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Freetown, Sierra Leone

Bolkan H.A.,Norwegian University of Science and Technology | Von Schreeb J.,Karolinska Institutet | Samai M.M.,University of the Sierra | Bash-Taqi D.A.,Ministry of Health and Sanitation | And 4 more authors.
Surgery (United States) | Year: 2015

Background Understanding a country's baseline operative actors and capacity is critical to improving the quality of services and outcomes. The aim of this study was to describe all operative providers and national operative production, to evaluate district and nationwide population rates for operations, and to estimate unmet operative need in Sierra Leone. Methods A nationwide, exhaustive, retrospective, facility-based study of operative actors and surgical procedures was performed in Sierra Leone. Between January and May 2013, 4 teams of 12 medical students collected data on the characteristics of the institutions and of the operations performed in 2012. Data were retrieved from the log books of operations, anesthesia, and delivery. Results A total of 24,152 operative procedures were identified, equal to a national rate of 400 operative procedures per 100,000 inhabitants (district range 32-909/100,000, interquartile range 95-502/100,000). Hernia repair was the most common operative procedure at 86.1 per 100,000 inhabitants (22.4% of the total national volume) followed by cesarean delivery at 80.6 per 100,000 (21.0% of the total). Private, nonprofit facilities performed 54.0% of the operations, compared with 39.6% by governmental and 6.4% by private for-profit facilities. More than 90% of the estimated operative need in Sierra Leone was unmet in 2012. Conclusion The unmet operative need in Sierra Leone is very high. The 30-fold difference in operative output between districts also is very high. As the main training institution, operative services within the governmental sector need to be strengthened. An understanding of the existing operative platform is a good start for expanding operative services. © 2015 Elsevier Inc. All rights reserved.

Lado M.,Kings College London | Walker N.F.,Kings College London | Walker N.F.,Imperial College London | Walker N.F.,University of Cape Town | And 16 more authors.
The Lancet Infectious Diseases | Year: 2015

Background: The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. Methods: In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospital's Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. Results: Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. Interpretation: Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. Funding: None. © 2015 Elsevier Ltd.

Gerstl S.,Medecins Sans Frontieres | Dunkley S.,Medecins Sans Frontieres | Mukhtar A.,Medecins Sans Frontieres | Baker S.,Ministry of Health and Sanitation | Maikere J.,Medecins Sans Frontieres
Transactions of the Royal Society of Tropical Medicine and Hygiene | Year: 2010

A study to measure adherence to artesunate and amodiaquine (AS+AQ) therapy in patients treated for uncomplicated malaria in community health centres (CHC) was conducted in Sierra Leone. Patients/caretakers were interviewed and remaining AS+AQ tablets at home after the last treatment dose were counted. Persons leaving CHCs with an AS+AQ prescription were also interviewed (exit interviews). In total, 118 patients were visited at home: 27 (22.9%) had one or more tablets left and were classed as certainly non-adherent; 34 (28.8%) were probably non-adherent [reported incorrect (n=27) or incomplete (n=7) intake]; and 57 (48.3%) were probably adherent. The main reasons for incomplete intake were sickness after one dose of AS+AQ, no food available for drug intake and forgetting to take them. For incorrect intake, reasons were vomiting after drug intake and incorrect instructions given by the CHC. Eighty-one percent of probably adherent patients reported following instructions given to them. In exit interviews, 82% of patients or caretakers of patients were able to repeat AS+AQ intake instructions correctly. Adherence to antimalarial treatment should not be taken for granted. Instructions on correct AS+AQ use should include discussion of disease symptoms as well as possible treatment side effects and how to manage them. Other factors are more difficult to influence, such as patients forgetting to take the treatment. © 2010 Royal Society of Tropical Medicine and Hygiene.

Gerstl S.,Medecins Sans Frontieres | Dunkley S.,Medecins Sans Frontieres | Mukhtar A.,Medecins Sans Frontieres | De Smet M.,Medecins Sans Frontieres | And 2 more authors.
Malaria Journal | Year: 2010

Background. Most malaria rapid diagnostic tests (RDTs) use HRP2 detection, including Paracheck-Pf, but their utility is limited by persistent false positivity after treatment. PLDH-based tests become negative more quickly, but sensitivity has been reported below the recommended standard of 90%. A new pLDH test, CareStart three-line P.f/PAN-pLDH, claims better sensitivity with continued rapid conversion to negative. The study aims were to 1) compare sensitivity and specificity of CareStart to Paracheck-Pf to diagnose falciparum malaria in children under five years of age, 2) assess how quickly false-positive CareStart tests become negative and 3) evaluate ease of use and inter-reader agreement of both tests. Methods. Participants were included if they were aged between two and 59 months, presenting to a Médecins Sans Frontières community health centre in eastern Sierra Leone with suspected malaria defined as fever (axillary temperature > 37.5°C) and/or history of fever in the previous 72 hours and no signs of severe disease. The same capillary blood was used for the RDTs and the blood slide, the latter used as the gold standard reference. All positive participants were treated with supervised artesunate and amodiaquine treatment for three days. Participants with a persistent false-positive CareStart, but a negative blood slide on Day 2, were followed with repeated CareStart and blood slide tests every seven days until CareStart became negative or a maximum of 28 days. Results. Sensitivity of CareStart was 99.4% (CI 96.8-100.0, 168/169) and of Paracheck-Pf, 98.8% (95% CI 95.8-99.8, 167/169). Specificity of CareStart was 96.0% (CI 91.9-98.4, 167/174) and of Paracheck-Pf, 74.7% (CI 67.6-81.0, 130/174) (p < 0.001). Neither test showed any change in sensitivity with decreasing parasitaemia. Of the 155 eligible follow-up CareStart participants, 63.9% (99/155) had a false-positive test on day 2, 21.3% (33/155) on day 7, 5.8% (9/155) on day 14, 1.9% (3/155) on day 21 and 0.6% (1/155) on day 28. The median time for test negativity was seven days. CareStart was as easy to use and interpret as Paracheck-Pf with excellent inter-reader agreement. Conclusions. Both RDTs were highly sensitive, met WHO standards for the detection of falciparum malaria monoinfections where parasitaemia was 100 parasites/l and were easy to use. CareStart persistent false positivity decreased quickly after successful anti-malarial treatment, making it a good choice for a RDT for a hyperendemic falciparum malaria area. © 2010 Gerstl et al; licensee BioMed Central Ltd.

de Souza D.K.,University of Ghana | Sesay S.,Ministry of Health and Sanitation | Moore M.G.,Ministry of Health and Social Welfare | Ansumana R.,Mercy Hospital Research Laboratory | And 9 more authors.
PLoS Neglected Tropical Diseases | Year: 2014

Background:In West Africa, the principal vectors of lymphatic filariasis (LF) are Anopheles species with Culex species playing only a minor role in transmission, if any. Being a predominantly rural disease, the question remains whether conflict-related migration of rural populations into urban areas would be sufficient for active transmission of the parasite.Methodology/Principal Findings:We examined LF transmission in urban areas in post-conflict Sierra Leone and Liberia that experienced significant rural-urban migration. Mosquitoes from Freetown and Monrovia, were analyzed for infection with Wuchereria bancrofti. We also undertook a transmission assessment survey (TAS) in Bo and Pujehun districts in Sierra Leone. The majority of the mosquitoes collected were Culex species, while Anopheles species were present in low numbers. The mosquitoes were analyzed in pools, with a maximum of 20 mosquitoes per pool. In both countries, a total of 1731 An. gambiae and 14342 Culex were analyzed for W. bancrofti, using the PCR. Two pools of Culex mosquitoes and 1 pool of An. gambiae were found infected from one community in Freetown. Pool screening analysis indicated a maximum likelihood of infection of 0.004 (95% CI of 0.00012-0.021) and 0.015 (95% CI of 0.0018-0.052) for the An. gambiae and Culex respectively. The results indicate that An. gambiae is present in low numbers, with a microfilaria prevalence breaking threshold value not sufficient to maintain transmission. The results of the TAS in Bo and Pujehun also indicated an antigen prevalence of 0.19% and 0.67% in children, respectively. This is well below the recommended 2% level for stopping MDA in Anopheles transmission areas, according to WHO guidelines.Conclusions:We found no evidence for active transmission of LF in cities, where internally displaced persons from rural areas lived for many years during the more than 10 years conflict in Sierra Leone and Liberia. © 2014 de Souza et al.

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