(3), 94–97. https://doi.org/10.1016/S0020-7519(01)00326-5
Boggild, A. K., Miranda-Verastegui, C., Espinosa, D., Arevalo, J., Martinez-Medina, D., Llanos-
Cuentas, A., & Low, D. E. (2008). Optimization of microculture and evaluation of
miniculture for the isolation of Leishmania parasites from cutaneous lesions in Peru. The
American Journal of Tropical Medicine and Hygiene, 79(6), 847–852.
Boggild, A. K., Valencia, B. M., Espinosa, D., Veland, N., Ramos, A. P., Arevalo, J., Llanos‐
Cuentas, A., & Low, D. E. (2010). Detection and Species Identification of Leishmania DNA
from Filter Paper Lesion Impressions for Patients with American Cutaneous Leishmaniasis.
Clinical Infectious Diseases, 50(1), e1–e6. https://doi.org/10.1086/648730
Bray, D. P., & Hamilton, J. G. (2013). Insecticide-impregnated netting as a potential tool for
long-lasting control of the leishmaniasis vector Lutzomyia longipalpis in animal shelters.
Parasites & Vectors, 6(1), 133. https://doi.org/10.1186/1756-3305-6-133
Browne, E. N. L., Maude, G. H., & Binka, F. N. (2001). The impact of insecticide-treated
bednets on malaria and anaemia in pregnancy in Kassena-Nankana district, Ghana: A
randomized controlled trial. Tropical Medicine and International Health, 6(9), 667–676.
https://doi.org/10.1046/j.1365-3156.2001.00759.x
Campbell, M. J., & Daniel, W. W. (1994). Biostatistics: A Foundation for Analysis in the Health
Sciences, Sixth edition (Vol. 780). John Wiley & Sons.
Campino, L., Cortes, S., Dionísio, L., Neto, L., Afonso, M. O., & Maia, C. (2013). The first
detection of Leishmania major in naturally infected Sergentomyia minuta in Portugal.
Memorias Do Instituto Oswaldo Cruz, 108(4), 516–518. https://doi.org/10.1590/0074-
0276108042013020
152
University of Ghana http://ugspace.ug.edu.gh
Chandler, D. J., & Fuller, L. C. (2018). The skin—A common pathway for integrating diagnosis
and management of NTDs. Tropical Medicine and Infectious Disease, 3(3), 1–11.
https://doi.org/10.3390/tropicalmed3030101
Claborn, D. (2010). The biology and control of leishmaniasis vectors. Journal of Global
Infectious Diseases, 2(2), 127. https://doi.org/10.4103/0974-777X.62866
Cruz, I., Cañavate, C., Rubio, J. M., Morales, M. A., Chicharro, C., Laguna, F., Jiménez-Mejías,
M., Sirera, G., Videla, S., & Alvar, J. (2002). A nested polymerase chain reaction (Ln-PCR)
for diagnosing and monitoring Leishmania infantum infection in patients co-infected with
human immunodeficiency virus. Transactions of the Royal Society of Tropical Medicine
and Hygiene, 96, S185–S189. https://doi.org/10.1016/s0035-9203(02)90074-x
Cruz, Israel, Millet, A., Carrillo, E., Chenik, M., Salotra, P., Verma, S., Veland, N., Jara, M.,
Adaui, V., Castrillón, C., Arévalo, J., Moreno, J., & Cañavate, C. (2013). An approach for
interlaboratory comparison of conventional and real-time PCR assays for diagnosis of
human leishmaniasis. Experimental Parasitology, 134(3), 281–289.
https://doi.org/10.1016/j.exppara.2013.03.026
Custodio, E., Gadisa, E., Sordo, L., Cruz, I., Moreno, J., Nieto, J., Chicharro, C., Aseffa, A.,
Abraham, Z., Hailu, T., & Cañavate, C. (2012). Factors Associated with Leishmania
Asymptomatic Infection: Results from a Cross-Sectional Survey in Highland Northern
Ethiopia. PLoS Neglected Tropical Diseases, 6(9).
https://doi.org/10.1371/journal.pntd.0001813
da Costa, C. A., de Toledo, V. P., Enaro, O., Williams, P., & Mayrink, W. (1996). Montenegro
skin test--evaluation of the composition and stability of the antigen preparation. Memórias
Do Instituto Oswaldo Cruz, 91(2), 193–194. https://doi.org/10.1590/S0074-
02761996000200013
Das, J. K., Salam, R. A., Arshad, A., Maredia, H., & Bhutta, Z. A. (2014). Community based
interventions for the prevention and control of Non-Helmintic NTD. Infectious Diseases of
Poverty, 3(1), 24. https://doi.org/10.1186/2049-9957-3-24
Davian C Whyte, Rachel Zufferey. (2017). Cutaneous Leishmaniasis: Update on Vaccine
Development. Human Parasitic Diseases, 9. https://doi.org/10.4137/hpd.s16588
de Araujo, Alberon Ribeiro; Portela, Nairomberg Cavalcanti; Feitosa, Ana Paula Sampaio; da
Silva, Otamires Alves;Ximenes, Ricardo Andrade Arraes;Alves, Luiz Carlos; Brayner, F.
A. ; (2016). RISK FACTORS ASSOCIATED WITH AMERICAN CUTANEOUS
LEISHMANIASIS. Revista Do Instituto de Medicina Tropical de Sao Paulo, 58:86(1), 2–7.
De Luca, P. M., & Macedo, A. B. B. (2016). Cutaneous leishmaniasis vaccination: A matter of
quality. Frontiers in Immunology, 7(APR), 1–8. https://doi.org/10.3389/fimmu.2016.00151
De Sousa, J. O., De Albuquerque, B. C., Coura, J. R., & Suárez-Mutis, M. C. (2019). Use and
retention of long-lasting insecticidal nets (LLINs) in a malaria risk area in the Brazilian
Amazon: A 5-year follow-up intervention. Malaria Journal, 18(1), 1–13.
https://doi.org/10.1186/s12936-019-2735-9
153
University of Ghana http://ugspace.ug.edu.gh
de Vries, H. J. C., Reedijk, S. H., & Schallig, H. D. F. H. (2015). Cutaneous Leishmaniasis:
Recent Developments in Diagnosis and Management. American Journal of Clinical
Dermatology, 16(2), 99–109. https://doi.org/10.1007/s40257-015-0114-z
Demographic and Health Surveys Methodology. (2012). Sampling and Household Listing
Manual. In Demographic and Health Surveys Methodology.
Desjeux, P. (1996). Leishmaniasis: Public health aspects and control. Clinics in Dermatology,
14(5), 417–423. https://doi.org/10.1016/0738-081X(96)00057-0
Desjeux, P. (2010). Prevention of Leishmania donovani infection. In BMJ (Clinical research ed.)
(Vol. 341, p. c6751).
Desrochers, R. E., Siekmans, K., Berti, P. R., Bramhill, K., Buchan, S. A., Battah, G. K.,
Gbetoglo, D., Vignikin, K., & Sabino, A. (2014). Effectiveness of post-campaign, door-to-
door, hang-up, and communication interventions to increase long-lasting, insecticidal bed
net utilization in Togo (2011–2012): a cluster randomized, control trial. Malaria Journal,
13(1), 260. https://doi.org/10.1186/1475-2875-13-260
Doe, E. D., Egyir-yawson, A., & Kwakye-nuako, G. (2019). Knowledge , Attitude and Practices
Related to Cutaneous Leishmaniasis in Endemic Communities in the Volta Region of
Ghana. International Journal of Healthcare Sciences, 7(1).
Dostálová, A., & Volf, P. (2012). Leishmania development in sand flies: Parasite-vector
interactions overview. Parasites and Vectors, 5(1), 1–12. https://doi.org/10.1186/1756-
3305-5-276
Ejov, M., & Dagne, D. (2014). Strategic framework for leishmaniasis control in the WHO
European Region 2014-2020. World Health Organization, 1–17.
Escamilla, V., Alker, A., Dandalo, L., Juliano, J. J., Miller, W. C., Kamthuza, P., Tembo, T.,
Tegha, G., Martinson, F., Emch, M., & Hoffman, I. F. (2017). Effects of community-level
bed net coverage on malaria morbidity in Lilongwe, Malawi. Malaria Journal, 16(1), 142.
https://doi.org/10.1186/s12936-017-1767-2
Faiman, R., Abbasi, I., Jaffe, C., Motro, Y., Nasereddin, A., Schnur, L. F., Torem, M., Pratlong,
F., Dedet, J. P., & Warburg, A. (2013). A Newly Emerged Cutaneous Leishmaniasis Focus
in Northern Israel and Two New Reservoir Hosts of Leishmania major. PLoS Neglected
Tropical Diseases, 7(2). https://doi.org/10.1371/journal.pntd.0002058
Faraj, C., Yukich, J., Adlaoui, E. B., Wahabi, R., Mnzava, A. P., Kaddaf, M., Laamrani, A.,
Idrissi, E., Ameur, B., & Kleinschmidt, I. (2016). Effectiveness and Cost of Insecticide-
Treated Bed Nets and Indoor Residual Spraying for the Control of Cutaneous
Leishmaniasis : A Cluster-Randomized Control Trial in Morocco. American Journal of
Therapeutics, 94(3), 679–685. https://doi.org/10.4269/ajtmh.14-0510
Flaxman, A. D., Fullman, N., Otten, M. W., Menon, M., Cibulskis, R. E., Ng, M., Murray, C. J.
L., & Lim, S. S. (2010). Rapid scaling up of insecticide-treated bed net coverage in Africa
and its relationship with development assistance for health: A systematic synthesis of
supply, distribution, and household survey data. PLoS Medicine, 7(8).
154
University of Ghana http://ugspace.ug.edu.gh
https://doi.org/10.1371/journal.pmed.1000328
Fokam, E. B., Kindzeka, G. F., Ngimuh, L., Dzi, K. T. J., & Wanji, S. (2017). Determination of
the predictive factors of long-lasting insecticide-treated net ownership and utilisation in the
Bamenda Health District of Cameroon. BMC Public Health, 17, 263–272.
https://doi.org/10.1186/s12889-017-4155-5
Foulet, F., Botterel, F., Buffet, P., Morizot, G., Rivollet, D., Deniau, M., Pratlong, F., Costa, J.
M., & Bretagne, S. (2007). Detection and identification of Leishmania species from clinical
specimens by using a real-time PCR assay and sequencing of the cytochrome b gene.
Journal of Clinical Microbiology, 45(7), 2110–2115. https://doi.org/10.1128/JCM.02555-06
Fryauff, D. J., Hanafi, H. A., Klena, J. D., Hoel, D. F., Appawu, M., Rogers, W., Puplampu, N.,
Odoom, S., Kweku, M., Koram, K., Wilson, M. D., Raczniak, G., & Boakye, D. (2006).
Short report: ITS-1 DNA sequence confirmation of Leishmania major as a cause of
cutaneous leishmaniasis from an outbreak focus in the Ho District, southeastern Ghana.
American Journal of Tropical Medicine and Hygiene, 75(3), 502–504.
https://doi.org/75/3/502 [pii]
Gabriel, Á., Valério-Bolas, A., Palma-Marques, J., Mourata-Gonçalves, P., Ruas, P., Dias-
Guerreiro, T., & Santos-Gomes, G. (2019). Cutaneous Leishmaniasis: The Complexity of
Host‘s Effective Immune Response against a Polymorphic Parasitic Disease. Journal of
Immunology Research, 2019, 1–16. https://doi.org/10.1155/2019/2603730
Ghana Health Service, G. (2017). National Malaria control Programme.
http://www.ghanahealthservice.org/ghs-subcategory.php?cid=4&scid=41
Ghana Statistical Service. (2014a). 2010 POPULATION & HOUSING CENSUS; DISTRICT
ANALYTICAL REPORT: Nkwanta north district.
Ghana Statistical Service. (2014b). 2010 Population and Housing Census. District Analytical
Report-Ho Municipality, 1–73.
Ghana Statistical Service. (2015). Ghana Demographic and Health Survey. Ghana Statistical
Service, 530. https://dhsprogram.com/pubs/pdf/FR307/FR307.pdf
Ghana Statistical Service (GSS). (2014). 2010 POPULATION & HOUSING CENSUS;
DISTRICT ANALYTICAL REPORT: Nkwanta south district.
GHS, N. M. C. P. (2015). Insecticide Treated Nets.
http://www.ghanahealthservice.org/malaria/item.php?nmcpiid=59&nmcpscid=116&nmcpci
d=85
González, U., Pinart, M., Reveiz, L., & Alvar, J. (2008). Interventions for Old World cutaneous
leishmaniasis ( Review ). Cochrane Database of Systematic Reviews, 4.
González, U., Pinart, M., Sinclair, D., Firooz, A., Enk, C., Id, V., Tm, E., Tristan, M., & Alvar, J.
(2015). Vector and reservoir control for preventing leishmaniasis ( Review ). Cochrane
Database of Systematic Reviews, 8.
https://doi.org/10.1002/14651858.CD008736.pub2.www.cochranelibrary.com
155
University of Ghana http://ugspace.ug.edu.gh
Goto, H., & Lindoso, J. (2010a). Current diagnosis and treatment of cutaneous and
mucocutaneous leishmaniasis. Expert Review of Anti-Infective Therapy, 8(May), 419–433.
https://doi.org/10.1586/eri.10.19
Goto, H., & Lindoso, J. A. L. (2010b). Current diagnosis and treatment of cutaneous and
mucocutaneous leishmaniasis. Expert Review of Anti-Infective Therapy, 8(4), 419–433.
https://doi.org/10.1586/eri.10.19
Grabowsky, M., Nobiya, T., & Selanikio, J. (2007). Sustained high coverage of insecticide-
treated bednets through combined Catch-up and Keep-up strategies. Tropical Medicine and
International Health, 12(7), 815–822. https://doi.org/10.1111/j.1365-3156.2007.01862.x
Gunay, F., Karakus, M., Oguz, G., Dogan, M., Karakaya, Y., Ergan, G., Kaynas, S., Kasap, O.
E., Ozbel, Y., & Alten, B. (2014). Evaluation of the efficacy of Olyset® Plus in a village-
based cohort study in the Cukurova Plain, Turkey, in an area of hyperendemic cutaneous
leishmaniasis. Journal of Vector Ecology : Journal of the Society for Vector Ecology, 39(2),
395–405. https://doi.org/10.1111/jvec.12115
Hailu, T. (2016). One health approach prospect for integrated control and elimination of visceral
leishmaniasis in Ethiopia: A narrative review article. Iranian Journal of Parasitology,
11(1), 1–9. https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84961793535&partnerID=40&md5=f254174ca204b08cf2c420da7ce2ab13
Hakizimana, E., Cyubahiro, B., Rukundo, A., Kabayiza, A., Mutabazi, A., Beach, R., Patel, R.,
Tongren, J. E., & Karema, C. (2014). Monitoring long-lasting insecticidal net (LLIN)
durability to validate net serviceable life assumptions, in Rwanda. Malaria Journal, 13(1),
1–8. https://doi.org/10.1186/1475-2875-13-344
Haldar, A. K., Sen, P., & Roy, S. (2011). Use of Antimony in the Treatment of Leishmaniasis:
Current Status and Future Directions. Molecular Biology International, 2011, 1–23.
https://doi.org/10.4061/2011/571242
Hay, R., & Asiedu, K. (2018). Skin-Related Neglected Tropical Diseases (Skin NTDs)—A New
Challenge. Tropical Medicine and Infectious Disease, 4(1), 4.
https://doi.org/10.3390/tropicalmed4010004
Hazavehei, S. M. M., Heshmati, H., Hasanzadeh, A., Pourmazar, S. A., & Maghsoodlou, D.
(n.d.). The Effect of Volunteer Health Workers Educational Program on the Basis of
BASNEF Model on Promotion of Their Practices about Cutaneous Leishmaniasis. 16–21.
Hodiamont, C. J., Kager, P. A., Bart, A., de Vries, H. J. C., van Thiel, P. P. A. M., Leenstra, T.,
de Vries, P. J., van Vugt, M., Grobusch, M. P., & van Gool, T. (2014). Species-Directed
Therapy for Leishmaniasis in Returning Travellers: A Comprehensive Guide. PLoS
Neglected Tropical Diseases, 8(5). https://doi.org/10.1371/journal.pntd.0002832
Jalouk, L., Al Ahmed, M., Gradoni, L., & Maroli, M. (2007). Insecticide-treated bednets to
prevent anthroponotic cutaneous leishmaniasis in Aleppo Governorate, Syria: results from
two trials. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(4),
360–367. https://doi.org/10.1016/j.trstmh.2006.07.011
156
University of Ghana http://ugspace.ug.edu.gh
Kar, K. (1995). Serodiagnosis of Leishmaniasis. Critical Reviews in Microbiology, 21(2), 123–
152. https://doi.org/10.3109/10408419509113537
Kayedi, M. H., Rassi, Y., Chegeni-Sharafi, A., Rostami, R., Rafizadeh, S., & Abdali, N. (2017).
Control of cutaneous leishmaniasis using deltamethrin treated nets in comparison to indoors
residual spraying in a rural area of Iran. Iranian Journal of Public Health, 46(6), 835–842.
Kebede, N., Worku, A., Ali, A., Animut, A., Negash, Y., Gebreyes, W. A., & Satoskar, A.
(2016). Community knowledge, attitude and practice towards cutaneous leishmaniasis
endemic area Ochello, Gamo Gofa Zone, South Ethiopia. Asian Pacific Journal of Tropical
Biomedicine, 6(7), 562–567. https://doi.org/10.1016/j.apjtb.2016.01.018
Kenubih, A., Dagnachew, S., Almaw, G., Abebe, T., Takele, Y., Hailu, A., & Lemma, W.
(2015). Preliminary survey of domestic animal visceral leishmaniasis and risk factors in
north-west Ethiopia. Tropical Medicine and International Health, 20(2), 205–210.
https://doi.org/10.1111/tmi.12418
Khatami, A., Emmelin, M., Talaee, R., Mohammadi, A. M., Aghazadeh, N., Firooz, A., &
Stenberg, B. (2018). Lived experiences of patients suffering from acute Old World
Cutaneous Leishmaniasis: A qualitative content analysis study from Iran. Journal of
Arthropod-Borne Diseases, 12(2), 180–195. https://doi.org/10.18502/jad.v12i2.44
Khosravani poor Hojatollah, Ghavam Abbas, Y. panah A. (2016). The impact of factors related
to preventive behaviors of Cutaneous Leishmaniasis among Families of Kherameh 2015.
Pars Journal of Medical Sciences, 14(1), 59–65.
Kilian, A., Balayo, C., Feldman, M., Koenker, H., Lokko, K., Ashton, R. A., Bruce, J., Lynch,
M., & Boulay, M. (2015). The effect of single or repeated home visits on the hanging and
use of insecticide-Treated mosquito nets following a mass distribution campaign - A cluster
randomized, controlled trial. PLoS ONE, 10(3), 1–21.
https://doi.org/10.1371/journal.pone.0119078
Kilian, A., Lawford, H., Ujuju, C. N., Abeku, T. A., Nwokolo, E., Okoh, F., & Baba, E. (2016).
The impact of behaviour change communication on the use of insecticide treated nets: A
secondary analysis of ten post-campaign surveys from Nigeria. Malaria Journal, 15(1), 1–
16. https://doi.org/10.1186/s12936-016-1463-7
Kilian, A., Wijayanandana, N., Ssekitoleeko, J., Killian, A., & Org, K. (2009). Review of
delivery strategies for insecticide treated mosquito nets – are we ready for the next phase of
malaria control efforts? TropIKA, 1–28. http://journal.tropika.net
Killeen, G. F., Smith, T. A., Ferguson, H. M., Mshinda, H., Abdulla, S., Lengeler, C., & Kachur,
S. P. (2007). Preventing Childhood Malaria in Africa by Protecting Adults from Mosquitoes
with Insecticide-Treated Nets. PLOS Medicine, 4(7), e229.
https://doi.org/10.1371/journal.pmed.0040229
Kimbi, H. K., Nkesa, S. B., Ndamukong-Nyanga, J. L., Sumbele, I. U. N., Atashili, J., & Atanga,
M. B. S. (2014). Socio-demographic factors influencing the ownership and utilization of
insecticide-treated bed nets among malaria vulnerable groups in the Buea Health District,
Cameroon. BMC Research Notes, 7, 624. https://doi.org/10.1186/1756-0500-7-624
157
University of Ghana http://ugspace.ug.edu.gh
Kone, A. K., Sa, D., Thera, M. A., Kayentao, K., Djimde, A., Delaunay, P., Kouriba, B.,
Giudice, P., Izri, A., Marty, P., & Doumbo, O. K. (2016). Epidemiology of the outbreak,
vectors and reservoirs of cutaneous leishmaniasis in Mali: A systematic review and meta-
analysis. Asian Pacific Journal of Tropical Medicine, 9(10), 985–990.
https://doi.org/10.1016/j.apjtm.2016.07.025
Kwakye-nuako, G. (2016). Investigation of a New Focus of Cutaneous Leishmaniasis in Ghana
By.
Kwakye-Nuako, G., Mosore, M. T., Duplessis, C., Bates, M. D., Puplampu, N., Mensah-Attipoe,
I., Desewu, K., Afegbe, G., Asmah, R. H., Jamjoom, M. B., Ayeh-Kumi, P. F., Boakye, D.
A., & Bates, P. A. (2015). First isolation of a new species of Leishmania responsible for
human cutaneous leishmaniasis in Ghana and classification in the Leishmania enriettii
complex. International Journal for Parasitology, 45(11), 679–684.
https://doi.org/10.1016/j.ijpara.2015.05.001
Kweku, M. A., Odoom, S., Puplampu, N., Desewu, K., Nuako, G. K., Gyan, B., Raczniak, G.,
Kronmann, K. C., Koram, K., Botero, S., Boakye, D., & Akuffo, H. (2011). An outbreak of
suspected cutaneous leishmaniasis in Ghana: lessons learnt and preparation for future
outbreaks. Global Health Action, 4, 1–9. https://doi.org/10.3402/gha.v4i0.5527
Kweku, M., Webster, J., Taylor, I., Burns, S., & Dedzo, M. (2007). Public-private delivery of
insecticide-treated nets: a voucher scheme in Volta Region, Ghana. Malaria Journal, 6, 14.
https://doi.org/10.1186/1475-2875-6-14
Landau, L. (2008). Leishmaniasis in Ghana. Ghana Medical Journal, 2005–2007.
http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:No+Title#0
Larsen, D. A., Keating, J., Miller, J., Bennett, A., Changufu, C., Katebe, C., & Eisele, T. P.
(2010). Barriers to insecticide-treated mosquito net possession 2 years after a mass free
distribution campaign in luangwa district, Zambia. PLoS ONE, 5(11).
https://doi.org/10.1371/journal.pone.0013129
Liu, H., Xu, J., Guo, X., Havumaki, J., Lin, Y., Yu, G., & Zhou, D. (2015). Coverage, use and
maintenance of bed nets and related influence factors in Kachin Special Region II,
northeastern Myanmar. Malaria Journal, 14(1), 212. https://doi.org/10.1186/s12936-015-
0727-y
Lysenko, A. J. (1971). Distribution of leishmaniasis in the Old World. Bulletin of the World
Health Organization, 44(4), 515–520.
Maia, C., & Depaquit, J. (2016). Can Sergentomyia (Diptera, Psychodidae) play a role in the
transmission of mammal-infecting Leishmania? Parasite (Paris, France), 23, 55.
https://doi.org/10.1051/parasite/2016062
Manzur, A., & Bari, A. (2016). Sensitivity of leishmanin skin test in patients of acute cutaneous
leishmaniasis. 9–11.
Marks, M., Goncalves, A., Vahi, V., Sokana, O., Puiahi, E., Zhang, Z., Dalipanda, T., Bottomley,
C., Mabey, D., & Solomon, A. W. (2014). Evaluation of a Rapid Diagnostic Test for Yaws
158
University of Ghana http://ugspace.ug.edu.gh
Infection in a Community Surveillance Setting. 8(9), 1–5.
https://doi.org/10.1371/journal.pntd.0003156
Marks, M., Yin, Y., Chen, X., Castro, A., Causer, L., Guy, R., Wangnapi, R., Mitjà, O., & Aziz,
A. (2020). Metaanalysis of the Performance of a Combined Treponemal and
Nontreponemal Rapid Diagnostic Test for Syphilis and Yaws. 63, 627–633.
https://doi.org/10.1093/cid/ciw348
Maroli, M., Feliciangeli, M. D., Bichaud, L., Charrel, R. N., & Gradoni, L. (2013). Phlebotomine
sandflies and the spreading of leishmaniases and other diseases of public health concern.
Medical and Veterinary Entomology, 27(2), 123–147. https://doi.org/10.1111/j.1365-
2915.2012.01034.x
Masmoudi, A., Hariz, W., Marrekchi, S., Amouri, M., & Turki, H. (2013). Old World cutaneous
leishmaniasis: Diagnosis and treatment. Journal of Dermatological Case Reports, 7(2), 31–
41. https://doi.org/10.3315/jdcr.2013.1135
Maxwell, C. A., Msuya, E., Sudi, M., Njunwa, K. J., Carneiro, I. A., & Curtis, C. F. (2002).
Effect of community-wide use of insecticide-treated nets for 3-4 years on malarial
morbidity in Tanzania. Tropical Medicine and International Health, 7(12), 1003–1008.
https://doi.org/10.1046/j.1365-3156.2002.00966.x
May-boucher, P. L. E., & Tenikue, M. (2015). Increasing anti-malaria bednets uptake using
information and distribution strategies. October.
Menezes, J. A., Ferreira, E. de C., Andrade-Filho, J. D., de Sousa, A. M., Morais, M. H. G.,
Rocha, A. M. S., Machado-Coelho, G. L. L., Lima, F. P., Madureira, A. P., Garcia, T. C.,
Freitas, C. R., Soares, R. P., & Margonari, C. (2015). An Integrated Approach Using Spatial
Analysis to Study the Risk Factors for Leishmaniasis in Area of Recent Transmission.
BioMed Research International, 2015(Cl), 621854. https://doi.org/10.1155/2015/621854
Mitropoulos, P., Konidas, P., & Durkin-Konidas, M. (2010). New World cutaneous
leishmaniasis: Updated review of current and future diagnosis and treatment. Journal of the
American Academy of Dermatology, 63(2), 309–322.
https://doi.org/10.1016/j.jaad.2009.06.088
Mondal, D., Das, M. L., Kumar, V., Huda, M. M., Das, P., Ghosh, D., Priyanka, J.,
Matlashewski, G., Kroeger, A., Upfill-Brown, A., & Chowdhury, R. (2016). Efficacy,
Safety and Cost of Insecticide Treated Wall Lining, Insecticide Treated Bed Nets and
Indoor Wall Wash with Lime for Visceral Leishmaniasis Vector Control in the Indian Sub-
continent: A Multi-country Cluster Randomized Controlled Trial. PLoS Neglected Tropical
Diseases, 10(8), 1–15. https://doi.org/10.1371/journal.pntd.0004932
Monroy-Ostria, A., Nasereddin, A., Monteon, V. M., Guzmán-Bracho, C., & Jaffe, C. L. (2014).
ITS1 PCR-RFLP diagnosis and characterization of leishmania in clinical samples and
strains from cases of human cutaneous leishmaniasis in states of the Mexican Southeast.
Interdisciplinary Perspectives on Infectious Diseases, 2014.
https://doi.org/10.1155/2014/607287
Moon, T. D., Hayes, C. B., Blevins, M., Lopez, M. L., Green, A. F., González-Calvo, L., &
159
University of Ghana http://ugspace.ug.edu.gh
Olupona, O. (2016). Factors associated with the use of mosquito bed nets: Results from two
cross-sectional household surveys in Zambézia Province, Mozambique. Malaria Journal,
15(1), 1–10. https://doi.org/10.1186/s12936-016-1250-5
Moosa-Kazemi, Seyed-Hassan;Yaghoobi-Ershadi, Mohammad-Reza;Akhavan, Amir-
Ahmad;Abdoli, Hamid; Zahraei-Ramazani, Ali-Reza; Jafari, Reza; Houshmand,
Badakhshan; Nadim, Abolhassan; Hosseini, M. (2007). Deltamethrin-impregnated bed nets
and curtains in an anthroponotic cutaneous leishmaniasis control program in northeastern
Iran. Annals of Saudi Medicine, 27(February), 6–12.
Müller, N., Welle, M., Lobsiger, L., Stoffel, M. H., Kühni Boghenbor, K., & Hilbe, M. (2009).
Occurrence of Leishmania sp. in cutaneous lesions of horses in Central Europe. Vet
Parasitol, 166. https://doi.org/10.1016/j.vetpar.2009.09.001
Mutinga, M. J., Massamba, N. N., Basimike, M., Kamau, C. C., Amimo, F. A., Onyido, A. E.,
Omogo, D. M., Kyai, F. M., & Wachira, D. W. (1994). Cutaneous leishmaniasis in Kenya:
Sergentomyia garnhami (Diptera Psychodidae), a possible vector of Leishmania major in
Kitui District: a new focus of the disease. East African Medical Journal, 71(7), 424–428.
Ngwibete, B. A., & James, O. (2016). Attitudes Toward Utilization Of Insecticide-Treated Bed
Nets Among Pregnant Women And Care-Takers Of Under-Five. Infection Control.Tips.
Ntuku, H. M., Ruckstuhl, L., Julo-Réminiac, J.-E., Umesumbu, S. E., Bokota, A., Tshefu, A. K.,
& Lengeler, C. (2017). Long-lasting insecticidal net (LLIN) ownership, use and cost of
implementation after a mass distribution campaign in Kasaï Occidental Province,
Democratic Republic of Congo. Malaria Journal, 16(1), 22. https://doi.org/10.1186/s12936-
016-1671-1
Nyavor, Kunche Delali; Kweku, Margaret; Agbemafle, Isaac; Takramah, Wisdom; Norman,
Ishmael;Tarkang, Elvis; Binka, F. (2017). Assessing the ownership, usage and knowledge
of Insecticide Treated Nets ( ITNs ) in Malaria Prevention in the Hohoe Municipality ,
Ghana. Pan African Medical Journal, 8688, 1–8.
https://doi.org/10.11604/pamj.2017.28.67.9934
Nzelu, C. O., Kato, H., Puplampu, N., Desewu, K., Odoom, S., Wilson, M. D., Sakurai, T.,
Katakura, K., & Boakye, D. A. (2014a). First Detection of Leishmania tropica DNA and
Trypanosoma Species in Sergentomyia Sand Flies (Diptera: Psychodidae) from an Outbreak
Area of Cutaneous Leishmaniasis in Ghana. PLoS Neglected Tropical Diseases, 23580424,
1–10. https://doi.org/10.1371/journal.pntd.0002630
Nzelu, C. O., Kato, H., Puplampu, N., Desewu, K., Odoom, S., Wilson, M. D., Sakurai, T.,
Katakura, K., & Boakye, D. A. (2014b). First Detection of Leishmania
tropica DNA and Trypanosoma Species in
Sergentomyia Sand Flies (Diptera: Psychodidae) from an Outbreak Area of
Cutaneous Leishmaniasis in Ghana. PLoS Negl Trop Dis, 8(2), e2630.
http://dx.doi.org/10.1371%2Fjournal.pntd.0002630
Oliveira, F., Doumbia, S., Anderson, J. M., Faye, O., Diarra, S. S., Traoré, P., Cisse, M., Camara,
G., Tall, K., Coulibaly, C. A., Samake, S., Sissoko, I., Traoré, B., Diallo, D., Keita, S.,
Fairhurst, R. M., Valenzuela, J. G., & Kamhawi, S. (2009). Discrepant prevalence and
160
University of Ghana http://ugspace.ug.edu.gh
incidence of Leishmania infection between two neighboring villages in Central Mali based
on leishmanin skin test surveys. PLoS Neglected Tropical Diseases, 3(12).
https://doi.org/10.1371/journal.pntd.0000565
Olliaro, P., Vaillant, M., Arana, B., Grogl, M., Modabber, F., Magill, A., Lapujade, O., Buffet,
P., & Alvar, J. (2013). Methodology of Clinical Trials Aimed at Assessing Interventions for
Cutaneous Leishmaniasis. PLoS Neglected Tropical Diseases, 7(3).
https://doi.org/10.1371/journal.pntd.0002130
Oriol Mitjà, Kingsley Asiedu, D. M. (2013). Yaws. Lancet, 381, 763–773.
https://doi.org/10.1177/0956462414549036
Oryan, A. (2014). Risk Factors Associated With Leishmaniasis. Tropical Medicine & Surgery,
02(03), 10–11. https://doi.org/10.4172/2329-9088.1000e118
Oryan, A., & Akbari, M. (2016). Worldwide risk factors in leishmaniasis. Asian Pacific Journal
of Tropical Medicine, 9(10), 925–932. https://doi.org/10.1016/j.apjtm.2016.06.021
Oryan, A., Alidadi, S., & Akbari, M. (2014). Risk Factors Associated With Leishmaniasis.
Tropical Medicine and Surgery, 2(3), 10–11. https://doi.org/10.4172/2329-9088.1000e118
Pace, D. (2014). Leishmaniasis. Journal of Infection, 69(S1), S10–S18.
https://doi.org/10.1016/j.jinf.2014.07.016
Pagheh, A., Fakhar, M., Mesgarian, F., Gholami, S., & Ahmadpour, E. (2014). An improved
microculture method for diagnosis of cutaneous leishmaniasis. Journal of Parasitic
Diseases, 38(4), 347–351. https://doi.org/10.1007/s12639-013-0316-3
Palumbo, E. (2009). Current treatment for cutaneous leishmaniasis: a review. American Journal
of Therapeutics, 16(2), 178–182. https://doi.org/10.1097/MJT.0b013e3181822e90
Parvizi, P., & Amirkhani, A. (2008). Mitochondrial DNA characterization of Sergentomyia
sintoni populations and finding mammalian Leishmania infections in this sandfly by using
ITS-rDNA gene. Iranian Journal of Veterinary Research, 9(1), 9–18.
Peabody, Taguiwalo, Robalino, F. (2006). Disease Control Priorities in Developing Countries
2nd edition. Disease Control Priorities in Developing Countries 2nd Edition, 1293–1307.
https://doi.org/10.1596/978-0-8213-6179- 5
Pedrosa, F. de A., & Ximenes, R. A. de A. (2009). Sociodemographic and environmental risk
factors for American cutaneous leishmaniasis (ACL) in the State of Alagoas, Brazil. The
American Journal of Tropical Medicine and Hygiene, 81(2), 195–201.
Picado, A., Das, M. L., Kumar, V., Kesari, S., Dinesh, D. S., Roy, L., Rijal, S., Das, P.,
Rowland, M., Sundar, S., Coosemans, M., Boelaert, M., & Davies, C. R. (2010). Effect of
village-wide use of long-lasting insecticidal nets on visceral Leishmaniasis vectors in India
and Nepal: A cluster randomized trial. PLoS Neglected Tropical Diseases, 4(1).
https://doi.org/10.1371/journal.pntd.0000587
Picado, A., Ostyn, B., Rijal, S., Sundar, S., Singh, S. P., Chappuis, F., Das, M. L., Khanal, B.,
Gidwani, K., Hasker, E., Dujardin, J. C., Vanlerberghe, V., Menten, J., Coosemans, M., &
161
University of Ghana http://ugspace.ug.edu.gh
Boelaert, M. (2015). Long-lasting Insecticidal Nets to Prevent Visceral Leishmaniasis in the
Indian Subcontinent; Methodological Lessons Learned from a Cluster Randomised
Controlled Trial. PLoS Neglected Tropical Diseases, 9(4), 4–11.
https://doi.org/10.1371/journal.pntd.0003597
Pinna, R. A., Silva-dos-santos, D., Perce-da-silva, D. S., Oliveira-ferreira, J., Villa-verde, D. M.
S., Luca, P. M. De, & Malchiodi, E. L. (2016). Malaria-Cutaneous Leishmaniasis Co-
infection : Influence on Disease Outcomes and Immune Response. Frontiers in
Microbiology, 7(June), 1–15. https://doi.org/10.3389/fmicb.2016.00982
Plaza, J. J. G., Hulak, N., Zhumadilov, Z., & Akilzhanova, A. (2016). Fever as an important
resource for infectious diseases research. Intractable and Rare Diseases Research, 5(2), 97–
102. https://doi.org/10.5582/irdr.2016.01009
Proctor, E. K., Powell, B. J., & McMillen, J. C. (2013). Implementation strategies:
recommendations for specifying and reporting. Implementation Science : IS, 8, 139.
https://doi.org/10.1186/1748-5908-8-139
Pulford, J., Hetzel, M. W., Bryant, M., Siba, P. M., & Mueller, I. (2011). Reported reasons for
not using a mosquito net when one is available: a review of the published literature. Malaria
Journal, 10(1), 83. https://doi.org/10.1186/1475-2875-10-83
Quinnell, R. J., & Courtenay, O. (2009). Transmission, reservoir hosts and control of zoonotic
visceral leishmaniasis. Parasitology, 136(14), 1915.
https://doi.org/10.1017/S0031182009991156
Raczniak, G., Villinski, J.T., Puplampu, N., Mechta, S., Klena, J.D., Felt, S., Abbassy, M.,
Hanafi, H., Hoel, D.F., Wilson, M., Boakye, D. (2008). Cutaneous leishmaniasis in the
Volta district of Ghana: An uncertain reservoir for focal disease outbreak. The Lybian
Journal of Infectious Diseases, 2(1), 26–30.
Ready, P. D. (2013). Biology of phlebotomine sand flies as vectors of disease agents. Annual
Review of Entomology, 58, 227–250. https://doi.org/10.1146/annurev-ento-120811-153557
Reis, L. D. C., De Brito, M. E. F., De Almeida, É. L., Félix, S. M., Medeiros, Â. C. R., Silva, C.
J., & Pereira, V. R. A. (2008). Clinical, epidemiological and laboratory aspects of patients
with American cutaneous leishmaniasis in the State of Pernambuco. Revista Da Sociedade
Brasileira de Medicina Tropical, 41(5), 439–443. https://doi.org/10.1590/S0037-
86822008000500001
Reithinger, Richard;Dujardin, Jean-Claude; Louzir, Hechmi; Pirmez, Claude; Alexander, Bruce;
Brooker, S. (2007). Cutaneous leishmaniasis. The Lancet, 146(3), 581–596.
https://doi.org/10.1016/j.annder.2019.02.002
Reithinger, R., & Dujardin, J. C. (2007). Molecular diagnosis of leishmaniasis: Current status
and future applications. Journal of Clinical Microbiology, 45(1), 21–25.
https://doi.org/10.1128/JCM.02029-06
Reithinger, R., Mohsen, M., & Leslie, T. (2010). Risk Factors for Anthroponotic Cutaneous
Leishmaniasis at the Household Level in Kabul , Afghanistan. PLoS Neglected Tropical
162
University of Ghana http://ugspace.ug.edu.gh
Diseases, 4(3), 1–8. https://doi.org/10.1371/journal.pntd.0000639
Reuss, S. M., Dunbar, M. D., Calderwood Mays, M. B., Owen, J. L., Mallicote, M. F., Archer, L.
L., & Wellehan, J. F. (2012). Autochtonous Leishmania siamensis in horse, Florida, USA.
Emerg Infect Dis, 18. https://doi.org/10.3201/eid1809.120184
Reyburn H, Ashford R, Mohsen M, Hewitt S, R. M. (2000). ITN against ACL in Afghanistan.
Trans R Soc Trop Med Hyg, 94(4), 361–366.
Roll Back Malaria. (2009). Guidelines for Core Population-Based Indicators. English.
http://www.rbm.who.int/toolbox/tool_GuidelinesForCorePopulationBasedIndicators.html
Rowland, T., Davidson, S. A., Kobylinski, K., Menses, C., & Rowton, E. (2015). Efficacy of
Permethrin Treated Bed Nets Against Leishmania major Infected Sand Flies. U.S. Army
Medical Department Journal, 10–15.
Ruoti, M., Oddone, R., Lampert, N., Orue, E., Miles, M. A., Alexander, N., Rehman, A. M.,
Njord, R., Shu, S., Brice, S., Sinclair, B., & Krentel, A. (2013). Mucocutaneous
leishmaniasis: knowledge, attitudes, and practices among paraguayan communities,
patients, and health professionals. J Trop Med, 2013, 538629.
https://doi.org/10.1155/2013/538629
Saberi, S., Zamani, A., Motamedi, N., Nilforoushzadeh, M. A., Jaffary, F., Rahimi, E., & Hejazi,
S. H. (2012). The Knowledge, Attitude, and Prevention Practices of Students Regarding
Cutaneous Leishmaniasis in the Hyperendemic Region of the Shahid Babaie Airbase.
Vector-Borne and Zoonotic Diseases, 12(4), 306–309.
https://doi.org/10.1089/vbz.2010.0259
Sadeghian, G., Ziaei, H., Bidabadi, L. S., & Nilforoushzadeh, M. A. (2013). Evaluation of
leishmanin skin test reaction in different variants of cutaneous leishmaniasis. Indian Journal
of Dermatology, 58(3), 239. https://doi.org/10.4103/0019-5154.110838
Saghafipour, A., Nejati, J., Mozaffari, E., & Rezaei, F. (2017). The Effectiveness of Education
Based on BASNEF Model on Promoting Preventive Behavior of Cutaneous Leishmaniasis
in Students. International Journal of Pediatrics, 5(42), 5125–5136.
https://doi.org/10.22038/ijp.2017.22373.1875
Samadoulougou, S., Pearcy, M., Yé, Y., & Kirakoya-Samadoulougou, F. (2017). Progress in
coverage of bed net ownership and use in Burkina Faso 2003–2014: evidence from
population-based surveys. Malaria Journal, 16(1), 302. https://doi.org/10.1186/s12936-017-
1946-1
Sarkari, B., Qasem, A., & Shafaf, M. R. (2014). Knowledge, attitude, and practices related to
cutaneous leishmaniasis in an endemic focus of cutaneous leishmaniasis, Southern Iran.
Asian Pacific Journal of Tropical Biomedicine, 4(7), 566–569.
https://doi.org/10.12980/APJTB.4.2014C744
Savoia, D. (2015). Recent updates and perspectives on leishmaniasis. Journal of Infection in
Developing Countries, 9(6), 588–596. https://doi.org/10.3855/jidc.6833
Seyoum, D., Speybroeck, N., Duchateau, L., Brandt, P., & Rosas-Aguirre, A. (2017). Long-
163
University of Ghana http://ugspace.ug.edu.gh
lasting insecticide net ownership, access and use in southwest Ethiopia: A community-based
cross-sectional study. International Journal of Environmental Research and Public Health,
14(11), 1–16. https://doi.org/10.3390/ijerph14111312
Sharma, U., & Singh, S. (2008). Insect vectors of Leishmania: Distribution, physiology and their
control. Journal of Vector Borne Diseases, 45(4), 255–272.
https://doi.org/10.1201/9781420088489.ch8
Steverding, D. (2017). The history of leishmaniasis. Parasites {&} Vectors, 10(1), 82.
https://doi.org/10.1186/s13071-017-2028-5
Stockdale, L., & Newton, R. (2013). A Review of Preventative Methods against Human
Leishmaniasis Infection. PLoS Neglected Tropical Diseases, 7(6), 1–15.
https://doi.org/10.1371/journal.pntd.0002278
Taslimi, Y., Sadeghipour, P., Habibzadeh, S., Mashayekhi, V., Mortazavi, H., Mü Ller, I., Lane,
M. E., Kropf, P., & Rafati, S. (2017). A novel non-invasive diagnostic sampling technique
for cutaneous leishmaniasis. 1–12. https://doi.org/10.1371/journal.pntd.0005750
Tayeh, A., Jalouk, L., & Al-Khiami, A. M. (1997). A Cutaneous Leishmaniasis Control Trial
Using Pyrethroid-Impregnated Bednets in Villages near Aleppo, Syria. In Who: Vol.
WHO/LEISH/.
Traore, B., Oliveira, F., Faye, O., Dicko, A., Coulibaly, A., Sissoko, I. M., Sibiry, S., Sogoba, N.,
Sangare, B., Coulibaly, Y. I., Traore, P., Traore, S. F., Anderson, M., Keita, S., Valenzuela,
J. G., Kamhawi, S., & Doumbia, S. (2016). Prevalence of Cutaneous Leishmaniasis in
Districts of High and Low Endemicity in Mali. PLoS Neglected Tropical Diseases, 10(11),
1–12. https://doi.org/10.1371/journal.pntd.0005141
Truppel, Jessé. Henrique., Otomura, Flavio., Teodoro, Ueslei., Massafera, Rubens., da Costa-
Ribeiro, Magda. Clara. Vieira., Catarino, Carolina. Motter., Dalagrana, Luana., Ferreira,
Maria. Eugênia. Moreira. Costa., Thomaz-Soccol, V. (2014). PLOS ONE : Can Equids Be a
Reservoir of Leishmania braziliensis in E ... PLoS ONE, 1–7.
https://doi.org/10.1371/journal.pone.0093731
Uribe-Restrepo, A., Cossio, A., Desai, M. M., Dávalos, D., & Castro, M. del M. (2018).
Interventions to treat cutaneous leishmaniasis in children: A systematic review. PLoS
Neglected Tropical Diseases, 12(12), 1–16. https://doi.org/10.1371/journal.pntd.0006986
Villinski, J. T., Klena, J. D., Abbassy, M., Hoel, D. F., Puplampu, N., Mechta, S., Boakye, D., &
Raczniak, G. (2008). Evidence for a new species of Leishmania associated with a focal
disease outbreak in Ghana. Diagnostic Microbiology and Infectious Disease, 60(3), 323–
327. https://doi.org/10.1016/j.diagmicrobio.2007.09.013
Wackwella, H., Ranasinghe, S., Wickremasinghe, R., Bandara, S., Sivanantharajah, S., Athauda,
I., Seneviratne, K., Navaratne, C., Matlashewski, G., Wickremasinghe, R., Munasinghe, A.,
Hulangamuwa, S., & Silva, O. (2013). Cross-Sectional Study to Assess Risk Factors for
Leishmaniasis in an Endemic Region in Sri Lanka. The American Journal of Tropical
Medicine and Hygiene, 89(4), 742–749. https://doi.org/10.4269/ajtmh.12-0640
164
University of Ghana http://ugspace.ug.edu.gh
Wanzira, H., Katamba, H., & Rubahika, D. (2016). Use of long-lasting insecticide-treated bed
nets in a population with universal coverage following a mass distribution campaign in
Uganda. Malaria Journal, 15(1), 311. https://doi.org/10.1186/s12936-016-1360-0
Weigle, K. A., Valderrama, L., Arias, A. L., Santrich, C., & Saravia, N. G. (1991). Leishmanin
skin test standardization and evaluation of safety, dose, storage, longevity of reaction and
sensitization. The American Journal of Tropical Medicine and Hygiene, 44(3), 260–271.
WHO/Department of Communicable Disease Prevention, C. and E. (1997). A cutaneous
leishmaniasis control trial using pyrethroid-impregnated bednets in villages near. Neglected
Tropical Diseases, May 1996, 1–2.
WHO. (2012). Accelerating Work To Overcome the Global Impact of Neglected Tropical
Diseases a Roadmap for Implementation.
WHO. (2016a). Leishmaniasis :The vector. The Vector, 1.
http://www.who.int/leishmaniasis/vector/en/
WHO. (2016b). World malaria report 2016. https://doi.org/10.4135/9781452276151.n221
WHO Global Malaria Programme. (2014a). WHO recommendations for achieving universal
coverage with long-lasting insecticidal nets in malaria control. Who, 2013(September 2013),
2013–2015.
http://www.who.int/malaria/publications/atoz/who_recommendations_universal_coverage_l
lins.pdf
WHO Global Malaria Programme. (2014b). WHO recommendations for achieving universal
coverage with long-lasting insecticidal nets in malaria control. October.
WHO, W. H. O. (2013). Sustaining the drive to overcome the global impact of neglected tropical
diseases. Second WHO Report on Neglected Tropical Diseases, 3.9, 67–71.
https://doi.org/10.1073/pnas.1415109111
Wilson, A. L., Boelaert, M., Kleinschmidt, I., Pinder, M., Scott, T. W., Tusting, L. S., &
Lindsay, S. W. (2015). Evidence-based vector control? Improving the quality of vector
control trials. Trends in Parasitology, 31(8), 380–390.
https://doi.org/10.1016/j.pt.2015.04.015
Wilson, A. L., Dhiman, R. C., Kitron, U., Scott, T. W., van den Berg, H., & Lindsay, S. W.
(2014). Benefit of Insecticide-Treated Nets, Curtains and Screening on Vector Borne
Diseases, Excluding Malaria: A Systematic Review and Meta-analysis. PLoS Neglected
Tropical Diseases, 8(10). https://doi.org/10.1371/journal.pntd.0003228
World Health Organization. (2009). Global Malaria Programme: Insecticide-Treated Mosquito
Nets. WHO Position Statement, 1–12. https://doi.org/10.1590/S0074-02762008005000009
World Health Organization. (2017a). Achieving and maintaining universal coverage with long-
lasting insecticidal nets for malaria control (Issue December).
http://apps.who.int/iris/bitstream/10665/259478/1/WHO-HTM-GMP-2017.20-
eng.pdf?ua=1
165
University of Ghana http://ugspace.ug.edu.gh
World Health Organization. (2017b). Malaria prevention works. In Malaria prevention works:
let‟s close the gap World Malaria Day 2017. https://doi.org/10.1024/1661-8157/a000672
World Health Organization. (2019a). World Malaria Report 2019.
World Health Organization, N. (2019b). Key facts (Issue March).
World Health Organization, N. (2019c). Promoting an integrated approach to enhance detection
of neglected tropical diseases of the skin (Issue March 2019).
Yadon, Z. E., Rodrigues, L. C., Davies, C. R., & Quigley, M. A. (2003). INDOOR AND
PERIDOMESTIC TRANSMISSION OF AMERICAN CUTANEOUS LEISHMANIASIS
IN NORTHWESTERN ARGENTINA : A RETROSPECTIVE CASE-CONTROL STUDY.
American Journal of Tropical Medicine and Hygiene, 68(5), 519–526.
Yaghoobi, M. R., Moosa, S. H., Zahraei, A. R., Jalai, A. R., Akhavan, A. A., Arandian, M. H.,
Abdoli, H., Houshmand, B., Nadim, A., & Hosseini, M. (2006). maniasis in a hyperendemic
area of Iran . S ANTÉ PUBLIQUE. 1, 43–48.
Yotsu, R. R. (2018). Integrated management of skin NTDs—lessons learned from existing
practice and field research. Tropical Medicine and Infectious Disease, 3(4).
https://doi.org/10.3390/tropicalmed3040120
Zeyrek, F. Y., Korkmaz, M., & Özbel, Y. (2007). Serodiagnosis of anthroponotic cutaneous
leishmaniasis (ACL) caused by Leishmania tropica in Sanliurfa Province, Turkey, where
ACL is highly endemic. Clinical and Vaccine Immunology, 14(11), 1409–1415.
https://doi.org/10.1128/CVI.00133-07
166
University of Ghana http://ugspace.ug.edu.gh
Appendix 1: ETHICAL CLEARANCE FOR THE STUDY
167
University of Ghana http://ugspace.ug.edu.gh
Appendix 2: Consent Form
TITLE: Leishmania infection and use of insecticide treated bed net in selected communities of Volta
region, Ghana –An implementation research
Principal Investigator: Mr. Richard Akuffo
School of Public Health, University of Ghana
Introduction: This consent form contains information about the research named above. In order to be
sure that you are informed about being in this research, please take the time to read this consent form.
You will also be asked to sign it or make your mark in front of a witness. A copy of the completed
consent form will be given to you. This consent form might contain some words that are unfamiliar to
you. Please ask for explanation of anything you may not understand.
General Information about the Research:
You are invited to participate in this research study titled, ―Leishmania infection and use of insecticide
treated bed net (ITN) in selected communities of Volta region, Ghana –An implementation research‖.
This study is part of a PhD research at the School of Public Health, University of Ghana and is sponsored
by the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health
Organization. Participation in this study is entirely voluntary. Before you decide to participate in this
study, please take as much time as you need to read this information sheet and to ask any questions you
may have about the study.
In the year 1999, there were some people from the Ho municipality who developed skin lesions (sores)
suspected to be cutaneous leishmaniasis. Samples from a few of the people who had developed such
lesions have been taken to identify the cause of the lesions. However, the magnitude of the lesions in the
municipality has not yet been well studied. As a result, this study is being conducted to investigate the
magnitude, distribution, as well as knowledge, attitudes and practices related to cutaneous leishmaniasis
in your community. Knowledge of this information will provide opportunity for us to investigate factors
which expose people to the infections which cause the lesions in your community. Subsequently, this
information will help health authorities in Ghana to protect people in the municipality against the
organism that causes the lesions.
Study Participants
You may participate in this study if you are between the ages of 2-65 years old, a permanent resident of
your community (resident for at least the past 12 months).
Study Procedures
If you agree to participate, we will ask of your age, ethnicity, profession and other basic questions about
your life and record your home location. We will perform a physical exam and take a brief medical
history.
If upon physical examination, we notice a lesion (sore), we will take a photograph of the sore.
Afterwards, we will take small skin sample from your sore. This will be done by scraping the sore and
using a thin needle to remove any fluid in the sore. This sample will be used for standard tests to find the
germ causing the sore. We will also perform a skin test called Leishmanin Skin Test or LST which
168
University of Ghana http://ugspace.ug.edu.gh
involves injection of the skin of your arm. Two days later, we will look for a bump at the injection site to
see if the skin reacts to the LST.
If your skin reacts to the LST, called LST positive, it means that you have already been naturally exposed
to the organism that causes the lesion. If your skin does not react to this test (called LST negative), it
means that you may have not been infected with the organism in the past.
Sand fly collection from homes
As part of this study, a random sample of households within your community shall be selected for sand
fly collections. If your household is selected, we shall place sand fly traps in your house including where
you sleep for 3 consecutive nights each month for 3 months. The traps do not contain any chemicals or
substances that could harm you. These traps use a small light to attract the sand flies. We may also put
traps near your animals if you have animals within your household. The sand flies will be trapped in a
container and held until our study team comes to remove the trap.
Risks/Discomforts: Performance of LST is associated with minimal discomfort. Although we will use
new needles that are very small to perform the skin test, this procedure may be slightly uncomfortable or
result in local skin irritation. In addition, fine needle aspirates (FNA) or skin scrapings of suspected CL
lesions may cause some discomfort and bleeding. After scraping, the small wound area will be covered
with an antiseptic ointment to avoid any risk of bacterial infection.
Potential Benefits: You may receive no direct benefit from participating in this study, but we may gain
knowledge about the distribution of cutaneous leishmaniasis (CL) in the Ho municipality which can help
Ghanaian health authorities to plan preventive measures against exposure to the organism that cause it..
Furthermore, if you are suspected to have CL upon screening, you will be directed to the nearest health
center for medical attention.
Alternatives to Participation: Participation in this study is completely voluntary, meaning you are free to
participate or not.
Confidentiality: Information provided by you or obtained from the LST will be strictly confidential. To
guard your identity, names will not be used on the data collection forms; only a research identification
number will be used. Findings from this study may be published, but we will never use your name or
identification information in any publication. The study staff and the ethics review committee may look at
your records obtained from this study. By agreeing to enroll in this study you give these people the right
to check your study records. However, they are required to keep any information provided by you or
others in this study private. Mr. Richard Akuffo from the School of Public Health, University of Ghana is
responsible for the long-term storage of the research records related to your participation in this study.
Compensation: There will be no compensation to you for being a part of this study.
Additional Cost: There will be no additional cost to you for participating in this study.
Future Use of Biological Materials: You will be asked if you will allow us to use any leftover specimens
for future testing or studies. Your/your child’s name will not be recorded on the sample and nobody will
know if it is yours/your child’s. If you do not want us to use these samples in the future you are free tell us
that you do not want any additional testing done. You/Your child may still participate in the study even if
you do not want any future testing on the samples you provide.
If You Have a Problem or Have Other Questions: You are encouraged to ask questions at any time
before and during the study. If you/your child have/has questions about this study, please contact Mr.
Richard Akuffo at +233-243834945 or richard.akuffo@gmail.com.
169
University of Ghana http://ugspace.ug.edu.gh
You may also contact Ghana Health Service Ethics Review Committee Administrator, Hannah Frimpong,
233 (0) 243235225 or 0507041223, Hannah.Frimpong@ghsmail.org
Participation Agreement: I have read the foregoing information, or it has been read to me. I have had
the opportunity to ask questions about it and any question I have asked have been answered to my
satisfaction. I consent voluntarily to participate in this study and understand that I have the right to
withdraw from the study at any time.
________________________________________________________ ____________________
Signature (or Thumbprint) of Participant (Parent or Legal Guardian) Date (DD/MM/YY)
I certify that the nature and purpose, the potential benefits, and possible risks associated with
participating in this research have been explained to the above individual.
____________________________________________________ ____________________
Printed Name and Signature of Person Who Obtained Consent Date (DD/MM/YY)
*If consent WAS provided, the patient will be enrolled in the study.
* If the patient did NOT consent to participate in the study, all study procedures must stop at this time.
Statement Regarding the Disposition of Biological Specimens: If you agree to participate in this
study and you have a skin lesion, we will take some specimen from your skin lesion. These samples will
be tested in Ghana at the Noguchi memorial institute for medical research (NMIMR) for the possible
cause of the lesions. The samples may be stored up to 10 years. If any sample remains after that time, it
will be destroyed. We are asking you to allow us to use any leftover specimens that we obtain today for
other laboratory tests in the future. Testing may be done to evaluate new ways to diagnose the skin
lesions. Before any future tests are carried out on any left-over samples, clearance will be obtained from
a recognized institutional review committee such as the Ghana Health Service (GHS) Ethical Review
Committee. We will not use these samples to perform any genetic testing. Your name will not be recorded
on the sample and nobody will know it is yours or your child’s. Because a name will not be recorded we
cannot provide you with the results of any future tests. If you do not want us to use these samples in the
future you are free to say that you do not want any additional testing done. You/your child may still
participate in the study even if you do not want any future testing done on the samples you provide.
Agreement Regarding the Disposition of Biological Specimens: I agree to allow NMIMR to store and
use any leftover samples taken today for laboratory tests in the future. I understand that no information
will be recorded that will identify those samples as belonging to me and I will not be notified of the results
of any future tests on these samples.
I wish I do not wish (to approve the storage of my sample for future research)
* If the patient does NOT authorize the use of biological material in future studies, the patient ID must
be recorded and all samples discarded after protocol procedures are complete.
170
University of Ghana http://ugspace.ug.edu.gh
St atement Regarding Child Assent:
For participants under the age of 18 years but greater than or equal to 5 years.
By making a mark or thumb printing below, it means that you understand and know the issues concerning
this research study. If you do not want to participate in this study, please do not sign this assent form. You
and your parents will be given a copy of this form after you have signed it.
This assent form which described the benefits, risks and procedures for the research titled “Leishmania
infection and use of insecticide treated bed net in selected communities of the Volta region, Ghana” has
been read and or explained to me. I have been given an opportunity to have any questions about the
research answered to my satisfaction. I agree to participate.
Age: Is the child between 5 and 18 years old? Yes No
Child’s Response to Participation: Yes No
Note: Any child whose age is greater than or equal to 5 years AND less than 18 years must
sign/thumbprint the space provided below.
Child’s Signature/Thumbprint _____________________________________ Date___________________
* If child assent WAS provided, the child will be enrolled in the study.
* If the child did NOT provide assent to participate in the study, all study procedures must stop at
this time.
171
University of Ghana http://ugspace.ug.edu.gh
Appendix 3: Individual case report
172
University of Ghana http://ugspace.ug.edu.gh
173
University of Ghana http://ugspace.ug.edu.gh
Appendix 4: Household Questionnaire
HOUSEHOLD QUESTIONNAIRE
HOUSEHOLD INFORMATION PANEL HH
HH1A. Cluster number: ___ ___ ___
HH2. Household number: __ __ __ | __ __ __
HH1B. Community name: ______________________
HH3. Interviewer name and number: HH4. Supervisor name and number:
Name _________________________ ___ ___ Name__________________________ ___ ___
HH5. Day / Month / Year of interview: ___ ___ / ___ ___ / ___ ___ ___ ___
HH6. Area: HH7. District: Ho ................................................... 1
Urban .............................................................. 1
Rural ............................................................... 2
Allow respondent to the Household Questionnaire enough time to read the household consent form or to
have it read to him/her before proceeding further with the questionnaire administration.
Is permission given?
Yes, permission is given Go to HH15 (on next page) to record the time and then begin the interview.
No, permission is not given Complete HH9. Discuss this result with your supervisor.
After all questionnaires for the household have been completed, fill in the following information:
HH8. Name of head of household: __________________________________________
HH9. Result of household interview:
Completed .................................................... 01 HH10. Respondent to household questionnaire:
No household member or no competent
respondent at home at time of visit ....... 02 Name: ____________________________________
Entire household absent for extended
period of time ....................................... 03 Line Number: ___ ___
Refused ........................................................ 04
Dwelling vacant / Address not a dwelling ....... 05
Dwelling destroyed ........................................ 06
Dwelling not found ........................................ 07 HH11. Total number of household
Other (specify) ________________________ 96 members: ___ ___
HH12. Number of women
HH13. Number of under-5s : ___ ___
age 15-49 years: ___ ___
Interview notes
174
University of Ghana http://ugspace.ug.edu.gh
HH14. Field edited by (name and number): ______________________________________ ___ ___
175
University of Ghana http://ugspace.ug.edu.gh
HOUSEHOLD LISTING FORM HL
HH15. FIRST, PLEASE TELL ME THE NAME OF EACH PERSON WHO USUALLY LIVES HERE, STARTING WITH THE HEAD OF THE HOUSEHOLD.
Record the time. List the head of the household in line 01. List names of all household members (HL2), their relationship to the household head (HL3), and their sex (HL4)
Then ask: ARE THERE ANY OTHERS WHO LIVE HERE, EVEN IF THEY ARE NOT AT HOME NOW?
Hours ........ __ __ If yes, complete listing for questions HL2-HL4. Then, ask questions starting with HL5 for each person at a time.
For household For
Minutes ..... __ __
members age Women children
15 and above age 15- under 5 For all household members
49 years of
age
HL1 HL2. HL3. HL4. HL5. HL6. HL7. HL8. HL9 HL10. HL11. HL12.
. Name WHAT IS IS WHAT IS (name)‟s HOW OLD WHAT IS WHAT IS WHERE WAS (name) BORN? FOR HOW MANY YEARS HAS (name)
Line THE (name) DATE OF BIRTH? IS (name)? (name)‟s (name)‟s LIVED IN THIS VILLAGE/ TOWN?
no. RELATION- MALE OR CURRENT NATIONALITY? Record zero if less than one year
SHIP OF FEMALE 98 DK 9998 DK MARITAL
(name) TO ? Record in STATUS?
THE HEAD Ensure that every completed Circle Circle
- 1 Married or OF HOUSE person less than 6 years. If line line IN THIS ELSEWHERE?
living together
HOLD? years of age has a age is 95 2 Divorced/ number number Insert VILLAGE
month and year of or above, separated if if child appropriate OR
birth record 3 Widowed woman is under nationality TOWN?
Insert village or town name
1 Male 4 Never married code and appropriate birthplace „95‟ is age 5 years
or lived code
15-49 of age
2 Female together
Line Name Relation M F MM Year Age Marital status 15-49 Under 5 Nationality Y N Village/Town Code Years
01 1 2 3 4 __ __ 1 2 0 1 1 2 _ _ __ __ __ __ __ __ 01 01 ________________| __ __ __ __
02 1 2 3 4 02 02 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ ________________| __ __ __ __
03 1 2 3 4 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ 03 03 ________________| __ __ __ __
04 1 2 3 4 04 04 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ ________________| __ __ __ __
05 1 2 3 4 1 2 05 05 __ __ 1 2 __ __ _ _ __ __ __ __ __ __ ________________| __ __ __ __
06 1 2 3 4 06 06 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ ________________| __ __ __ __
07 1 2 3 4 07 07 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ ________________| __ __ __ __
08 1 2 3 4 1 2 __ __ _ _ __ __ 08 08
__ __ 1 2
__ __ __ __ ________________| __ __ __ __
University of Ghana http://ugspace.ug.edu.gh
HL1 HL2. HL3. HL4. HL5. HL6. HL7. HL8. HL9 HL10. HL11. HL12.
. Name WHAT IS IS WHAT IS (name)‟s HOW OLD WHAT IS WHAT IS WHERE WAS (name) BORN? FOR HOW MANY YEARS HAS (name)
Line THE (name) DATE OF BIRTH? IS (name)? (name)‟s (name)‟s LIVED IN THIS VILLAGE/ TOWN?
no. RELATION- MALE OR CURRENT NATIONALITY? Record zero if less than one year
SHIP OF FEMALE 98 DK 9998 DK MARITAL
(name) TO ? Record in STATUS?
THE HEAD Ensure that every completed Circle Circle
1 Married or
OF HOUSE- person less than 6 years. If line line IN THIS ELSEWHERE?
living together
HOLD? years of age has a age is 95 2 Divorced/ number number Insert VILLAGE
month and year of or above, separated if if child appropriate OR
3 Widowed nationality TOWN? Insert village or town name birth record woman is under
1 Male „95‟ 4 Never married code
and appropriate birthplace
is age 5 years
or lived code
15-49 of age
2 Female together
Line Name Relation M F MM Year Age Marital status 15-49 Under 5 Nationality Y N Village/Town Code Years
09 1 2 3 4 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ 09 09 ________________| __ __ __ __
10 1 2 3 4 __ __ 1 2 1 2 __ __ _ _ __ __ __ __ __ __ 10 10 ________________| __ __ __ __
1 2 3 4 __ __ 11 1 2 1 2 1 2 3 8 __ __ _ _ __ __ __ __ __ __ 11 11 __ __ ________________| __ __ __ __
12 1 2 3 4 12 12 __ __ 1 2 1 2 1 2 3 8 __ __ _ _ __ __ __ __ __ __ __ __ ________________| __ __ __ __
13 1 2 3 4 __ __ 1 2 1 2 1 2 3 8 __ __ _ _ __ __ __ __ __ __ 13 13 __ __ ________________| __ __ __ __
14 1 2 3 4 14 14 __ __ 1 2 1 2 1 2 3 8 __ __ _ _ __ __ __ __ __ __ __ __ ________________| __ __ __ __
15 1 2 3 4 __ __ 1 2 1 2 1 2 3 8 __ __ _ _ __ __ __ __ __ __ 15 15 __ __ ________________| __ __ __ __
Tick here if additional questionnaire used
Probe for additional household members.
Probe especially for any infants or small children not listed, and others who may not be members of the family (such as servants, friends) but who usually live in the household.
* Codes for HL3: Relationship to head of household: .... Codes for HL10: Nationality Codes for HL11: Birthplace
University of Ghana http://ugspace.ug.edu.gh
01 Head 09 Brother-In-Law / Sister-In-Law 01 Ghanaian by birth 01 Western region 09 Upper East
02 Wife / Husband 10 Uncle / Aunt 02 Ghanaian by naturalisation 02 Central region 10 Upper West
03 Son / Daughter 11 Niece / Nephew 03 Dual nationality (Ghanaian & other) 03 Greater Accra 11 Africa
04 Son-In-Law / Daughter-In-Law 12 Other relative 04 African 04 Volta region 12 Europe
05 Grandchild 13 Adopted / Foster / Stepchild 05 European 05 Eastern region 13 Americas (North, South & Caribbean)
06 Parent 14 Not related 06 American (North, South & Caribbean 06 Ashanti region 14 Asia
07 Parent-In-Law 98 Don't know 07 Asian & Oceanian (incl. Australia & New Zealand) 07 Brong Ahafo region 15 Oceania
08 Brother / Sister 98 Don’t know 08 Northern region 98 Don’t know
University of Ghana http://ugspace.ug.edu.gh
RESIDENCE AND EDUCATION ED
For those 11years
For all household members For those 5 years of age and above
of age and above
ED1. ED2. ED3. ED4. ED5. ED6. ED7. ED8. ED9. ED10.
Name and age DID (name) DID (name) DOES (name) IN WHAT LANGUAGE HAS (name) DURING THE WHAT IS THE HIGHEST LEVEL OF DURING THIS SCHOOL YEAR,
Line STAY HERE LIVE HERE EXPECT TO CAN (name) READ EVER PRESENT SCHOOL (name) ATTENDED? WHICH LEVEL AND GRADE IS
no. Copy from Household Listing Form, LAST MOST OF THE LIVE HERE AND WRITE? ATTENDED SCHOOL YEAR, (name) ATTENDING?
WHAT IS HIGHEST GRADE (name)
HL2 and HL6 NIGHT? LAST 6 FOR MOST Code: SCHOOL OR DID (name)
COMPLETED AT THIS LEVEL? MONTHS? OF THE NEXT PRE- ATTEND 1 None (not literate) Level: Grade: Level: Grade
6 MONTHS? SCHOOL? SCHOOL OR 2 English only
PRESCHOOL AT 1 Yes 3 Ghanian only 0 Preschool 0 Preschool
1 Yes ANY TIME? 4 English & Ghanaian 1 Primary 1 Primary 2 NO 1 Yes
1 Yes ED10 2 Junior HS 2 N 5 English & French 98 DK
2 Junior HS 98 DK
2 NO O 3 Senior HS 3 Senior HS 6 Other language than 1 Yes 2 No ED9 8 DK 4 Higher 4 Higher Ghanaian, English
2 N 8 DK 8 DK or French O If less than 1
8 DK If level=0, skip grade, enter 00. If level=0, skip
Next to next line to next line
line
Line Name Age Yes No Yes No Yes No DK Literacy code Yes No Yes No Level Grade Level Grade
01 1 2 1 2 1 2 8 1 2 1ED10 2
Next Next
__ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
02 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
1 2 1 2 1 2 8 1 2 1ED10 2 Next Next 03 __ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
04 1 2 1 2 1 2 8 1 1 2 1ED10 2
Next Next
__ __ 2 3 4 5 6 8 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
05 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
06 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
1 2 1 2 1 2 8 Next Next 07 __ __ 1 2 3 4 5 6 8
1 2 1ED10 2
0 1 2 3 4 8 __ __ line 0 1 2 3 4 8 __ __ line
08 1 2 1 2 1 2 8 1 2 1ED10 2
Next Next
__ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ line 0 1 2 3 4 8 __ __ line
09 1 2 1 2 1 2 8 1 2 1ED10 2
Next Next
__ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ line 0 1 2 3 4 8 __ __ line
10 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ line 0 1 2 3 4 8 __ __ line
11 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ line 0 1 2 3 4 8 __ __ line
12 1 2 1 2 1 2 8 1 2 1ED10 2
Next Next
__ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
University of Ghana http://ugspace.ug.edu.gh
13 1 2 1 2 1 2 8 1 2 3 4 5 6 8 1 2 1ED10 2
Next Next
__ __ 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
14 1 2 1 2 1 2 8 1 2 1ED10 2
Next Next
__ __ 1 2 3 4 5 6 8 0 1 2 3 4 8 __ __ 0 1 2 3 4 8 line __ __ line
University of Ghana http://ugspace.ug.edu.gh
O
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
001 Does your household have any mosquito nets that can YES . . . . . . . . . . . . . . . . . . . . . . . 1....
be used while sleeping? NO . . . . . . . . . . . . . . . . . . . . . . . . . 2.... 136A
002 How many mosquito nets does your household have? NUMBER OF NETS
. . . . . . . . . . . . . .
IF 7 OR MORE NETS, RECORD '7'.
NET #1 NET #2 NET #3
003 ASK THE RESPONDENT TO OBSERVED OBSERVED OBSERVED
SHOW YOU ALL THE NETS IN HANGING . . . . . . . 1 HANGING . . . . . . . 1 HANGING . . . . . . . . . 1
OBSERVED OBSERVED OBSERVED
THE HOUSEHOLD NOT HANGING NOT HANGING NOT HANGING
OR PACKAGED . . . 2 OR PACKAGED . . . 2 OR PACKAGED . . . . . 2
IF MORE THAN 3 NETS, USE NOT OBSERVED . . 3 NOT OBSERVED . . 3 NOT OBSERVED . . . 3
ADDITIONAL QUESTIONNAIRE(S).
004 How many months ago did your MONTHS MONTHS MONTHS
household get the mosquito net? AGO . . . AGO . . . AGO . . .
IF LESS THAN ONE MONTH AGO, MORE THAN 36 MORE THAN 36 MORE THAN 36
RECORD '00'. MONTHS AGO . 95 MONTHS AGO . 95 MONTHS AGO . . 95
NOT SURE . . . . . . . 98 NOT SURE . . . . . . . 98 NOT SURE . . . . . . . . . 98
005 Where did you get this net? PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL/ GOVT. HOSPITAL/ GOVT. HOSPITAL/
POLYCLINIC . . . 11 POLYCLINIC . . . 11 POLYCLINIC . . . . . 11
181
University of Ghana http://ugspace.ug.edu.gh
GOVT. HEALTH GOVT. HEALTH GOVT. HEALTH
CENTE . . . . . . . 12 CENTER . . . . . . . 12 CENTE . . . . . . . . . 12
GOVT. HEALTH GOVT. HEALTH GOVT. HEALTH
POST/CHPS . . . 13 POST/CHPS . . . 13 POST/CHPS . . . . . 13
FIELDWORKER/ FIELDWORKER/ FIELDWORKER/
OUTREACH/ PEER OUTREACH/ PEER OUTREACH/ PEER
EDUCATOR . . . . . 14 EDUCATOR . . . . . 14 EDUCATOR . . . . . . . 14
CAMPAIGN . . . . . 15 CAMPAIGN . . . . . 15 CAMPAIGN . . . . . . . 15
OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC
16 16 16
(SPECIFY) (SPECIFY) (SPECIFY)
PRIVATE MEDICAL PRIVATE MEDICAL PRIVATE MEDICAL
SECTOR SECTOR SECTOR
PRIVATE HOSPITAL/ PRIVATE HOSPITAL PRIVATE HOSPITAL/
CLINIC . . . . . . . 21 CLINIC . . . . . . . 21 CLINIC . . . . . . . . . 21
PHARMACY/CHEMICAL/ PHARMACY/CHEMICAL/ PHARMACY/CHEMICAL/
DRUG STORE . . . 22 DRUG STORE . . . 22 DRUG STORE . . . . . 22
OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE
MEDICAL MEDICAL MEDICAL
26 26 26
(SPECIFY) (SPECIFY) (SPECIFY)
OTHER SOURCE OTHER SOURCE OTHER SOURCE
NGO/CBAs . . . . . 31 NGO/CBAs . . . . . 31 NGO/CBAs . . . . . . . 31
SHOP/MARKET . . . 32 SHOP/MARKET . . . 32 SHOP/MARKET . . . . . 32
STREET VENDOR . 33 STREET VENDOR . 33 STREET VENDOR . . 33
PETROL STATION/ PETROL STATION/ PETROL STATION/
MOBILE MART . . . 34 MOBILE MART . . . 34 MOBILE MART . . . . . 34
PRIMARY SCHOO . 35 PRIMARY SCHOO . 35 PRIMARY SCHOOL . . 35
OTHER 36 OTHER 36 OTHER 36
(SPECIFY) (SPECIFY) (SPECIFY)
DON’T KNOW . . . 98 DON’T KNOW . . . 98 DON’T KNOW . . . . . 98
182
University of Ghana http://ugspace.ug.edu.gh
NET #1 NET #2 NET #3
How much did it cost you to
006 obtain COST IN CEDIS COST IN CEDIS COST IN CEDIS
this net?
. . .
RECORD '00.00' IF FREE
DON’T KNOW . . DON’T KNOW . . DON’T KNOW . .
OF CHARGE. . 9998 . 9998 . 9998
OBSERVE OR ASK THE
007 BRAND/ LONG-LASTING LONG-LASTING LONG-LASTING
TYPE OF MOSQUITO NET. INSECTICIDE- INSECTICIDE- INSECTICIDE-
TREATED NET TREATED NET TREATED NET
(LLIN) (LLIN) (LLIN)
OLYSET 10 OLYSET OLYSET
IF BRAND IS UNKNOWN AND . . . . . . . . . . . . . . 10 . . . . . . . . . 10
YOU CANNOT OBSERVE THE PERMANET . . . 11 PERMANET . . . 11 PERMANET . . . . . 11
NET, SHOW PICTURES OF INTERCEPTOR . 12 INTERCEPTOR . 12 INTERCEPTOR . . 12
TYPICAL NET TYPES/BRANDS NETPROTECT . 13 NETPROTECT . 13 NETPROTECT . . 13
DURANET DURANET
. . . . .
. .
TO RESPONDENT. 14 DURANET . . . . . 14 . . . . . 14
LIFE NET
LIFE NET . . . . . .
. 15 LIFE NET . . . . . 15 . . . . . 15
DAWA PLUS
. .
DAWA PLUS . . . 16 DAWA PLUS . . . 16 . . . 16
MAGNET MAGNET
. . . . . . .
. .
MAGNET . . . . . 17 17 . . . . . 17
YORKOOL YORKOOL
. . . . . 18 YORKOOL . . . . . 18 . . . . . 18
. .
183
University of Ghana http://ugspace.ug.edu.gh
OTHER/ OTHER/ OTHER/
DK BRAND DK BRAND DK BRAND
. . .
. . .
19 . . 19 . . . 19
(SKIP TO (SKIP TO
134) (SKIP TO 134) 134)
'PRETREATED' 'PRETREATED'
NET NET 'PRETREATED' NET
OTHER/ OTHER/ OTHER/
DK BRAND . .
DK BRAND . . . 26 DK BRAND . . . 26 . . . 26
(SKIP TO (SKIP TO
134) (SKIP TO 134) 134)
OTHER OTHER OTHER
LOCALLY SEWN LOCALLY SEWN LOCALLY SEWN
NETS . . . . . . . . . 31 NETS . . . . . . . . . 31 NETS . . . . . . . . . . . 31
OTHER BRAND . OTHER BRAND .
OTHER BRAND . . . 96 . . 96 . . . . 96
DK BRAND . . . . . . DK BRAND . . . . . . . .
. 98 DK BRAND . . . . . . . 98 . 98
YES . . . . . . . . .
008 When you got the net, was it YES . . . . . . . . . . . 1 . . 1 YES . . . . . . . . . . . . . 1
already treated with an NO . . . . . . . . . . . . . .
insecticide NO . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . 2 . 2
NOT SURE . . . . . . NOT SURE . . . . . . . .
to kill or repel mosquitoes? . 8 NOT SURE . . . . . . . 8 . 8
YES . . . . . . . . .
009 Did anyone sleep under this YES . . . . . . . . . . . 1 . . 1 YES . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . .
mosquito net last night? NO . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . 2 . 2
(SKIP TO (SKIP TO (SKIP TO
136) 136) 136)
NOT SURE . . . . . . NOT SURE . . . . . . . .
. 8 NOT SURE . . . . . . . 8 . 8
NET #1 NET #2 NET #3
184
University of Ghana http://ugspace.ug.edu.gh
010 Who slept under this mosquito net
last night?
NAME_____________ NAME_____________ NAME_____________
RECORD THE PERSON'S NAME
AND LINE NUMBER FROM THE LINE LINE LINE
HOUSEHOLD SCHEDULE. NO. . . . . . NO. . . . . . NO. . . . . .
NAME_____________ NAME_____________ NAME_____________
LINE LINE LINE
NO. . . . . . NO. . . . . . NO. . . . . .
NAME_____________ NAME_____________ NAME_____________
LINE LINE LINE
NO. . . . . . NO. . . . . . NO. . . . . .
NAME_____________ NAME_____________ NAME_____________
LINE LINE LINE
NO. . . . . . NO. . . . . . NO. . . . . .
011 GO BACK TO 010 FOR GO BACK TO 010 FOR GO TO 010 IN FIRST
NEXT NET; OR, IF NO NEXT NET; OR, IF NO COLUMN OF A NEW
MORE NETS, MORE NETS, QUESTIONNAIRE;
GO TO 012A. GO TO 012A. OR, IF NO MORE
NETS, GO TO 012A.
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
185
University of Ghana http://ugspace.ug.edu.gh
012A During the last 12 months has any member of your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
household disposed of any treated net? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
(SKIP TO 136E)
012B How did you dispose of your last treated mosquito net? BURNED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BURIED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
GARBAGE OR REFUSE DUMP . . . . . . . . . . . . 3
REUSED FOR OTHER PURPOSE . . . . . . . . . . 4
OTHER 6
(SPECIFY)
DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 8
012C How long did you use the net before disposing of it? LESS THAN 2 YEARS . . . . . . . . . . . . . . . . . . . 1
2-4 YEARS . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
MORE THAN 4 YEARS . . . . . . . . . . . . . . . . . . . 3
DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 8
012D What was the main reason for disposing of this net? TORN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
COULD NOT REPEL MOSQUITOS ANYMORE . 2
GOT A NEW ONE . . . . . . . . . . . . . . . . . . . . . . . 3
OTHER (SPECIFY) ………………………………..6
DON’T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 8
012A Have you ever heard about malaria? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
186
University of Ghana http://ugspace.ug.edu.gh
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
013 In the past 6 months, have you seen or heard any
messages about malaria: YES NO
a) On the television? TELEVISION . . . . . . . . . . . . . . . . 1 2
b) On the radio? RADIO . . . . . . . . . . . . . . . . . . . . . 1 2
c) In a newspaper or magazine? NEWSPAPER/
MAGAZINE . . . . . . . . . . . . . . 1 2
d) From a poster? POSTER . . . . . . . . . . . . . . . . . . 1 2
e) From leaflets or brochures? LEAFLET/BROCHURE . . . . . . . . 1 2
f) From a health worker? HEALTH WORKER . . . . . . . . . . 1 2
g) From a Community volunteer/CHW/CBA?
VOLUNTEER . . . . . . . . . . . . . . 1 2
h) Anyone/anywhere else? Where/Whom? OTHER . . . . . . . . . . . . . . . . . . 1 2
Awareness about cutaneous Leishmaniasis
NO. QUESTIONS AND FILTERS CODING CATEGORIES
SKIP
014 Have you ever seen lesions like what is the YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
picture? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
Please show the pictures of the lesions to the
respondent
015 Have you ever heard about Cutaneous Leishmaniasis? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
(SKIP TO 017)
016 In the past 6 months, have you seen or heard any
187
University of Ghana http://ugspace.ug.edu.gh
messages about Cutaneous Leishmaniasis?: YES NO
a) On the television? TELEVISION . . . . . . . . . . . . . . . . 1 2
b) On the radio? RADIO . . . . . . . . . . . . . . . . . . . . . 1 2
c) In a newspaper or magazine? NEWSPAPER/
MAGAZINE . . . . . . . . . . . . . . 1 2
d) From a poster? POSTER . . . . . . . . . . . . . . . . . . 1 2
e) From leaflets or brochures? LEAFLET/BROCHURE . . . . . . . . 1 2
f) From a health worker? HEALTH WORKER . . . . . . . . . . 1 2
g) From a Community volunteer/CHW/CBA?
VOLUNTEER . . . . . . . . . . . . . . 1 2
h) Anyone/anywhere else? Where/Whom? OTHER . . . . . . . . . . . . . . . . . . 1 2
017 List any names used to describe cutaneous leishmaniasis/
the lesions in the picture shown, in this community: NAME 1 . . . . . . . . . . . . . . .…........
If ‘NO’ or ‘DON’T KNOW’ FOR 014 AND 015,
EXCLUDE FROM QUESTIONS UNDER CL
EXPERIENCE, AND CL KAP. THEY CAN NAME 2 . . . . . . . . . . . . . . . . . . . .
HOWEVER RESPOND TO QUESTIONS ON
SANDFLIES AND HOUSEHOLD
NAME 3 …………………………….
OTHER…………………………….
NO IDEA . . . . . . . . . . . . . . . . .….
CL Experience
018 Do you have a personal experience of cutaneous YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
leishmaniasis? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
019 Do you know anyone in this community (outside your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Household) who has had cutaneous leishmaniasis? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
188
University of Ghana http://ugspace.ug.edu.gh
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
020 Has any member of your household other than yourself YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
had a history of cutaneous leishmaniasis? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
021 How many members of your household (including you) . . . . . . . . . . . . . . . . ______. ______. . . . . . . . . . . . . . .
.
Have experienced cutaneous leishmaniasis? DON'T KNOW ………………………………. 3
022 Has any member of your household (including you) YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
experienced CL Within in the past two years? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ….3
023 How many members of your household (including you) . . . . . . . . . . . . ______. ______. . . . . . . . . . . . . .
experienced CL within the past two years? DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
024 Which month(s) of the year do you see cases of CL JANUARY……….1 FEBRUARY……….. 2
In this community? MARCH………….3 APRIL……………... 4
MAY………………5 JUNE……………… 6
JULY……………...7 AUGUST……….... 8
SEPTEMBER……9 OCTOBER……….. 10
NOVEMBER…….11 DECEMBER……... 12
ALL MONTHS……13 OTHER (SPECIFY)…14
DON'T KNOW … 15
025 Which age groups of people do you see with CL Children (<5 years). . . . . . . . . . . . . . . . . . . . . . . . 1
In this community? Children (5-17 years) . . . . . . . . . . . . . . . . . . . . . . 2
Young Adults (18 -35 years) . . . . . . . . . . . . . . . .
3
Older Adults (36-60 years)………………………… 4
Aged (>60 years)…………………………………… 5
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . … 6
189
University of Ghana http://ugspace.ug.edu.gh
026 Which occupational groups of people do see with Farmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CL in this community? Hunters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Traders……………………………………………… 3
Students/Pupils……………………………………… 4
Civil servants………………………………………… 5
Others (Specify)…………………………………… 6
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …
7
CL Knowledge
027 What is the cause of cutaneous leishmaniasis (CL)?
CL Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
………………………………………………………………………………… ……………………………………………………..1
………………………………………………………………………………………………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………………………….3
028 How is CL transmitted to people?
CL Transmission . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . …………………………………1
………………………………………………….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………………………..
……………………………………………………………………………………………………………………………………………………..
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ……………………………………………………………………………3
190
University of Ghana http://ugspace.ug.edu.gh
029 What are the symptoms of cutaneous leishmaniasis?
CL Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ……………………………………………………………………………… 1
………………………………………………….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………………
……………………………………………………………………………………………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ……………………………………………………………………………………………3
030 Is CL preventable? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
(SKIP TO 031)
031 How can CL be prevented?
CLPrevention methods. . . . . . . . . . . . . . . . . . . . …………………………………………………………………………1
………………………………………………………………………………………………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …….3
032 Is CL treatable? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
191
University of Ghana http://ugspace.ug.edu.gh
Knowledge about Sand flies
033 Can you differentiate sandflies from mosquitoes? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
NO, cannot tell the difference between them.. . . . . . 2
NO, Can recognize mosquitoes but never heard about
sand flies..3
NO, Can recognize mosquitoes but not sand
flies………………….4
Other(Specify)…………………………………………. 5
034 Can sand flies transmit any disease(s)? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
(SKIP TO 036)
035 Name the disease(s) that sand flies can transmit? DISEASE 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
DISEASE 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OTHER …………………………………………….3
DON'T KNOW . . . . . . . . . . . . . . . . . . . . …….. 4
036 Where do sand flies breed?
Sand fly breeding places. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………… 1
………………………………………………………………………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …….3
037 What is the most active biting time of sand flies? DURING DUSK AND DAWN. . . . . . . . . . . . . . . . . . . . .1
DURING MID NIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DURING DAY TIME……………………………………….3
AT ANY TIME………………………………………………4
OTHER (SPECIFY)………………………………………...5
192
University of Ghana http://ugspace.ug.edu.gh
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ……… .6
038 How can sand flies be controlled?
Sand fly control methods. . . . . . . . . . . . . . . . . . .………………………………………………………………………… 1
…………………………….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …….3
CL Related Attitude
039A Is CL a problem in this community? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . 3
(SKIP TO 040)
039B How is CL a problem in this community?
How CL is a problem?. . . . . . . . . . . . . . . . . . . …………………………………………………………………………… 1
…………………………………………………………………………………………………………………………………………………
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………………………….3
040 What do you think the outcome of CL will be if not Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .…. 1
treated? MULTIPLE RESPONSES ACCEPTED Disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 2
Scar………………………………………………….. 3
Self heal……………………………………………….4
Others (Specify)……………………………………….6
193
University of Ghana http://ugspace.ug.edu.gh
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . .… . 7
041 Compared with malaria, how serious do you Malaria is more serious than CL. . . . . . . . . . . . . . 1
Consider CL in this community? CL is more serious than malaria. . . . . . . . . . . . . . . 2
Both malaria and CL are equally serious….…… 3
Others (Specify)…………………………………… 6
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . … 7
042A Do you think there is a role(s) members of this community YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Can play to prevent CL in this community? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
(SKIP TO 043A)
042B What role(s) can members of this community play to prevent CL?
Community members role in CL prevention?. . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………1
…………………….………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …….3
043A Do you think there is a role(s) you can play YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
to prevent CL in your household? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …3
(SKIP TO 044)
043B What role(s) can you play to prevent CL in your household?
Community members role in CL prevention?. . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………1
…………………….………………………………………………………………………………………………………………………….
194
University of Ghana http://ugspace.ug.edu.gh
……………………………………………………………………………………………………………………………………………….
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …….3
044 Which age groups of people do you think can get CL Children (<5 years). . . . . . . . . . . . . . . . . . . . . . . . 1
in this community? Children (5-17 years) . . . . . . . . . . . . . . . . . . . . . . .2
Young Adults (18 -35 years) . . . . . . . . . . . . . . . . . 3
Older Adults (36-60 years)……………………………4
Aged (>60 years)………………………………………5
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . …… 6
045 Which occupational groups of people do you consider Farmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….1
Likely to get CL in this community? Hunters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ……2
Traders……………………………………………………3
Students/Pupils…………………………………………..4
Civil servants……………………………………………..5
Others (Specify)………………………………………….6
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ……….7
046 Where are you likely to go for treatment if you No where (No treatment) . . . . . . . . . . . . . . . . . . . . . . 1
get CL? No where (self treatment) . . . . . . . . . . . . . . . . .. . . . . 2
Hospital . . . . . . . . . . . . . . . . . ………………………3
Pharmacy……………………………………………… 4
Herbalist (Traditional healer)…………………………. 5
Other (Specify)…….……………………………………6
DON'T KNOW . . . . . . ……. . . . . . . . . . . . . . . . . . 7
047 Can someone have leishmaniasis and not show any YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………1
195
University of Ghana http://ugspace.ug.edu.gh
symptoms? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ………2
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . ………3
CL Related Practices
048 Where do you or or members of your household No where (No treatment) . . . . . . . . . . . . . . . . . . . . . . 1
go for treatment if you get CL? No where (self treatment) . . . . . . . . . . . . . . . . .. . . . . 2
MULTILE RESPONSES ACCEPTED Hospital . . . . . . . . . . . . . . . . . ……………………….…3
Pharmacy…………………………………………………4
Herbalist (Traditional healer)………………………….…5
No one in my household ever had………………………6
Other (Specify)…….………………………………………7
DON'T KNOW . . . . . . ……. . . . . . . . . . . . . . . . . . …8
049 What do you or members of your household do to prevent CL?
Household CL prevention method?. . . . . . . . . . . . . . . . . . . . . . . . ……………………………………………………1
……….………………………………………………………………………………………………………………………………….
Nothing . . . . . . . . . . . . . . . . . . . . . . . . ………………………………………………………………………………………..2
Don’t Know what to do to prevent CL…………………………………………………………………………………………..3
050 What is your preferred work time? Day time when temperature is high . . . . . . . . . . . . . . . . 1
Multiple answers accepted Early morning . . . . . . . . . . . . . . . . .. . . . . . . . ………. 2
In the evening . . . . . . . . . . . . . . . . . …………….. 3
At night)………………………….………………… 4
Other (Specify)…….……………………………… 5
196
University of Ghana http://ugspace.ug.edu.gh
DON'T KNOW . . . . . . ……. . . . . . . . . . . . . . . . . . 6
051A Do you sleep outdoors in the evening after 5pm? Yes, Very often (At least once a week) . . . . . . . . . …1
Multiple answers accepted Yes, Often (At least once a month) . . . . . . . . . . .. . . . . .2
Yes, Sometimes (At least once in six months)………...3
Yes, rarely (At least once in a year)
night)………………………….……………………………..4
No……………………………………………………………5
Other
(Specify)…….…………………………………………….6
(SKIP TO 052)
051B If you sleep outdoors after 5pm:
051B1 Do you sleep in insecticide treated bed net? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ……………1
NO . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . ……………2
OTHER . ………………………………………………3
051B2 Do you use mosquito coil? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OTHER . . . . . . . . . . . . . . . . . . . . . . . ………. 3
051B3 Do you use any insecticide other than YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Mosquito coil and ITN? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OTHER . . . . . . . . . . . . . . . . . . . . . . . . ……….. 3
051B4 Do you sleep near vegetation? YES . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OTHER . . . . . . . . . . . . . . . . . . . . . . . . . 3
197
University of Ghana http://ugspace.ug.edu.gh
WATER AND SANITATION WS
WS1. WHAT IS THE MAIN SOURCE OF Piped water
DRINKING WATER FOR MEMBERS OF Piped into dwelling ............................... 11
YOUR HOUSEHOLD? Piped into compound, yard or plot ........ 12
Piped to neighbour ............................... 13
Public tap / standpipe ........................... 14
Tube Well, Borehole................................. 21
Dug well
Protected well ...................................... 31
Unprotected well .................................. 32
Water from spring
Protected spring ................................... 41
Unprotected spring ............................... 42
Rainwater collection ................................. 51
Tanker-truck ............................................ 61
Cart with small tank / drum ....................... 71
Surface water (river, stream, dam, lake,
pond, canal, irrigation channel) ............. 81
Bottled water ............................................ 91
Other (specify) _____________________ 96
WS2. WHAT KIND OF TOILET FACILITY DO Flush / Pour flush
MEMBERS OF YOUR HOUSEHOLD Flush to piped sewer system ................ 11
USUALLY USE? Flush to septic tank .............................. 12
Flush to pit (latrine) .............................. 13
If “flush” or “pour flush”, probe: Flush to somewhere else ...................... 14
WHERE DOES IT FLUSH TO? Flush to unknown place / Not sure /
DK where ......................................... 15
If necessary, ask permission to observe Pit latrine
the facility. Ventilated Improved Pit latrine (VIP) .... 21
Pit latrine with slab ............................... 22
Pit latrine without slab / Open pit .......... 23
Composting toilet ..................................... 31
Bucket ..................................................... 41
Hanging toilet, hanging latrine .................. 51
No facility, bush, field ............................... 95 95Next
Other (specify) _____________________ 96 Module
198
University of Ghana http://ugspace.ug.edu.gh
WS3. DO YOU SHARE THIS FACILITY WITH Yes ............................................................ 1
OTHERS WHO ARE NOT MEMBERS OF No.............................................................. 2 2Next
YOUR HOUSEHOLD? odule
WS4. HOW MANY HOUSEHOLDS IN TOTAL USE
THIS TOILET FACILITY, INCLUDING YOUR Number of households (if less than 10) .. 0__
OWN HOUSEHOLD?
Ten or more households .......................... 10
DK ........................................................... 98
199
University of Ghana http://ugspace.ug.edu.gh
HOUSEHOLD CHARACTERISTICS HC
HC1A. WHAT IS THE RELIGION OF THE HEAD OF THIS Catholic 11
HOUSEHOLD?
Protestant (Anglican, Lutheran,
Presbyterian, Methodist, etc.) 12
Pentecostal/Charismatic 13
Other Christian 14
Moslem 21
Traditional/Spiritualist 31
Other (specify) ______________________ 96
No religion 41
HC1B. TO WHAT ETHNIC GROUP DOES THE HEAD OF Ewe 11
THIS HOUSEHOLD BELONG?
Ga-Dangme 12
Akan 21
Mole-Dagbani 31
Kokomba 32
Grusi 41
Other (specify) _____________________ 96
HC1C. IN THE LAST 4 WEEKS DID THE HEAD OF THIS Yes............................................................ 1 1HC1E
HOUSEHOLD DO ANY ACTIVITY OF AT LEAST ONE No ............................................................. 2 2HC1D
HOUR FOR PAY OR PROFIT OR FAMILY GAIN (IN
CASH OR IN KIND)?
HC1D. WHAT WAS THE HEAD OF HOUSEHOLD DOING? Did not work but had job to go back to 1 1HC1E
Unemployed, worked before and 2HC1E
available to work now 2
3HC2
Unemployed, never worked before 3
4HC2
Did not work before and not seeking work
now 4 8HC2
DK 8
200
University of Ghana http://ugspace.ug.edu.gh
HC1E. WHAT KIND OF WORK DID THE HEAD OF Description of work:
HOUSEHOLD DO?
------------------------------------------------------------.
This refers to the type of work the head of
household was doing. Use two or more words. For ------------------------------------------------------------.
example, street trader, cattle farmer, primary
------------------------------------------------------------.
schoolteacher, domestic worker, truck driver, filing
clerk, etc.
HC1F. WHAT IS THE AVERAGE MONTHLY INCOME OF
THIS HOUSEHOLD (GHS)? Monthly income………………………GHS
HC2A. HOW MANY ROOMS IN THIS HOUSEHOLD ARE
USED FOR SLEEPING? Number of rooms ................................ __ __
HC2B.HOW MANY WINDOWS ARE IN THIS HOUSEHOLD? Number of windows ............................ __ __
HC2C. HOW MANY WINDOWS IN THIS HOUSEHOLD Number of screened windows ............. __ __
HAVE SCREEN/NET?
HC3. Main material of the dwelling floor. Natural floor
Earth / Sand ........................................ 11
Record observation. Dung ................................................... 12
Rudimentary floor
Wood planks ........................................ 21
Palm / Bamboo .................................... 22
Finished floor
Parquet or polished wood .................... 31
Vinyl or asphalt strips ........................... 32
Ceramic tiles ........................................ 33
Cement ................................................ 34
Carpet ................................................. 35
Other (specify) _____________________ 96
201
University of Ghana http://ugspace.ug.edu.gh
HC4. Main material of the roof. Natural roofing
No Roof ............................................... 11
Record observation. Thatch / Palm leaf ................................ 12
Sod ...................................................... 13
Rudimentary Roofing
Rustic mat ........................................... 21
Palm / Bamboo .................................... 22
Wood planks ........................................ 23
Cardboard ........................................... 24
Finished roofing
Metal ................................................... 31
Wood ................................................... 32
Calamine / Cement fibre ...................... 33
Ceramic tiles ........................................ 34
Cement ................................................ 35
Roofing shingles .................................. 36
Other (specify) _____________________ 96
HC5. Main material of the exterior walls. Natural walls
No walls ............................................... 11
Record observation. Cane / Palm / Trunks ........................... 12
Dirt ...................................................... 13
Rudimentary walls
Bamboo with mud ................................ 21
Stone with mud .................................... 22
Uncovered adobe ................................ 23
Plywood ............................................... 24
Cardboard ........................................... 25
Reused wood....................................... 26
Finished walls
Cement ................................................ 31
Stone with lime / cement ...................... 32
Bricks .................................................. 33
Cement blocks ..................................... 34
Covered adobe .................................... 35
Wood planks / shingles ........................ 36
Other (specify) _____________________ 96
202
University of Ghana http://ugspace.ug.edu.gh
HC6. WHAT TYPE OF FUEL DOES YOUR HOUSEHOLD Electricity .................................................01 01HC8
MAINLY USE FOR COOKING? Liquefied Petroleum Gas (LPG) ................02 02HC8
Natural gas ..............................................03 03HC8
Biogas......................................................04 04HC8
Kerosene .................................................05
Coal / Lignite ............................................06
Charcoal ..................................................07
Wood .......................................................08
Straw / Shrubs / Grass .............................09
Animal dung .............................................10
Agricultural crop residue ...........................11
No food cooked in household ................... 95 95HC8
Other (specify) ______________________ 96
HC7. IS THE COOKING USUALLY DONE IN THE HOUSE, IN In the house
A SEPARATE BUILDING, OR OUTDOORS? In a separate room used an kitchen ……….1
Elsewhere in the house ……………………..2
In a separate building………………………..3
IF IN THE HOUSE PROBE IS IT DONE IN A SEPARATE Outdoors …………………………………….. 4
ROOM USED AS A KITCHEN?
Other (Specify) ……………………………… 6
HCB. DOES YOUR HOUSEHOLD HAVE: Yes No
[A] ELECTRICITY?
Electricity ………………………… 1 2
[B] A RADIO?
Radio ………………………………. 1 2
[C} A TELEVISION?
Television ………………………… 1 2
[D] A NON-MOBILE TELEPHONE? Non-mobile telephone …………… 1 2
[E] A REFRIGERATOR? Refrigerator ………………………… 1 2
[F] A GENERATOR Generator ………………………… 1 2
[G] A COMPUTER Computer …………………………… 1 2
[H] A SEWING MACHINE Computer …………………………….1 2
[I] A BED Bed ………………………………… 1 2
[ ] Table ………………………………… 1 2 J A TABLE
Cupboard /cabinet …………………..1 2
[K] A CUPBOARD /CABINET
203
University of Ghana http://ugspace.ug.edu.gh
HC9. DOES ANY MEMBER OF YOUR HOUSEHOLD OWN: Yes No
[A] A WATCH?
Watch ……………………………….. 1 2
[B] A MOBILE TELEPHONE Mobile telephone ………………… 1 2
[C] A BICYCLE Bicycle ………………………………..1 2
[D] A MOTORCYCLE OR SCOOTER? Motorcycle / Scooter ………………..1 2
[E] AN ANIMAL DRAWN CART? Animal drawn -cart ………………….1 2
[F] A CAR OR TRUCK? Car/ Truck …………………………….1 2
[G] A TRACTOR? Tractor ……………………………… 1 2
[H] A BOAT WITHOUT A MOTOR? Boat without motor ………………….1 2
[ ] Boat with motor ………………………1 2 I A BOAT WITH A MOTOR
HC10. DO YOU OR SOMEONE LIVING IN THIS Own …………………………………………...1
HOUSEHOLD OWN THIS DWELLING?
Rent ……………………………………………2
IF “NO THEN ASK: DO YOU RENT THIS DWELLING
FROM SOMEONE NOT LIVING IN THIS HOUSEHOLD? Other (Not owned / rented) (Specify)
IF” RENTED FROM SOMEONE ELSE”, CIRCLE “2” FOR
………………………………………………….6
OTHER RESPONSE, CIRCLE “6”
HC11. DOES ANY MEMBER OF THIS HOUSEHOLD OWN Yes …………………………………………1
ANY LAND THAT CAN BE USED FOR AGRICULTURE? No ………………………………………….2 2HC13
HC12. HOW MANY HECTARES, ACRES OR POLES OF Hectares ……………………………___ ___
AGRICULTURE LAND DO MEMBERS OF THIS
HOUSEHOLD OWN? Acres
IF LESS THAN I RECORD “00” IF 95 OR MORE RECORD
Poles ………………………………. ___ ___
“95” IF UNKNOWN RECORD “98”
DK………………………………………..98
HC13. DOES THIS HOUSEHOLD OWN ANY LIVESTOCK, Yes…………………………………………1
HERDS, OTHER FARMS ANIMALS OR POULTRY? No…………………………………………..2
2HC15
HC 14. HOW MANY OF THE FOLLOWING ANIMALS
How Many?
204
University of Ghana http://ugspace.ug.edu.gh
DOES THIS HOUSEHOLD HAVE? Cattle, milk cows, or bulls …….. ____ ___
[A] CATTLE, MILK COWS OR MULES?
Horses, donkeys or mules ………. ____ ___
[B] HORSES, DONKEYS OR MULES?
Goats ……………………………..____ ___
[C] GOATS Sheep …………………………….____ ___
[D] SHEEP? Pigs ………………………………____ ___
[E] PIGS Chickens …………………………____ ___
Dog ………………………………____ ___
[F] CHICKENS?
Ducks …………………………….____ ___
[H] DUCKS?
[I] OTHER POULTRY (TURKEYS OR OTHER)? Other poultry(Specify)
[J] OTHER =1? ……………………………………____ ___
Other -1 (specify )
[K] OTHER -2?
…………………………………….____ ___
Other -2 (specify )
IF NONE, RECORD “00” ……………………………………..____ ___
IF 95 OR MORE RECORD “95”
IF UNKNOWN RECORD “ 98”
HC15.DOES ANY MEMBER OF THIS HOUSEHOLD HAVE A
BANK ACCOUNT? Yes …………………………………………1
No…………………………………………..2
HC16. HOW MANY HOUSEHOLD MEMBERS ARE Number of persons ……………… ___ ___
REGISTERED WITH THE NATIONAL HEALTH
INSURANCE SCHEME? DK ………………………………………98
HC18. RECORD THE TIME. Hours and Minutes ___ ___ ___
205
University of Ghana http://ugspace.ug.edu.gh
Interviewer’s Observations
Field Editor’s Observations
Supervisor’s Observations
206