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1.
Int J Environ Res Public Health ; 19(7)2022 Mar 28.
Article in English | MEDLINE | ID: covidwho-1771195

ABSTRACT

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.


Subject(s)
COVID-19 , Anti-Bacterial Agents/therapeutic use , Azithromycin , COVID-19/drug therapy , COVID-19/epidemiology , Ceftriaxone , Cross-Sectional Studies , Health Facilities , Humans , Metronidazole , Pandemics , Policy , Sierra Leone/epidemiology
2.
Int J Environ Res Public Health ; 19(6)2022 03 10.
Article in English | MEDLINE | ID: covidwho-1765706

ABSTRACT

BACKGROUND: Monitoring of adverse drug reactions (ADRs) to antimicrobials is important, as they can cause life-threatening illness, permanent disabilities, and death. We assessed country-wide ADR reporting on antimicrobials and their outcomes. METHODS: A cross-sectional study was conducted using individual case safety reports (ICSRs) entered into the national pharmacovigilance database (VigiFlow) during 2017-2021. RESULTS: Of 566 ICSRs, inconsistent reporting was seen, with the highest reporting in 2017 and 2019 (mass drug campaigns for deworming), zero reporting in 2018 (reasons unknown), and only a handful in 2020 and 2021 (since COVID-19). Of 566 ICSRs, 90% were for antiparasitics (actively reported during mass campaigns), while the rest (passive reporting from health facilities) included 8% antibiotics, 7% antivirals, and 0.2% antifungals. In total, 90% of the reports took >30 days to be entered (median = 165; range 2-420 days), while 44% had <75% of all variables filled in (desired target = 100%). There were 10 serious ADRs, 18 drug withdrawals, and 60% of ADRs affected the gastrointestinal system. The patient outcomes (N-566) were: recovered (59.5%), recovering (35.5%), not recovered (1.4%), death (0.2%), and unknown (3.4%). There was no final ascertainment of 'recovering' outcomes. CONCLUSIONS: ADR reporting is inconsistent, with delays and incomplete data. This is a wake-up call for introducing active reporting and setting performance targets.


Subject(s)
COVID-19 , Drug-Related Side Effects and Adverse Reactions , Adverse Drug Reaction Reporting Systems , COVID-19/drug therapy , COVID-19/epidemiology , Cross-Sectional Studies , Drug-Related Side Effects and Adverse Reactions/epidemiology , Humans , Sierra Leone
3.
PLoS Negl Trop Dis ; 16(3): e0010080, 2022 03.
Article in English | MEDLINE | ID: covidwho-1736486

ABSTRACT

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.


Subject(s)
COVID-19 , Ebolavirus , Hemorrhagic Fever, Ebola , Attitude , Child, Preschool , Disease Outbreaks , Female , Hemorrhagic Fever, Ebola/epidemiology , Hemorrhagic Fever, Ebola/prevention & control , Humans , Infant , Infectious Disease Transmission, Vertical/prevention & control , Pregnancy , Sierra Leone/epidemiology
4.
BMC Health Serv Res ; 22(1): 197, 2022 Feb 14.
Article in English | MEDLINE | ID: covidwho-1686013

ABSTRACT

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.


Subject(s)
COVID-19 , Disease Outbreaks , Health Personnel , Humans , Inpatients , Pandemics , Prospective Studies , SARS-CoV-2 , Sierra Leone/epidemiology , World Health Organization
5.
BMJ Open ; 12(2): e052972, 2022 02 01.
Article in English | MEDLINE | ID: covidwho-1673434

ABSTRACT

OBJECTIVE: This study aimed to use qualitative interviews with surgical providers to explore challenges and solutions to providing surgical and anaesthesia care in Sierra Leone's hospitals. DESIGN: Data were collected through anonymous, semistructured interviews. We used a qualitative framework approach to analyse interview data and determine themes relating to challenges that were reported. SETTING: A purposive sample of 12 hospitals was selected throughout Sierra Leone to include district and referral hospitals of varying ownership (private, non-governmental organisation and government). PARTICIPANTS: The most senior surgical provider available during each hospital site visit participated in a semistructured interview. A total of 12 interviews were conducted. RESULTS: Providers described both challenges and solutions relating to the following categories: equipment and supplies, access to services, human resources, infrastructure, management and patient factors. These challenges were found to affect surgical care in hospitals by delaying surgical care, decreasing operative capacity and decreasing quality of care. Providers identified not only the root causes of these challenges, but also the varied workarounds and solutions they employ to overcome them. CONCLUSION: Surgical providers can offer important insights into challenges affecting surgical services in hospitals. Despite working in challenging environments with limited resources, providers have developed innovative solutions to improve surgical and anaesthesia care in hospitals in Sierra Leone. Qualitative research has an important role to play in improving understanding of the challenges facing surgeons in low-income countries.


Subject(s)
Anesthesiology , Surgeons , Hospitals , Humans , Qualitative Research , Sierra Leone , Workforce
6.
Lancet Glob Health ; 10(1): e114-e123, 2022 01.
Article in English | MEDLINE | ID: covidwho-1630866

ABSTRACT

BACKGROUND: Sierra Leone's child and maternal mortality rates are among the highest in the world. However, little is known about the causes of premature mortality in the country. To rectify this, the Ministry of Health and Sanitation of Sierra Leone launched the Sierra Leone Sample Registration System (SL-SRS) of births and deaths. Here, we report cause-specific mortality from the first SL-SRS round, representing deaths from 2018 to 2020. METHODS: The Countrywide Mortality Surveillance for Action platform established the SL-SRS, which involved conducting electronic verbal autopsies in 678 randomly selected villages and urban blocks throughout the country. 61 surveyors, in teams of four or five, enrolled people and ascertained deaths of individuals younger than 70 years in 2019-20, capturing verbal autopsies on deaths from 2018 to 2020. Centrally, two trained physicians independently assigned causes of death according to the International Classification of Diseases (tenth edition). SL-SRS death proportions were applied to 5-year mortality averages from the UN World Population Prospects (2019) to derive cause-specific death totals and risks of death nationally and in four Sierra Leone regions, with comparisons made with the Western region where Freetown, the capital, is located. We compared SL-SRS results with the cause-specific mortality estimates for Sierra Leone in the 2019 WHO Global Health Estimates. FINDINGS: Between Sept 1, 2019, and Dec 15, 2020, we enrolled 343 000 people and ascertained 8374 deaths of individuals younger than 70 years. Malaria was the leading cause of death in children and adults, nationally and in each region, representing 22% of deaths under age 70 years in 2020. Other infectious diseases accounted for an additional 16% of deaths. Overall maternal mortality ratio was 510 deaths per 100 000 livebirths (95% CI 483-538), and neonatal mortality rate was 31·1 deaths per 1000 livebirths (95% CI 30·4-31·8), both among the highest rates in the world. Haemorrhage was the major cause of maternal mortality and birth asphyxia or trauma was the major cause of neonatal mortality. Excess deaths were not detected in the months of 2020 corresponding to the peak of the COVID-19 pandemic. Half of the deaths occurred in rural areas and at home. If the Northern, Eastern, and Southern regions of Sierra Leone had the lower death rates observed in the Western region, about 20 000 deaths (just over a quarter of national total deaths in people younger than 70 years) would have been avoided. WHO model-based data vastly underestimated malaria deaths and some specific causes of injury deaths, and substantially overestimated maternal mortality. INTERPRETATION: Over 60% of individuals in Sierra Leone die prematurely, before age 70 years, most from preventable or treatable causes. Nationally representative mortality surveys such as the SL-SRS are of high value in providing reliable cause-of-death information to set public health priorities and target interventions in low-income countries. FUNDING: Bill & Melinda Gates Foundation, Canadian Institutes of Health Research, Queen Elizabeth Scholarship Program.


Subject(s)
Cause of Death , Mortality, Premature , Adolescent , Adult , Aged , COVID-19 , Child , Child Mortality , Child, Preschool , Female , Humans , Infant , Infant Mortality , Infant, Newborn , Malaria/mortality , Male , Maternal Mortality , Middle Aged , Sierra Leone/epidemiology
7.
Health Qual Life Outcomes ; 20(1): 10, 2022 Jan 15.
Article in English | MEDLINE | ID: covidwho-1636480

ABSTRACT

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.


Subject(s)
Hemorrhagic Fever, Ebola , Cross-Sectional Studies , Hemorrhagic Fever, Ebola/epidemiology , Humans , Quality of Life , Sierra Leone/epidemiology , Social Factors , Survivors
8.
Infect Genet Evol ; 98: 105208, 2022 03.
Article in English | MEDLINE | ID: covidwho-1611917

ABSTRACT

Since the beginning of the SARS-CoV-2 pandemic, the emergence of multiple new variants posed an increased risk to global public health. The aim of this study is to investigate SARS-CoV-2 variants and possible transmission of variants of concern (VOCs) in Sierra Leone. A total of 65 nasal swab samples were collected from COVID-19 cases in Sierra Leone, among which 24 samples were collected during the second wave and 41 samples were collected during the third wave. Nanopore sequencing generated 54 SARS-CoV-2 whole genomes. The second COVID-19 wave was mainly caused by R.1 lineage while the third COVID-19 wave was dominated by B.1.617.2 lineage (Delta variant). The phylogenetic analysis suggested multiple introductions of SARS-CoV-2 Delta variant into Sierra Leone and subsequent local transmission in this country. Our findings highlight the importance of genomic surveillance of SARS-CoV-2 variants and the urgent need for implementation of strengthened public health and social measures (PHSM) to control the spread of virus variants.


Subject(s)
COVID-19/genetics , Mutation , SARS-CoV-2/genetics , Genetic Variation , Genotype , Humans , Pandemics , Sierra Leone
9.
Viruses ; 13(11)2021 11 21.
Article in English | MEDLINE | ID: covidwho-1551629

ABSTRACT

Many countries in sub-Saharan Africa have experienced lower COVID-19 caseloads and fewer deaths than countries in other regions worldwide. Under-reporting of cases and a younger population could partly account for these differences, but pre-existing immunity to coronaviruses is another potential factor. Blood samples from Sierra Leonean Lassa fever and Ebola survivors and their contacts collected before the first reported COVID-19 cases were assessed using enzyme-linked immunosorbent assays for the presence of antibodies binding to proteins of coronaviruses that infect humans. Results were compared to COVID-19 subjects and healthy blood donors from the United States. Prior to the pandemic, Sierra Leoneans had more frequent exposures than Americans to coronaviruses with epitopes that cross-react with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), SARS-CoV, and Middle Eastern respiratory syndrome coronavirus (MERS-CoV). The percentage of Sierra Leoneans with antibodies reacting to seasonal coronaviruses was also higher than for American blood donors. Serological responses to coronaviruses by Sierra Leoneans did not differ by age or sex. Approximately a quarter of Sierra Leonian pre-pandemic blood samples had neutralizing antibodies against SARS-CoV-2 pseudovirus, while about a third neutralized MERS-CoV pseudovirus. Prior exposures to coronaviruses that induce cross-protective immunity may contribute to reduced COVID-19 cases and deaths in Sierra Leone.


Subject(s)
Antibodies, Viral/immunology , COVID-19/immunology , Middle East Respiratory Syndrome Coronavirus/immunology , SARS-CoV-2/immunology , Age Distribution , Alphacoronavirus/immunology , Antibodies, Neutralizing/blood , Antibodies, Neutralizing/immunology , Antibodies, Viral/blood , Antigens, Viral/immunology , Betacoronavirus/immunology , Blood Donors , Coronavirus Nucleocapsid Proteins/immunology , Cross Protection , Cross Reactions , Epitopes , Female , Humans , Male , Phosphoproteins/immunology , Sierra Leone , United States
10.
BMC Med Educ ; 21(1): 578, 2021 Nov 15.
Article in English | MEDLINE | ID: covidwho-1526629

ABSTRACT

BACKGROUND: Surgical logbooks are a commonly used tool for quality assurance of surgical training. Electronic logbooks are increasingly applied in low-resource settings, but there is limited research on their quality. The aim of this study is to evaluate the quality of an app-based surgical e-logbook system shortly after its implementation in a low-income country and to identify potential areas of improvement for the system. METHODS: Entries in the e-logbook system were cross-checked with hospital records and categorized as matched or overreported. Moreover, the hospital records were checked for underreported procedures. Additionally, semi-structured interviews were conducted with users of the e-logbook system. RESULTS: A total of 278 e-logbook database entries and 379 procedures in the hospital records from 14 users were analyzed. Matches were found in the hospital records for 67.3% of the database entries. Moreover, 32.7% of the database entries were overreported and 50.7% of the procedures in the hospital records were underreported. A previous study of an analog surgical logbook system in the same setting estimated that 73.1% of the entries were matches or close matches. Interviews with 12 e-logbook users found overall satisfaction but also identified potential areas of improvement, including the need for more training in the use of the system, modifications to improve user-friendliness, and better access to the necessary technology. CONCLUSIONS: A reliable documentation system is necessary to evaluate the quality of health workforce training. The early evaluation of a surgical e-logbook system in a low-income country showed that the collected data should be approached with caution. The quantitative analysis suggests that the e-logbook system needs to be improved in terms of accuracy. In interviews, users reported that digitalization of the logbook system was a much-needed innovation but also identified important areas of improvement. Recognition of these aspects at an early stage facilitates guidance and adjustment of further implementation and might improve the accuracy of the system.


Subject(s)
Documentation , Hospitals , Data Collection , Electronics , Sierra Leone
11.
BMC Public Health ; 21(1): 2066, 2021 11 11.
Article in English | MEDLINE | ID: covidwho-1526618

ABSTRACT

BACKGROUND: During the 2014-15 Ebola Virus Disease (EVD) epidemic, thousands of people in Sierra Leone were infected with the devastating virus and survived. Years after the epidemic was declared over, stigma toward EVD survivors and others affected by the virus is still a major concern, but little is known about the factors that influence stigma toward survivors. This study examines how key personal and ecological factors predicted EVD-related stigma at the height of the 2014-2015 epidemic in Sierra Leone, and the personal and ecological factors that shaped changes in stigma over time. METHODS: Using three waves of survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines factors associated with self-reported personal stigma toward Ebola survivors (11 items, α = 0.77) among 1008 adults (74.6% retention rate) from 63 census enumeration areas of the Western Rural and Western Urban districts of Sierra Leone. Participants were randomly sampled at the height of the EVD epidemic and followed up as the epidemic was waning and once the epidemic had been declared over by the WHO. Three-level mixed effects models were fit using Stata 16 SE to examine cross-sectional associations as well as predictors of longitudinal changes in stigma toward EVD survivors. RESULTS: At the height of the EVD epidemic, female sex, household wealth, post-traumatic stress, EVD-related fear and perceived infection risk are a few of the factors which predicted higher levels of stigma toward survivors. On average, stigma toward EVD survivors decreased significantly as the epidemic declined in Sierra Leone, but female sex, EVD fear, and risk perceptions predicted a slower rate of change. CONCLUSION: This study identified key individual and psychosocial characteristics which may predict higher levels of stigma toward infectious disease survivors. Future studies should pursue a better understanding of how personal characteristics and perceptions, including psychosocial distress, fear, and perceived infection risk serve as pathways for stigma in communities affected by infectious disease.


Subject(s)
Hemorrhagic Fever, Ebola , Adult , Cross-Sectional Studies , Fear , Female , Hemorrhagic Fever, Ebola/epidemiology , Humans , Longitudinal Studies , Prospective Studies , Sierra Leone/epidemiology , Survivors
12.
Viruses ; 13(11)2021 11 21.
Article in English | MEDLINE | ID: covidwho-1524180

ABSTRACT

Many countries in sub-Saharan Africa have experienced lower COVID-19 caseloads and fewer deaths than countries in other regions worldwide. Under-reporting of cases and a younger population could partly account for these differences, but pre-existing immunity to coronaviruses is another potential factor. Blood samples from Sierra Leonean Lassa fever and Ebola survivors and their contacts collected before the first reported COVID-19 cases were assessed using enzyme-linked immunosorbent assays for the presence of antibodies binding to proteins of coronaviruses that infect humans. Results were compared to COVID-19 subjects and healthy blood donors from the United States. Prior to the pandemic, Sierra Leoneans had more frequent exposures than Americans to coronaviruses with epitopes that cross-react with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), SARS-CoV, and Middle Eastern respiratory syndrome coronavirus (MERS-CoV). The percentage of Sierra Leoneans with antibodies reacting to seasonal coronaviruses was also higher than for American blood donors. Serological responses to coronaviruses by Sierra Leoneans did not differ by age or sex. Approximately a quarter of Sierra Leonian pre-pandemic blood samples had neutralizing antibodies against SARS-CoV-2 pseudovirus, while about a third neutralized MERS-CoV pseudovirus. Prior exposures to coronaviruses that induce cross-protective immunity may contribute to reduced COVID-19 cases and deaths in Sierra Leone.


Subject(s)
Antibodies, Viral/immunology , COVID-19/immunology , Middle East Respiratory Syndrome Coronavirus/immunology , SARS-CoV-2/immunology , Age Distribution , Alphacoronavirus/immunology , Antibodies, Neutralizing/blood , Antibodies, Neutralizing/immunology , Antibodies, Viral/blood , Antigens, Viral/immunology , Betacoronavirus/immunology , Blood Donors , Coronavirus Nucleocapsid Proteins/immunology , Cross Protection , Cross Reactions , Epitopes , Female , Humans , Male , Phosphoproteins/immunology , Sierra Leone , United States
13.
BMJ Glob Health ; 6(11)2021 11.
Article in English | MEDLINE | ID: covidwho-1515293

ABSTRACT

INTRODUCTION: As of 26 March 2021, the Africa Centres for Disease Control and Prevention had reported 4 159 055 cases of COVID-19 and 111 357 deaths among the 55 African Union member states; however, no country has published a nationally representative serosurvey as of October 2021. Such data are vital for understanding the pandemic's progression on the continent, evaluating containment measures, and policy planning. METHODS: We conducted a cross-sectional, nationally representative, age-stratified serosurvey in Sierra Leone in March 2021 by randomly selecting 120 Enumeration Areas throughout the country and 10 randomly selected households in each of these. One to two persons per selected household were interviewed to collect information on sociodemographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. Capillary blood was collected by fingerstick, and blood samples were tested using the Hangzhou Biotest Biotech RightSign COVID-19 IgG/IgM Rapid Test Cassette. Total seroprevalence was estimated after applying sampling weights. RESULTS: The overall weighted seroprevalence was 2.6% (95% CI 1.9% to 3.4%). This was 43 times higher than the reported number of cases. Rural seropositivity was 1.8% (95% CI 1.0% to 2.5%), and urban seropositivity was 4.2% (95% CI 2.6% to 5.7%). DISCUSSION: Overall seroprevalence was low compared with countries in Europe and the Americas (suggesting relatively successful containment in Sierra Leone). This has ramifications for the country's third wave (which started in June 2021), during which the average number of daily reported cases was 87 by the end of the month:this could potentially be on the order of 3700 actual infections per day, calling for stronger containment measures in a country with only 0.2% of people fully vaccinated. It may also reflect significant under-reporting of incidence and mortality across the continent.


Subject(s)
COVID-19 , SARS-CoV-2 , Cross-Sectional Studies , Humans , Prevalence , Seroepidemiologic Studies , Sierra Leone/epidemiology
14.
BMJ Glob Health ; 6(11)2021 11.
Article in English | MEDLINE | ID: covidwho-1511466

ABSTRACT

INTRODUCTION: Infectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information. METHODS: The Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding. RESULTS: At baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose-response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people's knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water. CONCLUSION: These results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective. TRIAL REGISTRATION NUMBER: NCT04112680.


Subject(s)
Drama , Communication , Humans , Sierra Leone/epidemiology , Surveys and Questionnaires
15.
PLoS One ; 16(10): e0258252, 2021.
Article in English | MEDLINE | ID: covidwho-1480449

ABSTRACT

BACKGROUND: Vaccine hesitancy is a complex, contested social phenomenon and existing research highlights the multifaceted role of trust in strengthening vaccine confidence. However, understanding public engagement with vaccination through the lens of (mis)trust requires more contextual evidence on trust's qualitative determinants. This includes expanding the geographic focus beyond current studies' focus on High Income Countries. Furthermore, obstacles remain in effectively integrating social science findings in the design of vaccine deployment strategies, and in ensuring that those who implement interventions and are affected by them are directly involved in producing knowledge about vaccination challenges. METHODS: We piloted a community-led ethnographic approach, training Community Health Workers (CHWs) in Kambia District, Sierra Leone, in qualitative social science methods. Methods included participant observation, participatory power mapping and rumour tracking, focus group discussions and key stakeholder interviews. CHWs, with the support of public health officials and professional social scientists, conducted research on vaccination challenges, analysed data, tested new community engagement strategies based on their findings and elicited local perspectives on these approaches. RESULTS: Our findings on vaccine confidence in five border communities highlighted three key themes: the impact of prior experiences with the health system on (mis)trust; relevance of livelihood strategies and power dynamics for vaccine uptake and access; and the contextual nature of knowledge around vaccines. Across these themes, we show how expressions of trust centered on social proximity, reliability and respect and the role of structural issues affecting both vaccine access and confidence. The pilot also highlighted the value and practical challenges to meaningfully co-designed research. CONCLUSION: There is scope for broader application of a community-led ethnographic approach will help redesign programming that is responsive to local knowledge and experience. Involving communities and low-cadre service providers in generating knowledge and solutions can strengthen relationships and sustain dialogue to bolster vaccine confidence.


Subject(s)
Anthropology, Cultural , Biomedical Research , Immunization Programs , Residence Characteristics , Social Behavior , Trust , Vaccination , Focus Groups , Health Personnel , Humans , Sierra Leone , Vaccines/immunology
16.
BMJ Open ; 11(10): e051645, 2021 10 20.
Article in English | MEDLINE | ID: covidwho-1476606

ABSTRACT

OBJECTIVES: Community health workers (CHWs) played important roles in supplementing scarce healthcare workforce in Sierra Leone during the Ebola outbreak, causing the government to launch the National Community Health Worker Policy 2016-2020. This study evaluated this ambitious policy and examined CHWs' sustainability through their job satisfaction and the underlying factors to inform new policy recommendations, especially the implication for COVID-19 containment. DESIGN: A mixed-methods approach applying structured questionnaires and semistructured interviews. SETTING AND PARTICIPANTS: 188 CHWs in Bombali District (key Ebola-stricken areas) of Sierra Leone, 184 of them participated in follow-up interviews. PRIMARY AND SECONDARY OUTCOME MEASURES: Quantitative and qualitative elements were triangulated to improve robustness of investigation: job satisfaction was measured by the Minnesota Satisfaction Questionnaire (MSQ), and factors associated with job satisfaction were identified through thematic analysis and multivariable logistic regression. RESULTS: The MSQ score of CHWs in Sierra Leone was 65.09, extremely low even among low-income and middle-income countries. Five themes (grouped from 16 subthemes) emerged through the semistructured interviews and were tested quantitatively. Payment was CHWs' top concern. Low stipend and payment tardiness were significantly associated with dissatisfaction. Those with Ebola experience were 5.20 times (95% CI 1.51 to 17.95, p=0.009) more likely to be dissatisfied. This study also found that working conditions, medical material supplies and career development were far from what the CHW policy promised. CHWs' commitment was the only 'positive' theme, and their intrinsic job satisfaction (mean=3.61) was much higher than the extrinsic job satisfaction (mean=2.72). CONCLUSIONS: Some critical components of the 2016 National Community Health Worker Policy, aiming to promote CHWs and strengthen primary healthcare, have severe shortfalls in practice. The Sierra Leone government should address the underlying factors that have impaired CHWs' job satisfaction to ensure sustainability of its CHW network, especially during the combat against COVID-19.


Subject(s)
COVID-19 , Hemorrhagic Fever, Ebola , Community Health Workers , Cross-Sectional Studies , Hemorrhagic Fever, Ebola/epidemiology , Hemorrhagic Fever, Ebola/prevention & control , Humans , Job Satisfaction , Qualitative Research , SARS-CoV-2 , Sierra Leone
17.
BMJ Glob Health ; 6(5)2021 05.
Article in English | MEDLINE | ID: covidwho-1476476

ABSTRACT

Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.


Subject(s)
Caregivers , Vaccines , Child , Humans , Immunization , Sierra Leone , Vaccination
18.
BMC Public Health ; 21(1): 1857, 2021 10 14.
Article in English | MEDLINE | ID: covidwho-1465324

ABSTRACT

BACKGROUND: Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior. METHODS: This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data. RESULTS: The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions. CONCLUSION: This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital).


Subject(s)
Hand Disinfection , Soaps , Female , Health Behavior , Humans , Poverty , Sierra Leone
19.
BMJ Glob Health ; 6(10)2021 10.
Article in English | MEDLINE | ID: covidwho-1462948

ABSTRACT

INTRODUCTION: The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS: Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS: From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION: The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.


Subject(s)
COVID-19 , Pandemics , Child , Female , Hospitals , Humans , Male , Pregnancy , SARS-CoV-2 , Sierra Leone/epidemiology
20.
Ann Epidemiol ; 64: 15-22, 2021 12.
Article in English | MEDLINE | ID: covidwho-1439847

ABSTRACT

PURPOSE: In 2015, the Sierra Leone Ministry of Health and Sanitation (MoHS) and the Centers for Disease Control and Prevention (CDC) agreed to consolidate data recorded by MoHS and international partners during the Ebola epidemic and create the Sierra Leone Ebola Database (SLED). The primary objectives were helping families to identify the location of graves of their loved ones who died from any cause at the time of the Ebola epidemic and creating a data source for epidemiological research. The Family Reunification Program fulfills the first SLED objective. The purpose of this paper is to describe the Family Reunification Program (Program) development, functioning, and results. METHODS: The MoHS, CDC, SLED Team, and Concern Worldwide developed, tested, and implemented methodology and tools to conduct the Program. Family liaisons were trained in protection of the personally identifiable information. RESULTS: The SLED Family Reunification Program allows families in Sierra Leone, who did not know the final resting place of their loved ones, to be reunited with their graves and to bring them relief and closure. CONCLUSION: Continuing family requests in search of the burial place of loved ones 5 years after the end of the epidemic shows that the emotional burden of losing a family member and not knowing the place of burial does not diminish with time. As of February 2021, the Program continues and is described to allow its replication for other emergency events including COVID-19 and new Ebola outbreaks.


Subject(s)
COVID-19 , Epidemics , Hemorrhagic Fever, Ebola , Disease Outbreaks , Hemorrhagic Fever, Ebola/epidemiology , Humans , SARS-CoV-2 , Sierra Leone/epidemiology
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