Digitalizing disease surveillance: experience from Sierra Leone.

The Integrated Disease Surveillance and Response (IDSR) system was adopted by the Sierra Leone Ministry of Health (MOH) in 2008, which was based on paper-based tools for health data recording and reporting from health facilities to the national level. The Sierra Leone MoH introduced the implementation of electronic case-based disease surveillance reporting of immediately notifiable diseases. This study aimed to document and describe the experience of Sierra Leone in transforming her paper-based disease surveillance system into an electronic disease surveillance system. Retrospective mixed methods of qualitative and quantitative data were reviewed. Qualitative data was collected by reviewing surveillance technical reports, epidemiological bulletins, COVID-19, IDSR technical guidelines, Digital Health strategy, and DHIS2 documentation. Content and thematic data analysis were performed for the qualitative data, while Microsoft Excel and DHIS2 platform were used for the quantitative data analysis to document the experience of Sierra Leone in digitalizing its disease surveillance system. In early 2017, a web-based electronic Case-Based Disease Surveillance (eCBDS) for real-time reporting of immediately notifiable diseases and health threats was piloted using the District Health Information System 2 (DHIS2) software. The eCBDS, integrates case profile, laboratory, and final outcome data. All captured data and information are immediately accessible to users with the required credentials. The system can be accessed via a browser or an Android DHIS2 application. By 2021, there was a significant increase in the proportion of immediately notifiable cases reported through the facility-level electronic platform, and more than 80% of the cases reported through the weekly surveillance platform had case-based data in eCBDS. Case-based data from the platform is analyzed and disseminated to stakeholders for public health decision-making. Several outbreaks of Lassa fever, Measles, vaccine-derived Polio, and Anthrax have been tracked in real-time through the eCBDS.

Behavioral practices towards antibiotic use among health care workers - Sierra Leone, 2021: a facility-based cross-sectional study.

Introduction: globally, antimicrobial resistance (AMR) kills around 1.27 million 700,000 people each year. In Sierra Leone, there is limited information on antibiotic use among healthcare workers (HCWs). We assessed antibiotic prescribing practices and associated factors among HCWs in Sierra Leone. Methods: we conducted a cross-sectional survey among HCWs. We collected data using a questionnaire containing a Likert scale for antibiotic prescribing practices. We categorized prescribing practices into good and poor practices. We calculated adjusted odds ratios (aOR) to identify risk factors. Results: out of 337 (100%) HCWs, 45% scored good practice. Out of the total, 131 (39%) of HCWS considered fever as an indication of antibiotic resistance and 280 (83%) HCWs prescribed antibiotics without performing microbiological tests and 114 (34%) prescribed a shorter course of antibiotics. Factors associated with good practice were being a doctor (aOR=1.95; CI: 1.07, 3.56), the internet as a source of information (aOR=2.00; CI: 1.10, 3.66), having a high perception that AMR is a problem in the health-facility (aOR=1.80; CI: 1.01, 3.23) and there is a connection between one´s prescription and AMR (aOR=2.15; CI: 1.07, 4.32). Conclusion: this study identified a low level of good practice toward antibiotic prescription. We initiated health education campaigns and recommended continuous professional development programs on antibiotic use.

An Assessment of Medication Errors Among Pediatric Patients in Three Hospitals in Freetown Sierra Leone: Findings and Implications for a Low-Income Country.

Background: Pediatric patients are prone to medicine-related problems like medication errors (MEs), which can potentially cause harm. Yet, this has not been studied in this population in Sierra Leone. Therefore, this study investigated the prevalence and nature of MEs, including potential drug-drug interactions (pDDIs), in pediatric patients. Methods: The study was conducted in three hospitals among pediatric patients in Freetown and consisted of two phases. Phase one was a cross-sectional retrospective review of prescriptions for completeness and accuracy based on the global accuracy score against standard prescription writing guidelines. Phase two was a point prevalence inpatient chart review of MEs categorized into prescription, administration, and dispensing errors and pDDIs. Data was analyzed using frequency, percentages, median, and interquartile range. Kruskal-Wallis H and Mann-Whitney U-tests were used to compare the prescription accuracy between the hospitals, with p<0.05 considered statistically significant. Results: Three hundred and sixty-six (366) pediatric prescriptions and 132 inpatient charts were reviewed in phases one and two of the study, respectively. In phase one, while no prescription attained the global accuracy score (GAS) gold standard of 100%, 106 (29.0%) achieved the 80-100% mark. The patient 63 (17.2%), treatment 228 (62.3%), and prescriber 33 (9.0%) identifiers achieved an overall GAS range of 80-100%. Although the total GAS was not statistically significant (p=0.065), the date (p=0.041), patient (p=<0.001), treatment (p=0.022), and prescriber (p=<0.001) identifiers were statistically significant across the different hospitals. For phase two, the prevalence of MEs was 74 (56.1%), while that of pDDIs was 54 (40.9%). There was a statistically positive correlation between the occurrence of pDDI and number of medicines prescribed (r=0.211, P=0.015). Conclusion: A Low GAS indicates poor compliance with prescription writing guidelines and high prescription errors. Medication errors were observed at each phase of the medication use cycle, while clinically significant pDDIs were also reported. Thus, there is a need for training on prescription writing guidelines and medication errors.

Hand Hygiene Practices and Promotion in Public Hospitals in Western Sierra Leone: Changes Following Operational Research in 2021.

Hand hygiene is the most important intervention for preventing healthcare-associated infections and can reduce preventable morbidity and mortality. We described the changes in hand hygiene practices and promotion in 13 public hospitals (six secondary and seven tertiary) in the Western Area of Sierra Leone following the implementation of recommendations from an operational research study. This was a "before and after" observational study involving two routine cross-sectional assessments using the WHO hand hygiene self-assessment framework (HHSAF) tool. The overall mean HHSAF score changed from 273 in May 2021 to 278 in April 2023; it decreased from 278 to 250 for secondary hospitals but increased from 263 to 303 for tertiary hospitals. The overall mean HHSAF score and that of the tertiary hospitals remained at the "intermediate" level, while secondary hospitals declined from "intermediate" to "basic" level. The mean score increased for the "system change" and "institutional safety climate" domains, decreased for "training and education" and "reminders in the workplace" domains, and remained the same for the "evaluation and feedback" domain. Limited resources for hand hygiene promotion, lack of budgetary support, and formalized patient engagement programs are the persistent gaps that should be addressed to improve hand hygiene practices and promotion.

High incidence of catheter-associated urinary tract infections and related antibiotic resistance in two hospitals of different geographic regions of Sierra Leone: a prospective cohort study.

OBJECTIVE: Catheter-associated urinary tract infections (CAUTI) are common worldwide, but due to limited resources, its actual burden in low-income countries is unknown. Currently, there are gaps in knowledge about CAUTI due to lack of surveillance activities in Sierra Leone. In this prospective cohort study, we aimed to determine the incidence of CAUTI and associated antibiotic resistance in two tertiary hospitals in different regions of Sierra Leone. RESULTS: The mean age of the 459 recruited patients was 48.8 years. The majority were females (236, 51.3%). Amongst the 196 (42.6%) catheterized patients, 29 (14.8%) developed CAUTI. Bacterial growth was reported in 32 (84%) patients. Escherichia coli (14, 23.7%), Klebsiella pneumoniae (10, 17.0%), and Klebsiella oxytoca (8, 13.6%) were the most common isolates. Most isolates were ESBL-producing Enterobacteriaceae (33, 56%) and WHO Priority 1 (Critical) pathogens (38, 71%). Resistance of K. pneumoniae, K. oxytoca, E. coli, and Proteus mirabilis was higher with the third-generation cephalosporins and penicillins but lower with carbapenems, piperacillin-tazobactam and amikacin. To reduce the high incidence of CAUTI and multi-drug resistance organisms, urgent action is needed to strengthen the microbiology diagnostic services and develop and implement catheter bundles that provide clear guidance for catheter insertion, care and removal.

Quality of Reporting of Adverse Drug Reactions to Antimicrobials Improved Following Operational Research: A before-and-after Study in Sierra Leone (2017-2023).

Background: The quality of pharmacovigilance data is important for guiding medicine safety and clinical practice. In baseline and follow-up studies after introducing interventions to improve the quality of reporting of Individual Case Safety Reports (ICSRs) in Sierra Leone, we compared (a) timeliness and completeness of reporting and (b) patient outcomes classified as 'recovering'. Methods: Baseline (January 2017-December 2021) and follow-up (June 2022-April 2023) studies of ICSRs in the national pharmacovigilance database. Interventions introduced following recommendations from the baseline study included: updating standard operating procedures and guidelines, setting performance targets follow-up of patient outcomes, and training. Results: There were 566 ICSRs in the baseline study and 59 in the follow-up study. Timelines (reporting < 30 days) improved by five-fold (10% at baseline to 47% in follow-up). For the completeness of variables in ICSRs (desired threshold ≥ 90%),this was 44% at baseline and increased to 80% in the follow-up study. 'Recovering' outcomes reduced from 36% (baseline study) to 3% (follow-up study, p < 0.001). Conclusions: Significant improvements in timeliness, completeness, and validation of ICSRs were observed following operational research in Sierra Leone. While enhancing pharmacovigilance and patient safety, this study highlights the important synergistic role operational research can play in improving monitoring and evaluation systems.

Antibiotic use and consumption among medical patients of two hospitals in Sierra Leone: a descriptive report.

BACKGROUND: Although one of the main drivers of antimicrobial resistance is inappropriate antibiotic prescribing, there are limited resources to support the surveillance of antibiotic consumption in low-income countries. In this study, we aimed to assess antibiotic use and consumption among medical patients of two hospitals in different geographic regions of Sierra Leone. METHODS: This is a cross-sectional study of adult (18 years or older) patients receiving medical care at two hospitals (34 Military Hospital-MH and Makeni Government Hospital-MGH) between March 2021 and October 2021. After admission to the medical or intensive care unit, patients were sequentially recruited by a nurse from each hospital. Demographic and clinical characteristics and information on the dose of antibiotics, their routes, and frequency of administration and duration were collected using a questionnaire adapted from previous studies and encrypted in EpiCollect software (Epic, Verona WI). A physician reviews and verifies each completed questionnaire. Data analysis was done using STATA version 16. RESULTS: The mean age of the 468 patients evaluated in this study was 48.6 years. The majority were women (241, 51.7%) and treated at MGH (245, 52.0%). Clinical diagnosis of bacterial infection was made in only 180 (38.5%) patients. Regardless of the diagnosis, most (442, 94.9%) patients received at least one antibiotic. Of a total 813 doses of antibiotics prescribed by the two hospitals, 424 (52.2%) were administered in MH. Overall, antibiotic consumption was 66.9 defined daily doses (DDDs) per 100 bed-days, with ceftriaxone being the most commonly used antibiotic (277, 34.1%). The ACCESS and WATCH antibiotics accounted for 18.9 DDDs per 100 bed-days (28.2%) and 48.0 DDDs per 100 bed-days (71.7%), respectively. None of the patients were prescribed a RESERVE antibiotics. The antibiotic consumption was lower in MH (61.3 DDDs per 100 bed-days) than MGH (76.5 DDDs per 100 bed-days). CONCLUSION: Antibiotic consumption was highest with ceftriaxone, followed by levofloxacin and metronidazole. Given the high rate of consumption of antibiotics in the WATCH category of the AWaRe classification, there is a need to initiate surveillance of antibiotic consumption and establish hospital-based antibiotic stewardship in these settings.

Have Hand Hygiene Practices in Two Tertiary Care Hospitals, Freetown, Sierra Leone, Improved in 2023 following Operational Research in 2021?

In 2021, an operational research study in two tertiary hospitals in Freetown showed poor hand hygiene compliance. Recommended actions were taken to improve the situation. Between February-April 2023, a cross-sectional study was conducted in the same two hospitals using the World Health Organization hand hygiene tool to assess and compare hand hygiene compliance with that observed between June-August 2021. In Connaught hospital, overall hand hygiene compliance improved from 51% to 60% (p < 0.001), and this applied to both handwash actions with soap and water and alcohol-based hand rub. Significant improvements were found in all hospital departments and amongst all healthcare worker cadres. In 34 Military Hospital (34MH), overall hand hygiene compliance decreased from 40% to 32% (p < 0.001), with significant decreases observed in all departments and amongst nurses and nursing students. The improvements in Connaught Hospital were probably because of more hand hygiene reminders, better handwash infrastructure and more frequent supervision assessments, compared with 34MH where interventions were less well applied, possibly due to the extensive hospital reconstruction at the time. In conclusion, recommendations from operational research in 2021 contributed towards the improved distribution of hand hygiene reminders, better handwash infrastructure and frequent supervision assessments, which possibly led to improved hand hygiene compliance in one of the two hospitals. These actions need to be strengthened, scaled-up and guided by ongoing operational research to promote good hand hygiene practices elsewhere in the country.

Assessing Changes in Surgical Site Infections and Antibiotic Use among Caesarean Section and Herniorrhaphy Patients at a Regional Hospital in Sierra Leone Following Operational Research in 2021.

Surgical site infections (SSIs) are a major public health threat to the success of surgery. This study assessed changes in SSIs and use of antibiotics among caesarean section (CS) and herniorrhaphy patients at a regional hospital in Sierra Leone following operational research. This was a comparative before and after study using routine hospital data. The study included all the CS and herniorrhaphy patients who underwent surgery between two time periods. Of the seven recommendations made in the first study, only one concerning improving the hospital's records and information system was fully implemented. Three were partially implemented and three were not implemented. The study population in both studies showed similar socio-demographic characteristics. The use of postoperative antibiotics for herniorrhaphy in both studies remained the same, although a significant increase was found for both pre- and postoperative antibiotic use in the CS patients, 589/596 (98.8%) in 2023 and 417/599 (69.6%) in 2021 (p < 0.001). However, a significant decrease was observed in the overall incidence of SSIs, 22/777 (2.8%) in 2023 and 46/681 (6.7%) in 2021 (p < 0.001), and the incidence of SSIs among the CS patients, 15/596 (2.5%) in 2023 and 45/599 (7.5%) in 2021 (p < 0.001). The second study highlights the potential value of timely assessment of the implementation of recommendations following operational research.

Improvement in the Surveillance System for Livestock Diseases and Antimicrobial Use Following Operational Research Studies in Sierra Leone January-March 2023.

In Sierra Leone, two operational research (OR) studies in 2019 and 2021 showed deficiencies in the data being captured by the Integrated Animal Disease Surveillance and Reporting (IADSR) system. This third OR study was conducted in 2023 to assess whether the second OR study's results and recommendations were disseminated with the key stakeholders, the uptake of the recommendations, improvements in data capture in the IADSR system, and to describe the data on livestock disease and antimicrobial use. In 2022, on seven occasions, the authors of the second OR study disseminated the study's findings. Of the four recommendations, the one on improving laboratory infrastructure for confirmation of animal disease was not implemented. The district animal health weekly surveillance reports received through the IADSR system were sustained at 88% between the second (2021) and third (2023) studies. In both studies, the proportion of sick animals receiving antibiotics (25%) remained the same, but the use of "critically important antimicrobials for veterinary use" declined from 77% (in 2021) to 69% (in 2023). The IADSR system has improved considerably in providing information on animal health and antibiotic use, and sequential OR studies have played a key role in its improvement.

Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study.

INTRODUCTION: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in 2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. METHODS: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0-25%), basic (25.1-50%), intermediate (50.1-75%), and advanced (75.1-100%). RESULTS: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. CONCLUSIONS: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.

Improvement in Infection Prevention and Control Compliance at the Three Tertiary Hospitals of Sierra Leone following an Operational Research Study.

Implementing infection prevention and control (IPC) programmes in line with the World Health Organization's (WHO) eight core components has been challenging in Sierra Leone. In 2021, a baseline study found that IPC compliance in three tertiary hospitals was sub-optimal. We aimed to measure the change in IPC compliance and describe recommended actions at these hospitals in 2023. This was a 'before and after' observational study using two routine cross-sectional assessments of IPC compliance using the WHO IPC Assessment Framework tool. IPC compliance was graded as inadequate (0-200), basic (201-400), intermediate (401-600), and advanced (601-800). The overall compliance scores for each hospital showed an improvement from 'Basic' in 2021 to 'Intermediate' in 2023, with a percentage increase in scores of 16.9%, 18.7%, and 26.9% in these hospitals. There was improved compliance in all core components, with the majority in the 'Intermediate' level for each hospital IPC programme. Recommended actions including the training of healthcare workers and revision of IPC guidelines were undertaken, but a dedicated IPC budget and healthcare-associated infection surveillance remained as gaps in 2023. Operational research is valuable in monitoring and improving IPC programme implementation. To reach the 'Advanced' level, these hospitals should establish a dedicated IPC budget and develop long-term implementation plans.

Burden of cardiometabolic risk factors and preclinical target organ damage among adults in Freetown, Sierra Leone: a community-based health-screening survey.

OBJECTIVE: To investigate the prevalence of cardiometabolic risk factors (CMRFs), target organ damage (TOD) and its associated factors among adults in Freetown, Sierra Leone. DESIGN: This community-based cross-sectional study used a stratified multistage random sampling method to recruit adult participants. SETTING: The health screening study was conducted between October 2019 and October 2021 in Western Area Urban, Sierra Leone. PARTICIPANTS: A total of 2394 adult Sierra Leoneans aged 20 years or older were enrolled. OUTCOME MEASURE: Anthropometric data, fasting lipid profiles, fasting plasma glucose, TOD, clinical profiles and demographic characteristics of participants were described. The cardiometabolic risks were further related to TOD. RESULTS: The prevalence of known CMRFs was 35.3% for hypertension, 8.3% for diabetes mellitus, 21.1% for dyslipidaemia, 10.0% for obesity, 13.4% for smoking and 37.9% for alcohol. Additionally, 16.1% had left ventricular hypertrophy (LVH) by ECG, 14.2% had LVH by two-dimensional echo and 11.4% had chronic kidney disease (CKD). The odds of developing ECG-LVH were higher with diabetes (OR=1.255, 95% CI (0.822 to 1.916) and dyslipidaemia (OR=1.449, 95% CI (0.834 to 2.518). Associated factors for higher odds of Left Ventricular Mass Index by echo were dyslipidaemia (OR=1.844, 95% CI (1.006 to 3.380)) and diabetes mellitus (OR=1.176, 95% CI (0.759 to 1.823)). The odds of having CKD were associated with diabetes mellitus (OR=1.212, 95% CI (0.741 to 1.983)) and hypertension (OR=1.163, 95% CI (0.887 to 1.525)). A low optimal cut-off point for ECG-LVH (male 24.5 mm vs female 27.5 mm) was required to maximise sensitivity and specificity by a receiver operating characteristics curve since the odds for LVH by ECG were low. CONCLUSIONS: This study provides novel data-driven information on the burden of CMRF and its association with preclinical TOD in a resource-limited setting. It illustrates the need for interventions in improving cardiometabolic health screening and management in Sierra Leonean.

High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone.

Objective: Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone. Methods: We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software. Results: Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%). Conclusions: We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

The burden of surgical site infections and related antibiotic resistance in two geographic regions of Sierra Leone: a prospective study.

Despite the prolongation of hospitalization, increase in morbidity, mortality and cost of care associated with both surgical site infections (SSIs) and antibiotic resistance, there are limited data on SSIs and antibiotic resistance to guide prevention strategies in Sierra Leone. This study assessed the burden of SSIs and related antibiotic resistance in the 34 Military Hospital (MH) and Makeni Government Hospital (MGH) located in two geographic regions of Sierra Leone using a prospective study design to collect data from adults aged 18 years or older. Of the 417 patients, 233 (55.9%) were enrolled in MGH. Most were women 294 (70.5%). The incidence rate of SSI was 5.5 per 1000 patient-days, and the cumulative incidence of SSI was 8.2%. Common bacteria isolated in MH were Escherichia coli (6,33.3%) and Pseudomonas aeruginosa (3,16.7%) and in MGH were P. aeruginosa (3,42.9%) and Proteus mirabilis (2,28.9%). Of the gram-negative bacteria, 40% were Extended-spectrum beta-lactamase-producing Enterobacteriaceae, 33% were Carbapenem-resistant P. aeruginosa and 10% were carbapenem-resistant Enterobacteriaceae. Although the incidence of SSIs in our study is lower than previously reported, the rate of antibiotic resistance reported in this study is high. Urgent action is needed to invest in the microbiology infrastructure to support SSI surveillance and prevention strategies.

Innovative approach to monitor performance of integrated disease surveillance and response after the Ebola outbreak in Sierra Leone: lessons from the field.

BACKGROUND: Supervision of healthcare workers improves performance if done in a supportive and objective manner. Regular supervision is a support function of Integrated Disease Surveillance and Response (IDSR) strategy and allows systematic monitoring of IDSR implementation. Starting 2015, WHO and other development partners supported the Ministry of Health and Sanitation (MoHS) to revitalize IDSR in Sierra Leone and to monitor progress through supportive supervision assessments. We report on the findings of these assessments. METHODS: This was a cross-sectional study where six longitudinal assessments were conducted in randomly selected health facilities. Health facilities assessed were 71 in February 2016, 99 in July 2016, 101 in May 2017, 126 in August 2018, 139 in February 2019 and 156 in August 2021. An electronic checklist based on selected core functions of IDSR was developed and uploaded onto tablets using the Open Data Kit (ODK) platform. Supervision teams interviewed health care workers, reviewed documents and made observations in health facilities. Supervision books were used to record feedback and corrective actions. Data from the supervisory visits was downloaded from ODK platform, cleaned and analysed. Categorical data was summarized using frequencies and proportions while means and medians were used for continuous variables. Z test was used to test for differences in proportions. RESULTS: Completeness of IDSR reporting improved from 84.5% in 2016 to 96% in 2021 (11.5% points; 95% CI 3.6, 21.9; P-value 0.003). Timeliness of IDSR reports improved from 80.3 to 92% (11.7% points; 95% CI 2.4, 22.9; P-value 0.01). There was significant improvement in health worker knowledge of IDSR concepts and tools, in availability of IDSR standard case definition posters and reporting tools and in data analysis practices. Availability of vaccines and temperature monitoring tools in health facilities also improved significantly but some indicators dropped such as availability of IDSR technical guidelines and malaria testing kits and drugs. CONCLUSION: Supervision using electronic tool contributed to health systems strengthening through longitudinal tracking of core IDSR indicators and other program indicators such as essential malaria commodities and availability and status of routine vaccines. Supervision using electronic tools should be extended to other programs.

Regulating clinical trials in a resource-limited setting during the Ebola public health emergency in Sierra Leone.

Clinical trials during public health emergencies of novel medical products such as therapeutics and vaccines in resource-limited settings are daunting due to the limited capacity for regulatory assessment. Regulating clinical trials during the Ebola outbreak in Sierra Leone required expedited evaluation to identify medical products that could be promptly introduced to combat the epidemic in the absence of approved treatment or prevention. This article explored the decisions taken by the Pharmacy Board of Sierra Leone through its Expert Committee on Medicine Safety and Clinical Trials regarding clinical trials oversight during the Ebola epidemic and the lessons learned. This independent expert committee assessed and provided scientific opinions to the Pharmacy Board of Sierra Leone to inform approval of all clinical trials within 10-15 working days. We also requested for assisted review from the African Vaccine Regulatory Forum and support from the US Food and Drug Administration through a unilateral recognition and reliance memorandum of understanding. In addition, the Agency-ensured structures and systems were in place for reporting and reviewing adverse events and serious adverse events, management of biological samples, submission and review of progress reports, and good clinical practice inspections. Unfortunately, the Ebola epidemic revealed many weaknesses in the country's clinical trials regulatory structure and processes. Government and partners should further offer more resources to build the clinical trial structures and systems so that the Agency will be better poised to handle future public health emergencies.

Evaluation of Drinking Water Quality and Bacterial Antibiotic Sensitivity in Wells and Standpipes at Household Water Points in Freetown, Sierra Leone.

Water quality surveillance can help to reduce waterborne diseases. Despite better access to safe drinking water in Sierra Leone, about a third of the population (3 million people) drink water from unimproved sources. In this cross-sectional study, we collected water samples from 15 standpipes and 5 wells and measured the physicochemical and bacteriological water quality, and the antimicrobial sensitivity of Escherichia coli (E. coli) in two communities in Freetown, Sierra Leone in the dry and wet seasons in 2021. All water sources were contaminated with E. coli, and all five wells and 25% of standpipes had at least an intermediate risk level of E. coli. There was no antimicrobial resistance detected in the E. coli tested. The nitrate level exceeded the WHO's recommended standard (>10 parts per million) in 60% of the wells and in less than 20% of the standpipes. The proportion of samples from standpipes with high levels of total dissolved solids (>10 Nephelometric Turbidity Units) was much higher in the rainy season (73% vs. 7%). The level of water contamination is concerning. We suggest options to reduce E. coli contamination. Further research is required to identify where contamination of the water in standpipes is occurring.

Assessment of Infection Prevention and Control Measures at Points of Entry in Sierra Leone in 2021: A Cross-Sectional Study.

Implementing and monitoring infection prevention and control (IPC) measures at immigration points of entry (PoEs) is key to preventing infections, reducing excessive use of antimicrobials, and tackling antimicrobial resistance (AMR). Sierra Leone has been implementing IPC measures at four PoEs (Queen Elizabeth II Quay port, Lungi International Airport, and the Jendema and Gbalamuya ground crossings) since the last Ebola outbreak in 2014-2015. We adapted the World Health Organization IPC Assessment Framework tool to assess these measures and identify any gaps in their components at each PoE through a cross-sectional study in May 2021. IPC measures were Inadequate (0-25%) at Queen Elizabeth II Quay port (21%; 11/53) and Jendema (25%; 13/53) and Basic (26-50%) at Lungi International Airport (40%; 21/53) and Gbalamuya (49%; 26/53). IPC components with the highest scores were: having a referral system (85%; 17/20), cleaning and sanitation (63%; 15/24), and having a screening station (59%; 19/32). The lowest scores (0% each) were reported for the availability of IPC guidelines and monitoring of IPC practices. This was the first study in Sierra Leone highlighting significant gaps in the implementation of IPC measures at PoEs. We call on the AMR multisectoral coordinating committee to enhance IPC measures at all PoEs.

Bacterial Isolates and Antibiotic Resistance of Escherichia coli Isolated from Fresh Poultry Excreta Used for Vegetable Farming in Freetown, Sierra Leone.

The transfer of antibiotic resistance from animals to humans is of concern in recent times. One potential source of such transfer is the untreated poultry excreta used as manure in farming. We aim to identify bacterial isolates and antibiotic susceptibility patterns of Escherichia coli in poultry excreta in Sierra Leone. This was a cross-sectional study of fresh poultry excreta samples collected from four commercial poultry sites in Freetown, Sierra Leone, from June−September 2021. Bacterial isolates were tested against eight antibiotics using established standards. Of 100 samples, 93 showed Escherichia coli (93%): of those, eight isolates also had Salmonella (8%). E. coli was 100% resistant to all three 'Watch' drugs (erythromycin, cefoxitin and streptomycin) and tetracycline. E. coli was least resistant to ampicillin (12%), followed by chloramphenicol (35%). The prevalence of multidrug resistance was 95.6%. Multiple antibiotic resistance index ranged from 0.5−0.7 (optimal < 0.2), indicating high prior exposure to antibiotics in these poultries. Such high levels of resistance in E. coli isolated from poultry excreta could pose a serious threat to humans. We recommend (i) routine surveillance to monitor antibiotic resistance in poultry excreta, (ii) using poultry excreta as manure only after treatment and (iii) restricting the use of antibiotics as prophylactics and growth promoters in poultry feeds.