1. Aflatoxin consumption, Health Effects and HIV: a preliminary report of the St. Markus Hospital and five regions of Ghana Inas K. Mahdi, MPH Candidate University of Alabama-Birmingham School of Public Health Department of Epidemiology/International Health August 9, 2004 Kumasi Center for Collaborative Research

2. Aflatoxin-Background Aflatoxin is a fungal toxin found on agricultural products such as maize, groundnuts, millet, and sorghum that have been improperly stored. Aflatoxin is a fungal toxin found on agricultural products such as maize, groundnuts, millet, and sorghum that have been improperly stored. Derived from Aspergillus flavus, which is contaminating corn and other widely-consumed crops in West Africa. The fungus produces Aflatoxin which penetrates the body through the consumption of grain-based food, or poultry and cattle fed with such food. Derived from Aspergillus flavus, which is contaminating corn and other widely-consumed crops in West Africa. The fungus produces Aflatoxin which penetrates the body through the consumption of grain-based food, or poultry and cattle fed with such food.

3. Aflatoxin- Background According to the World Health Organisation (WHO), the permitted level in food products of aflatoxin is zero parts per billion (0 ppb) for children, 20 ppb for adults and 55 ppb for animals. According to the World Health Organisation (WHO), the permitted level in food products of aflatoxin is zero parts per billion (0 ppb) for children, 20 ppb for adults and 55 ppb for animals. Some West African studies show populations consuming 100 ppb per day since they were born. Some West African studies show populations consuming 100 ppb per day since they were born. The corn seeds are severely damaged in West Africa because they remain too long in the fields where they are attacked by many insects. As a result, they generally have higher levels of Aflatoxin. The corn seeds are severely damaged in West Africa because they remain too long in the fields where they are attacked by many insects. As a result, they generally have higher levels of Aflatoxin. Improper drying practices Improper drying practices Classified as a Group 1 carcinogen- by WHO- enough evidence in naturally occurring Aflatoxin to cause cancer Classified as a Group 1 carcinogen- by WHO- enough evidence in naturally occurring Aflatoxin to cause cancer Immunosuppressive, mutagenic, and carcinogenic Immunosuppressive, mutagenic, and carcinogenic Combines with HBV to cause increased harm to the liver. Combines with HBV to cause increased harm to the liver.

4. Aflatoxin Aflatoxin is also indirectly absorbed by children through maternal milk. As a result, children’s immune systems are affected. Aflatoxin is also indirectly absorbed by children through maternal milk. As a result, children’s immune systems are affected. Found in contaminated cereals which are fed to growing children, have been found to cause growth stunting in children. ( Benin & Togo studies) Found in contaminated cereals which are fed to growing children, have been found to cause growth stunting in children. ( Benin & Togo studies) Combines with HBV to cause increased harm to the liver. Combines with HBV to cause increased harm to the liver. A recent study done in Sudan, a clear dose response relationship was found between increased peanut butter consumption and increasing incidence of hepatocellulararcinoma in individuals without HBV infection ( Omer, RE. et al., 2004) A recent study done in Sudan, a clear dose response relationship was found between increased peanut butter consumption and increasing incidence of hepatocellulararcinoma in individuals without HBV infection ( Omer, RE. et al., 2004) Omer found that of the cases demonstrated in the study, 27-60% of all cases can be attributed to Aflatoxin exposure and 49-52% to HBV infection. Omer found that of the cases demonstrated in the study, 27-60% of all cases can be attributed to Aflatoxin exposure and 49-52% to HBV infection.

5. Hepatitis B Prevalence 15%

6. HIV- Ashanti Region Background HIV prevalence in Ashanti Region estimated at 5 %. HIV prevalence in Ashanti Region estimated at 5 %. St. Markus sees a total of 350 patients St. Markus sees a total of 350 patients 68 of those patients are on ARV therapy. 68 of those patients are on ARV therapy. Interactive effects of HIV and Aflatoxin are yet to be thoroughly documented. Interactive effects of HIV and Aflatoxin are yet to be thoroughly documented. Aflatoxin suppresses the immune system which in addition to HIV further exposes the body to opportunistic infections. Aflatoxin suppresses the immune system which in addition to HIV further exposes the body to opportunistic infections. Likelihood of liver cancer is increased with increased regular intake of Aflatoxin and Hepatitis B. Likelihood of liver cancer is increased with increased regular intake of Aflatoxin and Hepatitis B. Exacerbates the current effects of HIV and can be argued that it leads to a faster progression to AIDS decreased quality of life of those infected. Exacerbates the current effects of HIV and can be argued that it leads to a faster progression to AIDS decreased quality of life of those infected. Our objectives were to (1) Examine current immune status of patients and opportunistic infections they present with and (2) Assess the correlation between immune status and AF levels. Our objectives were to (1) Examine current immune status of patients and opportunistic infections they present with and (2) Assess the correlation between immune status and AF levels.

7. St. Markus 91 new patients were recruited and interviewed. 91 new patients were recruited and interviewed. Questionnaires included questions on the basic symptomolgy of Aflatoxin ingestion and questions related to contaminated food products. Questionnaires included questions on the basic symptomolgy of Aflatoxin ingestion and questions related to contaminated food products. Most participants cited (85/91, 93%) said they could identify spoilage in food items. Most participants cited (85/91, 93%) said they could identify spoilage in food items. Of those who said they discarded food, some cited feeding the spoiled grains and food to animals. Of those who said they discarded food, some cited feeding the spoiled grains and food to animals. Symptoms of Hepatitis or Aflatoxin ingestion- Symptoms of Hepatitis or Aflatoxin ingestion- jaundice, nausea, vomiting, fever, stomach or joint pain jaundice, nausea, vomiting, fever, stomach or joint pain Further analysis of blood and urine samples will possibly show linkages between consumption of Aflatoxin and it’s effects on HIV. Further analysis of blood and urine samples will possibly show linkages between consumption of Aflatoxin and it’s effects on HIV.

8. Aflatoxin Consumption in Five Regions of Ghana

9. Regions Selected & #’s sampled Northern-130 samples Northern-130 samples Brong Ahafo-140 samples Brong Ahafo-140 samples Ashanti-390 samples Ashanti-390 samples Central-540 samples Central-540 samples Greater Accra-140 samples Greater Accra-140 samples Total-1340 samples Total-1340 samples

10. Aflatoxin consumption June- August 2004 June- August 2004 Total of 1300 sampled Total of 1300 sampled Personal interviews-?’s related to individual health status, family, storage methods, and disposal of spoiled foods Personal interviews-?’s related to individual health status, family, storage methods, and disposal of spoiled foods Urine samples collected Urine samples collected Groundnuts, corn, clay also collected Groundnuts, corn, clay also collected

11. Objectives Determine the levels of consumption of groundnuts and maize in five regions Determine the levels of consumption of groundnuts and maize in five regions Determine the levels of Aflatoxin in stored and consumed groundnuts and maize at the household level in Ghana. Determine the levels of Aflatoxin in stored and consumed groundnuts and maize at the household level in Ghana. Evaluate the levels of Aflatoxin in the urine of study participants. Evaluate the levels of Aflatoxin in the urine of study participants.

12. Methodology-summarized Personal survey and collection and testing of groundnut, maize, and urine samples Personal survey and collection and testing of groundnut, maize, and urine samples Market sampling- each region collects 3 samples of corn and groundnuts from at least 5 different markets. Market sampling- each region collects 3 samples of corn and groundnuts from at least 5 different markets.

13. Conclusions Analyses will be conducted to determine the exact concentrations of Aflatoxin at the household level in Ghana. Analyses will be conducted to determine the exact concentrations of Aflatoxin at the household level in Ghana. Bio-agriculturists anticipate developing edible products that will work to bind AF’s harmful effects on the body. Bio-agriculturists anticipate developing edible products that will work to bind AF’s harmful effects on the body.

14. References 1. http://www.saafost.org.za/dutton.html 1. http://www.saafost.org.za/dutton.html http://www.saafost.org.za/dutton.html 2. Prevalence of Blood-Borne Infectious Diseases in Blood Donors in Ghana 2. Prevalence of Blood-Borne Infectious Diseases in Blood Donors in Ghana William Ampofo,1* Nicholas Nii-Trebi,1 Justina Ansah,2 Kenji Abe,3 Hideo Naito,3 Simeon Aidoo,1 Victor Nuvor,1 James Brandful,1 Naoki Yamamoto,4 David Ofori-Adjei,1 and Koichi Ishikawa3 William Ampofo,1* Nicholas Nii-Trebi,1 Justina Ansah,2 Kenji Abe,3 Hideo Naito,3 Simeon Aidoo,1 Victor Nuvor,1 James Brandful,1 Naoki Yamamoto,4 David Ofori-Adjei,1 and Koichi Ishikawa3* 3. Nutr Cancer. 2004 Jan;48(1):15-21. Links Population-Attributable Risk of Dietary Respect to Aflatoxins and Hepatitis B Virus Infection with Hepatocellular Carcinoma. Omer RE, Kuijsten A, Kadaru AM, Kok FJ, Idris MO, El Khidir IM, Van 't Veer P. 3. Nutr Cancer. 2004 Jan;48(1):15-21. Links Population-Attributable Risk of Dietary Respect to Aflatoxins and Hepatitis B Virus Infection with Hepatocellular Carcinoma. Omer RE, Kuijsten A, Kadaru AM, Kok FJ, Idris MO, El Khidir IM, Van 't Veer P.Links