Date: Thu 1 Mar 2018
Source: Graphic Online [edited]
<https://www.graphic.com.gh/news/general-news/one-confirmed-dead-from-lassa-fever.html>

The Ghana Health Service (GHS) has confirmed the 1st recorded case of Lassa fever in the country at Tema General Hospital. Dr Anthony Nsiah-Asare, the director-general of the Ghana Health Service, who was speaking to the media in Accra on Thursday [1 Mar 2018], said one person has been confirmed dead from Lassa fever.

Lassa fever is transmitted to humans via contact with food or household items contaminated with the urine, saliva faeces, and blood of infected rodents.

The confirmation, Dr Nsiah-Asare said, followed a test conducted by the Noguchi Memorial Institute for Medical Research. He said that, currently, all the frontline staff at the hospital that handled the patient before he died were being screened, while further investigations to trace the background and all contacts of the deceased were being pursued to prevent the spread of the virus. He called on the public to be extremely cautious of rodents and maintain good hygiene. He also urged the public to report any suspected case of the disease.

The GHS in February 2018 issued an alert of the likelihood of an outbreak of Lassa fever in the country. The disease is said to have already affected several countries in West Africa with, over 300 cases and 31 deaths in Nigeria.

The GHS recommended the following to all health workers and institutions:

1. Surveillance on Lassa fever, and acute hemorrhagic fevers in general (using case definitions), should be enhanced.
2. Suspected cases of Lassa fever should be managed in specific isolation conditions.
3. Health workers should adhere to regular infection prevention and control (IPC) measures to prevent and protect against possible nosocomial transmission.
4. Blood samples from suspected case(s) should be taken and safely packaged and sent to Noguchi Memorial Institute for Medical Research (NMIMR) for laboratory investigations.
5. All levels (national, regional, districts and facilities) are requested to update their preparedness and response plans for Lassa fever and VHF in general, sensitize the respective staff, and create necessary public awareness.

Lassa fever [LF] is an acute viral haemorrhagic fever illness which is endemic in West Africa. The incubation period is 6-21 days. The onset of LF illness is often gradual, with non-specific signs and symptoms and commonly presents with fever, general weakness, and malaise at the early onset. After a few days, headache, sore throat, muscle pain, chest pain, vomiting, diarrhoea and abdominal pain may follow. Severe cases may progress to show facial swelling, and bleeding tendencies (from mouth, nose, vagina or gastrointestinal tract), and low blood pressure. Shock, seizures, disorientation, and coma may be seen in the late stages. Complications include: deafness, transient hair loss, and gait disturbance may occur during recovery. About 80 per cent of Lassa fever infections are mild or asymptomatic.

- Lassa fever virus is transmitted to humans via contact with food or household items contaminated with the urine, saliva faeces, and blood of the rodent (Multi-mammate rat).
- Person-to-person infections and laboratory transmission can also occur, particularly in hospitals lacking adequate infection prevent and control measures.
- The disease is endemic in the rodent population in parts of West Africa, and the multi-mammate rat serves as reservoir for the virus.
- Lassa fever is known to be endemic in Benin, Guinea, Liberia, Mali, Sierra Leone and parts of Nigeria, but probably exists in other West African countries as well.
- Ghana recorded the 1st confirmed case(s) in 2011 in 2 districts, one each in Ashanti and Eastern regions, then confirmed outbreaks of Lassa fever (see Lassa fever - Ghana: (AH, EP) susp. http://promedmail.org/post/20111220.3642).
- Early use of [Ribavirin] (within 7 days of disease onset), supportive care with re-hydration, and symptomatic treatment improve survival.
- There is no effective vaccine for the disease at the moment.  [byline: Seth J Bokpe]
======================
[Lassa fever has been active in several West African countries this year [2018], including Nigeria, Liberia ex Guinea, and Benin ex Nigeria, so it is not surprising that a case has been diagnosed in Ghana. Interestingly, this was predicted previously. In commenting on the 2011 cases in Ghana, the late Mod.CP commented that Lassa virus infection had not been recorded previously in Ghana, but the lesser prevalence of Lassa fever in Ghana was predicted by a spatial-climatic analysis of Lassa fever data from human cases and infected rodent hosts in West Africa during the period 1965-2007 (See Risk maps of Lassa fever in West Africa. PLoS Negl Trop Dis. 2009;3(3):e388) <http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000388;jsessionid=A18CA8161C084054F4225595CF9E71CB> and also the ProMED-mail archived report: Lassa fever, predictive maps - West Africa http://promedmail.org/post/20090428.1605).

Halting the acquisition of Lassa fever virus infection at its source -- at the village level -- is not easy. As noted previously, getting local people to understand that virus transmission to humans occurs when people are in contact with the reservoir rodent host, the multimammate mouse (in the genus _Mastomys_) or its excreta can be difficult. Preventing this contact requires understanding that leads to action. Rodent control and prevention of contact with rodent excreta have to be undertaken at the village level with individual households. This requires an extensive and continuous public education effort. Transmission of the virus also occurs in health facilities when personal protective equipment is not employed and barrier-nursing practices are not adequate to protect staff from blood and secretions of infected patients. Although no vaccine is available, Ribavirin has been used to successfully treat patients and is most effective if patients are treated early in the course of infection.

Images of the mastomys mouse, the rodent reservoir of Lassa fever virus, can be seen at
<https://www.inaturalist.org/taxa/45326-Mastomys-natalensis>. - ProMED Mod.TY]

[HealthMap/ProMED-mail map of Ghana:
<http://healthmap.org/promed/p/53>.]
Date: Sat 9 Dec 2017
Source: WHO, Weekly Bulletin on Outbreaks and Other Emergencies. Week 49: 2-9 Dec 2017 [edited]
<http://apps.who.int/iris/bitstream/10665/259635/1/OEW49-29122017.pdf>

New events: Influenza A H1N1 - Ghana
Event description: Ghana: 77 cases, 4 deaths. 5.2 percent case fatality rate

On 6 Dec 2017, the Ghana Ministry of Health notified WHO of a focal outbreak of influenza A H1N1 in a school in Kumasi city, Ashanti region. The event was detected on 30 Nov 2017 when a cluster of 13 cases of severe acute respiratory illness was reported from Kumasi Academy Senior High School. The initial cases developed illness on 29 Nov 2017 and 3 deaths were reported by 1 Dec 2017.

The case-patients presented with fever, cough, headache, joint and body pains, and abnormal chest auscultation. As of 9 Dec 2017, 77 cases with 4 deaths (case fatality rate 5.2 percent) have been the reported. The majority of the cases, 66 percent, were males and over 95 percent of the cases are teenagers. Thus far, the disease is still localized in the school as no cases have been reported among community members.

Laboratory specimens, including blood, cerebrospinal fluid, and throat swabs were collected from the case-patients and sent to Noguchi Memorial Institute for Medical Research (NMIMR), Kumasi Centre for Collaborative Research (KCCR), and other public health laboratories. Test results from NMIMR (a national influenza centre) released on 6 Dec 2017 indicated that 12 out of 19 throat swabs were positive for influenza A H1N1 2009 pandemic strain using polymerase chain reaction.

Corroborative test results from KCCR released on 7 Dec 2017 showed that seven out of 25 nasal and throat swabs were positive for influenza type A using quantitative real time polymerase chain reaction (rt-PCR).

2 blood specimens tested negative for Ebola and Marburg virus diseases, Lassa fever, yellow fever, dengue, chikungunya, and Zika virus. Specimens analyzed in other public health and research laboratories were negative for meningitis and encephalitis. Accordingly, the Ministry of Health has declared an outbreak of influenza A H1N1 pandemic strain as further epidemiological investigations are ongoing.

Kumasi Academy High School is a mixed sex school with total population of 3010 (2814 students including 541 day students, 127 teaching staff, and 73 non-teaching staff).

Public health actions
---------------------
The Minister of Health and the WHO Representative held a press briefing to inform the public and provide updates on the outbreak.  The Ministry of Health deployed a multi-disciplinary rapid response team to Kumasi to conduct the outbreak investigation and support response actions. WHO provided technical and logistical support to the investigation mission.  Active surveillance has been enhanced: a case definition was developed and active case search is being done among students and staff at the school and four healthcare facilities that treated the ill students. Suspected cases are being line listed.

Four hospitals in Kumasi have been designated as isolation and treatment centres. Doctors have been assigned to the school Sick Bay to provide high-level pre-referral care to students.  Public health education and community sensitization are ongoing. The Public Health Directorate has granted media interviews to provide updates on the outbreak and actions being taken. Simple messages on infection prevention and control have been developed for education at the school.

Situation interpretation
------------------------
The influenza A H1N1 virus that caused the 2009 pandemic is now a regular human influenza virus circulating seasonally worldwide. However, seasonal influenza spreads easily, with rapid transmission in crowded areas including schools. This is the case for the event in Kumasi, Ghana. When an infected person coughs or sneezes, droplets containing viruses (infectious droplets) are dispersed into the air and are spread to persons in close proximity who breathe these droplets in. The virus can also be spread by contamination of hands with influenza viruses, which are then deposited on fomites.

Ghana has a good influenza preparedness system. The National Influenza Centre at NMIMR is part of the Global Influenza Surveillance Network (GISN), coordinated by WHO since 1996. Furthermore, the country is benefiting from the Pandemic Influenza Preparedness (PIP) Framework for determination of influenza burden of disease. The PIP Framework facilitates sharing of influenza viruses and access to vaccines and other benefits to improve global pandemic influenza preparedness and response. These capabilities enhanced the ability to detect the current outbreak in real time and initiate containment measures. Going forward, it is necessary to remain vigilant and continue active epidemiologic and laboratory surveillance for early detection of further transmission of the virus in the community.
Date: Fri 8 Dec 2017
Source: YEN [edited]
<https://yen.com.gh/102560-mysterious-kumaca-deaths-caused-by-influenza-health-minister.html#102560>

Deaths at Kumasi Academy have been linked to spread of influenza. The health minister is calling for students to still stay on campus. It has emerged that the cause of mysterious deaths at the Kumasi Academy is due to type A influenza, the strain [that] causes the deadly swine flu.

Addressing the press in an emergency briefing, the health minister, Kwaku Agyeman-Manu, revealed that out of 44 cases reported, only 4 have died, bringing a total of 11 deaths in the year alone.

Samples of students taken for intense investigation at Nuguchi [Noguchi Memorial Institute for Medical Research, Accra] revealed that out of the 19 samples collected, 12 tested positive for influenza type A.

Meanwhile, the health minister is calling for all students to be kept on campus to provide that vaccinations to control the outbreak are ensured.  A senior pathologist at KATH, Dr Osei Sampene, revealed on Nyira FM that "all bodies of students from Kumasi Academy showed signs of a strange disease, which could also be one of its kind in Ghana." Meanwhile, vaccines are currently being administered to all students to protect them against possible viral or bacterial infections.

Parliament has summoned the minister for health, Kwaku Agyemang-Manu on updates related to the deaths of persons. According to him, any attempt by parents to send their wards home poses a serious national security threat since the cause of their deaths is strangely unknown.

The current atmosphere at Kumasi Academy is that of fear and uncertainty as parents run to the school to see if their wards are doing well, as others demand to take their wards home with them. The death toll continues to rise, as the total number of persons losing [their] lives in a week alone has reached 6. [Byline: Charles Ayitey]
Date: Thu 7 Dec 2017 11:12:36 AM GMT
Source: Myjoyonline, Nhyira FM report [edited]
<https://www.myjoyonline.com/lifestyle/2017/December-7th/no-more-deaths-at-kumaca-health-director-assures.php>

The Ghana Health Service has assured no further deaths at Kumasi Academy as students undergo [treatment with] azithromycin, a broad-spectrum antibiotics medication. [Ashanti] Regional Health Director, Dr Emmanuel Tinkorang, says every student at Kumasi Academy [KUMACA] will survive the attack of a suspected bacterial infection, which has claimed lives of at least 11 students.

Over 40 students have been affected, with 19 currently on admission at Kwame Nkrumah University of Science and Technology (KNUST) Hospital and Komfo Anokye Teaching Hospital. The assurance comes as students and teachers undergo antibiotics medication supplied by the World Health Organization. They are expected to complete the 3-dose medication they started on [Tue 5 Dec 2017].

Nineteen students, 16 on admission at Kwame Nkrumah University of Science and Technology Hospital and 3 at Komfo Anokye Teaching Hospital are said to be responding to treatment. Their high body temperatures are said to have normalised after taking azithromycin, a broad-spectrum antibiotic.

With these actions taken, Dr Tinkorang is full of hope that no student will die again at Kumasi Academy. "Every child will survive in this school. No child will die. I must assure you. Once you take the treatment, there would be no problem. Everybody will survive," he assured. Dr Tinkorang was speaking on [Tue 5 Dec 2017] during a meeting with parents, students, and teachers of KUMACA to begin the antibiotic medication. The Ministry of Education announced the school would be closed down to enable health officials to carry thorough investigations and surveillance in the school. [Byline: Ohemeng Tawiah]
Date: Sun 3 Dec 2017
Source: Modern Ghana [edited]
<https://www.modernghana.com/news/820355/meningitis-kills-another-student-at-kumasi-academythe-3rd.html>

A 1st-year-student of Kumasi Academy Senior High School (KUMACA) has died from meningitis bringing the death toll recorded under similar circumstances in the school to 3 in the last week [week of Sun 26 Nov 2017[. The death of [the student], a General Arts student who died at the Komfo Anokye Teaching Hospital (KATH) brings to 6 such occurrences this year [2017]. Luv News sources say several other students are on admission at the Kwame Nkrumah University of Science and Technology (KNUST) Hospital and KATH.  Ohemeng Tawiah reported the death of 2 students on [Fri 1 Dec 2017] who were rushed to the hospital after they complained of "fever-like conditions" at the school's clinic.
Up to 3 students of the school died under similar circumstances in April [2017] this year, sparking off chaotic uproar as parents besieged the school in a desperate move to take their wards home. [Please see prior ProMED-mail post Meningitis - Ghana: (AH) fatal, high school students, RFI http://promedmail.org/post/20170407.4953952.]

Meanwhile, results of a postmortem conducted on the deceased did not reveal meningitis as had been widely claimed by some students, the reporter added. Ohemeng Tawiah said blood samples of the affected students have been sent to the Noguchi Memorial Institute in Accra for examination.

The incident had come at a time the school is preparing to round up activities to climax the 60th-anniversary celebrations. As a result school authorities have remained tight-lipped over the incident, the reporter said.
=======================
[The above news report says that 3 students at the Kumasi Academy in Kumasi, Ghana died of meningitis in the past several days, although post-mortem exam "did not reveal meningitis". The above news report also says that 3 additional students had died in April 2017 "under similar circumstances at the [Kumasi] school," although a prior ProMED-mail post last April 2017 reported that 4 students had died out of 30 "confirmed cases" of pneumococcal meningitis at the Kumasi Academy school in Kumasi, Ghana. (Please see prior ProMED-mail post Meningitis - Ghana: (AH) fatal, high school students, RFI http://promedmail.org/post/20170407.4953952) and subsequent ProMED-mail post in Nov 2017 said, "a thorough autopsy revealed that 4 students of Kumasi Academy Senior High in the Ashanti region died this year [2017] of the disease [pneumococcal meningitis]." This November 2017 report said that a total of 93 people had died of pneumococcal meningitis in Ghana "since last year [2016]" (Meningitis, pneumococcal - Ghana: fatal, RFI http://promedmail.org/post/20171112.5439630.)

Kumasi Academy is a public secondary boarding school located in Asokore-Mampong, a suburb of the city of Kumasi, the capital of the Ashanti Region of Ghana (<https://en.wikipedia.org/wiki/Kumasi_Academy>). Maps of Ghana can be seen at <http://www.ezilon.com/maps/images/africa/political-map-of-Ghana.gif> and <http://healthmap.org/promed/p/50377>. The Ashanti Region is located in south-central Ghana and is 3rd largest of 10 administrative regions, with a population of about 3.6 million residents in 2000, accounting for 19.1 percent of Ghana's total population (<https://en.wikipedia.org/wiki/Ashanti_Region>).

The northern region of Ghana lies within the African meningitis belt where outbreaks of meningitis, usually due to _Neisseria meningitidis_, occur during the dry season, between November and May. The African meningitis belt is sub-Saharan and extends from Senegal in the west to Ethiopia in the east.

A map can be seen at
<http://wwwnc.cdc.gov/travel/pdf/yellowbook-2012-map3-13-frequent-epidemics-meningococcal-meningitis.pdf>.


However, several studies have emphasized that _Streptococcus pneumoniae_ may also cause outbreaks of bacterial meningitis in an epidemic pattern in the African meningitis belt during the dry season
(<http://jid.oxfordjournals.org/content/192/2/192.abstract?ijkey=9d47813b96aa1d50880f62e9e7efbc4d32bfea9a&keytype2=tf_ipsecsha>
and <http://cid.oxfordjournals.org/content/43/6/693.abstract?ijkey=7d2ca30004fffc8d1410102f6ec758a72efc1f82&keytype2=tf_ipsecsha>).

Some clarification would be appreciated from knowledgeable sources on the numbers of the affected Kumasi students and their exact diagnoses.

HealthMap/ProMED-mail map
Ashanti Region, Ghana: <http://healthmap.org/promed/p/2774>. - ProMED Mod.ML]
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