The impact of the COVID-19 pandemic on the provision & utilisation of primary health care services in Goma, Democratic Republic of the Congo, Kambia district, Sierra Leone & Masaka district, Uganda.

INTRODUCTION: This study aimed to determine whether the COVID-19 pandemic had an impact on essential primary healthcare services at public primary healthcare facilities. METHODS: The number of weekly consultations for antenatal care (ANC), outpatient (OPD), immunisations (EPI), family planning (FP) and HIV services, between January 2018 and December 2020, were collected from 25 facilities in Masaka district, Uganda, 21 in Goma, and 29 in Kambia district, Sierra Leone. Negative binomial regression models accounting for clustering and season were used to analyse changes in activity levels between 2018, 2019 and 2020. RESULTS: In Goma, we found no change in OPD, EPI or ANC consultations, FP was 17% lower in March-July 2020 compared to 2019, but this recovered by December 2020. New diagnoses of HIV were 34% lower throughout 2020 compared to 2019. In Sierra Leone, compared to the same periods in 2019, facilities had 18-29% fewer OPD consultations throughout 2020, and 27% fewer DTP3 doses in March-July 2020. There was no evidence of differences in other services. In Uganda there were 20-35% fewer under-5 OPD consultations, 21-66% fewer MCV1 doses, and 48-51% fewer new diagnoses of HIV throughout 2020, compared to 2019. There was no difference in the number of HPV doses delivered. CONCLUSIONS: The level of disruption varied across the different settings and qualitatively appeared to correlate with the strength of lockdown measures and reported attitudes towards the risk posed by COVID-19. Mitigation strategies such as health communications campaigns and outreach services may be important to limit the impact of lockdowns on primary healthcare services.

Challenges of hepatitis B treatment in rural Sub-Saharan Africa: Treatment initiation and outcomes from a public hospital-based clinic in Kono, Sierra Leone.

Despite a high prevalence, there are few successful models for de-centralizing diagnosis and treatment of chronic hepatitis B virus (HBV) infection among rural communities in Sub-Saharan Africa. We report baseline characteristics and 1 year retention outcomes for patients enrolled in a HBV clinic integrated within chronic disease services in a rural district hospital in Sierra Leone. We conducted a retrospective cohort study of patients with HBV infection enrolled between 30 April 2019 and 30 April 2021. Patients were eligible for 1 year follow-up if enrolled before 28 February 2020. Treatment eligibility at baseline was defined as cirrhosis (diagnosed by clinical criteria of decompensated cirrhosis, ultrasonographic findings or aspartate-aminotransferase-to-platelet ratio >2) or co-infection with HIV or HCV. Retention in care was defined as a documented follow-up visit at least 1 year after enrolment. We enrolled 623 individuals in care, median age of 30 years (IQR 23-40). Of 617 patients with available data, 97 (15.7%) had cirrhosis. Treatment was indicated among 113 (18.3%) patients and initiated among 74 (65.5%). Of 39 patients eligible for 1 year follow-up on treatment at baseline, 20 (51.3%) were retained at 1 year, among whom 12 (60.0%) had documented viral suppression. Among the 232 patients not initiated on treatment eligible for 1 year follow-up, 75 (32.3%) were retained at 1 year. Although further interventions are required to improve outcomes, our findings demonstrated feasibility of retention and treatment of patients with HBV infection in a rural district in Sub-Saharan Africa, when integrated with other chronic disease services.

Prevalence of immunoglobulin G and M to SARS-CoV-2 and other human coronaviruses in The Democratic Republic of Congo, Sierra Leone, and Uganda: A longitudinal study.

OBJECTIVES: We assessed the prevalence of immunoglobulin G (IgG) and IgM against four endemic human coronaviruses and two SARS-CoV-2 antigens among vaccinated and unvaccinated staff at health care centers in Uganda, Sierra Leone, and the Democratic Republic of Congo. METHODS: The government health facility staff who had patient contact in Goma (Democratic Republic of Congo), Kambia District (Sierra Leone), and Masaka District (Uganda) were enrolled. Questionnaires and blood samples were collected at three time points over 4 months. Blood samples were analyzed with the Luminex MAGPIXⓇ. RESULTS: Among unvaccinated participants, the prevalence of IgG/IgM antibodies against SARS-CoV-2 receptor-binding domain or nucleocapsid protein at enrollment was 70% in Goma (138 of 196), 89% in Kambia (112 of 126), and 89% in Masaka (190 of 213). The IgG responses against endemic human coronaviruses at baseline were not associated with SARS-CoV-2 sero-acquisition during follow-up. Among the vaccinated participants, those who had evidence of SARS-CoV-2 IgG/IgM at baseline tended to have higher IgG responses to vaccination than those who were SARS-CoV-2 seronegative at baseline, controlling for the time of sample collection since vaccination. CONCLUSION: The high levels of natural immunity and hybrid immunity should be incorporated into both vaccination policies and prediction models of the impact of subsequent waves of infection in these settings.

Evaluation of a Hypertension Surveillance System, Kenema Government Hospital, Sierra Leone, 2021.

This observational study assessed key attributes of the hypertension surveillance system at Kenema Government Hospital, Kenema District, Sierra Leone. We administered semistructured questionnaires; reviewed hospital registers, patient charts, and the District Health Information Software database; and rated the implementation status of each attribute as poor (1-3), average (4-6), or good (7-10). Of the 7 attributes, simplicity, flexibility, and acceptability were good; stability was average, but timeliness, sensitivity, and data quality were poor. Overall, the usefulness of the hypertension surveillance system was poor, as it did not monitor hypertension trends, nor was it linked to public health action.

Extending and Strengthening Routine DHIS2 Surveillance Systems for COVID-19 Responses in Sierra Leone, Sri Lanka, and Uganda.

The COVID-19 pandemic challenged countries to protect their populations from this emerging disease. One aspect of that challenge was to rapidly modify national surveillance systems or create new systems that would effectively detect new cases of COVID-19. Fifty-five countries leveraged past investments in District Health Information Software version 2 (DHIS2) to quickly adapt their national public health surveillance systems for COVID-19 case reporting and response activities. We provide background on DHIS2 and describe case studies from Sierra Leone, Sri Lanka, and Uganda to illustrate how the DHIS2 platform, its community of practice, long-term capacity building, and local autonomy enabled countries to establish an effective COVID-19 response. With these case studies, we provide valuable insights and recommendations for strategies that can be used for national electronic disease surveillance platforms to detect new and emerging pathogens and respond to public health emergencies.

Response to Mass-Casualty Incidents and Outbreaks: A Prehospital Disaster Training Package Developed for the National Emergency Medical Service in Sierra Leone.

Sierra Leone is a country highly prone to disasters, still recovering from the catastrophic 2014 Ebola epidemic. In 2018, the country launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the direct supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) to be delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center. This on-going training package represents the first Disaster Medicine training course for prehospital health professionals in Sierra Leone.

Estimation of Ebola's spillover infection exposure in Sierra Leone based on sociodemographic and economic factors.

Zoonotic diseases spread through pathogens-infected animal carriers. In the case of Ebola Virus Disease (EVD), evidence supports that the main carriers are fruit bats and non-human primates. Further, EVD spread is a multi-factorial problem that depends on sociodemographic and economic (SDE) factors. Here we inquire into this phenomenon and aim at determining, quantitatively, the Ebola spillover infection exposure map and try to link it to SDE factors. To that end, we designed and conducted a survey in Sierra Leone and implement a pipeline to analyze data using regression and machine learning techniques. Our methodology is able (1) to identify the features that are best predictors of an individual's tendency to partake in behaviors that can expose them to Ebola infection, (2) to develop a predictive model about the spillover risk statistics that can be calibrated for different regions and future times, and (3) to compute a spillover exposure map for Sierra Leone. Our results and conclusions are relevant to identify the regions in Sierra Leone at risk of EVD spillover and, consequently, to design and implement policies for an effective deployment of resources (e.g., drug supplies) and other preventative measures (e.g., educational campaigns).

Achieving Minimum Standards for Infection Prevention and Control in Sierra Leone: Urgent Need for a Quantum Leap in Progress in the COVID-19 Era!

INTRODUCTION: Good Infection prevention and control (IPC) is vital for tackling antimicrobial resistance and limiting health care-associated infections. We compared IPC performance before (2019) and during the COVID-19 (2021) era at the national IPC unit and all regional (4) and district hospitals (8) in Sierra Leone. METHODS: Cross-sectional assessments using standardized World Health Organizations IPC checklists. IPC performance scores were graded as inadequate = 0-25%, basic = 25.1-50%, intermediate = 50.1-75%, and advanced = 75.1-100%. RESULTS: Overall performance improved from 'basic' to 'intermediate' at the national IPC unit (41% in 2019 to 58% in 2021) and at regional hospitals (37% in 2019 to 54% in 2021) but remained 'basic' at district hospitals (37% in 2019 to 50% in 2021). Priority gaps at the national IPC unit included lack of: a dedicated IPC budget, monitoring the effectiveness of IPC trainings and health care-associated infection surveillance. Gaps at hospitals included no assessment of hospital staffing needs, inadequate infrastructure for IPC and lack of a well-defined monitoring plan with clear goals, targets and activities. CONCLUSION: Although there is encouraging progress in IPC performance, it is slower than desired in light of the COVID-19 pandemic. There is urgent need to mobilize political will, leadership and resources and make a quantum leap forward.

Epidemiological Trends of Coronavirus Disease 2019 in Sierra Leone From March 2020 to October 2021.

Coronavirus disease 2019 (COVID-19), a serious public health challenge the world over, has led to significant health concerns in Sierra Leone. In the present study, epidemic indices, such as the number of cases, positivity rate, reproduction rate (R0), case fatality rate (CFR), age, and sex, were used to characterize the epidemiological trends of COVID-19. As of October 31, 2021, a total of 6,398 cases and 121 related deaths had been confirmed. The total number of COVID-19 reverse transcription polymerase chain reaction (RT-PCR) tests conducted to October 31, 2021, was 249,534, and the average positivity rate was 2.56%. Three waves of COVID-19 were recorded, occurring during weeks 15-46 in 2020 (2,369 cases), week 47 in 2020 to week 16 in 2021 (1,665 cases), and weeks 17-43 in 2021 (2,364 cases), respectively. Remarkably, there was no increase in the numbers of confirmed COVID-19 cases despite rising test numbers throughout the three waves. Moreover, three high R0 values were observed before each wave. The number of positive cases significantly correlated with positive numbers of international arrivals (P < 0.01), deaths (P < 0.01), and the positivity rate of tested samples (P < 0.01). Moreover, all of the deaths occurred during the peak of the three waves. Our results indicate that there was a low level of COVID-19 epidemic in Sierra Leone and that COVID-19's introduction led to local transmission. It is vital to fight against the spread of SARS-CoV-2 from the source of origin by strengthening testing and management of people entering the country. Our findings will provide important clues for expanding sample screening and will contribute to the reasonable allocation of medical resources.

Pesticide Importation in Sierra Leone, 2010-2021: Implications for Food Production and Antimicrobial Resistance.

There are no previous studies reporting the type and quantity of pesticides for farming from Sierra Leone and the impact of Ebola or COVID-19 on importation. This study reviewed imported farming pesticides by the Sierra Leone, Ministry of Agriculture and Forestry (MAF), between 2010-2021. It was a descriptive study using routinely collected importation data. We found the MAF imported pesticides for farming only during 2010, 2014 and 2021, in response to growing food insecurity and associated with Ebola and COVID-19 outbreaks. Results showed insecticide importation increased from 6230 L in 2010 to 51,150 L in 2021, and importation of antimicrobial pesticides (including fungicides) increased from 150 kg in 2010 to 23,560 kg in 2021. The hazard class risk classification of imported pesticides decreased over time. Increasing amounts of imported fungicides could increase the risk of future fungal resistance among humans. We found that in responding to escalating food insecurity, the government dramatically increased the amount of pesticide importation to improve crop production. Further support is necessary to decrease the risk of worsening food shortages and the possible threat of emerging antimicrobial resistance. We recommend continued monitoring and surveillance, with further studies on the most appropriate response to these multiple challenges.

Beyond Lassa Fever: Systemic and structural barriers to disease detection and response in Sierra Leone.

BACKGROUND: Lassa fever (LF) often presents clinically as undifferentiated febrile illness. Lassa Fever cases in Sierra Leone have been falling since the 2014-2016 Ebola epidemic. Data from other LF endemic countries suggest that this is not a true reflection of local epidemiological decline, but rather a function of either health seeking behaviour or the health/referral system. In Sierra Leone, many other diseases present with a similar early clinical picture, including COVID-19 and Marburg Disease (which has recently emerged in neighbouring Guinea). This empirical study explores the implementation of health system processes associated with International Health Regulations (IHR) requirements for early detection and timely and effective responses to the spread of febrile disease, through the case study of LF in Sierra Leone. METHODOLOGY/PRINCIPAL FINDINGS: This study used a qualitative approach to analyse local policy and guidance documents, key informant interviews with policy and practice actors, and focus group discussions and in-depth interviews with health care workers (HCWs) and community health workers (CHWs) in Kenema District to examine the ways in which undifferentiated fever surveillance and response policies and processes were implemented in the post-Ebola period. Multiple challenges were identified, including: issues with the LF case definition, approaches to differential diagnosis, specimen transport and the provision of results, and ownership of laboratory data. These issues lead to delays in diagnosis, and potentially worse outcomes for individual patients, as well as affecting the system's ability to respond to outbreak-prone disease. CONCLUSIONS/SIGNIFICANCE: Identification of ways to improve the system requires balancing vertical disease surveillance programmes against other population health needs. Therefore, health system challenges to early identification of LF specifically have implications for the effectiveness of the wider Integrated Disease Surveillance and Response (IDSR) system in Sierra Leone more generally. Sentinel surveillance or improved surveillance at maternity facilities would help improve viral haemorrhagic fever (VHF) surveillance, as well as knowledge of LF epidemiology. Strengthening surveillance for vertical disease programmes, if correctly targeted, could have downstream benefits for COVID-19 surveillance and response as well as the wider health system-and therefore patient outcomes more generally.

Incidence of Surgical Site Infection and Use of Antibiotics among Patients Who Underwent Caesarean Section and Herniorrhaphy at a Regional Referral Hospital, Sierra Leone.

Surgical site infections (SSIs) are common postoperative complications. Surgical antibiotic prophylaxis (SAP) can prevent the occurrence of SSIs if administered appropriately. We carried out a retrospective cohort study to determine the incidence of SSIs and assess whether SAP were administered according to WHO guidelines for Caesarean section (CS) and herniorrhaphy patients in Bo regional government hospital from November 2019 to October 2020. The analysis included 681 patients (599 CSs and 82 herniorrhaphies). Overall, the SSI rate was 6.7% among all patients, and 7.5% and 1.2% among CS patients and herniorrhaphy patients, respectively. SAP was administered preoperatively in 85% of CS and 70% of herniorrhaphy patients. Postoperative antibiotics were prescribed to 85% of CS and 100% of herniorrhaphy patients. Ampicillin, metronidazole, and amoxicillin were the most commonly used antibiotics. The relatively low rate of SSIs observed in this study is probably due to improved infection prevention and control (IPC) measures following the Ebola outbreak and the current COVID-19 pandemic. A good compliance rate with WHO guidelines for preoperative SAP was observed. However, there was a high use of postoperative antibiotics, which is not in line with WHO guidelines. Recommendations were made to ensure the appropriate administration of SAP and reduce unnecessary use of antibiotics.

Has Ebola delayed progress on access to routine care and financial protection in Sierra Leone? Evidence from a difference-in-differences analysis with propensity score weighting.

INTRODUCTION: Covid-19 has highlighted the need to understand the long-term impact of epidemics on health systems. There is extensive evidence that the Ebola epidemic of 2014-16 dramatically reduced coverage of key reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators during the period of acute crisis in Sierra Leone. However, less is known about the longer lasting effects, and whether patients continue to be deterred from seeking care either through fear or cost some years after the end of the epidemic METHODS: We analysed nationally representative household surveys from before (2011) and after (2018) the Ebola epidemic to estimate the coverage of 11 indicators of access to RMNCAH, and affordability of care. We used a differences-in-differences analysis, exploiting the variation in epidemic intensity across chiefdoms, to identify the effect of epidemic intensity on access and affordability outcomes, with propensity score weighting to adjust for differences in underlying characteristics between chiefdoms. RESULTS: 13537 households were included across both datasets. Epidemic intensity was associated with a significant stalling in progress (-12.2 percentage points, 95% CI: 23.2 to -1.3, p = 0.029) in the proportion of births attended by a skilled provider. Epidemic intensity did not have a significant impact on any other indicator. CONCLUSION: While there is evidence that chiefdoms which experienced worse Ebola outbreaks had poorer coverage of attendance of skilled providers at birth than would have otherwise been expected, more broadly the intensity of the epidemic did not impact on most indicators. This suggests the measures to restore both staffing and trust were effective in supporting the health system to recover from Ebola.

Infection Prevention and Control in Three Tertiary Healthcare Facilities in Freetown, Sierra Leone during the COVID-19 Pandemic: More Needs to Be Done!

Infection Prevention and Control (IPC) measures are critical to the reduction in healthcare-associated infections, especially during pandemics, such as that of COVID-19. We conducted a hospital-based cross-sectional study in August 2021 at Connaught Hospital, Princess Christian Maternity Hospital and Ola During Children's Hospital located in Freetown, Sierra Leone. We used the World Health Organization's Infection Prevention and Control Assessment Framework Tool to assess the level of IPC compliance at these healthcare facilities. The overall IPC compliance score at Connaught Hospital was 323.5 of 800 points, 313.5 of 800 at Ola During Children's Hospital, 281 of 800 at Princess Christian Maternity Hospital, implying a 'Basic' IPC compliance grade. These facilities had an IPC program, IPC committees and dedicated IPC focal persons. However, there were several challenges, including access to safe and clean water and insufficient quantities of face masks, examination gloves and aprons. Furthermore, there was no dedicated budget or no healthcare-associated infection (HAI) surveillance, and monitoring/audit of IPC practices were weak. These findings are of concern during the COVID-19 era, and there is an urgent need for both financial and technical support to address the gaps and challenges identified.

Culture Requests and Multi-Drug Resistance among Suspected Urinary Tract Infections in Two Tertiary Hospitals in Freetown, Sierra Leone (2017-21): A Cross-Sectional Study.

In sub-Saharan Africa, there is limited information about the use of microbiology laboratory services in patients with suspected urinary tract infections (UTIs). This cross-sectional study assessed the requests for urine culture in patients with suspected UTI in two tertiary (maternal and paediatric) hospitals-Freetown and Sierra Leone, during May 2017-May 2021-and determined antimicrobial resistance (AMR) patterns among bacterial isolates. One laboratory served the two hospitals, with its electronic database used to extract information. Overall, there were 980 patients, of whom 168 (17%) had cultures requested and performed. Of these, 75 (45%) were culture positive. During 2017-2019, there were 930 patients, of whom 156 (17%) had cultures performed. During 2020-2021, when services were disrupted by the COVID-19 pandemic, there were 50 patients, of whom 12 (24%) had cultures performed. The four commonest isolates were Escherichia coli (36), Klebsiella pneumoniae (10), Staphylococcus aureus (9), and Pseudomonas spp. (6). There were high levels of AMR, especially for trimethoprim-sulfamethoxazole (47%), nalidixic acid (44%), nitrofurantoin (32%) and cefotaxime (36%). Overall, 41 (55%) bacterial isolates showed multidrug resistance, especially E. coli (58%), Pseudomonas spp. (50%), and S. aureus (44%). These findings support the need for better utilization of clinical microbiology services to guide antibiotic stewardship and monitoring of trends in resistance patterns.

Social and health factors associated with adverse treatment outcomes among people with multidrug-resistant tuberculosis in Sierra Leone: a national, retrospective cohort study.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is a global health emergency. We aimed to evaluate treatment outcomes among people with MDR-TB in Sierra Leone and investigate social and health factors associated with adverse treatment outcomes. METHODS: This national, retrospective cohort study recruited all people notified with MDR-TB to the Sierra Leone National TB Programme, admitted to Lakka hospital (Lakka, Western Area Rural District, Freetown, Sierra Leone) between April, 2017, and September, 2019. Participants were followed up to May, 2021. People who were eligible but had no social or health data available, or were subsequently found to have been misdiagnosed, were excluded from participation. MDR-TB treatment was with the 2017 WHO-recommended short (9-11 month) or long (18-24 month) aminoglycoside-containing regimens. Multivariable logistic regression models examined associations of programmatic social and health data with WHO-defined adverse treatment outcomes (death, treatment failure, loss to follow-up). FINDINGS: Of 370 notified MDR-TB cases, 365 (99%) were eligible for study participation (five participants were excluded due to lack of social or health data or misdiagnosis). Treatment was started by 341 (93%) of 365 participants (317 received the short regimen, 24 received the long regimen, and 24 received no treatment). Median age was 35 years (IQR 26-45), 263 (72%) of 365 were male and 102 (28%) were female, 71 (19%) were HIV-positive, and 127 (35%) were severely underweight (body-mass index <16·5 kg/m2). Overall, 267 (73%) of 365 participants had treatment success, 95 (26%) had an adverse outcome, and three (1%) were still on treatment in May, 2021. Age 45-64 years (adjusted odds ratio [aOR] 2·4, 95% CI 1·2-5·0), severe underweight (aOR 4·2, 1·9-9·3), untreated HIV (aOR 10, 2·6-40·0), chronic lung disease (aOR 2·0, 1·0-4·2), previously unsuccessful drug-sensitive tuberculosis retreatment (aOR 4·3, 1·0-19), and a long regimen (aOR 6·5, 2·3-18·0) were associated with adverse outcomes. A sensitivity analysis showed that prothionamide resistance (aOR 3·1, 95% CI 1·5-10·0) and aminoglycoside-related complete deafness (aOR 6·6, 1·3-35) were independently associated with adverse outcomes. INTERPRETATION: MDR-TB treatment success in Sierra Leone approached WHO targets and the short regimen was associated with higher success. The social and health factors associated with adverse outcomes in this study suggest a role for integrated tuberculosis, HIV, and non-communicable disease services alongside nutritional and socioeconomic support for people with MDR-TB and emphasise the urgent need to scale up coverage of all-oral aminoglycoside-sparing regimens. FUNDING: Wellcome Trust, Joint Global Health Trials.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy.

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

Qualitative evidence syntheses of attitudes and preferences to inform guidelines on infant feeding in the context of Ebola Virus Disease (EVD) transmission risk.

BACKGROUND: Breast-feeding holds considerable potential to reduce infant mortality. Feeding choices, already complex, take on additional complexity against a backdrop of the risk of transmissible Ebola Virus. This review describes the factors that influence infant feeding and attitudes of pregnant women, mothers, family members and health practitioners, policy makers and providers (midwives) concerning infant feeding when there is a risk of Mother-to-Child (MTC) transmission of Ebola Virus Disease (EVD). METHODOLOGY: A systematic review of qualitative studies identified through rigorous searches of thirteen online databases and additional citation searches of included studies was undertaken. Search terms included breast-feeding, breast-feeding, infant feeding; Ebola; and qualitative, interview(s) and findings. Independent extraction of data by two reviewers using predefined extraction forms. Studies were assessed using the CASP Qualitative checklist. PRINCIPAL FINDINGS: 5219 references were screened. 38 references related specifically to Ebola, and five papers met the inclusion criteria with data gathered from two settings: Guinea and Sierra Leone. The EVD outbreak had a significant impact on beliefs, attitudes, and resources to support infant feeding practices negatively affecting the nutritional status of children. The evidence from these studies highlight the need for guidance and appropriate psychosocial support need to be available to mothers who display symptoms and become infected and to front-line staff who are giving advice. Communities need to be engaged because stigma and fear may hinder uptake of appropriate interventions. The EVD outbreak caused multi-level system disruption akin to that seen following a natural disaster, meaning that logistics and coordination are critical and need adequate resourcing. Food production and distribution, and malnutrition screening are also disrupted and thereby compounding compromised nutritional status. The limited number of relevant studies highlights the need for further primary research, particularly in translation of messages to local settings. CONCLUSIONS: An EVD outbreak causes multi-level disruption that negatively impacts infant feeding and child care practices. Negative impacts have multiple causes and successful planning for Ebola outbreaks requires that nutrition of infants and young children is a priority. Lessons from the Ebola pandemic have wider applicability to other pandemic contexts including Covid-19.

Applying the WHO-ICRC BEC course to train emergency and inpatient healthcare workers in Sierra Leone early in the COVID-19 outbreak.

BACKGROUND: Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross's Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services. METHODS: We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants "very comfortable" with course skills using paired Student's t-tests and McNemar's exact tests, respectively. RESULTS: We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were "very comfortable" performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19. CONCLUSIONS: This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale.

Health-related quality of life among Ebola survivors in Sierra Leone: the role of socio-demographic, health-related and psycho-social factors.

BACKGROUND: Evidence of how social factors affect the health-related quality of life (HRQoL) of Ebola virus disease (EVD) survivors is limited. Our study explores the association between socio-demographic, health-related and psycho-social (stigma) factors and EVD survivors' health-related quality of life (HRQoL) in Sierra Leone. METHODS: We conducted a nationwide cross-sectional study among 358 EVD survivors between January and August 2018. We used a multistage sampling method to recruit EVD survivors, and the RAND 36-Item Health Survey item was used to assess the HRQoL. Data were analysed using descriptive statistics and multiple linear regression. RESULTS: When comparing by each dimension in relation to their respective summary scores, role limitation physical [0.00 (50.00)] and role limitation emotional [0.00 (33.33)] were the most affected physical health and mental health domains among EVD survivors respectively. EVD survivors who were older (ß = - 3.90, 95% CI - 6.47 to - 1.32, p = 0.003), had no formal education (ß = - 2.80, 95% CI - 5.16 to - 0.43, p = 0.021), experienced a unit increase in the number of post-Ebola symptoms (ß = - 1.08, 95% CI - 1.74 to - 0.43, p < 0.001) and experienced a unit increase in enacted stigma (ß = - 2.61, 95% CI - 4.02 to - 1.20, p < 0.001) were more likely to report a decreased level of physical health. EVD survivors who experienced a unit increase in the time spent in the Ebola treatment centre (ß = - 0.60, 95% CI - 0.103 to - 0.18, p = 0.006) and those who experienced a unit increase in enacted Stigma were more likely to report decreased levels of mental health (ß = - 1.50, 95% CI - 2.67 to - 0.33, p = 0.012). CONCLUSION: Sociodemographic, health-related, and psycho-social factors were significantly associated with decrease levels of HRQoL. Our findings improve our understanding of the factors that might influence the HRQoL and suggest the need for EVD survivors to be provided with a comprehensive healthcare package that caters for their physical and mental health needs.