Coverage survey and lessons learned from a pre-emptive cholera vaccination campaign in urban and rural communities affected by landslides and floods in Freetown Sierra Leone.

BACKGROUND: On 14 August 2017, massive landslides and floods hit Freetown (Sierra Leone). More than 1,000 people lost their lives while approximately 6,000 people were displaced. The areas most affected included parts of the town with challenged access to basic water and sanitation facilities, with communal water sources likely contaminated by the disaster. To avert a possible cholera outbreak following this emergency, the Ministry of Health and Sanitation (MoHS), supported by the World Health Organization (WHO) and international partners, including Médecins Sans Frontières (MSF) and UNICEF, launched a two-dose pre-emptive vaccination campaign using Euvichol™, an oral cholera vaccine (OCV). METHODS: We conducted a stratified cluster survey to estimate vaccination coverage during the OCV campaign and also monitor adverse events. The study population - subsequently stratified by age group and residence area type (urban/rural) - included all individuals aged 1 year or older, living in one of the 25 communities targeted for vaccination. RESULTS: In total 3,115 households were visited, 7,189 individuals interviewed; 2,822 (39%) people in rural and 4,367 (61%) in urban areas. The two-dose vaccination coverage was 56% (95% confidence interval (CI): 51.0-61.5), 44% (95%CI: 35.2-53.0) in rural and 57% (95%CI: 51.6-62.8) in urban areas. Vaccination coverage with at least one dose was 82% (95%CI: 77.3-85.5), 61% (95%CI: 52.0-70.2) in rural and 83% (95%CI: 78.5-87.1) in urban areas. CONCLUSIONS: The Freetown OCV campaign exemplified a timely public health intervention to prevent a cholera outbreak, even if coverage was lower than expected. We hypothesised that vaccination coverage in Freetown was sufficient in providing at least short-term immunity to the population. However, long-term interventions to ensure access to safe water and sanitation are needed.

Transitioning the COVID-19 response in the WHO African region: a proposed framework for rethinking and rebuilding health systems.

The onset of the pandemic revealed the health system inequities and inadequate preparedness, especially in the African continent. Over the past months, African countries have ensured optimum pandemic response. However, there is still a need to build further resilient health systems that enhance response and transition from the acute phase of the pandemic to the recovery interpandemic/preparedness phase. Guided by the lessons learnt in the response and plausible pandemic scenarios, the WHO Regional Office for Africa has envisioned a transition framework that will optimise the response and enhance preparedness for future public health emergencies. The framework encompasses maintaining and consolidating the current response capacity but with a view to learning and reshaping them by harnessing the power of science, data and digital technologies, and research innovations. In addition, the framework reorients the health system towards primary healthcare and integrates response into routine care based on best practices/health system interventions. These elements are significant in building a resilient health system capable of addressing more effectively and more effectively future public health crises, all while maintaining an optimal level of essential public health functions. The key elements of the framework are possible with countries following three principles: equity (the protection of all vulnerable populations with no one left behind), inclusiveness (full engagement, equal participation, leadership, decision-making and ownership of all stakeholders using a multisectoral and transdisciplinary, One Health approach), and coherence (to reduce the fragmentation, competition and duplication and promote logical, consistent programmes aligned with international instruments).

After action review of the response to an outbreak of Lassa fever in Sierra Leone, 2019: Best practices and lessons learnt.

BACKGROUND: In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two that were exported to the Netherlands. The outbreak tested multiple technical capacities in the International Health Regulations (2005) in a real-life setting. As such, an after action review (AAR) was undertaken as recommended by World Health Organization. We report on the findings of the AAR including best practices and lessons learnt. METHODS: A two stage review process was employed. The first stage involved national pillar level reviews for each technical pillar and one review of the district level response. The second stage brought together all pillars, including participants from the national and sub-national level as well as health sector partners. National guidelines were used as references during the deliberations. A standardized template was used to report on the key findings on what happened, what was supposed to happen, what went well and lessons learnt. RESULTS: This was a hospital associated outbreak that likely occurred due to a breach in infection prevention and control (IPC) practices resulting in three health workers being infected during a surgical operation. There was a delay in detecting the outbreak on time due to low index of suspicion among clinicians. Once detected, the outbreak response contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Notable gaps included delays in accessing local emergency funding and late distribution of IPC and laboratory supplies. CONCLUSIONS: The incident management system worked optimally to contain this outbreak. The core technical gaps identified in surveillance, IPC and delay in deployment of resources should be addressed through systemic changes that can mitigate future outbreaks.

Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes.

The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.

Prevalence of use of highly concentrated oxytocin or "pepper injection" in labor among clinicians undergoing emergency obstetric training in Sierra Leone.

OBJECTIVE: To examine the awareness, prevalence of use, and knowledge of risks of pepper injection (PI), an injection of highly concentrated oxytocin used to augment or induce labor, among clinicians. METHODS: An anonymous pre- and post-workshop evaluation conducted among 227 clinicians participating in emergency obstetric and newborn care training in Sierra Leone from June to October 2018. RESULTS: Overall, 225 participants completed the surveys. Of these, 198 (88.0%) of clinicians reported awareness of PI, and 123 (54.7%) self-reported prior use, which was highest among midwives (94/129; 72.9%). Before EmONC training, 82 (36.4%) clinicians reported that they were likely to use PI; this decreased to 39 (17.3%) after training (P<0.05). The mean number of participants correctly identifying risks of PI increased from 149 (66.2%) to 204 (90.7%) after training (P<0.05). CONCLUSION: There was widespread awareness of PI use among clinicians, and prevalent self-reported prior use among midwives. Risk awareness improved after EmONC training, and the proportion of clinicians reporting likelihood of future use decreased. Improper use of oxytocin may be a major contributor to maternal and newborn morbidity and mortality in Sierra Leone. Initiatives to educate clinicians and to regulate and stop the practice are needed.

A Public Health Response to a Mudslide in Freetown, Sierra Leone, 2017: Lessons Learnt.

On August 14, 2017, a 6-kilometer mudslide occurred in Regent Area, Western Area District of Sierra Leone following a torrential downpour that lasted 3 days. More than 300 houses along River Juba were submerged; 1141 people were reported dead or missing and 5905 displaced. In response to the mudslide, the World Health Organization (WHO) Country Office in Sierra Leone moved swiftly to verify the emergency and constitute an incident management team to coordinate the response. Early contact was made with the Ministry of Health and Sanitation and health sector partners. A Public Health Emergency Operations Center was set up to coordinate the response. Joint assessments, planning, and response among health sector partners ensured effectiveness and efficiency. Oral cholera vaccination was administered to high-risk populations to prevent a cholera outbreak. Surveillance for 4 waterborne diseases was enhanced through daily reporting from 9 health facilities serving the affected population. Performance standards from the WHO Emergency Response Framework were used to monitor the emergency response. An assessment of the country's performance showed that the country's response was well executed. To improve future response, we recommend enhanced district level preparedness, update of disaster response protocols, and pre-disaster mapping of health sector partners.

Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroon's 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

IgA antibodies to human immunodeficiency virus in serum, saliva and urine for early diagnosis of immunodeficiency virus infection in Ugandan infants.

The value of HIV-1 IgA antibodies for early diagnosis of HIV infection in infants in serum, saliva and urine was investigated at Mulago Hospital, Kampala. Sensitivity and specificity in serum of HIV-infected infants at different ages were: 0 to 1 months, 88 and 95%; 1 to 3 months, 88 and 97%; 4 to 6 months, 80 and 96%. They decreased between 67 and 77% and 80 to 91%, respectively, in older age groups. Sensitivity for saliva was lower (53 to 79%) and urine only 37 to 62%, although specificity was reasonably high (>85%). The high proportion of infants with raised HIV IgA in the first months of life (88%) may represent prenatal infection. Sensitivity of serum and especially salivary and urinary HIV IgA is too low to be of practical value for early diagnosis of HIV infection in infants.