Quality of life and quality-adjusted life years after stroke in Sierra Leone.

BACKGROUND: Stroke is a leading cause of mortality and negatively affects health-related quality of life (HRQoL). HRQoL after stroke is understudied in Africa and there are no reports of quality-adjusted life years after stroke (QALYs) in African countries. We determined the impact of stroke on HRQoL after stroke in Sierra Leone. We calculated QALYs at 1 year post-stroke and determined sociodemographic and clinical variables associated with HRQoL and QALYs in this population. METHODS: A prospective stroke register was established at the two-principal adult tertiary government hospitals in Freetown, Sierra Leone. Participants were followed up at 7, 90 days, and 1 year post-stroke to capture all-cause mortality and EQ-5D-3L data. QALYs were calculated at the patient level using EQ-5D-3L utility values and survival data from the register, following the area under the curve method. Utilities were based on the UK and Zimbabwe (as a sensitivity analysis) EQ-5D value sets, as there is no Sierra Leonean or West African value set. Explanatory models were developed based on previous literature to assess variables associated with HRQoL and QALYs at 1 year after stroke. To address missing values, Multiple Imputation by Chained Equations (MICE), with linear and logistic regression models for continuous and binary variables, respectively, were used. RESULTS: EQ-5D-3L data were available for 373/460 (81.1%), 360/367 (98.1%), and 299/308 (97.1%) participants at 7, 90 days, and 1 year after stroke. For stroke survivors, median EQ-5D-3L utility increased from 0.20 (95% CI: -0.16 to 0.59) at 7 days post-stroke to 0.76 (0.47 to 1.0) at 90 days and remained stable at 1 year 0.76 (0.49 to 1.0). Mean QALYs at 1 year after stroke were 0.28 (SD: 0.35) and closely associated with stroke severity. Older age, lower educational attainment, patients with subarachnoid hemorrhage and undetermined stroke types all had lower QALYs and lower HRQoL, while being the primary breadwinner was associated with higher HRQoL. Sensitivity analysis with the Zimbabwe value set did not significantly change regression results but did influence the absolute values with Zimbabwe utility values being higher, with fewer utility values less than 0. CONCLUSION: We generated QALYs after stroke for the first time in an African country. QALYs were significantly lower than studies from outside Africa, partially explained by the high mortality rate in our cohort. Further research is needed to develop appropriate value sets for West African countries and to examine QALYs lost due to stroke over longer time periods. DATA AVAILABILITY: The Stroke in Sierra Leone anonymized dataset is available on request to researchers, see data access section.

Prevalence and correlates of metabolic syndrome among adults in freetown, Sierra Leone: A comparative analysis of NCEP ATP III, IDF and harmonized ATP III criteria.

Background: Metabolic syndrome (MetS) is a global health concern, especially for low and middle-income countries with limited resources and information. The study's objective was to assess the prevalence of MetS in Freetown, Sierra Leone, using the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), International Diabetes Federation (IDF) and Harmonize ATP III. Additionally, we aimed to establish the concordance between these three different criteria used. Methods: This community-based health screening survey was conducted from October 2019 to October 2022. A multistage stratified random design was used to select adults aged 20 years and above. Mean, interquartile range (IQR), and logistic regression were used for statistical analysis. The kappa coefficient statistics resolved the agreement between these defined criteria. Results: The prevalence for NCEP ATP III, Harmonize ATP III and IDF criteria was 11.8 % (95 % CI: 9.0-15.15), 14.3 % (95 % CI: 11.3-18.0), and 8.5 % (95 % CI: 6.2-11.2), respectively for the 2394 selected adults. The kappa coefficient (κ) agreement between the MetS is: Harmonized ATP III and IDF criteria = [(208 (60.8 %); (κ = 0.62)]; Harmonized ATP III and NCEP ATP III = [(201 (58.7 %); (κ = 0.71)]; while IDF and NCEP ATP III was [(132 (38.6 %); (κ = 0.52)]. In the multivariable regression analysis, waist circumference correlated with all three MetS criteria: ATP III [AOR = 0.85; C.I 95 %: (0.40-1.78), p = 0.032], Harmonized ATP III [AOR = 1.14; C.I 95 %: (0.62-2.11), p = 0.024], IDF [AOR = 1.06; C.I 95 % (0.52-2.16), p = 0.018]. Conclusion: We reported a high prevalence of MetS in Freetown, Sierra Leone and identified waist circumference as a major risk factor for MetS. This underscores the crucial role of health education and effective management of MetS in Sierra Leone.

The Stigma of Epilepsy among Patients Attending the Epilepsy Clinic at Connaught Hospital, Sierra Leone.

BACKGROUND: Epilepsy is one of the world's most common neurological disorders with about eighty percent of cases living in low and middle-income countries. Due to superstitious cultural and traditional beliefs in Sub-Saharan Africa, the stigma associated with epilepsy is particularly disabling. Stigma negatively affects the psychosocial wellbeing of people with epilepsy (PWE) and their acceptance of medical treatment. Very limited studies have been done on the types and extent of stigma in PWE in Sierra Leone. OBJECTIVE: This study will assess the extent and correlates of perceived and enacted stigma among patients attending the epilepsy clinic at Connaught hospital in Freetown, Sierra Leone. METHODS: Using a semi-structured questionnaire to identify both perceived and enacted stigma, a cross-sectional descriptive study was conducted among patients attending the epilepsy clinic at Connaught hospital aged ten years and above with no major psychiatric co-morbidity. Frequency of stigma and socio-demographic and clinical correlates of stigma were determined. RESULTS: Of the 128 patients, (9 below 18 years) 57.8% were males. Participants had a mean age of 32.9 years. 53.9% and 79.9% of participants reported experiencing perceived and enacted stigma, respectively. Longer duration of illness and being single correlated with perceived stigma, while lower educational achievement and early age of onset of seizure correlated with enacted stigma. A seizure frequency of more than two attacks a month was significantly related to both forms of stigma. CONCLUSION: The level of epilepsy-related social stigma is high in Sierra Leone. This is likely due to poor community education, leading to misconceptions and biases. An appropriate educational intervention coupled with effective clinical management of cases is needed to mitigate epilepsy-related stigma. CONTEXTE: L'épilepsie est l'un des troubles neurologiques les plus courants dans le monde, avec environ quatre-vingts pour cent des cas vivant dans des pays à revenu faible et intermédiaire. En raison des croyances culturelles et traditionnelles superstitieuses en Afrique subsaharienne, la stigmatisation associée à l'épilepsie est particulièrement handicapante. La stigmatisation affecte négativement le bien-être psychosocial des personnes épileptiques (PWE) et leur acceptation du traitement médical. Très peu d'études ont été menées sur les types et l'étendue de la stigmatisation chez les PWE en Sierra Leone. OBJECTIF: Cette étude évaluera l'étendue et les corrélats de la stigmatisation perçue et manifeste chez les patients fréquentant la clinique de l'épilepsie à l'hôpital Connaught à Freetown, Sierra Leone. MÉTHODES: À l'aide d'un questionnaire semi-structuré pour identifier la stigmatisation perçue et manifeste, une étude descriptive transversale a été menée chez des patients fréquentant la clinique de l'épilepsie à l'hôpital Connaught, âgés de dix ans et plus, sans co-morbidité psychiatrique majeure. La fréquence de la stigmatisation et les corrélats socio-démographiques et cliniques de la stigmatisation ont été déterminés. RÉSULTATS: Sur les 128 patients (9 de moins de 18 ans), 57,8% étaient des hommes. Les participants avaient un âge moyen de 32,9 ans. 53,9% et 79,9% des participants ont signalé avoir éprouvé une stigmatisation perçue et manifeste, respectivement. Une durée plus longue de la maladie et le fait d'être célibataire étaient corrélés à la stigmatisation perçue, tandis qu'un niveau d'éducation inférieur et un jeune âge de début des crises étaient corrélés à la stigmatisation manifeste. Une fréquence de crises de plus de deux attaques par mois était significativement liée aux deux formes de stigmatisation. CONCLUSION: Le niveau de stigmatisation sociale liée à l'épilepsie est élevé en Sierra Leone. Cela est probablement dû à une éducation communautaire insuffisante, conduisant à des idées fausses et des préjugés.Une intervention éducative appropriée couplée à une gestion clinique efficace des cas est nécessaire pour atténuer la stigmatisation liée à l'épilepsie. Mots-clés: Épilepsie, Manifeste, Perçue, Stigmatisation, Sierra Leone.

Stroke in Sierra Leone. the stroke risk factors for people with HIV: A prospective case-control study.

BACKGROUND: HIV infection rates are relatively low in Sierra Leone and in West Africa but the contribution of HIV to the risk factors for stroke and outcomes is unknown. In this study, we examined stroke types, presentation, risk factors and outcome in HIV stroke patients compared with controls. METHODS: We used data from the Stroke in Sierra Leone Study at 2 tertiary hospitals in Freetown, Sierra Leone. A case control design was used to compare stroke type, presentation, risk factors and outcome in sero-positive HIV patients with HIV negative stroke controls. Controls were matched for age and gender and a 1:4 ratio cases to controls was used to optimize power. Analysis was performed using the Pearson x2 for categorical variable, Paired-T test and Mann-Whitney U test for continuous variables. A p-value of less than 0.05 was taken as the level of statistical significance. RESULTS: Of 511 (51.8%) stroke patients tested for HIV, 36 (7.1%) were positive. Univariate unmatched analysis showed a stroke mean age of 49 years in HIV-positive versus 58 years in HIV-negative population (p = <0.001). In the case-control group, ischaemic stroke is the major type reported in both populations, HIV-negative population: 77 (53.5%) versus HIV-positive: 25 (69.4%) (p = 0.084). Hypertension is the most prevalent risk factor in both groups, HIV-positive: 23 (63.9%) versus HIV-negative: 409 (86.1%) (p = 0.001). Lower CD4+ count is associated in-hospital mortality (p = <0.001). CONCLUSION: These findings support the current call for timely management of stroke and HIV through integrated care.

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.

Stroke in Sierra Leone: Case fatality rate and functional outcome after stroke in Freetown.

BACKGROUND: There is limited information on long-term outcomes after stroke in sub-Saharan Africa (SSA). Current estimates of case fatality rate (CFR) in SSA are based on small sample sizes with varying study design and report heterogeneous results. AIMS: We report CFR and functional outcomes from a large, prospective, longitudinal cohort of stroke patients in Sierra Leone and describe factors associated with mortality and functional outcome. METHODS: A prospective longitudinal stroke register was established at both adult tertiary government hospitals in Freetown, Sierra Leone. It recruited all patients ⩾ 18 years with stroke, using the World Health Organization definition, from May 2019 until October 2021. To reduce selection bias onto the register, all investigations were paid by the funder and outreach conducted to raise awareness of the study. Sociodemographic data, National Institute of Health Stroke Scale (NIHSS), and Barthel Index (BI) were collected on all patients on admission, at 7 days, 90 days, 1 year, and 2 years post stroke. Cox proportional hazards models were constructed to identify factors associated with all-cause mortality. A binomial logistic regression model reports odds ratio (OR) for functional independence at 1 year. RESULTS: A total of 986 patients with stroke were included, of which 857 (87%) received neuroimaging. Follow-up rate was 82% at 1 year, missing item data were <1% for most variables. Stroke cases were equally split by sex and mean age was 58.9 (SD: 14.0) years. About 625 (63%) were ischemic, 206 (21%) primary intracerebral hemorrhage, 25 (3%) subarachnoid hemorrhage, and 130 (13%) were of undetermined stroke type. Median NIHSS was 16 (9-24). CFR at 30 days, 90 days, 1 year, and 2 years was 37%, 44%, 49%, and 53%, respectively. Factors associated with increased fatality at any timepoint were male sex (hazard ratio (HR): 1.28 (1.05-1.56)), previous stroke (HR: 1.34 (1.04-1.71)), atrial fibrillation (HR: 1.58(1.06-2.34)), subarachnoid hemorrhage (HR: 2.31 (1.40-3.81)), undetermined stroke type (HR: 3.18 (2.44-4.14)), and in-hospital complications (HR: 1.65 (1.36-1.98)). About 93% of patients were completely independent prior to their stroke, declining to 19% at 1 year after stroke. Functional improvement was most likely to occur between 7 and 90 days post stroke with 35% patients improving, and 13% improving between 90 days to 1 year. Increasing age (OR: 0.97 (0.95-0.99)), previous stroke (OR: 0.50 (0.26-0.98)), NIHSS (OR: 0.89 (0.86-0.91)), undetermined stroke type (OR: 0.18 (0.05-0.62)), and ⩾1 in-hospital complication (OR: 0.52 (0.34-0.80)) were associated with lower OR of functional independence at 1 year. Hypertension (OR: 1.98 (1.14-3.44)) and being the primary breadwinner of the household (OR: 1.59 (1.01-2.49)) were associated with functional independence at 1 year. CONCLUSION: Stroke affected younger people and resulted in high rates of fatality and functional impairment relative to global averages. Key clinical priorities for reducing fatality include preventing stroke-related complications through evidence-based stroke care, improved detection and management of atrial fibrillation, and increasing coverage of secondary prevention. Further research into care pathways and interventions to encourage care seeking for less severe strokes should be prioritized, including reducing the cost barrier for stroke investigations and care.

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.

Risk factors, clinical outcomes and predictors of stroke mortality in Sierra Leoneans: A retrospective hospital cohort study.

BACKGROUND: Stroke data from Sierra Leone is limited, despite the increase in global burden of the disease. The aim of this study was to assess the risk factors, clinical outcomes and predictors of stroke mortality at a tertiary hospital in Freetown, Sierra Leone. METHODS: This retrospective cohort study was conducted on stroke patients admitted at the Connaught Teaching Hospital between 1st January to December 31, 2018. Clinical data related to stroke, with variables including patients' demographics, stroke subtype, vascular risk factors, modified Rankin Scale (mRS), and outcomes were documented. In-hospital mortality, associated risk factors and predictors of stroke were determined. The study was approved by the Sierra Leone Ethics and Scientific Review Committee. It was registered under Research Registry https://www.researchregistry.com/browse-the-registry#home/with the unique identifying number researchregistry6009. RESULT: We studied 178 (95 male and 83 female) patients. The mean age was 59.8 ± 14.0 years, median was 58.1years (ranging: 29-88 years). The commonest risk factors were hypertension (84.3%), tobacco smoking (35.9%) and alcohol (31.4%). Ischemic stroke confirmed by CT scan was 76.3%. In-hospital mortality was 34.8% and at discharge, mean modified Rankin Score (mRS) was 3.89 ± 1.62. The independent predictors for stroke mortality were: hypertension [AOR = 2.2; C.I 95%: (1.32-3.80), p = 0.001], previous stroke [AOR = 2.31; C.I 95%: (1.43-5.74), p = 0.001], GCS < 8 [AOR = 6.06; C.I 95%: (3.17-12.79), p < 0.001], clinical diagnosis in the absence of imaging [AOR = 3.11; C.I 95%: (2.1-9.87), p = 0.001], hemorrhagic stroke [AOR = 2.96; C.I 95%: (1.96-9.54), p < 0.001], and aspiration pneumonia [(AOR = 3.03; C.I 95%:(1.44-6.36), p = 0.001]. Women had poorer outcome than men. CONCLUSION: This study highlights a high stroke mortality in a resource limited hospital, with some stroke patients having difficulties in accessing Computer Tomogram (CT) scan services. It illustrates the need to establish a stroke care setting to improve the quality of stroke care.

Case Series of Severe Neurologic Sequelae of Ebola Virus Disease during Epidemic, Sierra Leone.

We describe a case series of 35 Ebola virus disease (EVD) survivors during the epidemic in West Africa who had neurologic and accompanying psychiatric sequelae. Survivors meeting neurologic criteria were invited from a cohort of 361 EVD survivors to attend a preliminary clinic. Those whose severe neurologic features were documented in the preliminary clinic were referred for specialist neurologic evaluation, ophthalmologic examination, and psychiatric assessment. Of 35 survivors with neurologic sequelae, 13 had migraine headache, 2 stroke, 2 peripheral sensory neuropathy, and 2 peripheral nerve lesions. Of brain computed tomography scans of 17 patients, 3 showed cerebral and/or cerebellar atrophy and 2 confirmed strokes. Sixteen patients required mental health followup; psychiatric disorders were diagnosed in 5. The 10 patients who experienced greatest disability had co-existing physical and mental health conditions. EVD survivors may have ongoing central and peripheral nervous system disorders, including previously unrecognized migraine headaches and stroke.

Monitoring Serious Adverse Events in the Sierra Leone Trial to Introduce a Vaccine Against Ebola.

Clinical Trials Registration: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Implementing an Ebola Vaccine Study - Sierra Leone.

In October 2014, the College of Medicine and Allied Health Sciences of the University of Sierra Leone, the Sierra Leone Ministry of Health and Sanitation, and CDC joined the global effort to accelerate assessment and availability of candidate Ebola vaccines and began planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE). STRIVE was an individually randomized controlled phase II/III trial to evaluate efficacy, immunogenicity, and safety of the recombinant vesicular stomatitis virus Ebola vaccine (rVSV-ZEBOV). The study population was health care and frontline workers in select chiefdoms of the five most affected districts in Sierra Leone. Participants were randomized to receive a single intramuscular dose of rVSV-ZEBOV at enrollment or to receive a single intramuscular dose 18-24 weeks after enrollment. All participants were followed up monthly until 6 months after vaccination. Two substudies separately assessed detailed reactogenicity over 1 month and immunogenicity over 12 months. During the 5 months before the trial, STRIVE and partners built a research platform in Sierra Leone comprising participant follow-up sites, cold chain, reliable power supply, and vaccination clinics and hired and trained at least 350 national staff. Wide-ranging community outreach, informational sessions, and messaging were conducted before and during the trial to ensure full communication to the population of the study area regarding procedures and current knowledge about the trial vaccine. During April 9-August 15, 2015, STRIVE enrolled 8,673 participants, of whom 453 and 539 were also enrolled in the safety and immunogenicity substudies, respectively. As of April 28, 2016, no Ebola cases and no vaccine-related serious adverse events, which by regulatory definition include death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability, were reported in the study population. Although STRIVE will not produce an estimate of vaccine efficacy because of low case frequency as the epidemic was controlled, data on safety and immunogenicity will support decisions on licensure of rVSV-ZEBOV.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

The effects of epilepsy on child education in Sierra Leone.

Epilepsy is associated with a significant burden of false beliefs and social stigma in the setting of Sub-Saharan Africa. To assess the impacts of epilepsy on child education in Sierra Leone (SL), we carried out a cross-sectional descriptive study examining its effects on school attendance, participation in physical activities, and social acceptance among classmates. We also assessed the knowledge, beliefs, and attitudes regarding epilepsy of both the children's caregivers and teachers. The data were collected at various epilepsy clinics and schools in Freetown, SL. A total of 50 patients were interviewed and questionnaires administered to their caregivers and teachers, making a total of 150 respondents. Fifty-one percent of the children were absent from school for >5 days per month. Ninety percent did not participate in games and sports, with the commonest reason being fear of occurrence of seizures. Thirty-six percent claimed having experienced negative attitude from their classmates. Regarding the caregivers, 48% believed that epilepsy was a medical illness, while 34% considered it a demonic manifestation. Forty-eight percent were apprehensive about sending their children to school, with 83% of these caregivers stating fear of seizures and potential injuries. Only 8% of the caregivers did not prevent their children from taking part in any physical activity at school. Regarding the teachers, 16% believed that epilepsy was a demonic manifestation, and 10% thought that it was contagious. Fourteen percent did not think that children with epilepsy should go to school, and 80% would prevent children with epilepsy from participating in games and sports. When faced with a child having a seizure, 48% would hold the child down, 12% would place a hard object in the child's mouth, and 12% would avoid any physical contact. In total, 20% of the children ceased attending school permanently; daily occurrence of seizures (p<0.05), negative attitude of classmates (p<0.001), and having an illiterate caregiver (p<0.02) all showed a significant association with permanent cessation of schooling. The study demonstrates significant negative impacts of epilepsy on child education. Notably, the reasons for permanent exclusion from school appear to be as much related to attitudes as to the medical aspects of the disease itself. The data thus highlight the need for educational programs to address the widely prevalent misconceptions among both caregivers and teachers.