Prevalence of hypertension, diabetes mellitus, and their risk factors in an informal settlement in Freetown, Sierra Leone: a cross-sectional study.

BACKGROUND: Noncommunicable diseases (NCDs), especially hypertension and diabetes mellitus are on the increase in sub-Saharan Africa (SSA). Informal settlement dwellers exhibit a high prevalence of behavioural risk factors and are highly vulnerable to hypertension and diabetes. However, no study has assessed the prevalence of hypertension, diabetes, and NCDrisk factors among informal settlement dwellers in Sierra Leone. We conducted a study in June 2019 to determine the prevalence of hypertension, diabetes, and NCD risk factors among adults living in the largest Sierra Leonean informal settlement (KrooBay). METHODS AND MATERIALS: We conducted a community-based cross-sectional survey among adults aged ≥ 35 years in the KrooBay community. Trained healthcare workers collected data on socio-demographic characteristics and self-reported health behaviours using the World Health Organization STEPwise surveillance questionnaire for chronic disease risk factors. Anthropometric, blood glucose, and blood pressure measurements were performed following standard procedures. Logistics regression was used for analysis and adjusted odd ratios with 95% confidence intervals were calculated to identify risk factors associated with hypertension. RESULTS: Of the 418 participants, 242 (57%) were females and those below the age of 45 years accounted for over half (55.3%) of the participants. The prevalence of smoking was 18.2%, alcohol consumption was 18.8%, overweight was 28.2%, obesity was 17.9%, physical inactivity was 81.5%, and inadequate consumption of fruits and vegetables was 99%. The overall prevalence of hypertension was 45.7% (95% CI 41.0-50.5%), systolic hypertension was 34.2% (95% CI 29.6-38.8%), diastolic blood pressure was 39.9% (95% CI 35.2-44.6), and participants with diabetes were 2.2% (95% CI 0.7-3.6%). Being aged ≥ 55 years (AOR = 7.35, 95% CI 1.49-36.39) and > 60 years (AOR 8.05; 95% CI 2.22-29.12), separated (AOR = 1.34; 95% 1.02-7.00), cohabitating (AOR = 6.68; 95% CL1.03-14.35), vocational (AOR = 3.65; 95% CI 1.81-7.39 ) and having a university education (AOR = 4.62; 95% CI 3.09-6.91) were found to be independently associated with hypertension. CONCLUSION: The prevalence of hypertension,and NCD risk factors was high among the residents of the Kroobay informal settlement. We also noted a low prevalence of diabetes. There is an urgent need for the implementation of health education, promotion, and screening initiatives to reduce health risks so that these conditions will not overwhelm health services.

Iron-rich food consumption and associated factors among children aged 6-23 months in Sierra Leone: multi-level logistic regression analysis.

BACKGROUND: Iron deficiency is the most common micronutrient deficiency worldwide. Also, iron deficiency is a significant public health problem in low- and middle-income countries. Thus, this study aimed to assess iron-rich food consumption and associated factors among children aged 6-23 months in Sierra Leone. METHOD: This study is a cross-sectional study based on data from the Sierra Leone Demographic and Health Survey dataset with a total weighted sample of 2622 children aged 6-23 months. Data cleaning, coding, and labeling were done using STATA version 14 software. A multilevel logistic regression model was employed to identify associated factors. RESULT: Almost half (53.38%) of children aged between 6-23 months consumed iron-rich foods. The odds of iron rich food consumption were high among children in the age group of 12-17 months (AOR = 4.81, 95% CI: 3.67, 6.31) and 18-23 months (AOR = 9.3, 95% CI: 6.55, 13.2), and who fed minimum acceptable diet (AOR = 22.5, 95% CI: 11.65, 43.46). Moreover, a child from a mother who had work (AOR = 1.49, 95% CI: 1.08, 2.06), and with a mother who had more than four ANC visits during her pregnancy of the most recent live birth (AOR = 1.87; 95%CI: 1.36-2.55) had higher odds of iron-rich food consumption compared to their counterparts. On the other hand, children who were breastfeeding (AOR = 0.72, 95% CI: 0.53, 0.97), and mothers aged 15-19 (AOR = 0.48, 95% CI: 0.27, 0.85) decreased the odds of iron rich food consumption. CONCLUSION: Consumption of iron-rich food is low among children aged 6-23 months in Sierra Leone. Iron-rich food consumption among children was significantly associated with maternal occupation, child's age, child's breastfeeding status, taking drugs for intestinal parasites, minimum acceptable diet, frequency, and timing of ANC, and region. Thus, special emphasis should be given to those children aged between 6-11 months, currently breastfeeding, children who did not get the minimum acceptable diet, and children from women who did not have work.

Prevalence and predictors of Aspergillus seropositivity and chronic pulmonary aspergillosis in an urban tertiary hospital in Sierra Leone: A cross-sectional study.

BACKGROUND: In the World Health Organization Global Tuberculosis (TB) Report 2022, 37% of pulmonary TB patients were clinically diagnosed and thus many people were treated for TB without evidence of the disease. Probably the most common TB misdiagnosis is chronic pulmonary aspergillosis (CPA). In this study, we aimed to assess the prevalence and predictors of Aspergillus seropositivity and CPA in patients with chronic respiratory symptoms in an urban tertiary hospital in Sierra Leone. METHODOLOGY/PRINCIPAL FINDINGS: We used a cross-sectional study design to recruit adults (≥18 years) from the Chest Clinic of Connaught Hospital, Freetown between November 2021 and July 2022. Aspergillus antibody was detected using LDBio Aspergillus IgM/IgG. Logistic regression was performed to assess the independent predictors of Aspergillus seropositivity and CPA. Of the 197 patients with chronic respiratory symptoms, 147 (74.6%) were male. Mean age was 47.1 ± 16.4 years. More than half (104, 52.8%) had been diagnosed with TB in the past, while 53 (26.9%) were on TB treatment at the time of recruitment. Fifty-two (26.4%) patients were HIV positive, 41 (20.8%) were seropositive for Aspergillus and 23 (11.6%) had CPA, 2 (3.8%) with current TB and 18 (17.3%) with past TB. Common radiologic abnormalities reported were localized fibrotic changes 62 (31.5%), consolidation 54 (27.4%), infiltrates 46 (23.4%), hilar adenopathy 40 (20.3%) and pleural effusion 35 (17.85) and thickening 23 (11.7%). Common symptoms were weight loss 144 (73.1%), cough 135 (68.5%), fever 117 (59.4%) and dyspnea 90 (45.7%). Current or past TB infection {aOR 3.52, 95% CI (1.46, 8.97); p = 0.005} was an independent predictor of Aspergillus seropositivity and CPA. CONCLUSIONS/SIGNIFICANCE: We report a high prevalence of Aspergillus antibody seropositivity and CPA, underscoring the need to integrate the prevention and management of pulmonary fungal infections with TB services and asthma care in order to reduce unnecessary morbidity and mortality.

The impact of the COVID-19 pandemic on the provision & utilisation of primary health care services in Goma, Democratic Republic of the Congo, Kambia district, Sierra Leone & Masaka district, Uganda.

INTRODUCTION: This study aimed to determine whether the COVID-19 pandemic had an impact on essential primary healthcare services at public primary healthcare facilities. METHODS: The number of weekly consultations for antenatal care (ANC), outpatient (OPD), immunisations (EPI), family planning (FP) and HIV services, between January 2018 and December 2020, were collected from 25 facilities in Masaka district, Uganda, 21 in Goma, and 29 in Kambia district, Sierra Leone. Negative binomial regression models accounting for clustering and season were used to analyse changes in activity levels between 2018, 2019 and 2020. RESULTS: In Goma, we found no change in OPD, EPI or ANC consultations, FP was 17% lower in March-July 2020 compared to 2019, but this recovered by December 2020. New diagnoses of HIV were 34% lower throughout 2020 compared to 2019. In Sierra Leone, compared to the same periods in 2019, facilities had 18-29% fewer OPD consultations throughout 2020, and 27% fewer DTP3 doses in March-July 2020. There was no evidence of differences in other services. In Uganda there were 20-35% fewer under-5 OPD consultations, 21-66% fewer MCV1 doses, and 48-51% fewer new diagnoses of HIV throughout 2020, compared to 2019. There was no difference in the number of HPV doses delivered. CONCLUSIONS: The level of disruption varied across the different settings and qualitatively appeared to correlate with the strength of lockdown measures and reported attitudes towards the risk posed by COVID-19. Mitigation strategies such as health communications campaigns and outreach services may be important to limit the impact of lockdowns on primary healthcare services.

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.

A seroepidemiological survey of adenovirus type 7 circulation among healthy adults in China and in Sierra Leone, West Africa.

Adenovirus type 7 (HAdV7) is one of the most pathogenic human adenoviruses (HAdVs) and can cause severe illness and even death, particularly in people with weakened immune systems. Many countries worldwide have experienced epidemics of this highly contagious pathogen, including China and Sierra Leone; however, studies describing the seroprevalence of anti-HAdV7 neutralizing antibodies (nAbs) are still lacking. Herein, we established an efficient neutralization assay based on a recombinant luciferase-expressing HAdV7 virus (HAd7-Luc) to monitor historical HAdV7 infections and predict outbreak distributions. Among the 2,350 serum samples collected from eight sites in China and Sierra Leone in this cross-sectional serological survey, the overall proportion of anti-HAdV7-seropositive individuals was nearly 60%, with higher seroprevalence rates in Sierra Leone than in China. Regionally, HAdV7 nAb titers were higher in China than in Sierra Leone and showed a geographic variation across different regions. Regardless of the location, the seropositive rate of HAdV7 nAb was lower than that of HAdV5 nAb, as was the nAb titer. The prevalence rates of antibodies against HAdV7 and HAdV5 were both related to age but not to sex. In addition, serologic cross-reactions were rarely observed among people infected with HAdV7 and HAdV5. These results indicate a humoral immune response acquired through endemic HAdV7 infection and enrich the understanding of not only the epidemiological prevention and control of HAdV7 but also the clinical application of HAdV7-based vaccines or gene therapy tools.

There is a great variety of orthopaedic conditions presenting to a large hospital in Sierra Leone: a 3-year prospective study.

PURPOSE: In Sierra Leone there is a large void in orthopaedic research into the type of orthopaedic injuries, both acute and chronic. Improved data collection is essential in providing insight to guide health care planning and research. This study aims to outline the types of orthopaedic injury sustained. METHOD: Data were prospectively collected by local surgeons in the Orthopaedic outpatient department at a large hospital between January 2016 and January 2019. RESULTS: The orthopaedic department saw a mean 728 patients per year, with mean age 24.0 years. The workload comprised of 64.92% acute orthopaedic conditions or their complications, with 35.08% elective orthopaedics. Fractures made up the largest proportion of clinical appointments, annually 244.33 fractures; however there was a high incidence of osteomyelitis. CONCLUSION: The study gives an important insight into the types and distribution of elective and trauma orthopaedic injuries sustained in Sierra Leone, which has not been previously reported, and highlights key areas where resources may be focused in order to improve clinical outcomes.

No smoking gun: tobacco taxation and smuggling in Sierra Leone.

OBJECTIVE: To evaluate the common industry claim that higher tobacco taxation leads to higher levels of smuggling, particularly in a limited state capacity setting. DESIGN: This paper evaluates the effects of a tobacco tax increase in Sierra Leone on smuggling by using gap analyses. Its models are based on multiple rounds of the Demographic and Health Survey and customs data as well as newly collected data on cigarette prices. RESULTS: The paper shows that despite a substantial increase in cigarette taxation, and despite the absence of other formal tobacco control policies, smuggling has not increased in Sierra Leone. Its primary model shows a decrease in cigarette smuggling by 16.74% following the tax increase, alongside a decrease in cigarette consumption more widely and an increase in tax revenue. CONCLUSIONS: By presenting a low income and lower enforcement capacity case study, this paper provides novel and critical evidence to the debate on the tax-smuggling link. Furthermore, it points to new questions on how states in these contexts can limit cigarette smuggling.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone.

BACKGROUND: Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic. METHODS: This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members. RESULTS: A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4-7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery. CONCLUSION: PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013-2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Case Report: Acral Melanoma with Giant Local Recurrence in Rural Sierra Leone.

Malignant melanoma is rare in West Africa. Few cases of giant melanoma have been reported globally. We present a case of acral melanoma with giant local recurrence on the foot of a black-skinned woman from rural Sierra Leone, managed with below-knee amputation. Atypical, late presentation, poor access to diagnostics, and underreporting may contribute to underappreciation of melanoma as a healthcare problem in West Africa. This case highlights the need for improved cancer and skin health surveillance structures in West Africa-most importantly, increasing access to histopathology.

Prevalence of risk factors for human immunodeficiency virus among women of reproductive age in Sierra Leone: a 2019 nationwide survey.

BACKGROUND AND AIM: For over 40 years of the HIV/AIDS global epidemic, no effective cure nor vaccine is yet available, making the current control strategies focused on curbing new infections through risk reduction. The study aimed to determine the prevalence of HIV risk factors and their associated socio-demographics among women of reproductive age in Sierra Leone. METHODS: We used weighted data from the Sierra Leone Demographic and Health Survey (SLDHS) of 2019 for 12,005 women aged 15-49 years. Multistage sampling was used to select study participants. Exposure to HIV risk factors was considered if a woman reported at least one of the following; having multiple sexual partners, transactional sex, non-condom use for the unmarried, and having other sexually transmitted infections (STIs). We, then, conducted multivariable logistic regression to explore the associated socio-demographics. All the analyses were done using SPSS (version 25). RESULTS: Of the 12,005 women, 38.1% (4577/12005) (95% confidence interval (CI) 37.3-39.0) had at least one of the four risk factors. Women of 15 to 19 years (adjusted odds ratio (AOR) = 1.34, 95% CI 1.00-1.80) and 20 to 34 years (AOR = 1.25, 95% CI 1.05-1.49) had more odds of having HIV risk factors compared to those of 35 to 49 years. Urban residents (AOR = 1.49, 95% CI 1.17-1.89) and those from the Northwestern region (AOR = 1.81, 95% CI 1.26-2.60) were also more likely to encounter HIV risk factors compared to their respective counterparts. Moreover, unmarried women (AOR = 111.17, 95% CI 87.55-141.18) and those working (AOR = 1.38, 95% CI 1.14-1.67) also had higher odds of having HIV risk factors, compared to their respective counterparts. Sex of household head and parity were also significant associates. CONCLUSIONS: More than a third of women in Sierra Leone had encountered at least one HIV risk factor, and this was associated with age, place of residence, region, marital status, working status, household head and parity. There is a need for strengthening HIV/AIDS education programs, laws and policies targeting the young, working, unmarried and urban-resident women.

Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared with Nutrition Counseling: A Retrospective Cohort Study.

BACKGROUND: There is uncertainty about whether children with moderate wasting should receive supplementary feeding. OBJECTIVES: We examined whether supplementary feeding compared with counseling alone in children with moderate wasting prevented progression to severe acute malnutrition (SAM) or death. METHODS: This was a retrospective, dual-cohort study in which 1791 children with moderate wasting were drawn from 2 prior randomized controlled trials that took place in the same location in rural Sierra Leone. A total of 1077 children received supplementary feeding, whereas 714 children received counseling alone. Children in both cohorts were followed for ≥24 wk from enrollment. The primary outcome was time to SAM or death using Kaplan-Meier analysis. Secondary outcomes included time to death as well as proportions of children with healthy midupper arm circumference (MUAC), moderate wasting, SAM, or death at 6, 12, and 24 wk from enrollment. RESULTS: Children who received supplementary feeding were less likely to develop SAM or die across the entire follow-up period (HR: 0.53; 95% CI: 0.44, 0.65; P < 0.001). Time to event for death alone also revealed a lower risk for children who received supplementary feeding (HR: 0.52; 95% CI: 0.28, 0.94; P = 0.03). Children who received supplementary feeding were more likely to have a healthy MUAC at 6 wk (RR: 2.0; 95% CI: 1.7, 2.2) and 12 wk (RR: 1.3; 95% CI: 1.2, 1.5), were less likely to develop SAM at 6 (RR: 0.7; 95% CI: 0.6, 0.9), 12 (RR: 0.5; 95% CI: 0.3, 0.8), and 24 wk (RR: 0.2; 95% CI: 0.1, 0.5), and had higher rates of gain in weight and MUAC at 6 and 12 wk. CONCLUSIONS: Supplementary feeding of children with moderate wasting reduces risk of SAM and death across 24 wk of follow-up.

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.

Determinants of low birth weight deliveries at five referral hospitals in Western Area Urban district, Sierra Leone.

BACKGROUND: Low birth weight (LBW) contributes significantly to infant and child mortality. Each year, about 20 1million deliveries are LBW with 96.5% occurring in developing countries. Whiles the incidence of LBW is reducing in other districts of Sierra Leone, it has been reported to be increasing in the Western Area Urban district. Determining the risk factors in a specific geographic area is important for identifying mothers at risk and thereby for planning and taking appropriate action. The current study sought to identify factors associated with LBW deliveries in the Western Area Urban district of Sierra Leone. METHODS: A hospital-based unmatched 1:2 case-control study was conducted among mothers who delivered live singleton babies from November, 2019 to February, 2020 in five referral health facilities. Mothers were conveniently sampled and sequentially enrolled into the study after delivery. Their antenatal care cards were reviewed and a pre-tested questionnaire administered to the mothers. Data analysis was done using Stata 15.0 and association between maternal socio-demographic, socio-economic, obstetric and lifestyle factors and LBW assessed using bivariable and multivariable logistic regression analyses. RESULTS: A total of 438 mothers (146 cases and 292 controls), mean age: 24.2 (±5.8) and 26.1 (±5.5) years for cases and controls respectively participated in the study. Multivariable analysis revealed that being unemployed (AoR = 2.52, 95% CI 1.16-5.49, p = 0.020), having anaemia during pregnancy (AoR = 3.88, 95% CI 1.90-7.90, p <  0.001), having less than 2 years inter-pregnancy interval (AoR = 2.53, 95% CI 1.11-5.73, p = 0.026), and smoking cigarettes during pregnancy (AoR = 4.36, 95% CI 1.94-9.80, p <  0.001) were significantly associated with having LBW babies. CONCLUSION: Factors associated with LBW identified were unemployment, anaemia during pregnancy, < 2 years inter-pregnancy interval and cigarette smoking during pregnancy. Health care providers should screen and sensitize mothers on the risk factors of LBW during antenatal sessions.

Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone.

BACKGROUND: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. METHODS: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. RESULTS: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. CONCLUSION: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation.

Implementation of the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) study: Lessons learned for vision health systems strengthening in Sierra Leone.

BACKGROUND: Following the West African Ebola virus disease (EVD) outbreak of 2013-2016 and more recent EVD outbreaks in the Democratic Republic of Congo, thousands of EVD survivors are at-risk for sequelae including uveitis, which can lead to unremitting inflammation and vision loss from cataract. Because of the known risk of Ebola virus persistence in ocular fluid and the need to provide vision-restorative, safe cataract surgery, the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) Study was implemented in Sierra Leone. During implementation of this multi-national study, challenges included regulatory approvals, mobilization, community engagement, infection prevention and control, and collaboration between multiple disciplines. In this report, we address the multifacted approach to address these challenges and the impact of implementation science research to address an urgent clinical subspecialty need in an outbreak setting. METHODOLOGY/PRINCIPAL FINDINGS: Given the patient care need to develop a protocol to evaluate ocular fluid for Ebola virus RNA persistence prior to cataract surgery, as well as protocols to provide reassurance to ophthalmologists caring for EVD survivors with cataracts, the EVICT study was designed and implemented through the work of the Ministry of Health, Sierra Leone National Eye Programme, and international partnerships. The EVICT study showed that all 50 patients who underwent ocular fluid sampling at 19 and 34 months, respectively, tested negative for Ebola virus RNA. Thirty-four patients underwent successful cataract surgery with visual acuity improvement. Here we describe the methodology for study implementation, challenges encountered, and key issues that impacted EVD vision care in the immediate aftermath of the EVD outbreak. Key aspects of the EVICT study included defining the pertinent questions and clinical need, partnership alignment with key stakeholders, community engagement with EVD survivor associations, in-country and international regulatory approvals, study site design for infection prevention and control, and thorough plans for EVD survivor follow-up care and monitoring. Challenges encountered included patient mobilization owing to transportation routes and distance of patients in rural districts. Strong in-country partnerships and multiple international organizations overcame these challenges so that lessons learned could be applied for future EVD outbreaks in West and Central Africa including EVD outbreaks that are ongoing in Guinea and Democratic Republic of Congo. CONCLUSIONS/SIGNIFICANCE: The EVICT Study showed that cataract surgery with a protocol-driven approach was safe and vision-restorative for EVD survivors, which provided guidance for EVD ophthalmic surgical care. Ophthalmologic care remains a key aspect of the public health response for EVD outbreaks but requires a meticulous, yet partnered approach with international and local in-country partners. Future efforts may build on this framework for clinical care and to improve our understanding of ophthalmic sequelae, develop treatment paradigms for EVD survivors, and strengthen vision health systems in resource-limited settings.

Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017.

BACKGROUND: The Lancet Commission on Global Surgery recommends a minimum of 20 surgical specialists and 5,000 annual operations per 100,000 population by 2030. In 2012, Sierra Leone was far from reaching these targets. This study aimed to assess the changes in surgical activity, surgical workforce, and surgical productivity between 2012 and 2017. METHODS: A nationwide, retrospective mapping of surgical activity and workforce in 2012 was repeated in 2017. All 60 facilities performing comprehensive surgery in Sierra Leone in 2017 were identified and data was obtained from surgical records and through structured interviews with facility directors. Annual estimates were calculated and compared with 2012. RESULTS: The surgical workforce increased from 164.5 to 312.8 full-time positions. The annual volume of surgeries was enhanced by 15.6% (95% CI: 7.8-23.4%) from 24,152 to 27,928 (26,048-29,808) operations. With simultaneous population growth, this led to a decrease in surgical volume from 400 to 372 procedures per 100,000 population and an unmet operative need of 92.7%. The mean productivity of surgical providers went from 2.8 to 1.7 surgeries per week per full-time position. An increasing number of caesarean deliveries were performed in public institutions, by associate clinicians. CONCLUSION: The unmet need for surgery in Sierra Leone remains very high, despite an increase in the surgical workforce, subsidizing maternal healthcare, and initiation of a surgical task-sharing program. The decline in surgical productivity with simultaneous increases in the surgical workforce calls for further exploration of the barriers to access and delivery of surgical care in Sierra Leone.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone.

INTRODUCTION: Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS: The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION: The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.