Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data.

INTRODUCTION: Sierra Leone is among the top countries with the highest maternal mortality rates. Although progress has been made in reducing maternal mortality, challenges remain, including limited access to skilled care and regional disparities in accessing quality care. This paper presents the first comprehensive analysis of the burden of different causes of maternal deaths reported in the Maternal Death Surveillance and Response (MDSR) system at the district level from 2016 to 2019. METHODS: The MDSR data are accessed from the Ministry of Health and Sanitation, and the secondary data analysis was done to determine the causes of maternal death in Sierra Leone. The proportions of each leading cause of maternal deaths were estimated by districts. A subgroup analysis of the selected causes of death was also performed. RESULTS: Overall, obstetric haemorrhage was the leading cause of maternal death (39.4%), followed by hypertensive disorders (15.8%) and pregnancy-related infections (10.1%). Within obstetric haemorrhage, postpartum haemorrhage was the leading cause in each district. The burden of death due to obstetric haemorrhage slightly increased over the study period, while hypertensive disorders showed a slightly decreasing trend. Disparities were found among districts for all causes of maternal death, but no clear geographical pattern emerged. Non-obstetric complications were reported in 11.5% of cases. CONCLUSION: The MDSR database provides an opportunity for shared learning and can be used to improve the quality of maternal health services. To improve the accuracy and availability of data, under-reporting must be addressed, and frontline community staff must be trained to accurately capture and report death events.

CRADLE-5: a stepped-wedge type 2 hybrid implementation-effectiveness cluster randomised controlled trial to evaluate the real-world scale-up of the CRADLE Vital Signs Alert intervention into routine maternity care in Sierra Leone-study protocol.

BACKGROUND: The CRADLE Vital Signs Alert intervention (an accurate easy-to-use device that measures blood pressure and pulse with inbuilt traffic-light early warning system, and focused training package) was associated with reduced rates of eclampsia and maternal death when trialled in urban areas in Sierra Leone. Subsequently, implementation was successfully piloted as evidenced by measures of fidelity, feasibility and adoption. The CRADLE-5 trial will examine whether national scale-up, including in the most rural areas, will reduce a composite outcome of maternal and fetal mortality and maternal morbidity and will evaluate how the CRADLE package can be embedded sustainably into routine clinical pathways. METHODS: CRADLE-5 is a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care across eight rural districts in Sierra Leone (Bonthe, Falaba, Karene, Kailahun, Koinadugu, Kono, Moyamba, Tonkolili). Each district will cross from control to intervention at six-weekly intervals over the course of 1 year (May 2022 to June 2023). All women identified as pregnant or within six-weeks postpartum presenting for maternity care in the district are included. Primary outcome data (composite rate of maternal death, stillbirth, eclampsia and emergency hysterectomy) will be collected. A mixed-methods process and scale-up evaluation (informed by Medical Research Council guidance for complex interventions and the World Health Organization ExpandNet tools) will explore implementation outcomes of fidelity, adoption, adaptation and scale-up outcomes of reach, maintenance, sustainability and integration. Mechanisms of change and contextual factors (barriers and facilitators) will be assessed. A concurrent cost-effectiveness analysis will be undertaken. DISCUSSION: International guidance recommends that all pregnant and postpartum women have regular blood pressure assessment, and healthcare staff are adequately trained to respond to abnormalities. Clinical effectiveness to improve maternal and perinatal health in more rural areas, and ease of integration and sustainability of the CRADLE intervention at scale has yet to be investigated. This trial will explore whether national scale-up of the CRADLE intervention reduces maternal and fetal mortality and severe maternal adverse outcomes and understand the strategies for adoption, integration and sustainability in low-resource settings. If successful, the aim is to develop an adaptable, evidence-based scale-up roadmap to improve maternal and infant outcomes. TRIAL REGISTRATION: ISRCTN 94429427. Registered on 20 April 2022.

Improvement in Infection Prevention and Control Compliance at the Three Tertiary Hospitals of Sierra Leone following an Operational Research Study.

Implementing infection prevention and control (IPC) programmes in line with the World Health Organization's (WHO) eight core components has been challenging in Sierra Leone. In 2021, a baseline study found that IPC compliance in three tertiary hospitals was sub-optimal. We aimed to measure the change in IPC compliance and describe recommended actions at these hospitals in 2023. This was a 'before and after' observational study using two routine cross-sectional assessments of IPC compliance using the WHO IPC Assessment Framework tool. IPC compliance was graded as inadequate (0-200), basic (201-400), intermediate (401-600), and advanced (601-800). The overall compliance scores for each hospital showed an improvement from 'Basic' in 2021 to 'Intermediate' in 2023, with a percentage increase in scores of 16.9%, 18.7%, and 26.9% in these hospitals. There was improved compliance in all core components, with the majority in the 'Intermediate' level for each hospital IPC programme. Recommended actions including the training of healthcare workers and revision of IPC guidelines were undertaken, but a dedicated IPC budget and healthcare-associated infection surveillance remained as gaps in 2023. Operational research is valuable in monitoring and improving IPC programme implementation. To reach the 'Advanced' level, these hospitals should establish a dedicated IPC budget and develop long-term implementation plans.

Neural tube defects as a cause of death among stillbirths, infants, and children younger than 5 years in sub-Saharan Africa and southeast Asia: an analysis of the CHAMPS network.

BACKGROUND: Neural tube defects are common birth defects resulting in severe morbidity and mortality; they can largely be prevented with periconceptional maternal intake of folic acid. Understanding the occurrence of neural tube defects and their contribution to mortality in settings where their burden is highest could inform prevention and health-care policy. We aimed to estimate the mortality attributed to neural tube defects in seven countries in sub-Saharan Africa and southeast Asia. METHODS: This analysis used data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network and health and demographic surveillance systems from South Africa, Mozambique, Bangladesh, Kenya, Mali, Ethiopia, and Sierra Leone. All stillbirths and infants and children younger than 5 years who died, who were enrolled in CHAMPS, whose families consented to post-mortem minimally invasive tissue sampling (MITS) between Jan 1, 2017, and Dec 31, 2021, and who were assigned a cause of death by a determination of cause of death panel as of May 24, 2022, were included in this analysis, regardless the cause of death. MITS and advanced diagnostic methods were used to describe the frequency and characteristics of neural tube defects among eligible deaths, identify risk factors, and estimate the mortality fraction and mortality rate (per 10 000 births) by CHAMPS site. FINDINGS: Causes of death were determined for 3232 stillbirths, infants, and children younger than 5 years, of whom 69 (2%) died with a neural tube defect. Most deaths with a neural tube defect were stillbirths (51 [74%]); 46 (67%) were neural tube defects incompatible with life (ie, anencephaly, craniorachischisis, or iniencephaly) and 22 (32%) were spina bifida. Deaths with a neural tube defect were more common in Ethiopia (adjusted odds ratio 8·09 [95% CI 2·84-23·02]), among female individuals (4·40 [2·44-7·93]), and among those whose mothers had no antenatal care (2·48 [1·12-5·51]). Ethiopia had the highest adjusted mortality fraction of deaths with neural tube defects (7·5% [6·7-8·4]) and the highest adjusted mortality rate attributed to neural tube defects (104·0 per 10 000 births [92·9-116·4]), 4-23 times greater than in any other site. INTERPRETATION: CHAMPS identified neural tube defects, a largely preventable condition, as a common cause of death among stillbirths and neonatal deaths, especially in Ethiopia. Implementing interventions such as mandatory folic acid fortification could reduce mortality due to neural tube defects. FUNDING: Bill & Melinda Gates Foundation.

Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities.

BACKGROUND: In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels. METHODS: Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020. RESULTS: Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option. CONCLUSION: Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.

Unsafe abortion is a leading cause of death and disability among women of reproductive age. Medical management of abortion with mifepristone and misoprostol pills, or just misoprostol, is a safe and effective way to end a pregnancy. Owing to an increase in the number of medical abortion products that have entered country health systems, we examined access to these medicines from supply to demand in selected countries. The overarching goal of the national landscape assessments was to produce evidence to support advocacy efforts and policymaking for improved access to quality medical abortion products that is appropriate to the needs of the country. This paper aims to describe key findings across eight country settings on the availability of medical abortion medicines and identify key opportunities to improve access to them across countries.

Scale-up of a novel vital signs alert device to improve maternity care in Sierra Leone: a mixed methods evaluation of adoption.

BACKGROUND: The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device-designed specifically to improve maternity care in low resource settings-had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone. METHODS: This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with 'CRADLE Champions' in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework. FINDINGS: Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59-90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: 'the technology' (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and 'the organisation' (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving). CONCLUSIONS: Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.

Many women die during pregnancy and childbirth from causes that could be prevented, and the vast majority of these deaths occur in low-resource settings. The 'CRADLE Vital Signs Alert' is a medical device that helps identify problems during pregnancy­designed specifically for healthcare professionals in low-resource settings. However, for unknown reasons, the device appears to have varying impact according to the country or setting in which it is used. This study aimed to explore in depth whether, and why, healthcare professionals in Sierra Leone adopted the device and engaged in training (or not). Between March 2020 and January 2021, the CRADLE device and training package was disseminated across 8 districts in Sierra Leone. This relied on a few healthcare workers (nominated 'CRADLE Champions') to voluntarily distribute the devices and training in their local areas. Group discussions were held with CRADLE Champions in each district after the rollout to gather their feedback. In addition, the proportion of facilities trained in each district was recorded. The study found differences in how well the device and training was adopted in each district. Common challenges reported across districts related to technological difficulties (such as issues charging the devices) and organisational barriers (such as high levels of staff turnover at facilities). These findings will help to inform future rollout of the CRADLE device and training in Sierra Leone and highlight factors that may need to be considered by those implementing other health technologies in similar settings.

Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes.

The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.

Bacterial Isolates and Antibiotic Resistance of Escherichia coli Isolated from Fresh Poultry Excreta Used for Vegetable Farming in Freetown, Sierra Leone.

The transfer of antibiotic resistance from animals to humans is of concern in recent times. One potential source of such transfer is the untreated poultry excreta used as manure in farming. We aim to identify bacterial isolates and antibiotic susceptibility patterns of Escherichia coli in poultry excreta in Sierra Leone. This was a cross-sectional study of fresh poultry excreta samples collected from four commercial poultry sites in Freetown, Sierra Leone, from June−September 2021. Bacterial isolates were tested against eight antibiotics using established standards. Of 100 samples, 93 showed Escherichia coli (93%): of those, eight isolates also had Salmonella (8%). E. coli was 100% resistant to all three 'Watch' drugs (erythromycin, cefoxitin and streptomycin) and tetracycline. E. coli was least resistant to ampicillin (12%), followed by chloramphenicol (35%). The prevalence of multidrug resistance was 95.6%. Multiple antibiotic resistance index ranged from 0.5−0.7 (optimal < 0.2), indicating high prior exposure to antibiotics in these poultries. Such high levels of resistance in E. coli isolated from poultry excreta could pose a serious threat to humans. We recommend (i) routine surveillance to monitor antibiotic resistance in poultry excreta, (ii) using poultry excreta as manure only after treatment and (iii) restricting the use of antibiotics as prophylactics and growth promoters in poultry feeds.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy.

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

The impact on key indicators of reproductive and child health after changes in program modalities in Sierra Leone, 2019.

BACKGROUND AND AIMS: In 2018, the transition to routine vitamin A supplementation (VAS) was integrated with caregivers' preparation of nutritious complementary food from local produce and confidential counseling and provision of modern contraceptives. In 2019, funding for complementary food ceased and Community Health Workers (CHWs) were trained to track defaulters, while national efforts to improve Health Management Information Systems, supply chains and reduce teenage pregnancies were intensified. We report on key indicators after these changes and in comparison, to those previously published. METHODS: The same Lot Quality Assurance Sampling methodology was used in both assessments: 19 villages were randomly selected in each of five lots in each of three districts then caregivers of children 6-59 months age randomly selected and interviewed. RESULTS: Coverage of VAS, Albendazole, and Pentavalent 3 before and after these changes was over 80%, 75%, and 80% respectively, equitable by sex, age, caregiver's religion, and educational status. Comparison with 2018 found more lots failed to reach 80% VAS by verbal affirmation (10 vs 2), and coverage in one district (Bo) had dropped (77.5% vs 92.3%). Fewer caregivers were aware that VAS should be taken every 6 months (27% vs 50%), that complementary feeding should start at 6 months (63% vs 77%) or were providing minimal dietary diversity (27% vs 45%). There was an increase in caregivers using modern contraception (45% vs 35%), obtaining information about contraception from a friend (14% vs 9%), while fewer thought country rope/herbs (traditional contraceptives) were "effective" (11% vs 21%) and stockouts of contraceptives at health facilities had dropped (24% vs 55%). Stipends for CHWs cost approximately $750 K vs complementary food: $112 K. CONCLUSION: Overall coverage for VAS, Albendazole, and Pentavalent remained effective but VAS had dropped significantly in one district. Complementary feeding practices had declined. Awareness, uptake, and contraceptives supply chains had improved.

High Levels of Antibiotic Resistance Patterns in Two Referral Hospitals during the Post-Ebola Era in Free-Town, Sierra Leone: 2017-2019.

The Post-Ebola era (2017-2019) presented an opportunity for laboratory investments in Sierra Leone. US CDC supported the Ministry of Health and Sanitation to establish a microbiological unit for routine antimicrobial sensitivity testing in two referral (pediatric and maternity) hospitals in Freetown. This study describes resistance patterns among patients' laboratory samples from 2017 to 2019 using routine data. Samples included urine, stool, cerebrospinal fluid, pus-wound, pleural fluid, and high vaginal swabs. Selected Gram-positive and Gram-negative bacterial isolates were tested for antimicrobial susceptibility. Of 200 samples received by the laboratory, 89 returned positive bacterial isolates with urine and pus-wound swabs accounting for 75% of positive isolates. The number of positive isolates increased annually from one in 2017 to 42 in 2018 and 46 in 2019. Resistance of the cultures to at least one antibiotic was high (91%), and even higher in the pediatric hospital (94%). Resistance was highest with penicillin (81%) for Gram-positive bacteria and lowest with nitrofurantoin (13%). Gram-negative bacteria were most resistant to ampicillin, gentamycin, streptomycin, tetracycline, cephalothin and penicillin (100%) and least resistant to novobiocin (0%). Antibiotic resistance for commonly prescribed antibiotics was high in two referral hospitals, highlighting the urgent need for antimicrobial stewardship and access to reserve antibiotics.

National Antimicrobial Consumption: Analysis of Central Warehouses Supplies to In-Patient Care Health Facilities from 2017 to 2019 in Uganda.

Antimicrobial consumption (AMC) surveillance at global and national levels is necessary to inform relevant interventions and policies. This study analyzed central warehouse antimicrobial supplies to health facilities providing inpatient care in Uganda. We collected data on antimicrobials supplied by National Medical Stores (NMS) and Joint Medical Stores (JMS) to 442 health facilities from 2017 to 2019. Data were analyzed using the World Health Organization methodology for AMC surveillance. Total quantity of antimicrobials in defined daily dose (DDD) were determined, classified into Access, Watch, Reserve (AWaRe) and AMC density was calculated. There was an increase in total DDDs distributed by NMS in 2019 by 4,166,572 DDD. In 2019, Amoxicillin (27%), Cotrimoxazole (20%), and Metronidazole (12%) were the most supplied antimicrobials by NMS while Doxycycline (10%), Amoxicillin (19%), and Metronidazole (10%) were the most supplied by JMS. The majority of antimicrobials supplied by NMS (81%) and JMS (66%) were from the Access category. Increasing antimicrobial consumption density (DDD per 100 patient days) was observed from national referral to lower-level health facilities. Except for NMS in 2019, total antimicrobials supplied by NMS and JMS remained the same from 2017 to 2019. This serves as a baseline for future assessments and monitoring of stewardship interventions.

Prevalence of use of highly concentrated oxytocin or "pepper injection" in labor among clinicians undergoing emergency obstetric training in Sierra Leone.

OBJECTIVE: To examine the awareness, prevalence of use, and knowledge of risks of pepper injection (PI), an injection of highly concentrated oxytocin used to augment or induce labor, among clinicians. METHODS: An anonymous pre- and post-workshop evaluation conducted among 227 clinicians participating in emergency obstetric and newborn care training in Sierra Leone from June to October 2018. RESULTS: Overall, 225 participants completed the surveys. Of these, 198 (88.0%) of clinicians reported awareness of PI, and 123 (54.7%) self-reported prior use, which was highest among midwives (94/129; 72.9%). Before EmONC training, 82 (36.4%) clinicians reported that they were likely to use PI; this decreased to 39 (17.3%) after training (P<0.05). The mean number of participants correctly identifying risks of PI increased from 149 (66.2%) to 204 (90.7%) after training (P<0.05). CONCLUSION: There was widespread awareness of PI use among clinicians, and prevalent self-reported prior use among midwives. Risk awareness improved after EmONC training, and the proportion of clinicians reporting likelihood of future use decreased. Improper use of oxytocin may be a major contributor to maternal and newborn morbidity and mortality in Sierra Leone. Initiatives to educate clinicians and to regulate and stop the practice are needed.

Investing in Operational Research Capacity Building for Front-Line Health Workers Strengthens Countries' Resilience to Tackling the COVID-19 Pandemic.

(1) Introduction. The Structured Operational Research and Training IniTiative (SORT IT) supports countries to build operational research capacity for improving public health. We assessed whether health workers trained through SORT IT were (1) contributing to the COVID-19 pandemic response and if so, (2) map where and how they were applying their SORT IT skills. (2) Methods. An online questionnaire survey of SORT IT alumni trained between 2009 and 2019. (3) Results. Of 895 SORT IT alumni from 93 countries, 652 (73%) responded to the survey and 417 were contributing to the COVID-19 response in 72 countries. Of those contributing, 307 (74%) were applying their SORT IT skills to tackle the pandemic in 60 countries and six continents including Africa, Asia, Europe, South Pacific and North/South America. Skills were applied to all the pillars of the emergency response with the highest proportions of alumni applying their skills in data generation/analysis/reporting (56%), situation analysis (55%) and surveillance (41%). Skills were also being used to mitigate the health system effects of COVID-19 on other diseases (27%) and in conducting research (26%). (4) Conclusion. Investing in people and in research training ahead of public health emergencies generates downstream dividends by strengthening health system resilience for tackling pandemics. It also strengthens human resources for health and the integration of research within health systems.

The Transmission Chain Analysis of 2014-2015 Ebola Virus Disease Outbreak in Koinadugu District, Sierra Leone: An Observational Study.

INTRODUCTION: Sierra Leone experienced an unprecedented Ebola virus disease (EVD) outbreak in all its districts. Koinadugu District was the last to report an EVD case. Several outbreak response strategies were implemented. As part of lessons learnt, we conducted an observational study to describe the transmission chain in the district and the impact of the control measures implemented to contain the outbreak. METHODS: We reconstructed the transmission chain, positioning both confirmed and probable cases, described the distribution of the EVD confirmed cases in the context of the routes of transmission (Community, Funeral or Health facility setting) and assessed the impact of control measures using the surveillance data collected during the outbreak. RESULTS: All 142 confirmed and probable EVD cases registered were fully resolved in the transmission chain. 72.5% of all the EVD cases in the district were exposed in the community, 26.1% exposed during funerals, and 1.4% exposed in the health facility setting. Health-care workers contributed little to the EVD outbreak. 71.1% of EVD transmission occurred among family members. Female EVD cases generated more secondary cases than their male counterparts (P = 0.03). With removal of EVD cases from the community and admission to the community care center (CCC), the EVD transmission in the community decreased to substantially lower rates. In addition, transmission due to exposure in health facilities was further reduced with the implementation of full infection and prevention controls. CONCLUSION: This study details the transmission chain of EVD in a rural district setting and the public health interventions implemented to successfully limit the outbreak to just one of 11 chiefdoms. Heightened community-based surveillance for early case detection, swift isolation of suspect cases, efficient contact tracing and monitoring, and good infection prevention and control measures in health facilities were highly effective in limiting transmission and, eventually, breaking the transmission chain. CCCs were also instrumental in achieving early isolation and basic care for suspect cases, while ensuring that their family members who were close contacts remained in the community for easy contact tracing and monitoring. These were very useful lessons learnt that would inform the management of future outbreaks.

The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage.

BACKGROUND: Medical management of miscarriage allows women to avoid the risks associated with surgical intervention. In 2011 the early pregnancy assessment service (EPAS) at the Royal Prince Alfred Hospital (RPAH) in Sydney, Australia introduced medical management of miscarriage with single-dose 800 µg vaginal misoprostol. AIMS: We sought to investigate the impact of the introduction of medical management had on the proportion of women having surgery and conservative management and to examine the success and complication rates of medical management. MATERIALS AND METHODS: We undertook a retrospective cohort study that included all women diagnosed with a miscarriage from 12 months prior to and 18 months after the introduction of medical management. Successful management was defined as the absence of retained products of conception or endometrial thickness less than 15 mm on ultrasound at two weeks. The change in management choices over time, the success rates and complication rates were measured. RESULTS: Of 1102 women in the final analysis, 446 were in Group A (before medical management) and 656 in Group B (after medical management). Primary surgical procedures fell significantly for missed miscarriages from 68 to 48% (P < 0.001) and primary conservative management reduced for incomplete miscarriages (63-44%; P = 0.01). Overall 89 of 108 (82.4%) patients managed medically had a resolution within two weeks. One in ten presented with a complication. DISCUSSION: The introduction of medical management led to a statistically significant reduction in the proportion of women undergoing primary surgical management of missed miscarriage. Success and complication rates were similar to other studies.