Perspectives and experiences of healthcare providers on the response to the COVID-19 pandemic in three maternal and neonatal referral hospitals in Guinea in 2020: a qualitative study.

BACKGROUND: The COVID-19 pandemic has adversely affected access to essential healthcare services. This study aimed to explore healthcare providers' perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea. METHODS: We conducted a longitudinal qualitative study between June and December 2020 in two maternities and one neonatology referral ward in Conakry and Mamou. Participants were purposively recruited to capture diversity of professional cadres, seniority, and gender. Four rounds of in-depth interviews (46 in-depth interviews with 18 respondents) were conducted in each study site, using a semi-structured interview guide that was iteratively adapted. We used both deductive and inductive approaches and an iterative process for content analysis. RESULTS: We identified four themes and related sub-themes presented according to whether they were common or specific to the study sites, namely: 1) coping strategies & care reorganization, which include reducing staffing levels, maintaining essential healthcare services, suspension of staff daily meetings, insertion of a new information system for providers, and co-management with COVID-19 treatment center for caesarean section cases among women who tested positive for COVID-19; 2) healthcare providers' behavior adaptations during the response, including infection prevention and control measures on the wards and how COVID-19-related information influenced providers' daily work; 3) difficulties encountered by providers, in particular unavailability of personal protective equipment (PPE), lack of financial motivation, and difficulties reducing crowding in the wards; 4) providers perceptions of healthcare service use, for instance their fear during COVID-19 response and perceived increase in severity of complications received and COVID-19 cases among providers and parents of newborns. CONCLUSION: This study provides insights needed to be considered to improve the preparedness and response of healthcare facilities and care providers to future health emergencies in similar contexts.

IFNγ, TNFα polymorphisms and IFNγ serum levels are associated with the clearance of drug-resistant P. falciparum in Malian children.

Host immunity has been suggested to clear drug-resistant parasites in malaria-endemic settings. However, the immunogenetic mechanisms involved in parasite clearance are poorly understood. Characterizing the host's immunity and genes involved in controlling the parasitic infection can inform the development of blood-stage malaria vaccines. This study investigates host regulatory cytokines and immunogenomic factors associated with the clearance of Plasmodium falciparum carrying a chloroquine resistance genotype. Biological samples from participants of previous drug efficacy trials conducted in two Malian localities were retrieved. The P. falciparum chloroquine resistance transporter (Pfcrt) gene was genotyped using parasite DNA. Children carrying parasites with the mutant allele (Pfcrt-76T) were classified based on their ability to clear their parasites. The levels of the different cytokines were measured in serum. The polymorphisms of specific human genes involved in malaria susceptibility were genotyped using human DNA. The prevalence of the Pfcrt-76T was significantly higher in Kolle than in Bandiagara (81.6 % vs 38.6 %, p < 10-6). The prevalence of children who cleared their mutant parasites was significantly higher in Bandiagara than in Kolle (82.2 % vs 67.4 %, p < 0.05). The genotyping of host genes revealed that IFN-γ -874 T and TNF-α -308A alleles were positively associated with parasite clearance. Cytokine profiling revealed that IFN-γ level was positively associated with parasite clearance (p = 0.04). This study highlights the role of host's immunity and immunogenetic factors to clear resistant parasites, suggesting further characterization of these polymorphisms may help to develop novel approaches to antiparasitic treatment strategies.

Variations in the use of malaria preventive measures among pregnant women in Guinea: a secondary analysis of the 2012 and 2018 demographic and health surveys.

BACKGROUND: Despite its effectiveness, the optimal use of the combination of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) remains low in malaria-endemic areas. Therefore, this study analyzed its variations and predictors in Guinea. METHODS: This study was a secondary analysis of the 2012 and 2018 Guinea Demographic and Health Surveys (DHS). It included women who had given birth 3 years before each DHS, slept on ITN and took at least one dose of SP. Use was complete if a pregnant woman slept on ITNs and took SP (at least two doses in 2012; at least three doses in 2018). Moran indices were used to determine spatial autocorrelation and classification methods to identify malaria preventive measures (MPM) predictors. RESULTS: In 2012, 60.88% of pregnant women had incomplete use of MPMs compared with 79.11% in 2018. Associated factors with incomplete MPMs in 2012 were as follows: having an indirect link with the head of household (AOR = 2.23, 95% CI 1.08-4.61) and performing at least 4 ANC visits (AOR = 0.66, 95% CI 0.44-0.99). In 2018: Living in households of 2 to 5 people (AOR = 0.54, 95% CI 0.36-0.80), have a man as the head of the household (AOR = 0.56, 95% CI 0.35-0.89), perform the first ANC in the second trimester of pregnancy (AOR = 0.74, 95% CI 0.54-0.99), perform at least 4 ANC visits (AOR = 0.47, 95% CI 0.36-0.62), have a job (AOR = 0. 67, 95% CI 0.50-0.88), give birth in a public health facility (AOR = 0.53, 95% CI 0.39-0.72) and the middle wealth quintile (AOR = 1.56, 95% CI 1.07-2.26). Analyses revealed a global autocorrelation (Moran index = 0.0009, p = 0.2349) and high-high clusters in Mamou in 2012. In 2018, autocorrelation was found (I Moran = 0.0169, p ≤ 0.05), with spatial clusters in 4 regions. CONCLUSION: The link with the head of household and the number of ANC visits were the main factors in MPMs. It is essential to implement strategies at the household level and health system level and monitor them to reduce inequality across regions.

Facilitators and barriers to COVID-19 vaccination among healthcare workers and the general population in Guinea.

INTRODUCTION: The advent of the effective COVID-19 vaccine was the most eagerly expected worldwide. However, this hope quickly became hesitation and denial in many countries, including Guinea. Understanding the reasons for low vaccine coverage is essential to achieving herd immunity leading to disease control. This study aimed to comprehend the facilitators and barriers to the acceptance COVID-19 vaccine in Guinea. METHODS: The survey focused on healthcare workers (HCWs) and the general population (GP) in 4 natural regions in Guinea from 23 March 2021 to 25 August 2021. We used the Fishbein integration model to study the behaviours of HWCs and GP regarding vaccination. A mixed cross-sectional study collected knowledge, attitudes, norms, and perceptions. Regression and thematic content analysis identified the main facilitators and barriers to vaccination. RESULTS: We surveyed 3547 HCWs and 3663 GP. The proportion of people vaccinated was 65% among HCWs and 31% among the GP. For HCWs: the main factors associated with vaccination against COVID-19 were as follows: absence of pregnancy AOR = 4.65 [3.23-6.78], being supportive of vaccination AOR = 1.94 [1.66-2.27] and being an adult AOR = 1.64 [1.26-2.16]. Regarding the GP, the following factors increased the odds of vaccination: absence of pregnancy AOR = 1.93 [CI 1.01-3.91], being favourable for vaccination AOR = 3.48 [CI 2.91-4.17], being an adult AOR = 1.72 [CI 1.38-2.14] and being able to get the vaccine AOR = 4.67 [CI 3.76-5.84]. Semi-interviews revealed fear, lack of trust, and hesitant perception of the government as potential barriers to vaccination. CONCLUSION: This study suggests that beliefs and negative perceptions are potential barriers to vaccination against COVID-19 among HCWs and the GP. Policies should emphasise practical strategies to mitigate these barriers among young people and pregnant women. Lastly, there is a need to improve access to vaccines in the GP.

PREVAIL IV: A Randomized, Double-Blind, 2-Phase, Phase 2 Trial of Remdesivir vs Placebo for Reduction of Ebola Virus RNA in the Semen of Male Survivors.

BACKGROUND: Ebola virus RNA persists in the semen of male Ebola survivors for months to years after the acute infection, and male-to-female sexual transmission of the virus is well documented. We investigated whether remdesivir can safely reduce persistence of seminal Ebola virus RNA. METHODS: We recruited men with persistent seminal Ebola RNA in Liberia and Guinea. Participants were randomized 1:1 to receive intravenous remdesivir (GS-5734; Gilead Sciences) or matching placebo administered once daily by intravenous infusion over 1 hour on 5 consecutive days. Stratification was by country and number of positive (1 or 2) preenrollment semen tests. We evaluated the difference in mean assay negativity rate (ANR), that is, the proportion of negative tests for each participant in each group in the treatment (days 1-28) and follow-up (months 2-6) phases on an intention-to-treat basis. RESULTS: We enrolled 38 men from July 2016 through June 2018. The mean treatment phase ANRs were 85% (standard deviation [SD] = 24%) and 76% (SD = 30%) in the remdesivir and placebo arms, respectively (P = .270). The mean follow-up phase ANRs were 96% (SD = 10%) and 81% (SD = 29%) in the remdesivir and placebo arms, respectively (P = .041). The 5-day remdesivir regimen was well tolerated with no safety concerns. CONCLUSIONS: In this small trial, remdesivir 100 mg/day for 5 days safely reduced the presence of Ebola virus RNA in the semen of Ebola survivors 2 to 6 months after administration. A larger follow-up study is necessary to confirm results. Clinical Trials Registration . NCT02818582.

Plasmodium falciparum kelch 13 Mutations, 9 Countries in Africa, 2014-2018.

The spread of drug resistance to antimalarial treatments poses a serious public health risk globally. To combat this risk, molecular surveillance of drug resistance is imperative. We report the prevalence of mutations in the Plasmodium falciparum kelch 13 propeller domain associated with partial artemisinin resistance, which we determined by using Sanger sequencing samples from patients enrolled in therapeutic efficacy studies from 9 sub-Saharan countries during 2014-2018. Of the 2,865 samples successfully sequenced before treatment (day of enrollment) and on the day of treatment failure, 29 (1.0%) samples contained 11 unique nonsynonymous mutations and 83 (2.9%) samples contained 27 unique synonymous mutations. Two samples from Kenya contained the S522C mutation, which has been associated with delayed parasite clearance; however, no samples contained validated or candidate artemisinin-resistance mutations.

Malaria epidemiology and anti-malarial drug efficacy in Guinea: a review of clinical and molecular studies.

Malaria is one of the leading causes of mortality and morbidity in Guinea. The entire country is considered at risk of the disease. Transmission occurs all year round with peaks occurring from July through October with Plasmodium falciparum as the primary parasite species. Chloroquine (CQ) was the first-line drug against uncomplicated P. falciparum in Guinea until 2005, prior to the adoption of artemisinin-based combination therapy (ACT). In this review, data on therapeutic efficacy of CQ and artemisinin-based combinations reported in published literature is summarized. Against CQ, a failure rate of 27% (12/44) was reported in a study in 1992; a median failure rate of 15.6% [range: 7.7-28.3; 8 studies] was observed during 1996-2001, and 81% (17/21) of the patients failed to clear parasitaemia in a study conducted in 2007. For artemisinin-based combinations, three published studies were identified (1495 patients; 2004-2016); all three studies demonstrated day 28 polymerase chain reaction corrected efficacy > 95%. One study characterized kelch-13 mutations (389 tested; samples collected in 2016) with no evidence of mutations currently known to be associated with artemisinin resistance. The impact of the ongoing COVID-19 pandemic and widespread usage of counterfeit medicines are immediate challenges to malaria control activities in Guinea.

Retention of healthcare workers 1 year after recruitment and deployment in rural settings: an experience post-Ebola in five health districts in Guinea.

BACKGROUND: Guinea undertook health workforce reform in 2016 following the Ebola outbreak to overcome decades-long shortages and maldistribution of healthcare workers (HCWs). Specifically, over 5000 HCWs were recruited and deployed to rural health districts and with a signed 5-year commitment for rural medical practice. Governance structures were also established to improve the supervision of these HCWs. This study assessed the effects of this programme on local health systems and its influence on HCWs turnover in rural Guinea. METHODS: An exploratory study design using a mixed-method approach was conducted in five rural health districts. Data were collected through semi-structured questionnaires, in-depth interview guides, and documentary reviews. RESULTS: Of the 611 HCWs officially deployed to the selected districts, 600 (98%) took up duties. Female HCWs (64%), assistant nurses (39%), nurses (26%), and medical doctors (20%) represented the majority. Findings showed that 69% of HCWs were posted in health centres and the remaining in district hospitals and the health office (directorate); the majority of which were medical doctors, nurses, and midwives. The deployment has reportedly enhanced quality and timely data reporting. However, challenges were faced by local health authorities in the posting of HCWs including the unfamiliarity of some with primary healthcare delivery, collaboration conflicts between HCWs, and high feminization of the recruitment. One year after their deployment, 31% of the HCWs were absent from their posts. This included 59% nurses, 29% medical doctors, and 11% midwives. The main reasons for absenteeism were unknown (51%), continuing training (12%), illness (10%), and maternity leave (9%). Findings showed a confusion of roles and responsibilities between national and local actors in the management of HCWs, which was accentuated by a lack of policy documents. CONCLUSION: The post-Ebola healthcare workers policy appears to have been successfully positive in the redistribution of HCWs, quality improvement of staffing levels in peripheral healthcare facilities, and enhancement of district health office capacities. However, greater attention should be given to the development of policy guidance documents with the full participation of all actors and a clear distinction of their roles and responsibilities for improved implementation and efficacy of this programme.

Factors Associated with Malaria Preventive Measures among Pregnant Women in Guinea.

Background: Malaria control interventions have been scaled up, particularly those in pregnant women in Guinea. Despite that, coverage of key malaria preventive measure (MPM) indicators remains low. Therefore, it is vital to understand the reasons behind that, especially for the low coverage of sulfadoxine-pyrimethamine (SP) and long-lasting insecticide-treated bed nets (LLIN). Methods: We conducted a cross-sectional survey in nine district hospitals in Guinea. Pregnant women received for delivery were interviewed to collect sociodemographic and obstetrical parameters. Associated factors with MPMs were investigated through univariate analysis and classification and regression tree (CART). Results: A total of 2248 parturients participated in this study. Among pregnant women using mosquito nets (63.5% (61.4%, 65.5%)), only 41.2% (39.1%, 43.3%) had used it regularly during the last two weeks preceding delivery. Similarly, most pregnant women (57.9% (55.8%, 59.9%)) had received less than three doses of SP, and only a few pregnant women (23.9% (22.1%, 25.7%)) have benefited from full MPMs. Parturient's age, marital status, time spent in residence, place of residence, level of education, distance from home to the health centre, health conditions, occupation, head of the household's occupation, the presence of garbage and stagnant water in the neighbourhood, source of running water, and the number of pregnancies were significantly statistically associated with MPMs in pregnant women. However, the number of antenatal care visits (ANC), means of transportation used by the pregnant woman to accomplish ANCs, and stagnant water in the neighbourhood were the three preponderant factors. Conclusion: The low coverage of SP and LLINs among pregnant women requires revitalising some strategies, especially improving ANC coverage and more efforts to reduce inequalities in access to those services due to sociodemographic status. Education on the benefits of these MPMs should also be emphasised.

Outcomes of blended learning for capacity strengthening of health professionals in Guinea.

BACKGROUND: Quality human resources constitute an essential pillar of an effective health system. This paper analyzes the outcomes of blended learning for post-Ebola capacity strengthening of health professionals in Guinea. METHODS: Two courses lasting 3 months each (7-8 modules) were developed and implemented: one in Primary Health Care (eSSP) and the other in Sexual and Reproductive Health Services Management (eSSR). Both eSSP and eSSR courses were offered online on the Moodle platform, followed by a face-to-face capacity-building workshop. A cross-sectional study using a mixed-methods approach was conducted in 2018-19. As outcomes, we described learners' sociodemographic characteristics, course completion and success, and perceptions of the courses and support from the instructors, analyzed the factors associated with learners' successful completion and reported on learners' feedback on their blended learning experience. Quantitative data were analyzed using the STATA 15 software, and qualitative data were analyzed through content analysis. RESULTS: Overall, 282 health professionals were enrolled for both eSSP and eSSR courses. The completion rate was 69.5% (196/282). The success rate for learners who completed the courses was 80% (156/196), and the overall success rate for enrollees was 55% (156/282). The dropout and abstention rates were 22 and 9%, respectively. On both eSSP and eSSR courses, the success rate of women enrolled was higher than or equal to men's. The success rate of medical doctors enrolled (53% for eSSP and 67% for eSSR) was higher than for other health professionals, in particular nurses (9% for eSSP) and midwives (40% for eSSR). Course type was associated with success (AOR = 1.93; 95% CI = 1.15-3.24). Most learners strongly agreed that the courses are relevant for targeted health professionals (81 to 150/150), pdf course materials are well-structured and useful (105/150), the content of the modules is relevant, comprehensible, and clear (90/150), self-assessment quizzes are helpful (105/150), summative assessment assignments are relevant (90/150), the course administrators and IT manager were responsive to learners' concerns (90/150), they will recommend the courses to colleagues and friends (120/150). CONCLUSION: Two blended courses for capacity strengthening of health professionals were successfully developed and implemented in Guinea.

Efficacy and safety of artesunate-amodiaquine and artemether-lumefantrine and prevalence of molecular markers associated with resistance, Guinea: an open-label two-arm randomised controlled trial.

BACKGROUND: Anti-malarial resistance is a threat to recent gains in malaria control. This study aimed to assess the efficacy and safety of artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) in the management of uncomplicated malaria and to measure the prevalence of molecular markers of resistance of Plasmodium falciparum in sentinel sites in Maferinyah and Labé Health Districts in Guinea in 2016. METHODS: This was a two-arm randomised controlled trial of the efficacy of AL and ASAQ among children aged 6-59 months with uncomplicated Plasmodium falciparum malaria in two sites. Children were followed for 28 days to assess clinical and parasitological response. The primary outcome was the Kaplan-Meier estimate of Day 28 (D28) efficacy after correction by microsatellite-genotyping. Pre-treatment (D0) and day of failure samples were assayed for molecular markers of resistance in the pfk13 and pfmdr1 genes. RESULTS: A total of 421 participants were included with 211 participants in the Maferinyah site and 210 in Labé. No early treatment failure was observed in any study arms. However, 22 (5.3%) participants developed a late treatment failure (8 in the ASAQ arm and 14 in the AL arm), which were further classified as 2 recrudescences and 20 reinfections. The Kaplan-Meier estimate of the corrected efficacy at D28 was 100% for both AL and ASAQ in Maferinyah site and 99% (95% Confidence Interval: 97.2-100%) for ASAQ and 99% (97.1-100%) for AL in Labé. The majority of successfully analysed D0 (98%, 380/389) and all day of failure (100%, 22/22) samples were wild type for pfk13. All 9 observed pfk13 mutations were polymorphisms not associated with artemisinin resistance. The NFD haplotype was the predominant haplotype in both D0 (197/362, 54%) and day of failure samples (11/18, 61%) successfully analysed for pfmdr1. CONCLUSION: This study observed high efficacy and safety of both ASAQ and AL in Guinea, providing evidence for their continued use to treat uncomplicated malaria. Continued monitoring of ACT efficacy and safety and molecular makers of resistance in Guinea is important to detect emergence of parasite resistance and to inform evidence-based malaria treatment policies.

Frequency, characteristics and hospital outcomes of road traffic accidents and their victims in Guinea: a three-year retrospective study from 2015 to 2017.

BACKGROUND: Road traffic accidents (RTA) remain a global public health concern in developing countries. The aim of the study was to document the frequency, characteristics and hospital outcomes of road traffic accidents in Guinea from 2015 to 2017. METHODS: We conducted a retrospective cohort study using medical records of RTA victims from 20 hospitals and a cross-sectional study of RTA cases from eight police stations in eight districts in Guinea, West Africa. Data analysis included descriptive statistics, trends of RTA, a sequence of interrupted time-series models and a segmented ordinary least-squares (OLS) regression. RESULTS: Police stations recorded 3,140 RTA over 3 years with an overall annual increase in RTA rates from 14.0 per 100,000 population in 2015, to 19.2 per 100,000 population in 2016 (37.1% annual increase), to 28.7 per 100,000 population in 2017 (49.5% annual increase). Overall, the injury rates in 2016 and 2017 were .05 per 100,000 population higher on average per month (95% CI: .03-.07). Deaths from RTA showed no statistical differences over the 3 years and no association of RTA trends with season was found. Overall, 27,751 RTA victims were admitted to emergency units, representing 22% of all hospitals admissions. Most victims were males (71%) and young (33%). Deaths represented 1.4% of all RTA victims. 90% of deaths occurred before or within 24 h of hospital admission. Factors associated with death were being male (p = .04), being a child under 15 years (p = .045) or an elderly person aged ≥65 years (p < .001), and having head injury or coma (p < .001). CONCLUSIONS: RTA rates in Guinea are increasing. There is a need for implementing multisectoral RTA prevention measures in Guinea.

Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools.

BACKGROUND: Reducing maternal mortality still remains a major challenge in low-income countries. This study aims to explore how digital communication tools can be used to evaluate the maternal deaths surveillance and response (MDSR) system at the health district level in Guinea. METHODS: A descriptive cross-sectional study was conducted, using an innovative digital approach called District.Team, from April to September 2017. This study targeted all 38 district medical officers in Guinea. In addition to district medical officers, the participation of health actors from regional and central levels were also expected in the online discussion forum. Data collected through the questionnaire were mixed and those from the online discussion forum were entirely qualitative. RESULTS: In total, 23 (61%) district medical officers (DMOs) participated in the study. Out of health districts (87%) which had updated guidelines and standards for the MDSR, 4 (20%) did not apply the content. In two health districts (8.7%), not all health facilities had maternal deaths notification forms. Three districts (13%) did not have maternal death review committees. In 2016, only half (50.2%) of reported maternal deaths were reviewed. The main recommendation formulated was related to quality of care. Other needs were also highlighted including continuous training of health care providers on emergency obstetric and neonatal care. Less than half (45%) of the review committee's recommendations were implemented. Six health districts (26.1%) did not have a response plan to reported maternal deaths and no district annual report on the MDSR was published in 2016. The weaknesses identified were, among others, insufficiency of human resources and lack of financial resources. Fifty-eight messages related to MDSR weaknesses and improvement solutions were posted in the online discussion forum by 28 participants (23 DMOs and 5 health actors from regional and central levels). CONCLUSION: Digital tools can be used to assess the functioning of a system like maternal deaths surveillance and response. Moreover, the findings of the evaluation conducted will help stakeholders (starting from the health districts themselves) to design strategies and interventions for an effective MDSR.

Capacity Development through the US President's Malaria Initiative-Supported Antimalarial Resistance Monitoring in Africa Network.

Antimalarial drug resistance is an evolving global health security threat to malaria control. Early detection of Plasmodium falciparum resistance through therapeutic efficacy studies and associated genetic analyses may facilitate timely implementation of intervention strategies. The US President's Malaria Initiative-supported Antimalarial Resistance Monitoring in Africa Network has assisted numerous laboratories in partner countries in acquiring the knowledge and capability to independently monitor for molecular markers of antimalarial drug resistance.

Profile and reintegration experience of Ebola survivors in Guinea: a cross-sectional study.

OBJECTIVE: To describe the experience of Guinean Ebola virus disease (EVD) survivors in Guinea, up to ten months after discharge from the Ebola treatment unit. METHODS: Cross-sectional study using a standardised semistructured questionnaire among survivors from Conakry and Coyah districts in 2015 in Guinea. We used proportions, mean (standard deviation) and median (interquartile range) to summarise the variables. The McNemar chi-square test was used to compare proportions. RESULTS: The 121 EVD survivors interviewed had a median reintegration time from discharge of 18 weeks (IQR: 14-32 weeks). Most survivors were aged 15-44 years (87.6%) with secondary to higher level of education (68.6%), and 25.6% were healthcare workers. The majority reported a lower socio-economic status (90%), a less favourable work situation (79%) and psychological status (60%). About 31% reported physical health problems. Most survivors reported lower levels of reintegration with friends and at work place (72%) and lower acceptance by others in general (71%) in the period after the EVD as compared to the period before the EVD. Only 55 survivors (45.5%) were involved in one or more activities of the EVD response: participation in clinical studies on the EVD (44 survivors, 36.4%), community sensitisation (28 survivors, 23.1%) or work in Ebola treatment and/or transit centres (23 survivors, 21.7%). CONCLUSION: There is a need for a long-term follow-up of EVD survivors in Guinea and more efforts to support their social, professional and economic reintegration, especially in rural areas.

Maternal and Child Health Services in the Context of the Ebola Virus Disease: Health Care Workers' Knowledge, Attitudes and Practices in Rural Guinea.

The objective of this study was to document maternal and child health care workers' knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved.

Correction: Experimental Treatment with Favipiravir for Ebola Virus Disease (the JIKI Trial): A Historically Controlled, Single-Arm Proof-of-Concept Trial in Guinea.

[This corrects the article DOI: 10.1371/journal.pmed.1001967.].

Experimental Treatment with Favipiravir for Ebola Virus Disease (the JIKI Trial): A Historically Controlled, Single-Arm Proof-of-Concept Trial in Guinea.

BACKGROUND: Ebola virus disease (EVD) is a highly lethal condition for which no specific treatment has proven efficacy. In September 2014, while the Ebola outbreak was at its peak, the World Health Organization released a short list of drugs suitable for EVD research. Favipiravir, an antiviral developed for the treatment of severe influenza, was one of these. In late 2014, the conditions for starting a randomized Ebola trial were not fulfilled for two reasons. One was the perception that, given the high number of patients presenting simultaneously and the very high mortality rate of the disease, it was ethically unacceptable to allocate patients from within the same family or village to receive or not receive an experimental drug, using a randomization process impossible to understand by very sick patients. The other was that, in the context of rumors and distrust of Ebola treatment centers, using a randomized design at the outset might lead even more patients to refuse to seek care. Therefore, we chose to conduct a multicenter non-randomized trial, in which all patients would receive favipiravir along with standardized care. The objectives of the trial were to test the feasibility and acceptability of an emergency trial in the context of a large Ebola outbreak, and to collect data on the safety and effectiveness of favipiravir in reducing mortality and viral load in patients with EVD. The trial was not aimed at directly informing future guidelines on Ebola treatment but at quickly gathering standardized preliminary data to optimize the design of future studies. METHODS AND FINDINGS: Inclusion criteria were positive Ebola virus reverse transcription PCR (RT-PCR) test, age ≥ 1 y, weight ≥ 10 kg, ability to take oral drugs, and informed consent. All participants received oral favipiravir (day 0: 6,000 mg; day 1 to day 9: 2,400 mg/d). Semi-quantitative Ebola virus RT-PCR (results expressed in "cycle threshold" [Ct]) and biochemistry tests were performed at day 0, day 2, day 4, end of symptoms, day 14, and day 30. Frozen samples were shipped to a reference biosafety level 4 laboratory for RNA viral load measurement using a quantitative reference technique (genome copies/milliliter). Outcomes were mortality, viral load evolution, and adverse events. The analysis was stratified by age and Ct value. A "target value" of mortality was defined a priori for each stratum, to guide the interpretation of interim and final analysis. Between 17 December 2014 and 8 April 2015, 126 patients were included, of whom 111 were analyzed (adults and adolescents, ≥13 y, n = 99; young children, ≤6 y, n = 12). Here we present the results obtained in the 99 adults and adolescents. Of these, 55 had a baseline Ct value ≥ 20 (Group A Ct ≥ 20), and 44 had a baseline Ct value < 20 (Group A Ct < 20). Ct values and RNA viral loads were well correlated, with Ct = 20 corresponding to RNA viral load = 7.7 log10 genome copies/ml. Mortality was 20% (95% CI 11.6%-32.4%) in Group A Ct ≥ 20 and 91% (95% CI 78.8%-91.1%) in Group A Ct < 20. Both mortality 95% CIs included the predefined target value (30% and 85%, respectively). Baseline serum creatinine was ≥110 µmol/l in 48% of patients in Group A Ct ≥ 20 (≥300 µmol/l in 14%) and in 90% of patients in Group A Ct < 20 (≥300 µmol/l in 44%). In Group A Ct ≥ 20, 17% of patients with baseline creatinine ≥110 µmol/l died, versus 97% in Group A Ct < 20. In patients who survived, the mean decrease in viral load was 0.33 log10 copies/ml per day of follow-up. RNA viral load values and mortality were not significantly different between adults starting favipiravir within <72 h of symptoms compared to others. Favipiravir was well tolerated. CONCLUSIONS: In the context of an outbreak at its peak, with crowded care centers, randomizing patients to receive either standard care or standard care plus an experimental drug was not felt to be appropriate. We did a non-randomized trial. This trial reaches nuanced conclusions. On the one hand, we do not conclude on the efficacy of the drug, and our conclusions on tolerance, although encouraging, are not as firm as they could have been if we had used randomization. On the other hand, we learned about how to quickly set up and run an Ebola trial, in close relationship with the community and non-governmental organizations; we integrated research into care so that it improved care; and we generated knowledge on EVD that is useful to further research. Our data illustrate the frequency of renal dysfunction and the powerful prognostic value of low Ct values. They suggest that drug trials in EVD should systematically stratify analyses by baseline Ct value, as a surrogate of viral load. They also suggest that favipiravir monotherapy merits further study in patients with medium to high viremia, but not in those with very high viremia. TRIAL REGISTRATION: ClinicalTrials.gov NCT02329054.

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review.

OBJECTIVE: To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps. METHODS: A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature. RESULTS: A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death. CONCLUSION: Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.

A descriptive longitudinal study protocol: recurrence and pregnancy post-repair of obstetric fistula in Guinea.

BACKGROUND: Obstetric fistula is a serious medical condition which affects women in low income countries. Despite the progress of research on fistula, there is little data on long term follow-up after surgical repair. The objective of this study is to analyse the factors associated with the recurrence of fistula and the outcomes of pregnancy following fistula repair in Guinea. METHODS: A descriptive longitudinal study design will be used. The study will include women who underwent fistula repair between 2012 and 2015 at 3 fistula repair sites supported by the Fistula Care Project in Guinea (Kissidougou Prefectoral Hospital, Labé Regional Hospital and Jean Paul II Hospital of Conakry). Participants giving an informed consent after a home visit by the Fistula Counsellors will be interviewed for enrolment at least 3 months after hospital discharge The study enrolment period is January 1, 2012 - June 30, 2015. Participants will be followed-up until June 30, 2016 for a maximum follow up period of 48 months. The sample size is estimated at 364 women. The cumulative incidence rates of fistula recurrence and pregnancy post-repair will be calculated using Kaplan-Meier methods and the risk factor analyses will be performed using adjusted Cox regression. The outcomes of pregnancy will be analysed using proportions, the Pearson's Chi Square (χ2) and a logistic regression with associations reported as risk ratios with 95 % confidence intervals. All analyses will be done using STATA version 13 (STATA Corporation, College Station, TX, USA) with a level of significance set at P < 0.05. DISCUSSION: This study will contribute to improving the prevention and management of obstetric fistula within the community and support advocacy efforts for the social reintegration of fistula patients into their communities. It will also guide policy makers and strategic planning for fistula programs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02686957 . Registered 12 February 2016 (Retrospectively registered).