Immunisation coverage and factors associated with incomplete immunisation in children under two during the COVID-19 pandemic in Sierra Leone.

BACKGROUND: Routine childhood immunisation is one of the most important life-saving public health interventions. However, many children still have inadequate access to these vaccines and millions remain (partially) unvaccinated globally. As the COVID-19 pandemic disrupted health systems worldwide, its effects on immunisation have become apparent. This study aimed to estimate routine immunisation coverage among children under two in Sierra Leone and to identify factors associated with incomplete immunisation during the COVID-19 pandemic. METHODS: A cross-sectional household survey was conducted in three districts in Sierra Leone: Bombali, Tonkolili and Port Loko. A three-stage cluster sampling method was followed to enrol children aged 10-23 months. Information regarding immunisation status was based on vaccination cards or caretaker's recall. Using WHO's definition, a fully immunised child received one BCG dose, three oral polio vaccine doses, three pentavalent vaccine doses and one measles-containing vaccine dose. Following the national schedule, full immunisation status can be achieved at 9 months of age. Data were weighted to reflect the survey's sampling design. Associations between incomplete immunisation and sociodemographic characteristics were assessed through multivariable logistic regression. RESULTS: A total of 720 children were enrolled between November and December 2021. Full vaccination coverage was estimated at 65.8% (95% CI 60.3%-71.0%). Coverage estimates were highest for vaccines administered at birth and decreased with doses administered subsequently. Adjusting for age, the lowest estimated coverage was 40.7% (95% CI 34.5%-47.2%) for the second dose of the measles-containing vaccine. Factors found to be associated with incomplete immunisation status were: living in Port Loko district (aOR = 3.47, 95% CI = 2.00-6.06; p-value < 0.001), the interviewed caretaker being Muslim (aOR = 1.94, 95% CI = 1.25-3.02; p-value = 0.015) and the interviewed caretaker being male (aOR = 1.93, 95% CI = 1.03-3.59, p-value = 0.039). CONCLUSION: Though full immunisation coverage at district level improved compared with pre-pandemic district estimates from 2019, around one in three surveyed children had missed at least one basic routine vaccination and over half of eligible children had not received the recommended two doses of a measles-containing vaccine. These findings highlight the need to strengthen health systems to improve vaccination uptake in Sierra Leone, and to further explore barriers that may jeopardise equitable access to these life-saving interventions.

Lessons From the COVID-19 Pandemic Response Implementation: A Case Study of South Sudan and Sierra Leone.

INTRODUCTION: The COVID-19 pandemic caused havoc to health systems worldwide and in countries that already had weak health systems. There are lessons to be learned that could contribute to improved response preparedness to future public health emergencies, but there is little documentation on best practices in fragile countries. We describe lessons from South Sudan and Sierra Leone during the COVID-19 response implementation. METHODS: We conducted a retrospective descriptive analysis of COVID-19 vaccination implementation at national and subnational levels between 2020 and 2022 in South Sudan and Sierra Leone to identify those practices that had a positive impact on public health. RESULTS: Several interventions were identified that not only improved the COVID-19 situation but also had a positive effect on routine immunizations. The development of a near-real-time vaccination dashboard gave stakeholders a quick look at vaccine implementation, allowing them to make decisions based on current data. The experience acquired from deploying the COVID-19 dashboard has since been applied to the development of a routine immunization dashboard in South Sudan. Surge vaccination was an effective approach to improving COVID-19 vaccination uptake. A measles reactive campaign was conducted during the initial stages of the pandemic when movement was restricted; experience gained from that effort was subsequently applied to COVID-19 mass vaccination initiatives and outbreak reactive campaigns. Additional vaccinators recruited for COVID-19 response also received comprehensive Immunization in Practice training, allowing them to provide routine childhood vaccinations alongside COVID-19 vaccination, contributing to the maintenance of routine vaccination services in both countries. CONCLUSION: Lessons were learned during the COVID-19 response implementation that have had a positive impact on routine health services. However, it is essential that these effects are maintained and further refined to strengthen the country's preparedness for future public health emergencies and better support the broader immunization service delivery.

Using photovoice methodology to uncover individual-level, health systems, and contextual barriers to uptake of second dose of measles containing vaccine in Western Area Urban, Sierra Leone, 2020.

Background: Vaccination coverage for the second dose of the measles-containing vaccine (MCV2) among children has remained stagnant in Sierra Leone at nearly 67% since its introduction in 2015. Identifying community-specific barriers faced by caregivers in accessing MCV2 services for their children and by health workers in delivering MCV2 is key to informing strategies to improve vaccination coverage. Methods: We used Photovoice, a participatory method using photographs and narratives to understand community barriers to MCV2 uptake from March- September 2020. Six female and five male caregivers of MCV2-eligible children (15-24 months of age), and six health care workers (HCWs) in Freetown, Sierra Leone participated. After having an orientation to photovoice, they photographed barriers related to general immunization and MCV2 uptake in their community. This was followed by facilitated discussions where participants elaborated on the barriers captured in the photos. Transcripts from the six immunization-related discussions were analyzed to deduce themes through open-ended coding. A photo exhibition was held for participants to discuss the barriers and suggested solutions with decision-makers, such as the ministry of health. Results: We identified and categorized nine themes into three groups: 1) individual or caregiver level barriers (e.g., caregivers' lack of knowledge on MCV2, concerns about vaccine side effects, and gender-related barriers); 2) health system barriers, such as HCWs' focus on children below one year and usage of old child health cards; and 3) contextual barriers, such as poverty, poor infrastructure, and the COVID-19 pandemic. Participants suggested the decision-makers to enhance community engagement with caregivers and HCW capacity including, increasing accountability of their work using performance-based approaches, among different strategies to improve MCV2 uptake. Conclusion: Photovoice can provide nuanced understanding of community issues affecting MCV2. As a methodology, it should be integrated in broader intervention planning activities to facilitate the translation of community-suggested strategies into action.

Coverage of intermittent preventive treatment of malaria in infants after four years of implementation in Sierra Leone.

BACKGROUND: Intermittent Preventive Treatment of malaria in infants (IPTi) is a malaria control strategy consisting of the administration of an anti-malarial drug alongside routine immunizations. So far, this is being implemented nationwide in Sierra Leone only. IPTi has been renamed as Perennial Malaria Chemoprevention -PMC-, accounting for its recently recommended expansion into the second year of life. Before starting a pilot implementation on PMC, the currently implemented strategy and malaria prevalence were assessed in young children in selected areas of Sierra Leone. METHODS: A cross-sectional, community-based, multi-stage cluster household survey was conducted from November to December 2021 in selected districts of the Northern and northwestern provinces of Sierra Leone among 10-23 months old children, whose caretakers gave written informed consent to participate in the survey. Coverage of IPTi and malaria prevalence-assessed with rapid diagnostic tests-were calculated using percentages and 95% confidence intervals weighted for the sampling design and adjusted for non-response within clusters. Factors associated with RDT + and iPTi coverage were also assessed. RESULTS: A total of 720 children were recruited. Coverage of three IPTi doses was 50.57% (368/707; 95% CI 45.38-55.75), while prevalence of malaria infection was 28.19% (95% CI 24.81-31.84). Most children had received IPTi1 (80.26%, 574/707; 95% CI 75.30-84.44), and IPTi2 (80.09%, 577/707; 95% CI 76.30-83.40) and over half of the children also received IPTi3 (57.72%, 420/707; 95% CI 53.20-62.11). The uptake of each IPTi dose was lower than that of the vaccines administered at the same timepoint at all contacts. CONCLUSION: In Sierra Leone, half of the children received the three recommended doses of IPTi indicating an increase in its uptake compared to previous data of just a third of children receiving the intervention. However, efforts need to be made in improving IPTi coverage, especially in the planned expansion of the strategy into the second year of life following recent WHO guidelines.

Prioritizing Health Care Strategies to Reduce Childhood Mortality.

Importance: Although child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking. Objective: To investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network. Design, Setting, and Participants: This cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids. Main Outcomes and Measures: For each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged <28 days), and infant and child deaths (aged 1 month to <5 years). Results: Of 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]). Conclusions and Relevance: In this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.

Assessing the impact of the routine childhood hepatitis B immunization program and the need for hepatitis B vaccine birth dose in Sierra Leone, 2018.

Sierra Leone is highly endemic for hepatitis B virus (HBV) infection and thus recommends three doses of hepatitis B vaccine (HepB3) from 6 weeks of age but does not recommend a birth dose (HepB-BD) to prevent mother-to-child transmission (MTCT). We evaluated impact of the existing HepB3 schedule and risk for MTCT of HBV. We conducted a community-based serosurvey among 4-30-month-olds, their mothers, and 5-9-year-olds in three districts in Sierra Leone. Participants had an HBV surface antigen (HBsAg) rapid test; all HBsAg-positive and one HBsAg-negative mother per cluster were tested for HBV markers. We collected children's HepB3 vaccination history. Among 1889 children aged 4-30 months, HepB3 coverage was 85% and 20 (1·3% [95% CI 0·8-2·0]) were HBsAg-positive, of whom 70% had received HepB3. Among 2025 children aged 5-9 years, HepB3 coverage was 77% and 32 (1·6% [1·1-2·3]) were HBsAg-positive, of whom 56% had received HepB3. Of 1776 mothers, 169 (9·8% [8·1-11·7]) were HBsAg-positive. HBsAg prevalence was 5·9% among children of HBsAg-positive mothers compared to 0·7% among children of HBsAg-negative mothers (adjusted OR = 10·6 [2·8-40·8]). HBsAg positivity in children was associated with maternal HBsAg (p = 0·026), HBV e antigen (p < 0·001), and HBV DNA levels ≥ 200 000 IU/mL (p < 0·001). HBsAg prevalence was lower among children than mothers, for whom HepB was not available, suggesting routine infant HepB vaccination has lowered HBV burden. Since HBsAg positivity in children was strongly associated with maternal HBV infection and most of the HBsAg-positive children in the survey received HepB3, HepB-BD may prevent MTCT and chronic HBV infection.

Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone, 2019.

Background: The 2014-2016 Ebola epidemic disrupted childhood immunization in Sierra Leone, Liberia, and Guinea. After the epidemic, the Government of Sierra Leone prioritized community engagement to increase vaccination confidence and uptake. To support these efforts, we examined potential drivers of vaccination confidence and uptake in Sierra Leone. Methods: We conducted a population-based household survey with primary caregivers of children in a birth cohort of 12 to 23 months in four districts with low vaccination coverage in Sierra Leone in 2019. Modified Poisson regression modeling with robust variance estimation was used to examine if perceived community engagement in planning the immunization program in the community was associated with vaccination confidence and having a fully vaccinated child. Results: The sample comprised 621 age-eligible children and their caregivers (91% response rate). Half of the caregivers (52%) reported that it usually takes too long to get to the vaccination site, and 36% perceived that health workers expect money for vaccination services that are supposed to be given at no charge. When mothers were the decision-makers of the children's vaccination, 80% of the children were fully vaccinated versus 69% when fathers were the decision-makers and 56% when other relatives were the decision-makers. Caregivers with high confidence in vaccination were more likely to have fully vaccinated children compared to caregivers with low confidence (78% versus 53%). For example, caregivers who thought vaccines are 'very much' safe were more likely to have fully vaccinated children than those who thought vaccines are 'somewhat' safe (76% versus 48%). Overall, 53% of caregivers perceived high level of community engagement, 41% perceived medium level of engagement, and 6% perceived low level of engagement. Perceiving high community engagement was associated with expressing high vaccination confidence (adjusted prevalence ratio (aPR) = 2.60; 95% confidence interval (CI) = 1.67-4.04) and having a fully vaccinated child (aPR = 1.67; 95% CI = 1.18-2.38). Conclusions: In these four low coverage districts in Sierra Leone, the perceived level of community engagement was strongly associated with vaccination confidence among caregivers and vaccination uptake among children. We have provided exploratory cross-sectional evidence to inform future longitudinal assessments to further investigate the potential causal effect of community engagement on vaccination confidence and uptake.

Role of Information Sources in Vaccination Uptake: Insights From a Cross-Sectional Household Survey in Sierra Leone, 2019.

INTRODUCTION: There is limited understanding of the potential impact of information sources on vaccination attitudes and behaviors in low-income countries. We examined how exposure to immunization information sources may be associated with vaccination uptake in Sierra Leone. METHODS: In 2019, a household survey was conducted using multistage cluster sampling to randomly select 621 caregivers of children aged 12-23 months in 4 districts in Sierra Leone. We measured exposure to various sources of immunization information and 2 outcomes: (1) vaccination confidence using an aggregate score (from 12 Likert items, informed by previously validated scale) that was dichotomized into a binary variable; (2) uptake of the third dose of diphtheria-pertussis-tetanus-hepatitis B-Haemophilus influenzae type-b-pentavalent vaccine (penta-3) based on card record or through caregiver recall when card was unavailable. Associations between information sources and the outcomes were examined using modified Poisson regression with robust variance estimator. RESULTS: Weighted estimate for penta-3 uptake was 81% (75.2%-85.5%). The likelihood of uptake of penta-3 was significantly greater when caregiver received information from health facilities (adjusted prevalence ratio [aPR]=1.26, 95% confidence interval [CI]=1.1, 1.5), faith leaders (aPR=1.16, 95% CI=1.1, 1.3), and community health workers (aPR=1.13, 95% CI=1.003, 1.3). Exposure to greater number of information sources was associated with high penta-3 uptake (aPR=1.05, 95% CI=1.02, 1.1). DISCUSSION: Immunization information received during health facility visits and through engagement with religious leaders may enhance vaccination uptake. Assessments to understand context-specific information dynamics should be prioritized in optimizing immunization outcomes.

Community Health Workers' Experiences in Strengthening the Uptake of Childhood Immunization and Malaria Prevention Services in Urban Sierra Leone.

Introduction: Community health workers (CHWs) play an integral role in Sierra Leone's health systems strengthening efforts. Our goal was to understand CHWs' experiences of providing immunization and malaria prevention services in urban settings and explore opportunities to optimize their contributions to these services. Methods: In 2018, we conducted an exploratory qualitative assessment in the Western Area Urban district, which covers most of the capital city of Freetown. We purposively selected diverse health facilities (i.e., type, ownership, setting) and recruited CHWs through their supervisors. We conducted eight focus group discussions (FGD) with CHWs, which were audio-recorded. The topics explored included participants' background, responsibilities and priorities of urban CHWs, sources of motivation at work, barriers to CHWs' immunization and malaria prevention activities, and strategies used to address these barriers. The local research team transcribed and translated FGDs into English; then we used qualitative content analysis to identify themes. Results: Four themes emerged from the qualitative content analysis: (1) pride, compassion, recognition, and personal benefits are important motivating factors to keep working as CHWs; (2) diverse health responsibilities and competing priorities result in overburdening of CHWs; (3) health system- and community-level barriers negatively affect CHWs' activities and motivation; (4) CHWs use context-specific strategies to address challenges in their work but require further support. Conclusion: Focused support for CHWs is needed to optimize their contributions to immunization and malaria prevention activities. Such interventions should be coupled with systems-level efforts to address the structural barriers that negatively affect CHWs' overall work and motivation, such as the shortage of work supplies and the lack of promised financial support.

A scorecard of progress towards measles elimination in 15 west African countries, 2001-19: a retrospective, multicountry analysis of national immunisation coverage and surveillance data.

BACKGROUND: The WHO Regional Office for the Africa Regional Immunization Technical Advisory Group, in 2011, adopted the measles control and elimination goals for all countries of the African region to achieve in 2015 and 2020 respectively. Our aim was to track the current status of progress towards measles control and elimination milestones across 15 west African countries between 2001 and 2019. METHODS: We did a retrospective multicountry series analysis of national immunisation coverage and case surveillance data from Jan 1, 2001, to Dec 31, 2019. Our analysis focused on the 15 west African countries that constitute the Economic Community of West African States. We tracked progress in the coverage of measles-containing vaccines (MCVs), measles supplementary immunisation activities, and measles incidence rates. We developed a country-level measles summary scorecard using eight indicators to track progress towards measles elimination as of the end of 2019. The summary indicators were tracked against measles control and elimination milestones. FINDINGS: The weighted average regional first-dose MCV coverage in 2019 was 66% compared with 45% in 2001. 73% (11 of 15) of the west African countries had introduced second-dose MCV as of December, 2019. An estimated 4 588 040 children (aged 12-23 months) did not receive first-dose MCV in 2019, the majority (71%) of whom lived in Nigeria. Based on the scorecard, 12 (80%) countries are off-track to achieving measles elimination milestones; however, Cape Verde, The Gambia, and Ghana have made substantial progress. INTERPRETATION: Measles will continue to be endemic in west Africa after 2020. The regional measles incidence rate in 2019 was 33 times the 2020 elimination target of less than 1 case per million population. However, some hope exists as countries can look at the efforts made by Cape Verde, The Gambia, and Ghana and learn from them. FUNDING: None.

Data on the implementation of VaxTrac electronic immunization registry in Sierra Leone.

Following the piloting of VaxTrac, an electronic immunization registry (EIR), we conducted a rapid assessment in November-December 2017 to evaluate the use of the EIR in 10 health facilities in Western Area Urban district in Sierra Leone [1]. In this data-in-brief report, we provide additional descriptive data from the assessment of the VaxTrac EIR in Sierra Leone. The assessment comprised aggregate data on vaccine doses administered that were abstracted from VaxTrac and three paper-based sources (daily tally sheets, register of children under the age of 2 years, and a summary form of doses administered). Data were abstracted for the following six vaccine doses in the immunization schedule in Sierra Leone: 1) Bacillus Calmette-Guérin vaccine, 2) first dose of pentavalent vaccine, 3) second dose of pentavalent vaccine, 4) third dose of pentavalent vaccine, 5) first dose of measles-containing vaccine, and 6) second dose of measles-containing vaccine. We descriptively analysed the abstracted data to examine the congruity between VaxTrac records and the three paper-based sources. Bar graphs were generated to visually depict the variations in number of administered vaccine doses by data source for each health facility. We provide the aggregated data for each vaccine dose abstracted by data source from each health facility as supplemental material (Excel file). The supplementary data reveal patterns in the congruity of vaccine doses captured that have implications for policy and programmatic decisions regarding the use of VaxTrac and other similar EIRs in low resource urban settings.

Assessment of VaxTrac electronic immunization registry in an urban district in Sierra Leone: Implications for data quality, defaulter tracking, and policy.

BACKGROUND: In 2016, the Sierra Leone Ministry of Health and Sanitation (MoHS) piloted VaxTrac, an electronic immunization registry (EIR), in an urban district to improve management of vaccination records and tracking of children who missed scheduled doses. We aimed to document lessons learned to inform decision-making on VaxTrac and similar EIRs' future use. METHODS: Ten out of 50 urban health facilities that implemented VaxTrac were purposively selected for inclusion in a rapid mixed-method assessment from November to December 2017. For a one-month period, records of six scheduled vaccine doses among children < 2 years old in VaxTrac were abstracted and compared to three paper-based records (register of under-two children, daily tally sheet, and monthly summary form). We used the under-two register as the reference gold standard for comparison purposes. We interviewed and observed 10 heath workers, one from each selected facility, who were using VaxTrac. RESULTS: Overall, VaxTrac captured < 65% of the vaccine doses reported in the paper-based sources, but in the largest health facility VaxTrac captured the highest number of doses. Two additional notable patterns emerged: 1) the aggregated data sources reported higher doses administered compared to the under-two register and VaxTrac; 2) data sources that need real-time data capture during the vaccination session reported fewer doses administered compared to the monthly HF2 summary form. Health workers expressed that the EIR helped them to shorten the time to manage, summarize, and report vaccination records. Workflows for data entry in VaxTrac were inconsistent among facilities and rarely integrated into existing processes. Data sharing restrictions contributed to duplicate records. CONCLUSION: Although VaxTrac helped to shorten the time to manage, summarize, and report vaccination records, data sharing restrictions coupled with inconsistent and inefficient workflows were major implementation challenges. Readiness-to-introduce and sustainability should be carefully considered before implementing an EIR.

Access, demand, and utilization of childhood immunization services: A cross-sectional household survey in Western Area Urban district, Sierra Leone, 2019.

BACKGROUND: Urban childhood immunization programs face unique challenges in access, utilization, and demand due to frequent population movement between and within localities, sprawling informal settlements, and population heterogeneity. We conducted a cross-sectional household survey in the Western Area Urban district, Sierra Leone, stratified by slums and non-slums as defined by the United Nations Development Program. METHODS: Based on data from child vaccination cards, weighted vaccination coverage was estimated from 450 children aged 12-36 months (household response rate = 83%). Interviews with 444 caregivers identified factors related to accessing routine immunization services. Factors associated with coverage in bivariate analyses were examined in multivariate models using backward stepwise procedure. RESULTS: Coverage was similar in slums and non-slums for 3-doses of diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b (pentavalent) vaccine (86%, 92%) and second dose of measles vaccine (33%, 29%). In a multivariate logistic regression model, incomplete pentavalent vaccine coverage was associated with being second or later birth order (adjusted odds ratio (aOR) = 4.5 (95% confidence interval (CI) = 1.4-14.9), a household member not approving of childhood vaccinations (aOR = 7.55, 95% CI = 1.52-37.38), self-reported delay of child receiving recommended vaccinations (aOR = 4.8, 95% CI = 1.0-22.1), and living in a household made of natural or rudimentary materials (aOR = 3.5, 95% CI = 1.2-10.6). Overall, the majority (>70%) of caregivers reported occupation as petty trader and <50% reported receiving vaccination information via preferred communication sources. CONCLUSIONS: Although vaccination coverage in slums was similar to non-slums, study findings support the need for targeted interventions to improve coverage, especially for the second dose of measles vaccine to avoid large scale measles outbreaks. Strategies should focus on educating household members via preferred communication channels regarding the importance of receiving childhood vaccinations on time for all offspring, not just the first born. Vaccination coverage could be further improved by increasing accessibility through innovative strategies such as increasing the number of vaccination days and modifying hours.

Causes of hospitalization and predictors of HIV-associated mortality at the main referral hospital in Sierra Leone: a prospective study.

BACKGROUND: HIV infection is a growing public health problem in Sierra Leone and the wider West Africa region. The countrywide HIV prevalence was estimated at 1.7% (67,000 people), with less than 30% receiving life-saving ART in 2016. Thus, HIV-infected patients tend to present to health facilities late, with high mortality risk. METHODS: We conducted a prospective study of HIV inpatients aged ≥15 years at Connaught Hospital in Freetown-the main referral hospital in Sierra Leone-from July through September 2017, to assess associated factors and predictors of HIV-related mortality. RESULTS: One hundred seventy-three HIV inpatients were included, accounting for 14.2% (173/1221) of all hospital admissions during the study period. The majority were female (59.5%, 70/173), median age was 34 years, with 51.4% (89/173) of them diagnosed with HIV infection for the first time during the current hospitalization. The most common admitting diagnoses were anemia (48%, 84/173), tuberculosis (24.3%, 42/173), pneumonia (17.3%, 30/173) and diarrheal illness (15.0%, 26/173). CD4 count was obtained in 64.7% (112/173) of patients, with median value of 87 cells/µL (IQR 25-266), and was further staged as severe immunosuppression: CD4 < 100 cells/µL (50%, 56/112); AIDS: CD4 < 200 cells/µL (69.6%, 78/112); and late-stage HIV disease: CD4 < 350 cells/µL (83%, 93/112). Fifty-two patients (30.1%, 52/173) died during hospitalization, 23% (12/52) of them within the first week. The leading causes of death were anemia (23.1%, 12/52), pneumonia (19.2%, 10/52), diarrheal illness (15.4%, 8/52) and tuberculosis (13.6%, 7/52). Neurological symptoms, i.e., loss of consciousness (p = 0.04) and focal limb weakness (p = 0.04); alcohol use (p = 0.01); jaundice (p = 0.02); cerebral toxoplasmosis (p = 0.01); and tuberculosis (p = 0.04) were significantly associated with mortality; however, only jaundice (AOR 0.11, 95% CI [0.02-0.65]; p = 0.01) emerged as an independent predictor of mortality. CONCLUSION: HIV-infected patients account for a substantial proportion of admissions at Connaught Hospital, with a high morbidity and in-hospital mortality burden. These findings necessitate the implementation of specific measures to enhance early HIV diagnosis and expand treatment access to all HIV-infected patients in Sierra Leone.

Machine-learning Prognostic Models from the 2014-16 Ebola Outbreak: Data-harmonization Challenges, Validation Strategies, and mHealth Applications.

BACKGROUND: Ebola virus disease (EVD) plagues low-resource and difficult-to-access settings. Machine learning prognostic models and mHealth tools could improve the understanding and use of evidence-based care guidelines in such settings. However, data incompleteness and lack of interoperability limit model generalizability. This study harmonizes diverse datasets from the 2014-16 EVD epidemic and generates several prognostic models incorporated into the novel Ebola Care Guidelines app that provides informed access to recommended evidence-based guidelines. METHODS: Multivariate logistic regression was applied to investigate survival outcomes in 470 patients admitted to five Ebola treatment units in Liberia and Sierra Leone at various timepoints during 2014-16. We generated a parsimonious model (viral load, age, temperature, bleeding, jaundice, dyspnea, dysphagia, and time-to-presentation) and several fallback models for when these variables are unavailable. All were externally validated against two independent datasets and compared to further models including expert observational wellness assessments. Models were incorporated into an app highlighting the signs/symptoms with the largest contribution to prognosis. FINDINGS: The parsimonious model approached the predictive power of observational assessments by experienced clinicians (Area-Under-the-Curve, AUC = 0.70-0.79, accuracy = 0.64-0.74) and maintained its performance across subcohorts with different healthcare seeking behaviors. Age and viral load contributed > 5-fold the weighting of other features and including them in a minimal model had a similar AUC, albeit at the cost of specificity. INTERPRETATION: Clinically guided prognostic models can recapitulate clinical expertise and be useful when such expertise is unavailable. Incorporating these models into mHealth tools may facilitate their interpretation and provide informed access to comprehensive clinical guidelines. FUNDING: Howard Hughes Medical Institute, US National Institutes of Health, Bill & Melinda Gates Foundation, International Medical Corps, UK Department for International Development, and GOAL Global.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background: Sierra Leone was severely affected by the 2014/2015 Ebola outbreak and is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods: This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,200 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results: Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period.  During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period (P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions: Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

A Qualitative Evaluation of a Decision Support System for District-Level Disease Surveillance in Sierra Leone.

A decision support system for district-level disease surveillance was piloted with the Port Loko District Health Management Team in Sierra Leone. Through a qualitative evaluation, the study explores the impact of the system on disease surveillance workflows. Results indicate that the system aided decision making for operational tasks, and reduced the time taken to analyze and report surveillance data. In addition, the study discusses the challenges of deploying a pilot system during the Ebola recovery in Sierra Leone, and proposes a high-level architecture for a modular, interoperable decision support system for disease surveillance for public health decision makers in low-resource health systems.

Overcoming Operational Challenges to Ebola Case Investigation in Sierra Leone.

The Ebola virus disease (EVD) epidemic that hit West Africa in 2013 was the worst outbreak of EVD in recorded history. While much has been published regarding the international and national-level EVD responses, there is a dearth of literature on district-level coordination and operational structures, successes, and failures. This article seeks to understand how the EVD response unfolded at the district level, namely the challenges to operationalizing EVD surveillance over the course of the outbreak in Port Loko and Kambia districts of Sierra Leone. We present here GOAL Global's understanding of the fundamental challenges to case investigation operations during the EVD response, including environmental and infrastructural, sociocultural, and political and organizational challenges, with insight complemented by a survey of 42 case investigators. Major challenges included deficiencies in transportation and communication resources, low morale and fatigue among case investigators, mismanagement of data, mistrust among communities, and leadership challenges. Without addressing these operational challenges, technical surveillance solutions are difficult to implement and hold limited relevance, due to the poor quality and quantity of data being collected. The low prioritization of operational needs came at a high cost. To mediate this, GOAL addressed these operational challenges by acquiring critical transportation and communication resources to facilitate case investigation, including vehicles, boats, fuel, drivers, phones, and closed user groups; addressing fatigue and low morale by hiring more case investigators, making timely payments, arranging for time off, and providing meals and personal protective equipment; improving data tracking efforts through standard operating procedures, training, and mentorship to build higher-quality case histories and make it easier to access information; strengthening trust in communities by ensuring familiarity and consistency of case investigators; and improving operational leadership challenges through meetings and regular coordination, establishing an active surveillance strategy in Port Loko, and conducting an after-action review. Resolving or addressing these challenges was of primary importance, and requisite for the implementation of technical epidemiological complements to EVD case investigation.

Influence of Referral Pathway on Ebola Virus Disease Case-Fatality Rate and Effect of Survival Selection Bias.

Case-fatality rates in Ebola treatment centers (ETCs) varied widely during the Ebola virus disease (EVD) outbreak in West Africa. We assessed the influence of referral pathway on ETC case-fatality rates with a retrospective cohort of 126 patients treated at the Mathaska ETC in Port Loko, Sierra Leone. The patients consisted of persons who had confirmed EVD when transferred to the ETC or who had been diagnosed onsite. The case-fatality rate for transferred patients was 46% versus 67% for patients diagnosed onsite (p = 0.02). The difference was mediated by Ebola viral load at diagnosis, suggesting a survival selection bias. Comparisons of case-fatality rates across ETCs and clinical management strategies should account for potential survival selection bias.

Design and evaluation of a web-based decision support tool for district-level disease surveillance in a low-resource setting.

During the 2014 West African Ebola Virus outbreak it became apparent that the initial response to the outbreak was hampered by limitations in the collection, aggregation, analysis and use of data for intervention planning. As part of the post-Ebola recovery phase, IBM Research Africa partnered with the Port Loko District Health Management Team (DHMT) in Sierra Leone and GOAL Global, to design, implement and deploy a web-based decision support tool for district-level disease surveillance. This paper discusses the design process and the functionality of the first version of the system. The paper presents evaluation results prior to a pilot deployment and identifies features for future iterations. A qualitative assessment of the tool prior to pilot deployment indicates that it improves the timeliness and ease of using data for making decisions at the DHMT level.