A 7-Month Review of Clinical and Demographic Predictors of Childhood Mortality in a Tertiary Children Hospital in Freetown, Sierra Leone.

BACKGROUND: Sierra Leone ranks among nations with unacceptably high infant and under-5 mortality rates. Understanding the clinical and demographic dynamics that underpin paediatric mortalities is not only essential but fundamental to the formulation and implementation of effective healthcare interventions that would enhance child survival. SUBJECTS AND MATERIAL: This was a 7-month review of all mortalities from May 24th 2021 to December 31st 2021 at Ola During Children's Hospital in Freetown, Sierra Leone. Information on biodata, presenting complaints, illness duration, diagnoses, treatment given inclusive of point-of-care investigations, and duration of hospital stay retrieved from all mortalities were entered into Excel spreadsheets and were analyzed using SPSS version 25.0 for IBM. Multivariable regression analysis was done to determine factors independently associated with mortalities within 24 hours of admission. All associations were considered significant if p < 0.05. RESULTS: There were 840 deaths out of 5920 children admitted during the period giving a mortality of 14.2% with a male-to-female ratio of 1:1. Three hundred and four (36.2%) of these deaths occurred in the neonatal age group while 63.8% occurred in the post neonatal age group. Perinatal asphyxia was the leading cause of neonatal deaths while acute respiratory infections and severe malaria were the leading causes of post neonatal deaths. The majority (64.8%) of the mortalities occurred within the first 24 hours of admission. In a multivariable regression, only transfusion status and use of respiratory support were independently associated with mortality within 24 hours of admission (P<0.05). CONCLUSION: Paediatric mortality in Sierra Leone is high and is caused mainly by preventable morbidities such as perinatal asphyxia and infections. Most of the deaths occurred within 24 hours of admission. It is recommended that patients should be brought to the hospital early and preventive measures be instituted to address these causes.

CONTEXTE: La Sierra Leone se classe parmi les nations ayant des taux de mortalité infantile et des moins de cinq ans inacceptables. Comprendre la dynamique clinique et démographique qui sous-tend les mortalités pédiatriques est non seulement essentiel mais fondamental pour la formulation et la mise en œuvre d'interventions efficaces en matière de santé qui amélioreraient la survie des enfants. SUJETS ET MATÉRIEL: Il s'agissait d'une revue de sept mois de toutes les mortalités du 24 mai 2021 au 31 décembre 2021 à l'Hôpital Ola During Children's à Freetown, Sierra Leone. Les informations sur les données biométriques, les plaintes de présentation, la durée de la maladie, les diagnostics, les traitements administrés, y compris les investigations sur le lieu de soins, et la durée du séjour à l'hôpital ont été saisies dans des feuilles de calcul Excel et analysées à l'aide de SPSS version 25.0 pour IBM. Une analyse de régression multivariée a été effectuée pour déterminer les facteurs indépendamment associés aux mortalités dans les 24 heures suivant l'admission. Toutes les associations étaient considérées comme significatives si p < 0,05. RÉSULTATS: Il y a eu 840 décès sur 5920 enfants admis pendant la période, ce qui donne une mortalité de 14,2 % avec un rapport hommefemme de 1:1. Trois cent quatre (36,2 %) de ces décès sont survenus dans le groupe d'âge néonatal, tandis que 63,8 % sont survenus dans le groupe d'âge post-néonatal. L'asphyxie périnatale était la principale cause de décès néonatal, tandis que les infections respiratoires aiguës et le paludisme grave étaient les principales causes de décès post-néonatal. La majorité (64,8 %) des mortalités sont survenues dans les premières 24 heures suivant l'admission. Dans une régression multivariée, seul le statut transfusionnel et l'utilisation d'un support respiratoire étaient indépendamment associés à la mortalité dans les 24 heures suivant l'admission (P<0,05). CONCLUSION: La mortalité pédiatrique en Sierra Leone est élevée et est principalement causée par des morbidités évitables telles que l'asphyxie périnatale et les infections. La plupart des décès surviennent dans les 24 heures suivant l'admission. Il est recommandé que les patients soient amenés à l'hôpital tôt et que des mesures préventives soient mises en place pour traiter ces causes. MOTS CLÉS: Mortalité pédiatrique, Profil clinique, Déterminants, Freetown.

Sero-prevalence of syphilis infection among people living with HIV in Sierra Leone: a cross-sectional nationwide hospital-based study.

BACKGROUND: Globally, there were an estimated 7.1 million new syphilis infections in 2020, with more than 30% of these new infections reported in African countries such as Sierra Leone. Despite this, there is no HIV-specific syphilis screening program in Sierra Leone. Thus, data are needed to inform public health practice. In this study, we aimed to determine the prevalence of syphilis seropositivity and factors associated with syphilis seropositivity among people living with HIV (PLHIV). METHODS: A cross-sectional study was conducted at 10 health facilities in Sierra Leone, among adults with HIV, aged 18 years or older, from September 2022 to January 2023. Parameters of interest were collected including age, sex, marriage, antiretroviral therapy (ART) regimen, HIV viral load, duration of ART treatment, and hospital level of care. The syphilis antibody was detected by a rapid test based on immunochromatography assay. Data were analyzed using R-software version 4.2.3 (R Core Team, Vienna, Austria). Pearson's χ2 test, Fisher's exact test and Kruskal-Wallis H test were applied to assess the differences in syphilis seropositivity between groups as appropriate. Univariate logistic regression and multivariate logistic regression analysis was used to assess factors associated with syphilis seropositivity. The level of statistical significance was set at P < 0.05. RESULTS: Of the 3082 PLHIV individuals in our study, 2294 (74.4%) were female and 2867 (93.0%) were receiving ART. With a median age of 36 years, 211 (6.8%, 95% CI 6.0-7.7) were positive for syphilis. The prevalence of syphilis was highest in people aged 60 years and over (21.1%, 95%CI 14.7-29.2), followed by people aged 50-60 years (15.5%, 95%CI 11.9-19.9) and in the widowed population (11.9%, 95%CI 8.9-15.8). There were no differences in syphilis seropositivity between gender, ART status, ART regimen, duration of ART, HIV viral load and hospital level of care. Older age (50-60 years: adjusted OR 3.49, 95%CI 2.09-5.85 P < 0.001; 60-100 years: adjusted OR 4.28, 95%CI 2.21-8.17, P < 0.001) was an independent predictor of seropositive syphilis. CONCLUSIONS: We observed a high prevalence of syphilis among PLHIV. Older people and widowed population have higher syphilis seropositivity. Older age was an independent predictor of syphilis positivity. Therefore, we call for the integration of syphilis screening, treatment and prevention in HIV services.

Actor-network analysis of community-based organisations in health pandemics: evidence from the COVID-19 response in Freetown, Sierra Leone.

Freetown, Sierra Leone, is confronted with health risks that are compounded by rapid unplanned urbanisation and weak capacities of local government institutions. Addressing them implies a shared responsibility between government and non-state actors. In low-income areas, the role of community-based organisations (CBOs) in combating health disasters is well-recognised. Yet, empirical evidence on how they have utilised their networks and coordinated community-level strategies in responding to the COVID-19 pandemic is scant. This paper, based on a qualitative study in two informal settlements in Freetown, employs actor-network theory to understand how CBOs problematise COVID-19 as a health risk, interact with other entities, and the subsequent tensions that arise. The findings show that community vulnerabilities and past experiences of health disasters informed CBOs' perception of COVID-19 as a communal emergency. In response, they coordinated sensitisation and mobilisation programmes by relying on a network of actors to support COVID-19 risk reduction strategies. Nonetheless, misunderstandings among them caused friction.

Factors associated with adherence to treatment in patients with open angle glaucoma in Sierra Leone, West Africa: patient demographics and questionnaire.

BACKGROUND: Glaucoma is a significant cause of blindness worldwide. It is more common, presents earlier and is more aggressive in those of African descent. Non-adherence and poor knowledge of glaucoma is a significant barrier to treatment and has been associated with low health literacy. We aim to establish the factors contributing to late presentation, treatment non-adherence and disease progression in glaucoma patients in Sierra Leone. This will help better understand the challenges eye services face, highlight fields requiring development in patient-clinician interaction and identify areas or specific vulnerable patient groups in which resources should be focused. METHODS: Prospective, consecutive recruitment of 120 patients with POAG attending the Lowell and Ruth Gess Eye Hospital and the Connaught Government Teaching Hospital, Freetown, Sierra Leone between February and April 2020. Data were collected from 3 sources: (1) review of clinical notes since first attendance, (2) semi-structured interviews and (3) assessment of study participant's drop instillation technique using a structured checklist. Descriptive statistics was performed for demographic data and other relevant data points. Logistic regression was used for analysis of target variables. RESULTS: The average age was 62 years with more males (52.6%). Agricultural workers and informal street traders represented 13.2% of participants' occupation. 25.8% of participants had no formal school, and 47.4% had either a degree or a diploma. This is out of proportion with the general population and may represent a hidden demographic of glaucoma patients. Drop instillation technique was successful in 52% of study participants. Notable responses to the questionnaire were 30% of patients did not know the name of their eye condition and 22% had no knowledge of glaucoma. CONCLUSION: Investment in a wide-ranging and robust screening programme and public health campaigns targeting these vulnerable groups and high-risk individuals, for example with a positive family history, alongside improved patient education and staff training is required to improve glaucoma care. Support from government, international organisations and the private sector is required to reduce the economic burden of blindness in Sierra Leone.

Forensic parameters and genetic structure analysis of 30 autosomal InDels of the population in Freetown, Sierra Leone.

As the origin of modern humanity, African populations show high genetic diversity and are attracting increasing academic attention. However, populations living in West Africa have so far received less study and exploration. In this study, we analyze 30 insertion/deletion (InDel) loci of 516 samples from Freetown, Sierra Leone, to evaluate the forensic properties and reveal the genetic structure in Freetown, Sierra Leone, West Africa. No significant linkage disequilibrium (LD) between 30 InDels was observed after the Bonferroni correction. The random match probability (RMP), the combined power of exclusion for duos (CPE duos), and the combined power of exclusion for trios (CPE trios) were 6.823 × 10-11, 0.9168, and 0.9731, respectively. Null alleles and off-ladder alleles were observed, suggesting that we should be cautious when using this kit for forensic caseworks in African populations. In the population comparison study, we found that the Freetown population is genetically closer to geographically distinct West Africans and has a closer genetic relationship with the Bantu-speaking populations than other African populations.

Risk factors for preeclampsia and eclampsia at a main referral maternity hospital in Freetown, Sierra Leone: a case-control study.

BACKGROUND: In the African region, 5.6% of pregnancies are estimated to be complicated by preeclampsia and 2.9% by eclampsia, with almost one in ten maternal deaths being associated with hypertensive disorders. In Sierra Leone, representing one of the countries with the highest maternal mortality rates in the world, 16% of maternal deaths were caused by pregnancy-induced hypertension in 2016. In the light of the high burden of preeclampsia and eclampsia (PrE/E) in Sierra Leone, we aimed at assessing population-based risk factors for PrE/E to offer improved management for women at risk. METHODS: A facility-based, unmatched observational case-control study was conducted in Princess Christian Maternity Hospital (PCMH). PCMH is situated in Freetown and is the only health care facility providing 'Comprehensive Emergency Obstetric and Neonatal Care services' throughout the entire country. Cases were defined as pregnant or postpartum women diagnosed with PrE/E, and controls as normotensive postpartum women. Data collection was performed with a questionnaire assessing a wide spectrum of factors influencing pregnant women's health. Statistical analysis was performed by estimating a binary logistic regression model. RESULTS: We analyzed data of 672 women, 214 cases and 458 controls. The analysis yielded several independent predictors for PrE/E, including family predisposition for PrE/E (AOR = 2.72, 95% CI: 1.46-5.07), preexisting hypertension (AOR = 3.64, 95% CI: 1.32-10.06), a high mid-upper arm circumflex (AOR = 3.09, 95% CI: 1.83-5.22), presence of urinary tract infection during pregnancy (AOR = 2.02, 95% CI: 1.28-3.19), presence of prolonged diarrhoea during pregnancy (AOR = 2.81, 95% CI: 1.63-4.86), low maternal assets (AOR = 2.56, 95% CI: 1.63-4.02), inadequate fruit intake (AOR = 2.58, 95% CI: 1.64-4.06), well or borehole water as the main source of drinking water (AOR = 2.05, 95% CI: 1.31-3.23) and living close to a waste deposit (AOR = 1.94, 95% CI: 1.15-3.25). CONCLUSION: Our findings suggest that systematic assessment of identified PrE/E risk factors, including a family predisposition for PrE/E, preexisting hypertension, or obesity, should be performed early on in ANC, followed by continued close monitoring of first signs and symptoms of PrE/E. Additionally, counseling on nutrition, exercise, and water safety is needed throughout pregnancy as well as education on improved hygiene behavior. Further research on sources of environmental pollution in Freetown is urgently required.

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.

Mapping deforestation and urban expansion in Freetown, Sierra Leone, from pre- to post-war economic recovery.

Freetown, the capital of Sierra Leone has experienced vast land-cover changes over the past three decades. In Sierra Leone, however, availability of updated land-cover data is still a problem even for environmental managers. This study was therefore, conducted to provide up-to-date land-cover data for Freetown. Multi-temporal Landsat data at 1986, 2001, and 2015 were obtained, and a maximum likelihood supervised classification was employed. Eight land-cover classes or categories were recognized as follows: water, wetland, built-up, dense forest, sparse forest, grassland, barren, and mangrove. Land-cover changes were mapped via post-classification change detection. The persistence, gain, and loss of each land-cover class, and selected land conversions were also quantified. An overall classification accuracy of 87.3 % and a Kappa statistic of 0.85 were obtained for the 2015 map. From 1986 to 2015, water, built-up, grassland, and barren had net gains, whereas forests, wetlands, and mangrove had net loses. Conversion analyses among forests, grassland, and built-up show that built-up had targeted grassland and avoided forests. This study also revealed that, the overall land-cover change at 2001-2015 was higher (28.5 %) than that recorded at 1986-2001 (20.9 %). This is attributable to the population increase in Freetown and the high economic growth and infrastructural development recorded countrywide after the civil war. In view of the rapid land-cover change and its associated environmental impacts, this study recommends the enactment of policies that would strike a balance between urbanization and environmental sustainability in Freetown.

Physicochemical quality assessment of various brands of paracetamol tablets sold in Freetown Municipality.

Paracetamol is a widely used over-the-counter drug for managing fever and pain, but its quality may vary among different brands, especially in low- and middle-income countries, where counterfeit and substandard medicines are prevalent. This study evaluated the physicochemical properties of fifteen brands of 500 mg paracetamol tablets sold in various pharmacies in Freetown, Sierra Leone using identification tests, friability tests, assay, dissolution tests, and mass variation. The results showed that three brands were not registered with the Pharmacy Board of Sierra Leone, and two brands did not meet the requirement for labelling (no manufacturing date). All the brands met the requirement for mass variation, friability tests and assays. The percentage assay of the different brands ranged from 96.17 %w/w to 101.97 %w/w. However, two brands did not meet the specification for dissolution, with P012 releasing about 21.23 % ± 5.76 of the drug within 45min. Most of the paracetamol brands evaluated met the physicochemical test specification. However, two brands failed the dissolution test, two brands did not meet the labelling requirement and three brands were identified as unregistered products with the National Medicines Regulatory Authority in Sierra Leone. This study underscores the necessity of enhancing monitoring and post-market surveillance of pharmaceuticals in Sierra Leone to ensure they comply with regulatory requirements.

Establishing an Antimicrobial Stewardship Program in Sierra Leone: A Report of the Experience of a Low-Income Country in West Africa.

Antimicrobial Resistance (AMR) is a growing global health challenge that threatens to undo gains in human and animal health. Prevention and control of AMR requires functional antimicrobial stewardship (AMS) program, which is complex and often difficult to implement in low- and middle-income countries. We aimed to describe the processes of establishing and implementing an AMS program at Connaught Hospital in Sierra Leone. The project involved the setting up of an AMS program, capacity building and performing a global point prevalence survey (GPPS) at Sierra Leone's national referral hospital. Connaught Hospital established a multidisciplinary AMS subcommittee in 2021 to provide AMS services such as awareness campaigns, education and training and review of guidelines. We performed a GPPS on 175 patients, of whom more than half (98, 56.0%) were prescribed an antibiotic: 63 (69.2%) in the surgical wards and 53 (51.2%) in the medical wards. Ceftriaxone (60, 34.3%) and metronidazole (53, 30.3%) were the most common antibiotics prescribed to patients. In conclusion, it is feasible to establish and implement an AMS program in low-income countries, where most hospitalized patients were prescribed an antibiotic.

Antibiotic use and consumption in Freetown, Sierra Leone: A baseline report of prescription stewardship in outpatient clinics of three tertiary hospitals.

Objective: As there are no country-representative data on bacterial sensitivities to guide antimicrobial stewardship (AMS) interventions, an AMS programme was established in the outpatient clinics of three tertiary hospitals in Freetown, Sierra Leone. Methods: The study employed a cross-sectional design to collect antibiotic prescribing data from 370 pregnant women and lactating mothers, 314 children and 229 regular patients in the outpatient clinics of the Princess Christian Maternity Hospital (PCMH), Ola During Children's Hospital and Connaught Hospital (CH), respectively, in April 2022. All data were analysed using Stata Version 16. Results: Of 913 patients, most were female (n=635, 69.5%), treated at PCMH (n=370, 40.5%) and had a bacterial infection (n=661, 72.4%). The indication for prescribing antibiotics was inappropriate in 252 (27.6%) patients. Of the 1236 prescriptions, 393 (31.8%) were made at CH. The duration of antibiotic use was not stated in 230 (18.6%) prescriptions. Overall antibiotic consumption was 55.3 defined daily doses per 1000 outpatient-days. Conclusion: Gaps in antibiotic prescriptions were identified in the outpatient clinics of three national referral hospitals in Sierra Leone. In order to combat antimicrobial resistance, AMS interventions are needed to reduce the prescription of antibiotics for inappropriate indications or without specified duration.

Making every death count: institutional mortality accuracy at Ola During Children's Hospital, Sierra Leone.

INTRODUCTION: health care data accuracy feeds the development of sound healthcare policy and the prioritisation of interventions in scarce resource environments. We designed a retrospective study at the sole paediatric government hospital in Sierra Leone to examine mortality statistics, specifically: the accuracy of mortality data collected in 2017; and the quality of cause of death (CoD) reporting for 2017. METHODS: the retrospective audit included all available mortality statistics collected at the hospital during the 2017 calendar year. For the purpose of calculating a mortality rate, admission data was additionally gathered. Four different hospital entities were identified that collected mortality data (the Monitoring and Evaluation (M&E) office; the nurse ledgers; the office of births and deaths; and the mortuary). Data from each hospital entity were used for the comparative analysis. RESULTS: striking differences were found in the rate of hospital mortality reported by different entities. The M&E office (responsible for providing data to the ministry of health and sanitation) reported a hospital mortality rate of 2.94% in 2017. Mortuary and nursing admissions records showed a hospital mortality rate of 18.7%. Discrepancies and issues of quality in CoD reporting between hospital entities were identified. CONCLUSION: significant variations were found in the generation of official hospital mortality data. Mortality data informs health service prioritisation, resource distribution, outcome measures and epidemiological surveillance. Resources to support quality improvement initiatives are needed in the creation of an in-hospital system that reports accurate data with a process for real-time institutional data feedback.