Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone.

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Maintaining high moisture content of macadamia nuts-in-shell during storage induces brown centres in raw kernels.

BACKGROUND: Kernel brown centres in macadamia are a defect causing internal discolouration of kernels. This study investigates the effect on the incidence of brown centres in raw kernel after maintaining high moisture content in macadamia nuts-in-shell stored at temperatures of 30°C, 35°C, 40°C and 45°C. RESULTS: Brown centres of raw kernel increased with nuts-in-shell storage time and temperature when high moisture content was maintained by sealing in polyethylene bags. Almost all kernels developed the defect when kept at high moisture content for 5 days at 45°C, and 44% developed brown centres after only 2 days of storage at high moisture content at 45°C. This contrasted with only 0.76% when stored for 2 days at 45°C but allowed to dry in open-mesh bags. At storage temperatures below 45°C, there were fewer brown centres, but there were still significant differences between those stored at high moisture content and those allowed to dry (P < 0.05). CONCLUSION: Maintenance of high moisture content during macadamia nuts-in-shell storage increases the incidence of brown centres in raw kernels and the defect increases with time and temperature. On-farm nuts-in-shell drying and storage practices should rapidly remove moisture to reduce losses. Ideally, nuts-in-shell should not be stored at high moisture content on-farm at temperatures over 30°C.

Quality changes in macadamia kernel between harvest and farm-gate.

BACKGROUND: Macadamia integrifolia, Macadamia tetraphylla and their hybrids are cultivated for their edible kernels. After harvest, nuts-in-shell are partially dried on-farm and sorted to eliminate poor-quality kernels before consignment to a processor. During these operations, kernel quality may be lost. In this study, macadamia nuts-in-shell were sampled at five points of an on-farm postharvest handling chain from dehusking to the final storage silo to assess quality loss prior to consignment. Shoulder damage, weight of pieces and unsound kernel were assessed for raw kernels, and colour, mottled colour and surface damage for roasted kernels. RESULTS: Shoulder damage, weight of pieces and unsound kernel for raw kernels increased significantly between the dehusker and the final silo. Roasted kernels displayed a significant increase in dark colour, mottled colour and surface damage during on-farm handling. CONCLUSION: Significant loss of macadamia kernel quality occurred on a commercial farm during sorting and storage of nuts-in-shell before nuts were consigned to a processor. Nuts-in-shell should be dried as quickly as possible and on-farm handling minimised to maintain optimum kernel quality.

Dropping macadamia nuts-in-shell reduces kernel roasting quality.

BACKGROUND: Macadamia nuts ('nuts-in-shell') are subjected to many impacts from dropping during postharvest handling, resulting in damage to the raw kernel. The effect of dropping on roasted kernel quality is unknown. Macadamia nuts-in-shell were dropped in various combinations of moisture content, number of drops and receiving surface in three experiments. After dropping, samples from each treatment and undropped controls were dry oven-roasted for 20 min at 130 °C, and kernels were assessed for colour, mottled colour and surface damage. RESULTS: Dropping nuts-in-shell onto a bed of nuts-in-shell at 3% moisture content or 20% moisture content increased the percentage of dark roasted kernels. Kernels from nuts dropped first at 20%, then 10% moisture content, onto a metal plate had increased mottled colour. Dropping nuts-in-shell at 3% moisture content onto nuts-in-shell significantly increased surface damage. Similarly, surface damage increased for kernels dropped onto a metal plate at 20%, then at 10% moisture content. CONCLUSION: Postharvest dropping of macadamia nuts-in-shell causes concealed cellular damage to kernels, the effects not evident until roasting. This damage provides the reagents needed for non-enzymatic browning reactions. Improvements in handling, such as reducing the number of drops and improving handling equipment, will reduce cellular damage and after-roast darkening.

Facility-Level Approaches for COVID-19 When Caseload Surpasses Surge Capacity.

As COVID-19 cases continue to increase globally, fragile health systems already facing challenges with health system infrastructure, SARS-CoV-2 diagnostic capacity, and patient isolation capabilities may be left with few options to effectively care for acutely ill patients. Haiti-with only two laboratories that can perform reverse transcriptase PCR for SARS-CoV-2, a paucity of hospital beds, and an exponential increase in cases-provides an example that underpins the need for immediate infrastructure solutions for the crisis. We present two COVID-19 treatment center designs that leverage lessons learned from previous outbreaks of communicable infectious diseases and provide potential solutions when caseload exceeds existing capacity, with and without access to SARS-CoV-2 testing. These designs are intended for settings in which health facilities and testing resources for COVID-19 are surpassed during the pandemic, are adaptable to local conditions and constraints, and mitigate the likelihood of nosocomial transmission while offering an option to care for hospitalized patients.

Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti.

Three decades ago, the world's ministries of health declared primary health care--the delivery of basic preventive and curative services--a top priority. Since then, however, the world's poorest countries have not met most primary health care goals. Twenty-six years after the Declaration of Alma Ata, we are said to be living in a time of "limited resources," a phrase that construes various health interventions as competing priorities. As HIV has become the leading infectious cause of adult death in much of the world, it is difficult to argue that AIDS prevention and care are not ranking priorities for primary health care, yet precisely such arguments have held sway among international health policy makers. We present new information emerging from the scale-up of an established and integrated AIDS prevention-and-care program, based initially in a squatter settlement in central Haiti, to a second site in rural Haiti. The program includes robust prevention efforts as well as community-based therapy for advanced AIDS; three related components--women's health and active case finding and therapy for tuberculosis and sexually transmitted infections--were central to this effort. We tracked changes in key indices over the 14 months following the introduction of these services to a public clinic in central Haiti. We found that integrated AIDS prevention and care, including the use of antiretroviral agents, to be feasible in resource-poor settings and that such efforts may have favorable and readily measured impact on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion. Other collateral benefits, though less readily measured, include improved staff morale and enhanced confidence in public health and medicine. We conclude that improving AIDS prevention and treatment can help to reinvigorate flagging efforts to promote universal primary health care.

The "first" case of cholera in Haiti: lessons for global health.

Cholera is an acute watery diarrheal disease caused by infection with Vibrio cholerae. The disease has a high fatality rate when untreated and outbreaks of cholera have been increasing globally in the past decade, most recently in Haiti. We present the case of a 28-year-old Haitian male with a history of severe untreated mental health disorder that developed acute fatal watery diarrhea in mid-October 2010 in central Haiti after drinking from the local river. We believe he is the first or among the first cases of cholera in Haiti during the current epidemic. By reviewing his case, we extracted lessons for global health on the importance of mental health for overall health, the globalization of diseases in small communities, and the importance of a comprehensive approach to the health of communities when planning services in resource-poor settings.

Ultrastructure of Macadamia (Proteaceae) embryos: implications for their breakage properties.

BACKGROUND AND AIMS: Macadamia integrifolia, M. tetraphylla and their hybrids are cultivated for their edible kernels. Whole kernels, i.e. intact mature embryos with cotyledons fused together, are highly valued and breakage of embryos into halves results in loss of value for the commercial macadamia industry. The morphology and ultrastructure of the mature macadamia embryo, with particular emphasis on the break zone between cotyledons, were investigated. Differences in breakage between different macadamia cultivars were also examined. METHODS: Manual cracking was used to compare breakage in five cultivars and the ultrastructure of the break zone between the cotyledons was examined using light and transmission electron microscopy. KEY RESULTS: Breakage of macadamia embryos was strongly dependent on genotype of the female parent, with cultivars 'HAES 344' and 'HAES 741' much more likely to break than 'HV A16' and 'HAES 835'. Cotyledons were surrounded by a layer of cuticle resulting in a double cuticle in the break zone between the cotyledons. Three major differences have been found in the ultrastructure of the double cuticle between cultivars: a thicker cuticle in the low-whole cultivar; convolutions in the cuticle of a low-whole cultivar, and the presence of more electron-dense objects in the high-whole cultivar. CONCLUSIONS: Breakage of macadamia embryos depends on the cultivar, with clear ultrastructural differences in the break zone between cultivars. To ensure commercial benefits, macadamia breeding programs should identify germplasm with structural characteristics that ensure high percentages of whole kernel.