Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data.

INTRODUCTION: Sierra Leone is among the top countries with the highest maternal mortality rates. Although progress has been made in reducing maternal mortality, challenges remain, including limited access to skilled care and regional disparities in accessing quality care. This paper presents the first comprehensive analysis of the burden of different causes of maternal deaths reported in the Maternal Death Surveillance and Response (MDSR) system at the district level from 2016 to 2019. METHODS: The MDSR data are accessed from the Ministry of Health and Sanitation, and the secondary data analysis was done to determine the causes of maternal death in Sierra Leone. The proportions of each leading cause of maternal deaths were estimated by districts. A subgroup analysis of the selected causes of death was also performed. RESULTS: Overall, obstetric haemorrhage was the leading cause of maternal death (39.4%), followed by hypertensive disorders (15.8%) and pregnancy-related infections (10.1%). Within obstetric haemorrhage, postpartum haemorrhage was the leading cause in each district. The burden of death due to obstetric haemorrhage slightly increased over the study period, while hypertensive disorders showed a slightly decreasing trend. Disparities were found among districts for all causes of maternal death, but no clear geographical pattern emerged. Non-obstetric complications were reported in 11.5% of cases. CONCLUSION: The MDSR database provides an opportunity for shared learning and can be used to improve the quality of maternal health services. To improve the accuracy and availability of data, under-reporting must be addressed, and frontline community staff must be trained to accurately capture and report death events.

SARS-CoV-2 seroprevalence and associated factors, based on HIV serostatus, in young people in Sofala province, Mozambique.

INTRODUCTION: In Sofala province (Mozambique), young people living with HIV (YPLHIV) are estimated at 7% among people aged 15-24 years. Even though the COVID-19 pandemic threatened HIV health services, data on the impact of COVID-19 on YPLHIV people are lacking. This study aimed at exploring the seroprevalence of SARS-CoV-2 and associated factors among young people based on their HIV status. METHODS: A cross-sectional study was conducted, including people aged 18-24 attending a visit at one of the adolescent-friendly health services in Sofala province between October and November 2022. People vaccinated against SARS-COV-2 or YPLHIV with WHO stage III-IV were excluded. A SARS-CoV-2 antibodies qualitative test and a questionnaire investigating socio-demographic and clinical characteristics were proposed. SARS-CoV-2 seroprevalence was calculated with Clopper-Pearson method. The odds ratio (OR) of a positive SARS-CoV-2 antibodies test was estimated through multivariable binomial logistic regression. RESULTS: In total, 540 young people including 65.8% women and 16.7% YPLHIV participated in the survey.. The mean age was 20.2 years (SD 2.0). Almost all the sample (96.1%) reported adopting at least one preventive measure for COVID-19. The weighted seroprevalence of SARS-CoV-2 in the whole sample was 46.8% (95%CI 42.6-51.2) and 35.9% (95%CI 25.3-47.5) in YPLHIV. The adjusted OR of testing positive at the SARS-CoV-2 antibodies test was higher in students compared to workers (aOR:2.02[0.95CI 1.01-4.21]) and in those with symptoms (aOR:1.52[0.95CI 1.01-2.30]). There were no differences based on HIV status(aOR:0.663[95%CI 0.406-1.069]). Overall, COVID-19 symptoms were reported by 68 (28.2%) people with a positive serological SARS-CoV-2 test and by 7 (21.7%) YPLHIV (p = 0.527). No one required hospitalization. CONCLUSIONS: SARS-CoV-2 seroprevalence was 46.8% without differences in risk of infection or clinical presentation based on HIV status. This result may be influenced by the exclusion of YPLHIV with advanced disease. The higher risk among students suggests the schools' role in spreading the virus. It's important to continue monitoring the impact of COVID-19 on YPLHIV to better understand its effect on screening and adherence to treatment.

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia.

Introduction: Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes. Methods: An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics. Results: During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively). Conclusion: Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

COVID-19 vaccines and a perspective on Africa.

Vaccines have dramatically changed the COVID-19 pandemic. Over 30 vaccines that were developed on four main platforms are currently being used globally, but a deep dissection of the immunological mechanisms by which they operate is limited to only a few of them. Here, we review the evidence describing specific aspects of the modes of action of COVID-19 vaccines; these include innate immunity, trained innate immunity, and mucosal responses. We also discuss the use of COVID-19 vaccines in the African continent which is ridden with inequality in its access to vaccines and vaccine-related immunological research. We argue that strengthening immunology research in Africa should inform on fundamental aspects of vaccination, including the relevance of genetics, trained innate immunity, and microbiome diversity.

Malaria, HIV and Malnutrition among Internally Displaced People in Mozambique During COVID-19 Pandemic: Results from a Community-Based Intervention.

Background: The spread of COVID-19 poses an unprecedented challenge to care delivery in post-disaster and conflict situations. In Mozambique, the 2019 cyclone Idai and the violence by Non-State-Armed-Groups devastated the province of Sofala and Cabo Delgado respectively and led to the displacement of thousands of people living in poor and overcrowded conditions. The pandemic has further aggravated the situation. Doctors with Africa CUAMM (University college for aspiring missionary doctors) implemented surveillance activities in these regions between October 2020 and September 2021. The aim of this study is to give an overview of the prevalence of malaria, malnutrition, COVID-19 related symptoms and access to HIV testing. Methods: Data were collected in targeted internally displaced people (IDP) sites in Sofala and Cabo Delgado province between 31st January and 25th September 2021. The tool used enabled to assess COVID-19 symptoms, risk of HIV infection, malaria cases and malnutrition in children under five. Results: The project reached 93 503 people. During the study period, 13.6% people reported at least one symptom suggestive of COVID-19 infection. Malaria Rapid Diagnostic Tests (RDT) were administered to 86% of the recruited people (n = ?), with a positive diagnosis in the 4.5% of them (n = ?). Among the recruited Internally Displaced Persons (IDP), 23.1% were considered eligible for HIV screening, but only 1.4% were referred for testing. Acute malnutrition was found in 6.3% of children screened and, among these, a higher prevalence of concurrent COVID-19 symptoms was reported. Discussion: Our study highlights the importance of mass clinical screening for COVID-19 infection in this target population to enact prevention behavior, although this may not be enough, due to the pivotal role played by asymptomatic transmissions. Considering the overlap of the symptoms of COVID-19 and malaria, a combined diagnostic algorithm is urgently needed to avoid underdiagnosing malaria. Moreover, the high prevalence of respiratory symptoms in malnourished children confirmed the known correlation between malnutrition and respiratory infection. Finally, access to HIV screening needs to be implemented, given the high prevalence of people with HIV risk factors to avoid diagnostic delay. Conclusions: Population-specific needs make necessary to develop new screening methods that respond to the specific characteristics of the target population.

High Prevalence of Mental Health Disorders in Adolescents and Youth Living with HIV: An Observational Study from Eight Health Services in Sofala Province, Mozambique.

Adolescent mental health (MH) is a significant global health concern, which is extremely relevant when referring to adolescents and youth living with HIV (AYHIV). In Mozambique, ∼52% of the population is <18 years and the country has the world's eighth highest HIV prevalence (insert citation). We performed an observational study to evaluate anxiety, depression, post-traumatic stress disorder (PTSD) and alcohol-drug abuse in adolescents and youth assessing health services in Sofala Province, Mozambique. From November 20, 2019, to November 20, 2021, all adolescents and youth (10-24 years) accessing one of the psychological services offered at 8 Servicios Amigos dos Adolescentes (SAAJ) of the Sofala Province were screened by a psychologist using the following standardized tools: Generalized Anxiety Disorder-7 (GAD-7) for anxiety, Patient Health Questionnaire-9 (PHQ-9) for depression, Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) for PTSD, and Cut down, Annoyed, Guilty, and Eye-opener Adapted to Include Drugs (CAGE-AID) for alcohol-drug abuse. Overall, 2108 adolescents and youth were included in the study (63% female, median age: 19 years). Of them, 1096 (52%) were HIV positive. AYHIV had higher scores at the four tools tested and for concomitant MH disorders (GAD-7, PHQ-9, PTSD-5, and CAGE). The multivariable logistic regressions showed a greater probability to be GAD-7 > 10 for women, [adjusting odds ratio (AOR): 1.46, 95% confidence interval (CI): 1.01-2.10], for workers (AOR: 2.18, 95% CI: 1.12-4.23) and people living with HIV (AOR: 1.78, 95% CI: 1.25-2.54). Higher values of CAGE (≥2) and PTSD (≥3) seemed to be associated only with HIV-positive status (AOR: 4.87, 95% CI: 3.72-6.38 and AOR: 1.73, 95% CI: 1.28-237). These data further reinforce the urgent need for a global health policy action with focused intervention on MH in AYHIV patients.

Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study.

INTRODUCTION: Sierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality. METHODS: We collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data. RESULTS: At the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%. CONCLUSION: NEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.

Parents' Experience and Satisfaction in Neonatal Intensive Care Units in Ethiopia: A Multicenter Cross-Sectional Study Using an Adapted Version of EMPATHIC-N.

Background: In neonatal intensive care units (NICU) setting, parents' experience and satisfaction permit to evaluate clinical practice and improve the care of infants and parents. Little is known about this topic in low resource settings. The aim of this study was to (1) translate, adapt and validate the EMpowerment of PArents in THe Intensive Care-Neonatology (EMPHATIC-N) questionnaire in two languages in Ethiopia (2) explore parents' satisfaction with the care received in the NICUs in three hospitals; and, (3) explore socio-demographic characteristics and level of the NICU influence on the EMPATHIC-N domains. Methods: This was a cross-sectional multicenter study. Participants were recruited from three different NICUs in Ethiopia upon discharge. We reduced the original EMPATHIC-N instrument to 38 items, culturally adapted and validated it in two local languages. Confirmatory Factor Analysis (CFA) was applied to verify the factor structure of the questionnaire, investigating the relationship between items and the five latent domains. Single item scores and the aggregate scores of the domains were investigated across NICUs and in the sample overall. Differences in the distribution of the domain scores were tested according to socio-demographic participants' characteristics. The scores of four general questions about overall experience and satisfaction were investigated in relation to the participant's characteristics and NICU levels. Qualitative data were collected using four open-ended questions and a synthesis of results was provided. Results: Almost all the parents answered to the questionnaire (92%, n = 386). Questionnaire items on satisfaction on average scored more than four. The highest mean scores were obtained for Parental participation (median: 5.17; iqr: 4.67-5.62), while they were lower for Organization/Hospital environment (median: 4.67; iqr:4.33-5.17). Different levels of parent satisfaction were observed across the NICU levels showing a statistically higher satisfaction in level II NICU compared to the other levels. Education, place of residence and length of stay were associated with parental satisfaction and experience. Conclusion: This study validated two Ethiopian versions of the EMPATHIC-N questionnaire to assess parents' experience and satisfaction during their child's stay in the NICU. The differences found across the three levels of NICU suggest the need to further investigate the determinants of satisfaction.

Determinants of breastfeeding practice in Pujehun district, southern Sierra Leone: a mixed-method study.

BACKGROUND: It is well established that exclusive breastfeeding can play a critical role in reducing child morbidity and mortality. Limited research has been done thus far on the practice and perceptions of breastfeeding in Sierra Leone, where more than 10 % of children die before the age of five. This study aimed to gain understanding into and explore both matters in order to develop recommendations for effective strategies to promote breastfeeding practice in Pujehun District, Southern Sierra Leone. METHODS: This exploratory mixed-method study included a cross-sectional survey of 194 mothers, semi-structured interviews and focus group discussions. Logistic regression analysis was used calculated odds ratios of factors associated with primarily breastfeeding practice, defined as 'Children under six months of age who are fed with breast milk only and children older than six months of age that were exclusively breastfed up to six months', based on recall from birth. Exclusive breastfeeding rate was based on breastfeeding practice 24 h prior to the survey. Qualitative data was analysed through a deductive approach, using a pre-determined framework on determinants of breastfeeding. RESULTS: This study revealed an exclusive breastfeeding rate of 62.8% (95% CI 53.9, 71.7); dropping from 74% in the 0-1-month age group to 33% in the 4-5 months group. Triangulation of qualitative and quantitative data revealed enabling factors for primarily breastfeeding practice included mothers receiving support during their first breastfeed, pregnant women being provided with information on the benefits of the practice, counselling by nurses, support from husbands, and women's awareness of how their friends and family members fed their own babies. The main barriers were a lack of encouragement by husbands, women's perception that their infants' stools were abnormal or that they were not producing enough breast milk. CONCLUSIONS: Although the exclusive breastfeeding may have risen over recent years, a gap remains compared to World Health Organization recommendations. According to the breastfeeding determinants identified in this study, promotion of counselling by a nurse, encouragement of husbands' support, and improve knowledge of mothers on breastfeeding are recommended to be incorporated in the design of future health programs.

Mozambican Adolescents and Youths during the COVID-19 Pandemic: Knowledge and Awareness Gaps in the Provinces of Sofala and Tete.

(1) Background: Mozambique has an average population age of 17 years and adolescents and youths have a pivotal role in SARS-CoV-2 pandemic control. (2) Methods: We conducted a cross-sectional study in order to assess the awareness and information needs with regard to COVID-19 among a sample of adolescents and youths from two different Mozambican provinces. (3) Results: Only 25% of adolescents and youths had a high level of awareness and only 543/2170 participants reported a high level of knowledge regarding COVID-19. In our multivariate model, significant predictors of reporting a high level of knowledge about COVID-19 include female sex (O.R. = 1.47; 95% confidence interval (CI) 1.23-2.89), having a house without a thatched roof (O.R. = 1.85; 95% CI 1.02-2.95) and HIV-positive status (O.R. = 1.56; 95% CI 1.36-2.87). (4) Conclusions: Our study highlights an important and relevant knowledge gap in adolescents and youths with respect to the COVID-19 pandemic. Involving young people and adolescents in the fight against SARS-CoV-2 is an essential strategy, especially in countries where the national average age is young, such as Mozambique, and where this epidemic can aggravate an already fragile health system.

Seroprevalence of hepatitis B and hepatitis C among blood donors in Sierra Leone: A multi-year retrospective study.

OBJECTIVES: In Sierra Leone, very little data are available on hepatitis B virus (HBV) and hepatitis C virus (HCV) prevalence. Blood donor screening permits estimation of the prevalence of transfusion transmissible infections in a general open population. We analyzed blood donor data in Sierra Leone to estimate national viral hepatitis prevalence and identify risk factors for hepatitis infection among the donor population. METHODS: We conducted a retrospective data analysis in five government hospitals. We collected HBV and HCV screening results, donor demographics, and donation type (family replacement or voluntary donor; first-time or repeat). Univariate and multivariate analyses were performed to determine associations between infections and socio-demographic factors. RESULTS: The number of donors screened was 29,713. The overall prevalence was: 10.8% (3200) for HBV and 1.2% (357) for HCV. HBV infection was most strongly associated with male sex (p: <0.0001) and younger age (p: <0.0004 for the 22-27 age group). Both HBV and HCV infection were higher in certain locations. CONCLUSION: Our findings stress the presence of viral hepatitis infection throughout the country and the need to invest in safe blood services, vaccination and treatment of viral hepatitis at the national level.

Analysis of caesarean section and neonatal outcome using the Robson classification in a rural district hospital in Tanzania: an observational retrospective study.

OBJECTIVE: Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania. DESIGN: Observational retrospective study. SETTING: St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania. PARTICIPANTS: 3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015. RESULTS: The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%). CONCLUSION: We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions.

Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: a prospective observational study.

OBJECTIVES: To assess the trends concerning utilisation of maternal and child health (MCH) services before, during and after the Ebola outbreak, quantifying the contribution of a reorganised referral system (RS). DESIGN: A prospective observational study of MCH services. SETTING: Pujehun district in Sierra Leone, 77 community health facilities and 1 hospital from 2012 to 2017. MAIN OUTCOME MEASURES: MCH utililization was evaluated by assessing: (1) institutional deliveries, Cesarean-sections, paediatric and maternity admissions and deaths, and major direct obstetric complications (MDOCs), at hospital level; (2) antenatal care (ANC) 1 and 4, institutional delivery and family planning, at community level. Contribution of a strengthened RS was also measured. RESULTS: At hospital level, there is a significant difference between trends Ebola versus pre-Ebola for maternal admissions (7, 95% CI 4 to 11, p<0.001), MDOCs (4, 95% CI 1 to 7, p=0.006) and institutional deliveries (4, 95% CI 2 to 6, p=0.001). There is also a negative trend in the transition from Ebola to post-Ebola for maternal admissions (-7, 95% CI -10 to -4, p<0.001), MDOCs (-4, 95% CI -7 to -1, p=0.009) and institutional deliveries (-3, 95% CI -5 to -1, p=0.001). The differences between trends pre-Ebola versus post-Ebola are only significant for paediatric admissions (3, 95% CI 0 to 5, p=0.035). At community level, the difference between trends Ebola versus pre-Ebola and Ebola versus post-Ebola are not significant for any indicators. The differences between trends pre-Ebola versus post-Ebola show a negative difference for institutional deliveries (-7, 95% CI -10 to -4, p<0.001), ANC 1 (-6, 95% CI -10 to -3, p<0.001), ANC 4 (-8, 95% CI -11 to -5, p<0.001) and family planning (-85, 95% CI -119 to -51, p<0.001). CONCLUSIONS: A stronger health system compared with other districts in Sierra Leone and a strengthened RS enabled health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic.

Breast Tuberculosis in Women: A Systematic Review.

Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl-Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.