Engaging the public in decisions about emergency vaccine deployment strategies: Lessons from scenario-based discussions in Sierra Leone.

ABSTRACTThe COVID-19 pandemic has amplified discussions on emergency vaccine deployment strategies, with current perspectives often neglecting extensive community involvement in ethical, logistical and political aspects. Existing social science literature predominantly delves into factors influencing trust, overlooking the untapped potential for community engagement.Our study examines community preparedness in Sierra Leone's Kambia District, exploring diverse viewpoints on vaccine deployment strategies, emphasising Ebola and COVID-19 vaccinations. Utilising extensive ethnographic research from the Ebola vaccine trials (EBOVAC Salone) conducted in Kambia District from 2015 to 2021, including participant observation and tailored focus group discussions, we investigated various deployment scenarios with community leaders and citizens.Our findings underscore the multifaceted contributions of social science research with communities in shaping emergency vaccination strategies. These contributions span logistical insights, aligning campaigns with local livelihoods and social structures, and grounded ethical concerns assessing social justice outcomes across epidemic scenarios. This study emphasises the imperative of integrating discussions on vaccine confidence and deployment. It highlights communities' proficiency in epidemiological reasoning and their ability to bring this in conversation with salient socio-cultural, economic and religious dimensions. We therefore promote the cultivation of public dialogue, collaborative creation of impactful vaccination initiatives alongside relevant communities in recognition of their invaluable perspectives .

Assessing geographical variation in ovulatory cycle knowledge among women of reproductive age in Sierra Leone: Analysis of the 2019 Demographic and Health Survey.

BACKGROUND: Sierra Leone has poor indicators of reproductive health and a high prevalence of unintended pregnancies. To date, no study has explored determinants of ovulatory cycle knowledge in Sierra Leone. We investigated geographic region to determine where the needs for improved ovulatory cycle knowledge are greatest in Sierra Leone. METHODS: This is a cross-sectional study of women of reproductive age (n = 15,574) based on the 2019 Sierra Leone Demographic and Health Survey. Geographic region and sociodemographic covariates were included in a multivariate logistic regression model predicting the odds that participants possessed accurate knowledge of when in the ovulatory cycle pregnancy initiation is most likely. RESULTS: In Sierra Leone, 39.8% (CI = 37.4-40.9) of 15-49-year-old women had accurate knowledge of the ovulatory cycle. Women in the Northern and Southern regions possessed the highest prevalence of correct knowledge (46.7%, CI = 43.1-50.3 and 45.1%, CI = 41.9-48.2, respectively). Women from the Northwestern (AOR = 0.29, CI = 0.22-0.38), Eastern (AOR = 0.55, CI = 0.41-0.72), and Western regions (AOR = 0.63, CI = 0.50-0.80) had significantly lower odds of accurate ovulatory cycle knowledge compared to others. Women aged 15-19, those with a primary school education, and participants with a parity of none all had the lowest odds of correct ovulatory cycle knowledge as well. CONCLUSION: Less than four in ten women in Sierra Leone had accurate knowledge of when in the ovulatory cycle pregnancy is most likely to occur. This suggests that family planning outreach programs should include education on the ovulatory cycle and the importance of understanding the implications of its timing. This can reduce the risk of unintended pregnancies throughout Sierra Leone, and can have an especially positive impact in the Northwestern, Eastern, and Western regions, where ovulatory cycle knowledge was significantly lower.

Alcohol use among in-school adolescents in Sierra Leone.

OBJECTIVE: To examine the prevalence of alcohol use and its associated factors among in-school adolescents in Sierra Leone. DESIGN: Data for the study was sourced from the 2017 Sierra Leone Global School-Based Student Health Survey, a nationally representative survey conducted among in-school adolescents aged 10-19 years using a multistage sampling methodology. Percentages were used to present the prevalence of alcohol use among in-school adolescents. Multivariable binary logistic regression analysis was performed to examine the factors associated with alcohol use among in-school adolescents. The results were presented using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI). SETTING: Sierra Leone. PARTICIPANTS: A weighted sample of 1730 in-school adolescents in Sierra Leone. OUTCOME MEASURE: Current alcohol use. RESULTS: The prevalence of alcohol use among in-school adolescents was 10.7% (7.3, 15.3). In-school adolescents in senior secondary schools were more likely to use alcohol compared with those in junior secondary school (aOR=2.13; 95% CI 1.37, 3.30). The odds of alcohol use was higher among in-school adolescents who were truant at school relative to those who were not (aOR=2.24; 95% CI 1.54, 3.26). Also, in-school adolescents who were bullied (aOR=1.85; 95% CI 1.24, 2.76), ever engaged in sexual intercourse (aOR=2.06; 95% CI 1.39, 3.06), and used marijuana (aOR=3.36; 95% CI 1.72, 6.53) were more likely to use alcohol compared with those who were not. However, in-school adolescents who reported that their parents understood their problems (aOR=0.52; 95% CI 0.33, 0.82) had a lower likelihood of consuming alcohol. CONCLUSION: Our study has shown that alcohol use is prevalent among in-school adolescents in Sierra Leone. Grade level, experiences of being bullied, history of sexual intercourse, truancy at school, and previous use of marijuana were the factors influencing alcohol use among in-school adolescents. The findings emphasise the necessity of creating school-based health interventions in Sierra Leone that can effectively identify in-school adolescents potentially vulnerable to alcohol-related issues. Also, existing policies and programmes aimed at reducing alcohol use among in-school adolescents need to be strengthened.

Methodological issues of retrospective surveys for measuring mortality of highly clustered diseases: case study of the 2014-16 Ebola outbreak in Bo District, Sierra Leone.

BACKGROUND: There is a lack of empirical data on design effects (DEFF) for mortality rate for highly clustered data such as with Ebola virus disease (EVD), along with a lack of documentation of methodological limitations and operational utility of mortality estimated from cluster-sampled studies when the DEFF is high. OBJECTIVES: The objectives of this paper are to report EVD mortality rate and DEFF estimates, and discuss the methodological limitations of cluster surveys when data are highly clustered such as during an EVD outbreak. METHODS: We analysed the outputs of two independent population-based surveys conducted at the end of the 2014-2016 EVD outbreak in Bo District, Sierra Leone, in urban and rural areas. In each area, 35 clusters of 14 households were selected with probability proportional to population size. We collected information on morbidity, mortality and changes in household composition during the recall period (May 2014 to April 2015). Rates were calculated for all-cause, all-age, under-5 and EVD-specific mortality, respectively, by areas and overall. Crude and adjusted mortality rates were estimated using Poisson regression, accounting for the surveys sample weights and the clustered design. RESULTS: Overall 980 households and 6,522 individuals participated in both surveys. A total of 64 deaths were reported, of which 20 were attributed to EVD. The crude and EVD-specific mortality rates were 0.35/10,000 person-days (95%CI: 0.23-0.52) and 0.12/10,000 person-days (95%CI: 0.05-0.32), respectively. The DEFF for EVD mortality was 5.53, and for non-EVD mortality, it was 1.53. DEFF for EVD-specific mortality was 6.18 in the rural area and 0.58 in the urban area. DEFF for non-EVD-specific mortality was 1.87 in the rural area and 0.44 in the urban area. CONCLUSION: Our findings demonstrate a high degree of clustering; this contributed to imprecise mortality estimates, which have limited utility when assessing the impact of disease. We provide DEFF estimates that can inform future cluster surveys and discuss design improvements to mitigate the limitations of surveys for highly clustered data.

Main findings: For humanitarian organizations it is imperative to document the methodological limitations of cluster surveys and discuss the utility.Added knowledge: This paper adds new knowledge on cluster surveys for highly clustered data such us in Ebola virus disease.Global health impact of policy and action: We provided empirical estimates and discuss design improvements to inform future study.

Reservoir displacement by an invasive rodent reduces Lassa virus zoonotic spillover risk.

The black rat (Rattus rattus) is a globally invasive species that has been widely introduced across Africa. Within its invasive range in West Africa, R. rattus may compete with the native rodent Mastomys natalensis, the primary reservoir host of Lassa virus, a zoonotic pathogen that kills thousands annually. Here, we use rodent trapping data from Sierra Leone and Guinea to show that R. rattus presence reduces M. natalensis density within the human dwellings where Lassa virus exposure is most likely to occur. Further, we integrate infection data from M. natalensis to demonstrate that Lassa virus zoonotic spillover risk is lower at sites with R. rattus. While non-native species can have numerous negative effects on ecosystems, our results suggest that R. rattus invasion has the indirect benefit of decreasing zoonotic spillover of an endemic pathogen, with important implications for invasive species control across West Africa.

Hepatitis E Seroprevalence and Detection of Genotype 3 Strains in Domestic Pigs from Sierra Leone Collected in 2016 and 2017.

Hepatitis E virus (HEV) is the main cause of acute hepatitis in humans worldwide and is responsible for a large number of outbreaks especially in Africa. Human infections are mainly caused by genotypes 1 and 2 of the genus Paslahepevirus, which are exclusively associated with humans. In contrast, viruses of genotypes 3 and 4 are zoonotic and have their main reservoir in domestic and wild pigs, from which they can be transmitted to humans primarily through the consumption of meat products. Both genotypes 3 and 4 are widespread in Europe, Asia, and North America and lead to sporadic cases of hepatitis E. However, there is little information available on the prevalence of these genotypes and possible transmission routes from animal reservoirs to humans in African countries. We therefore analysed 1086 pig sera collected in 2016/2017 in four districts in Sierra Leone for antibodies against HEV using a newly designed in-house ELISA. In addition, the samples were also analysed for HEV RNA by quantitative real-time RT-PCR. The overall seroprevalence in Sierra Leone was low with only 44 positive sera and a prevalence of 4.0%. Two serum pools were RT-PCR-positive and recovered partial sequences clustered into the genotype 3 (HEV-3) of the order Paslahepevirus, species Paslahepevirus balayani. The results are the first evidence of HEV-3 infection in pigs from Sierra Leone and demonstrate a low circulation of the virus in these animals to date. Further studies should include an examination of humans, especially those with close contact with pigs and porcine products, as well as environmental sampling to evaluate public health effects within the framework of a One Health approach.

Sosuga Virus Detected in Egyptian Rousette Bats (Rousettus aegyptiacus) in Sierra Leone.

Sosuga virus (SOSV), a rare human pathogenic paramyxovirus, was first discovered in 2012 when a person became ill after working in South Sudan and Uganda. During an ecological investigation, several species of bats were sampled and tested for SOSV RNA and only one species, the Egyptian rousette bat (ERBs; Rousettus aegyptiacus), tested positive. Since that time, multiple other species have been sampled and ERBs in Uganda have continued to be the only species of bat positive for SOSV infection. Subsequent studies of ERBs with SOSV demonstrated that ERBs are a competent host for SOSV and shed this infectious virus while exhibiting only minor infection-associated pathology. Following the 2014 Ebola outbreak in West Africa, surveillance efforts focused on discovering reservoirs for zoonotic pathogens resulted in the capture and testing of many bat species. Here, SOSV RNA was detected by qRT-PCR only in ERBs captured in the Moyamba District of Sierra Leone in the central region of the country. These findings represent a substantial range extension from East Africa to West Africa for SOSV, suggesting that this paramyxovirus may occur in ERB populations throughout its sub-Saharan African range.

Cannabis use and its psychosocial correlates among school-going adolescents in Sierra Leone.

BACKGROUND: In Sierra Leone, adolescents are increasingly engaging in risky activities, including cannabis use, which can lead to substance abuse, poor academic performance, and psychotic symptoms. This study aims to investigate the prevalence and associated factors of cannabis use among school-going adolescents in the country. METHOD: Data for the study was sourced from the 2017 Sierra Leone Global School-based Student Health Survey (GSHS), a nationally representative survey conducted among adolescents aged 10-19 years using a multistage sampling methodology. A weighted sample of 1,467 adolescents in Sierra Leone was included in the study. The study utilised bivariate and multivariable logistic regression analysis to identify factors linked to cannabis use, presenting results using adjusted odds ratios and 95% confidence intervals. RESULTS: The prevalence of cannabis use was 5.1% [3.0,8.6] among school-going adolescents in Sierra Leone. School-going adolescents who attempted suicide [aOR = 6.34, 95% CI = 1.71-23.45], used amphetamine [aOR = 15.84, 95% CI = 7.94-31.62] and were involved in sexual risk behaviour [aOR = 5.56, 95% CI = 2.18-14.20] were more likely to be associated with cannabis use. CONCLUSION: In Sierra Leone, a small but non-trivial minority of students use cannabis. Ever-used amphetamines or methamphetamines, suicidal attempts, and sexual risk behaviour were the factors associated with cannabis use in Sierra Leone. The development of school-based health intervention programmes is crucial to address the risk factors associated with cannabis use among school-going adolescents.

Prevalence of hypertension, diabetes mellitus, and their risk factors in an informal settlement in Freetown, Sierra Leone: a cross-sectional study.

BACKGROUND: Noncommunicable diseases (NCDs), especially hypertension and diabetes mellitus are on the increase in sub-Saharan Africa (SSA). Informal settlement dwellers exhibit a high prevalence of behavioural risk factors and are highly vulnerable to hypertension and diabetes. However, no study has assessed the prevalence of hypertension, diabetes, and NCDrisk factors among informal settlement dwellers in Sierra Leone. We conducted a study in June 2019 to determine the prevalence of hypertension, diabetes, and NCD risk factors among adults living in the largest Sierra Leonean informal settlement (KrooBay). METHODS AND MATERIALS: We conducted a community-based cross-sectional survey among adults aged ≥ 35 years in the KrooBay community. Trained healthcare workers collected data on socio-demographic characteristics and self-reported health behaviours using the World Health Organization STEPwise surveillance questionnaire for chronic disease risk factors. Anthropometric, blood glucose, and blood pressure measurements were performed following standard procedures. Logistics regression was used for analysis and adjusted odd ratios with 95% confidence intervals were calculated to identify risk factors associated with hypertension. RESULTS: Of the 418 participants, 242 (57%) were females and those below the age of 45 years accounted for over half (55.3%) of the participants. The prevalence of smoking was 18.2%, alcohol consumption was 18.8%, overweight was 28.2%, obesity was 17.9%, physical inactivity was 81.5%, and inadequate consumption of fruits and vegetables was 99%. The overall prevalence of hypertension was 45.7% (95% CI 41.0-50.5%), systolic hypertension was 34.2% (95% CI 29.6-38.8%), diastolic blood pressure was 39.9% (95% CI 35.2-44.6), and participants with diabetes were 2.2% (95% CI 0.7-3.6%). Being aged ≥ 55 years (AOR = 7.35, 95% CI 1.49-36.39) and > 60 years (AOR 8.05; 95% CI 2.22-29.12), separated (AOR = 1.34; 95% 1.02-7.00), cohabitating (AOR = 6.68; 95% CL1.03-14.35), vocational (AOR = 3.65; 95% CI 1.81-7.39 ) and having a university education (AOR = 4.62; 95% CI 3.09-6.91) were found to be independently associated with hypertension. CONCLUSION: The prevalence of hypertension,and NCD risk factors was high among the residents of the Kroobay informal settlement. We also noted a low prevalence of diabetes. There is an urgent need for the implementation of health education, promotion, and screening initiatives to reduce health risks so that these conditions will not overwhelm health services.

Geographic Disparities in Domestic Pig Population Exposure to Ebola Viruses, Guinea, 2017-2019.

Although pigs are naturally susceptible to Reston virus and experimentally to Ebola virus (EBOV), their role in Orthoebolavirus ecology remains unknown. We tested 888 serum samples collected from pigs in Guinea during 2017-2019 (between the 2013-16 epidemic and its resurgence in 2021) by indirect ELISA against the EBOV nucleoprotein. We identified 2 hotspots of possible pig exposure by IgG titer levels: the northern coast had 48.7% of positive serum samples (37/76), and Forest Guinea, bordering Sierra Leone and Liberia, where the virus emerged and reemerged, had 50% of positive serum samples (98/196). The multitarget Luminex approach confirms ELISA results against Ebola nucleoprotein and highlights cross-reactivities to glycoprotein of EBOV, Reston virus, and Bundibugyo virus. Those results are consistent with previous observations of the circulation of Orthoebolavirus species in pig farming regions in Sierra Leone and Ghana, suggesting potential risk for Ebola virus disease in humans, especially in Forest Guinea.

Impact assessment of onchocerciasis through lymphatic filariasis transmission assessment surveys using Ov-16 rapid diagnostic tests in Sierra Leone.

BACKGROUND: Onchocerciasis is endemic in 14 of Sierra Leone's 16 districts with high prevalence (47-88.5%) according to skin snips at baseline. After 11 rounds of mass treatment with ivermectin with good coverage, an impact assessment was conducted in 2017 to assess the progress towards eliminating onchocerciasis in the country. METHODS: A cluster survey was conducted, either integrated with lymphatic filariasis (LF) transmission assessment survey (TAS) or standalone with the LF TAS sampling strategy in 12 (now 14) endemic districts. Finger prick blood samples of randomly selected children in Grades 1-4 were tested in the field using SD Bioline Onchocerciasis IgG4 rapid tests. RESULTS: In total, 17,402 children aged 4-19 years in 177 schools were tested, and data from 17,364 children aged 4-14 years (14,230 children aged 5-9 years) were analyzed. Three hundred forty-six children were confirmed positive for Ov-16 IgG4 antibodies, a prevalence of 2.0% (95% CI 1.8-2.2%) in children aged 4-14 years with prevalence increasing with age. Prevalence in boys (2.4%; 95% CI 2.1-2.7%) was higher than in girls (1.6%; 95% CI 1.4-1.9%). There was a trend of continued reduction from baseline to 2010. Using data from children aged 5-9 years, overall prevalence was 1.7% (95% CI 1.5-1.9%). The site prevalence ranged from 0 to 33.3% (median prevalence = 0.0%): < 2% in 127 schools, 2 to < 5% in 34 schools and ≥ 5% in 16 schools. There was a significant difference in average prevalence between districts. Using spatial analysis, the Ov-16 IgG4 antibody prevalence was predicted to be < 2% in coastal areas and in large parts of Koinadugu, Bombali and Tonkolili Districts, while high prevalence (> 5%) was predicted in some focal areas, centered in Karene, Kailahun and Moyamba/Tonkolili. CONCLUSIONS: Low Ov-16 IgG4 antibody prevalence was shown in most areas across Sierra Leone. In particular, low seroprevalence in children aged 5-9 years suggests that the infection was reduced to a low level after 11 rounds of treatment intervention. Sierra Leone has made major progress towards elimination of onchocerciasis. However, attention must be paid to those high prevalence focal areas.

Prevalence and predictors of lifetime amphetamine use among in-school adolescents in Sierra Leone.

OBJECTIVE: This study examined the prevalence of amphetamine use and its associated factors among in-school adolescents in Sierra Leone. DESIGN: Data for the study was sourced from the 2017 Sierra Leone Global School-based Health Survey. Percentages with confidence intervals (CIs) were used to present the prevalence of amphetamine use among in-school adolescents. A multivariable binary logistic regression analysis was employed to examine the factors associated with amphetamine use. The results were presented using adjusted odds ratios (aORs) with 95% CIs. SETTING: Sierra Leone. PARTICIPANTS: A weighted sample of 1,314 in-school adolescents in Sierra Leone. OUTCOME MEASURE: Lifetime amphetamine use. RESULTS: The prevalence of amphetamine use was 6.1% (3.9%-9.5%). In-school adolescents who planned suicide were more likely to use amphetamine compared with those who did not (aOR 2.54; 95% CI 1.02 to 6.31). Also, the odds of amphetamine use were higher among in-school adolescents who received support from their peers (aOR 3.19, 95% CI 1.71 to 5.96), consumed alcohol (aOR 4.85, 95% CI 2.61 to 9.03), and those who had previously used marijuana (aOR 13.31, 95% CI 6.61 to 28.78) compared with those who did not receive any support, never consumed alcohol, and never used marijuana, respectively. CONCLUSION: Amphetamine use is prevalent among in-school adolescents in Sierra Leone. There is a need to implement comprehensive public health policies that extend beyond school-based psychobehavioural therapies. These policies should specifically address the considerable risk factors associated with amphetamine use among in-school adolescents in Sierra Leone.

A qualitative study examining the health system's response to COVID-19 in Sierra Leone.

The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

The economic burden of Ebola virus disease: a review and recommendations for analysis.

BACKGROUND: Ebola virus disease (EVD) continues to be a major public health threat globally, particularly in the low-and-middle-income countries (LMICs) of Africa. The social and economic burdens of EVD are substantial and have triggered extensive research into prevention and control. We aim to highlight the impact and economic implications, identify research gaps, and offer recommendations for future economic studies pertaining to EVD. METHOD: We conducted a comprehensive librarian-led search in PubMed/Medline, Embase, Google Scholar, EconLit and Scopus for economic evaluations of EVD. After study selection and data extraction, findings on the impact and economics of EVD were synthesized using a narrative approach, while identifying gaps, and recommending critical areas for future EVD economic studies. RESULTS: The economic evaluations focused on the burden of illness, vaccine cost-effectiveness, willingness-to-pay for a vaccine, EVD funding, and preparedness costs. The estimated economic impact of the 2014 EVD outbreak in Guinea, Liberia, and Sierra Leone across studies ranged from $30 billion to $50 billion. Facility construction and modification emerged as significant cost drivers for preparedness. The EVD vaccine demonstrated cost-effectiveness in a dynamic transmission model; resulting in an incremental cost-effectiveness ratio of about $96 per additional disability adjusted life year averted. Individuals exhibited greater willingness to be vaccinated if it incurred no personal cost, with a minority willing to pay about $1 for the vaccine. CONCLUSIONS: The severe impact of EVD puts pressure on governments and the international community for better resource utilization and re-allocation. Several technical and methodological issues related to economic evaluation of EVD remain to be addressed, especially for LMICs. We recommend conducting cost-of-sequelae and cost-of-distribution analyses in addition to adapting existing economic analytical methods to EVD. Characteristics of the affected regions should be considered to provide evidence-based economic plans and economic-evaluation of mitigations that enhance resource allocation for prevention and treatment.

Ebola virus disease (EVD) is a serious health problem, not only in Africa where there have been outbreaks but in other parts of the world as well. In addition to its severe health implications and resultant death, EVD also poses significant impact across several sectors, including food and agriculture, transportation, education, among others, ultimately impacting the economies of affected countries. While some studies have estimated the economic burden of EVD, there remains questions that need addressing. We conducted a review of published studies to estimate what is known about the economic burden of EVD, identified research gaps. Studies looked at how much money EVD costs in terms of prevention and treatment, while others reported on people's willingness to pay for a vaccine. The estimated economic impact of the 2014 EVD outbreak in Guinea, Liberia, and Sierra Leone ranged from approximately $30 billion to $50 billion across studies. Healthcare facility construction and modification were significant cost factors for response preparedness for EVD outbreaks. While the EVD vaccine showed cost-effectiveness, surveys of people across various regions revealed that more individuals were willing to get vaccinated if it was free, with a minority willing to pay a median of about $1 for the vaccine. The severe impact of EVD puts pressure on governments and the international community to use resources more efficiently. We recommend conducting analyses on the costs of long-term effects of EVD and costs of vaccine and treatment distribution, as well as adapting existing economic methods to the specific characteristics of affected regions. This would help create evidence-based economic plans and evaluations of strategies to enhance resource allocation for EVD prevention and treatment.

Molecular determinants of multidrug-resistant tuberculosis in Sierra Leone.

Multidrug-resistant tuberculosis (MDR-TB) management has become a serious global health challenge. Understanding its epidemic determinants on the regional level is crucial for developing effective control measures. We used whole genome sequencing data of 238 of Mycobacterium tuberculosis complex (MTBC) strains to determine drug resistance profiles, phylogeny, and transmission dynamics of MDR/rifampicin-resistant (RR) MTBC strains from Sierra Leone. Forty-two strains were classified as RR, 196 as MDR, 5 were resistant to bedaquiline (BDQ) and clofazimine (CFZ), but none was found to be resistant to fluoroquinolones. Sixty-one (26%) strains were resistant to all first-line drugs, three of which had additional resistance to BDQ/CFZ. The strains were classified into six major MTBC lineages (L), with strains of L4 being the most prevalent, 62% (n = 147), followed by L6 (Mycobacterium africanum) strains, (21%, n = 50). The overall clustering rate (using ≤d12 single-nucleotide polymorphism threshold) was 44%, stratified into 31 clusters ranging from 2 to 16 strains. The largest cluster (n = 16) was formed by sublineage 2.2.1 Beijing Ancestral 3 strains, which developed MDR several times. Meanwhile, 10 of the L6 strains had a primary MDR transmission. We observed a high diversity of drug resistance mutations, including borderline resistance mutations to isoniazid and rifampicin, and mutations were not detected by commercial assays. In conclusion, one in five strains investigated was resistant to all first-line drugs, three of which had evidence of BDQ/CFZ resistance. Implementation of interventions such as rapid diagnostics that prevent further resistance development and stop MDR-TB transmission chains in the country is urgently needed. IMPORTANCE: A substantial proportion of MDR-TB strains in Sierra Leone were resistant against all first line drugs; however this makes the all-oral-six-month BPaLM regimen or other 6-9 months all oral regimens still viable, mainly because there was no FQ resistance.Resistance to BDQ was detected, as well as RR, due to mutations outside of the hotspot region. While the prevalence of those resistances was low, it is still cause for concern and needs to be closely monitored.

Higher local Ebola incidence causes lower child vaccination rates.

Ebola is a highly infectious and often fatal zoonotic disease endemic to West and Central Africa. Local outbreaks of the disease are common, but the largest recorded Ebola epidemic originated in Guinea in December 2013, spreading to Liberia, and Sierra Leone in the following year and lasting until April 2016. The epidemic presented a serious challenge to local healthcare systems and foreign aid agencies: it degraded services, caused the loss of healthcare professionals, disrupted the economy, and reduced trust in modern healthcare. This study aims to estimate the extent to which variation in one long-term measure of the quality of local healthcare (the child vaccination rate) is a consequence of local variation in the intensity of the epidemic. Applying a "difference-in-differences" model to household survey data from before and after the epidemic, we show that in 2018-2019, overall rates of vaccination for BCG, DPT, measles, and polio are lower in Guinean and Sierra Leonean districts that had a relatively high incidence of Ebola; statistical analysis indicates that this is a causal effect. The effects of the epidemic on access to healthcare have been local effects, at least in part.

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.

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.

Female Genital Mutilation and Sexual Risk Behaviors of Adolescent Girls and Young Women Aged 15-24 Years: Evidence From Sierra Leone.

PURPOSE: Considering the high levels of female genital mutilation (FGM) in Sierra Leone with over 83% of girls and young women aged 15-24 years having undergone the practice, the study explores the potential influence of FGM on sexual behaviors of adolescent girls and young women (AGYW) in Sierra Leone. METHODS: Cross-sectional data from the 2019 Demographic Health Survey were utilized to examine the association between FGM and three sexual behaviors; sexual debut before 18 years, child marriage and adolescent motherhood. To model this association, a generalized estimation equation technique was employed, while controlling for socio-demographic characteristics. Additionally, the study corrected for multiple-hypothesis testing using the Benjamini-Hochberg procedure with a specified false discovery rate of 0.05. Finally, percentage predicted probabilities of occurrence of the sexual risk behaviors in the presence of FGM were also calculated. RESULTS: Of the 5524 AGYW, 76% had undergone FGM. FGM was associated with all three sexual risk behaviors. Sexual debut before 18 years had the highest predicted probability increase (+18.00 ppt, 95% CI: 14.41 to -21.59), followed by adolescent motherhood (+13.38 ppt, 95% CI: 10.16-16.60) and child marriage (+12.61 ppt; 95% CI: 10.22-15.01). Education was found to be protective against all three sexual risk behaviors. DISCUSSION: The findings of this study demonstrate that FGM remains a prevalent practice in Sierra Leone, even among the younger generation. This practice is strongly associated with sexual behaviors that pose a significant risk to the health outcomes of AGYW. Investments in education by removing barriers to access for AGYW could lead to multiple gains.