Maternal mortality review in a major tertiary referral hospital in Liberia, 2018-2021.

Objectives: Anecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020-2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study design: We conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. Method: The maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. Results: There are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14-45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9-10.6, p < 0.001). Conclusion: The maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

A review of the John F. Kennedy Medical Center's response to the COVID-19 pandemic in Liberia.

Objective: Over the past decades, the world has experienced a series of emerging and re-emerging infectious disease pandemics with dire consequences for economies and healthcare delivery. Hospitals are expected to have the ability to detect and respond appropriately to epidemics with minimal disruptions to routine services. We sought to review the John F. Kennedy Medical Center's readiness to respond to the COVID-19 pandemic. Methods: We used the pretest-posttest design in June 2021 and May 2023 to assess the hospital's improvements in its COVID-19 readiness capacity by collecting data on the hospital's characteristics and using the WHO COVID-19 Rapid hospital readiness checklist. We scored each readiness indicator according to the WHO criteria and the hospital's overall readiness score, performed the chi-square test for the change in readiness (change, 95% CI, p-value) between 2021 and 2023, and classified the center's readiness (poor: < 50%, fair: 50-79%, or satisfactory: ≥80%). The overall hospital readiness for COVID-19 response was poor in 2021 (mean score = 49%, 95% CI: 39-57%) and fair in 2023 (mean score = 69%, 95% CI: 56-81%). The mean change in hospital readiness was 20% (95% CI: 5.7-35%, p-value = 0.009). Between 2021 and 2023, the hospital made satisfactory improvements in leadership and incident management system [from 57% in 2021 to 86% in 2023 (change = 29%, 95% CI: 17-41%, p < 0.001)]; risk communication and community engagement [38-88% (change = 50%, 95% CI: 39-61%, p < 0.001)]; patient management [63-88% (change = 25%, 95% CI: 14-36%, p < 0.001)]; and rapid identification and diagnosis [67-83% (change = 16%, 95% CI: 4.2-28%, p = 0.009)]. The hospital made fair but significant improvements in terms of coordination and communication [42-75% (change = 33%, 95% CI: 20-46%, p < 0.001)], human resources capacity [33-75% (change = 42%, 95% CI: 29-55%, p < 0.001)], continuation of critical support services [50-75% (PD = 25%, 95% CI: 12-38%, p < 0.001)], and IPC [38-63% (change = 25%, 12-38%, p < 0.001)]. However, there was no or unsatisfactory improvement in terms of surveillance and information management; administration, finance, and business continuity; surge capacity; and occupational and mental health psychosocial support. Conclusion: Substantial gaps still remain in the hospital's readiness to respond to the COVID-19 outbreak. The study highlights the urgent need for investment in resilient strategies to boost readiness to respond to future outbreaks at the hospital.

Gaps and Opportunities in HIV Service Delivery in High Volume HIV Care Centers in Liberia: Lessons From the Field.

Background: Human Immunodeficiency Virus (HIV) infection continues to have a profound humanitarian and public health impact in western and central Africa, a region that risks being left behind in the global response to ending the AIDS epidemic. In Liberia, where the health system is being rebuilt following protracted civil wars and an Ebola virus disease outbreak, the Resilient and Responsive Health System (RRHS) is assisting with quality HIV services delivery through support from PEPFAR and HRSA but gaps remain across the cascade of care from diagnosis to viral load suppression. Objective: To highlight gaps in HIV service delivery in Liberia, identify opportunities and offer recommendations for improving the quality of service delivery. Methods: A narrative review of relevant literature was conducted following a search of all local and online databases known to the authors. Findings: Antiretroviral therapy (ART) has transformed the HIV response in Liberia by averting deaths, improving quality of life, and preventing new HIV infections but critical gaps remain. These include weak HIV prevention and testing strategies; suboptimal ART initiation and retention in care; low viral load testing volumes, commodity supply chain disruptions and a HIV workforce built on non-physician healthcare workers. In the context of the prevailing socioeconomic, heath system and programmatic challenges, these will impact achievement of the UNAIDS targets of 95-95-95 by 2030 and ending the epidemic. Conclusion: Combination prevention approaches are necessary to reach the most at risk populations, while a robust health workforce operating through facilities and communities will be needed to reach people with undiagnosed HIV earlier to provide efficient and effective services to ensure that people know their HIV status, receive and sustain ART to achieve viral suppression to maintain a long and healthy life within the framework of overall health system strengthening, achieving universal health coverage and the sustainable development goal.

High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities.

Background: HIV/AIDS remains one of the world's most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic. Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions. Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [<15 years, age 15-24 years and >=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed. Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15-24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2-3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018. Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.

Facing COVID-19 in Liberia: Adaptations of the Resilient and Responsive Health Systems Initiative.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia's National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia's fourth year, impacted educational programs and threatened the project's continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia's 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.

The impact of the 2014 Ebola epidemic on HIV disease burden and outcomes in Liberia West Africa.

BACKGROUND: Detailed longitudinal studies of HIV-positive individuals in West Africa are lacking. Here the HIV prevalence, incidence, all-cause mortality, and the proportion of individuals receiving treatment with cART in two cohorts of participants in Ebola-related studies are described. SETTING: Individuals of all ages were enrolled and followed at four sites in the area of Monrovia, Liberia. METHODS: Two cohorts identified in response to the Ebola epidemic are described to provide insights into the current state of the HIV epidemic. HIV testing was performed at baseline for participants in both cohorts and during follow-up in one cohort. RESULTS: Prevalence and incidence of HIV (prevalence of 3.1% for women and 1.4% for men and incidence of 3.3 per 1,000) were higher in these cohorts compared to 2018 national estimates (prevalence of 1.3% and incidence of 0.39 per 1,000). Most participants testing positive did not know their status prior to testing. Of those who knew they were HIV positive, 7.9% reported being on antiretroviral treatment. The death rate among those with HIV was 12.3% compared to 1.9% in HIV-negative individuals (adjusted odds ratio of 6.87). While higher levels of d-dimer were associated with increased mortality, this was not specific to those with HIV, however lower hemoglobin levels were associated with increased mortality among those with HIV. CONCLUSION: These findings point to a need to perform further research studies aimed at fulfilling these knowledge gaps and address current shortcomings in the provision of care for those living with HIV in Liberia.

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.

Body Fluid Testing at John F. Kennedy Medical Center in Liberia.

OBJECTIVES: To apply a simple method to validate testing for albumin, glucose, lactate dehydrogenase (LDH) and total protein (TP) in peritoneal, pleural, and cerebrospinal fluids (CSF) at a hospital in Liberia. METHODS: Serum and body fluid specimens were mixed to create 100% serum and 25%, 50%, 75%, and 100% fluid tubes, which were tested on a Biotecnica BT3500. Differences less than 10% between calculated and measured concentrations were considered acceptable. RESULTS: The means (confidence intervals) of the percent differences were: albumin/peritoneal 12.8 (6.0-19.7), albumin/pleural 2.8 (1.3-4.2), albumin/CSF 4.8 (2.2-7.5), glucose/peritoneal 4.0 (1.9-6.0), glucose/pleural 4.4 (3.1-5.7), glucose/CSF 2.9 (1.8-4.0), LDH/peritoneal 9.5 (6.3-12.7), LDH/pleural 9.5 (5.4-13.6), LDH/CSF 9.2 (5.2-13.3), TP/peritoneal 7.6 (3.8-11.4), TP/pleural 3.8 (1.5-6.2), and TP/CSF 4.5 (1.0-8.1). CONCLUSIONS: All mean differences except for one were less than 10%, allowing for the adoption of clinical testing. The mixing study is a low-cost method for quality-assured testing that can be performed by resource-limited laboratories.