Ministry Of Health And Sanitation Research Articles

Attitudes toward COVID-19 Vaccination: Staff and Patient Perspectives at Six Health Facilities in Sierra Leone.

Sierra Leone is a West African country with a population of over 8 million. With more than half of Sierra Leone's population living in rural areas, it is important to understand rural populations' access to and attitudes toward the COVID-19 vaccine. In November 2021, the rate of vaccination coverage in Sierra Leone was only 7% for one dose and 4% for two doses. Understanding perspectives of health facility staff and patients can help strengthen future vaccine campaigns. We conducted a cross-sectional study, between March 2022 and May 2022, of clinical staff, non-clinical staff, and adult (>18 years) patients/caregivers attending six Ministry of Health and Sanitation (MoHS) facilities supported by Partners In Health, four in the Kono district and two in the Western Urban Area district, the capital of Sierra Leone. We assessed the opportunity to vaccinate, vaccine uptake, and intention to vaccinate. Out of the 2015 participants, 11.4% were clinical staff, 18.8% were non-clinical staff, and 69.8% were patients/caregivers. Less than half of the patients/caregivers had the opportunity to be vaccinated (42%), and 22% of patients/caregivers were fully vaccinated. Among the unvaccinated population, 44% would refuse a vaccine if offered to them at no cost. Lack of access to COVID-19 vaccines and to official education messaging, especially for patients and caregivers, is still an underlying problem in Sierra Leone for vaccine uptake, rather than a lack of willingness to be vaccinated.

Response to Mass-Casualty Incidents and Outbreaks: A Prehospital Disaster Training Package Developed for the National Emergency Medical Service in Sierra Leone

Introduction:In 2018 Sierra Leone, a country highly prone to disasters, launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks.Method:The DTP was designed following the six-step approach to curriculum and training development with the ultimate goal of creating a workforce comprising qualified emergency responders with specific professional competencies to respond to outbreaks and MCIs. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center.Results:Starting on July 19, 2021, the ToT course was delivered to the seven national trainers. All trainers successfully passed the final examination and achieved high scores in the practical sessions, demonstrating active participation, commitment to the project, and good awareness. Following the ToT course, the series of cascade trainings started on August 2, 2021, delivered by the just-trained national trainers under the direct supervision of the two training managers.Conclusion:The NEMS’ DTP is the very first Disaster Medicine training course delivered to prehospital healthcare providers in Sierra Leone. The authors believe that the provision of the DTP to all NEMS personnel has the potential to improve Disaster Medicine culture among health professionals in the Country.

Coverage survey and lessons learned from a pre-emptive cholera vaccination campaign in urban and rural communities affected by landslides and floods in Freetown Sierra Leone.

On 14 August 2017, massive landslides and floods hit Freetown (Sierra Leone). More than 1,000 people lost their lives while approximately 6,000 people were displaced. The areas most affected included parts of the town with challenged access to basic water and sanitation facilities, with communal water sources likely contaminated by the disaster. To avert a possible cholera outbreak following this emergency, the Ministry of Health and Sanitation (MoHS), supported by the World Health Organization (WHO) and international partners, including Médecins Sans Frontières (MSF) and UNICEF, launched a two-dose pre-emptive vaccination campaign using Euvichol™, an oral cholera vaccine (OCV). We conducted a stratified cluster survey to estimate vaccination coverage during the OCV campaign and also monitor adverse events. The study population - subsequently stratified by age group and residence area type (urban/rural) - included all individuals aged 1year or older, living in one of the 25 communities targeted for vaccination. In total 3,115 households were visited, 7,189 individuals interviewed; 2,822 (39%) people in rural and 4,367 (61%) in urban areas. The two-dose vaccination coverage was 56% (95% confidence interval (CI): 51.0-61.5), 44% (95%CI: 35.2-53.0) in rural and 57% (95%CI: 51.6-62.8) in urban areas. Vaccination coverage with at least one dose was 82% (95%CI: 77.3-85.5), 61% (95%CI: 52.0-70.2) in rural and 83% (95%CI: 78.5-87.1) in urban areas. The Freetown OCV campaign exemplified a timely public health intervention to prevent a cholera outbreak, even if coverage was lower than expected. We hypothesised that vaccination coverage in Freetown was sufficient in providing at least short-term immunity to the population. However, long-term interventions to ensure access to safe water and sanitation are needed.

Innovative approach to monitor performance of integrated disease surveillance and response after the Ebola outbreak in Sierra Leone: lessons from the field

BackgroundSupervision of healthcare workers improves performance if done in a supportive and objective manner. Regular supervision is a support function of Integrated Disease Surveillance and Response (IDSR) strategy and allows systematic monitoring of IDSR implementation. Starting 2015, WHO and other development partners supported the Ministry of Health and Sanitation (MoHS) to revitalize IDSR in Sierra Leone and to monitor progress through supportive supervision assessments. We report on the findings of these assessments.MethodsThis was a cross-sectional study where six longitudinal assessments were conducted in randomly selected health facilities. Health facilities assessed were 71 in February 2016, 99 in July 2016, 101 in May 2017, 126 in August 2018, 139 in February 2019 and 156 in August 2021. An electronic checklist based on selected core functions of IDSR was developed and uploaded onto tablets using the Open Data Kit (ODK) platform. Supervision teams interviewed health care workers, reviewed documents and made observations in health facilities. Supervision books were used to record feedback and corrective actions. Data from the supervisory visits was downloaded from ODK platform, cleaned and analysed. Categorical data was summarized using frequencies and proportions while means and medians were used for continuous variables. Z test was used to test for differences in proportions.ResultsCompleteness of IDSR reporting improved from 84.5% in 2016 to 96% in 2021 (11.5% points; 95% CI 3.6, 21.9; P-value 0.003). Timeliness of IDSR reports improved from 80.3 to 92% (11.7% points; 95% CI 2.4, 22.9; P-value 0.01). There was significant improvement in health worker knowledge of IDSR concepts and tools, in availability of IDSR standard case definition posters and reporting tools and in data analysis practices. Availability of vaccines and temperature monitoring tools in health facilities also improved significantly but some indicators dropped such as availability of IDSR technical guidelines and malaria testing kits and drugs.ConclusionSupervision using electronic tool contributed to health systems strengthening through longitudinal tracking of core IDSR indicators and other program indicators such as essential malaria commodities and availability and status of routine vaccines. Supervision using electronic tools should be extended to other programs.

Response to Mass-Casualty Incidents and Outbreaks: A Prehospital Disaster Training Package Developed for the National Emergency Medical Service in Sierra Leone.

Sierra Leone is a country highly prone to disasters, still recovering from the catastrophic 2014 Ebola epidemic. In 2018, the country launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the direct supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) to be delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center. This on-going training package represents the first Disaster Medicine training course for prehospital health professionals in Sierra Leone.

Finding the graves: SLED Family Reunification Program

PurposeIn 2015, the Sierra Leone Ministry of Health and Sanitation (MoHS) and the Centers for Disease Control and Prevention (CDC) agreed to consolidate data recorded by MoHS and international partners during the Ebola epidemic and create the Sierra Leone Ebola Database (SLED). The primary objectives were helping families to identify the location of graves of their loved ones who died from any cause at the time of the Ebola epidemic and creating a data source for epidemiological research. The Family Reunification Program fulfills the first SLED objective. The purpose of this paper is to describe the Family Reunification Program (Program) development, functioning, and results. MethodsThe MoHS, CDC, SLED Team, and Concern Worldwide developed, tested, and implemented methodology and tools to conduct the Program. Family liaisons were trained in protection of the personally identifiable information. ResultsThe SLED Family Reunification Program allows families in Sierra Leone, who did not know the final resting place of their loved ones, to be reunited with their graves and to bring them relief and closure. ConclusionContinuing family requests in search of the burial place of loved ones 5 years after the end of the epidemic shows that the emotional burden of losing a family member and not knowing the place of burial does not diminish with time. As of February 2021, the Program continues and is described to allow its replication for other emergency events including COVID-19 and new Ebola outbreaks.

Building the Sierra Leone Ebola Database: organization and characteristics of data systematically collected during 2014–2015 Ebola epidemic

PurposeDuring the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS), the US Centers for Disease Control and Prevention, and responding partners under the coordination of the National Ebola Response Center (NERC) and the MoHS's Emergency Operation Center (EOC) systematically recorded information from the 117 Call Center system and district alert phone lines, case investigations, laboratory sample testing, clinical management, and safe and dignified burial records. Since 2017, CDC assisted MoHS in building and managing the Sierra Leone Ebola Database (SLED) to consolidate these major data sources. The primary objectives of the project were helping families to identify the location of graves of their loved ones who died at the time of the Ebola epidemic through the SLED Family Reunification Program and creating a data source for epidemiological research. The objective of this paper is to describe the process of consolidating epidemic records into a useful and accessible data collection and to summarize data characteristics, strength, and limitations of this unique information source for public health research. MethodsBecause of the unprecedented conditions during the epidemic, most of the records collected from responding organizations required extensive processing before they could be used as a data source for research or the humanitarian purpose of locating burial sites. This process required understanding how the data were collected and used during the outbreak. To manage the complexity of processing the data obtained from various sources, the Sierra Leone Ebola Database (SLED) Team used an organizational strategy that allowed tracking of the data provenance and lifecycle. ResultsThe SLED project brought raw data into one consolidated data collection. It provides researchers with secure and ethical access to the SLED data and serves as a basis for the research capacity building in Sierra Leone. The SLED Family Reunification Program allowed Sierra Leonean families to identify location of the graves of loved ones who died during the Ebola epidemic. ConclusionsThe SLED project consolidated and utilized epidemic data recorded during the Sierra Leone Ebola Virus Disease outbreak that were collected and contributed to SLED by national and international organizations. This project has provided a foundation for developing a method of ethical and secure SLED data access while preserving the host nation's data ownership. SLED serves as a data source for the SLED Family Reunification Program and for epidemiological research. It presents an opportunity for building research capacity in Sierra Leone and provides a foundation for developing a relational database. Large outbreak data systems such as SLED provide a unique opportunity for researchers to improve responses to epidemics and indicate the need to include data management preparedness in the plans for emergency response.

Designing, Implementing, and Managing a National Emergency Medical Service in Sierra Leone.

Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.

The Design and Implementation of an IPC Certificate Course: Experiences From Sierra Leone

Background: Trained infection prevention and control (IPC) practitioners are critical to reducing healthcare-associated infections (HAI) and improving patient safety. Despite having HAI rates 3 times higher than high-income countries, many low- and middle-income countries (LMICs) lack trained IPC professionals. During the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS) recognized this need and appointed and trained IPC focal persons at all district hospitals. Following the outbreak, MoHS requested assistance from the US CDC to develop and implement a comprehensive IPC training program for IPC specialists. Methods: The CDC, alongside its partners, convened a multidisciplinary team to develop an IPC certificate course. ICAP led the curriculum development process using a “backwards design” approach, starting with development of competencies and learning objectives, then designing an evaluation framework and learning strategies, and finally, identifying course content. The curriculum was based on existing resources, primarily designed for high-income countries, which were adapted to the Sierra Leone context and aligned with national IPC policies and guidelines. Additionally, an IPC steering committee, led by MoHS, was established to provide national leadership and oversight and make country-level decisions regarding accreditation and career pathways for IPC specialists. Results: The course includes three 2-week workshops over 6 months consisting of classroom didactics and hands-on activities. Topics include standard and transmission-based precautions, microbiology, laboratory, HAI, quality improvement, leadership, and scientific writing. Between sessions, participants conduct IPC activities at their work site and share results during subsequent workshops. Participants receive electronic tablets, which contain course content, assessment tools, and references, to upload their work into a cloud-based storage system for facilitators to provide feedback. They also receive in-person mentorship and connect with peers through a group messaging platform to share lessons learned. Participants’ knowledge and skills are assessed using a before-and-after test and observing them perform IPC practices using standardized checklists. The first cohort of 25 participants will complete the course in November 2019. Conclusions: The IPC certificate course is the first comprehensive, competency-based IPC training in Sierra Leone. Successes, challenges, sustainability, and lessons learned remain to be determined; however, based on similar models, the course has the potential to significantly improve IPC in Sierra Leone. Additionally, it is a model that can be replicated in other resource-limited settings.Funding: NoneDisclosure:None

Narrative Case study: The most essential determinants to child and maternal health in Sierra Leone

Abstract Background Sierra Leone is one of the poorest countries in the world, suffering from some of the worst maternal and child health outcomes. In 2013, it had a maternal mortality ratio of 1165/10000 live births and an under-five mortality of 156/1000 live births. The country has introduced a number of policies and interventions to tackle maternal and child health issues but still retains one of the highest global mortality rates. The purpose of this study is to determine the most essential determinants to infant, child and maternal health and recommend some interventions and policy changes to improve their health outcomes. Methods A small review of relevant policies and papers and analysis of relevant maternal and child health data and statistics was conducted to inform questions for Key Informant Interviews. Interviews were then conducted with relevant stakeholders to child and maternal health from UN Organisations, international NGOs and the Ministry of Health and Sanitation (MoHS). Results Analysis of transcribed Interview data with NVIVO showed that the most essential determinants were the lack of effective coordination between the MoHS and partners due to the emergency mindset, systematic problems with the attitude of the healthcare workforce especially towards women and socio-cultural restriction on women restricting their ability to make choices about their own health and lives Conclusions The study found that there was a focus on policies and interventions targeted at improving clinical determinants and health statistics while consideration of socio-cultural context were negligible. An inclusion of interventions focused on women's empowerment and increasing their voices will help to tackle some of these most essential determinants. Key messages Sierra Leone has the policy environment, political will, and technical expertise to continue making improvements to their high maternal and child mortality problem. An emergency mindset approach, and interventions targeted only at reducing clinical determinants of maternal mortality are missing out on addressing wider socio-cultural issues to improving health.

Institutionalized data quality assessments: a critical pathway to improving the accuracy of integrated disease surveillance data in Sierra Leone

BackgroundPublic health agencies require valid, timely and complete health information for early detection of outbreaks. Towards the end of the Ebola Virus Disease (EVD) outbreak in 2015, the Ministry of Health and Sanitation (MoHS), Sierra Leone revitalized the Integrated Disease Surveillance and Response System (IDSR). Data quality assessments were conducted to monitor accuracy of IDSR data.MethodsStarting 2016, data quality assessments (DQA) were conducted in randomly selected health facilities. Structured electronic checklist was used to interview district health management teams (DHMT) and health facility staff. We used malaria data, to assess data accuracy, as malaria was endemic in Sierra Leone. Verification factors (VF) calculated as the ratio of confirmed malaria cases recorded in health facility registers to the number of malaria cases in the national health information database, were used to assess data accuracy. Allowing a 5% margin of error, VF < 95% were considered over reporting while VF > 105 was underreporting. Differences in the proportion of accurate reports at baseline and subsequent assessments were compared using Z-test for two proportions.ResultsBetween 2016 and 2018, four DQA were conducted in 444 health facilities where 1729 IDSR reports were reviewed. Registers and IDSR technical guidelines were available in health facilities and health care workers were conversant with reporting requirements. Overall data accuracy improved from over- reporting of 4.7% (VF 95.3%) in 2016 to under-reporting of 0.2% (VF 100.2%) in 2018. Compared to 2016, proportion of accurate IDSR reports increased by 14.8% (95% CI 7.2, 22.3%) in May 2017 and 19.5% (95% CI 12.5–26.5%) by 2018. Over reporting was more common in private clinics and not- for profit facilities while under-reporting was more common in lower level government health facilities. Leading reasons for data discrepancies included counting errors in 358 (80.6%) health facilities and missing source documents in 47 (10.6%) health facilities.ConclusionThis is the first attempt to institutionalize routine monitoring of IDSR data quality in Sierra Leone. Regular data quality assessments may have contributed to improved data accuracy over time. Data compilation errors accounted for most discrepancies and should be minimized to improve accuracy of IDSR data.

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

BackgroundIn 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. MethodsTen 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. ResultsOverall, 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. ConclusionAlthough 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.

Engaging communities in collecting and using results from verbal autopsies for child deaths: an example from urban slums in Freetown, Sierra Leone.

BackgroundVerbal autopsies (VAs) can provide important epidemiological information about the causes of child deaths. Though studies have been conducted to assess the validity of various types of VAs, the programmatic experience of engaging local communities in collecting and using VA has received little attention in the published literature. Concern Worldwide, an international non-governmental organization (NGO), in collaboration with the Ministry of Health and Sanitation (MOHS), has implemented a VA protocol in five urban slums of Freetown, Sierra Leone. This paper provides VA results and describes lessons learned from the VA process.MethodsUnder-five child deaths were registered by Community Health Workers (CHWs) in five urban slums between 2014 and 2017, and a specially trained local clinician used a VA protocol to interview caretakers. Symptoms were analysed using InterVA-4 computerized algorithm, a probabilistic expert-driven model to determine the most likely cause of death. Themes in care-seeking were extracted from multiple-choice and open-ended questions. VAs were implemented in collaboration with the community and the results were shared with community stakeholders in participatory review meetings.ResultsMain challenges included limitations in death notification and capacity to conduct VA for all notified deaths. A total of 215 VA were available for analysis. Among 79 neonatal deaths aged 0-27 days, the most common cause of death was neonatal pneumonia (55%); among 136 children deaths aged 1-4 years, the most common causes were malaria (56%) and pneumonia (41%). Key themes in care-seeking identified included use of traditional medicine (14% of deaths), absence of care-seeking (23% of deaths), and difficultly reaching the health facility (8% of deaths that occurred at home) during fatal illness.ConclusionsConducting VAs as a collaborative process with communities is challenging but can provide valuable data that can be used for local-level decision-making. The findings have practical implications for engaging the community and CHWs in reducing the number of these preventable deaths through expanded efforts at prevention, early and appropriate treatment, and reduction of barriers to care-seeking. A functional end-to-end VA system can enhance meaningful routine vital events monitoring by community, national, and international stakeholders.

Revitalization of integrated disease surveillance and response in Sierra Leone post Ebola virus disease outbreak

BackgroundThe Ministry of Health and Sanitation (MOHS) in Sierra Leone partially rolled out the implementation of Integrated Disease Surveillance and Response (IDSR) in 2003. After the Ebola virus disease outbreak in 2014–2015, there was need to strengthen IDSR to ensure prompt detection and response to epidemic-prone diseases. We describe the processes, successes and challenges of revitalizing public health surveillance in a country recovering from a protracted Ebola virus disease outbreak.MethodsThe revitalization process began with adaptation of the revised IDSR guidelines and development of customized guidelines to suit the health care systems in Sierra Leone. Public health experts defined data flow, system operations, case definitions, frequency and channels of reporting and dissemination. Next, phased training of IDSR focal persons in each health facility and the distribution of data collection and reporting tools was done. Monitoring activities included periodic supportive supervision and data quality assessments. Rapid response teams were formed to investigate and respond to disease outbreak alerts in all districts.ResultsSubmission of reports through the IDSR system began in mid-2015 and by the 35th epidemiologic week, all district health teams were submitting reports. The key performance indicators measuring the functionality of the IDSR system in 2016 and 2017 were achieved (WHO Africa Region target ≥80%); the annual average proportion of timely weekly health facility reports submitted to the next level was 93% in 2016 and 97% in 2017; the proportion of suspected outbreaks and public health events detected through the IDSR system was 96% (n = 87) in 2016 and 100% (n = 85) in 2017.ConclusionWith proper planning, phased implementation and adequate investment of resources, it is possible to establish a functional IDSR system in a country recovering from a public health crisis. A functional IDSR system requires well trained workforce, provision of the necessary tools and guidelines, information, communication and technology infrastructure to support data transmission, provision of timely feedback as well as logistical support.

Strengthening the Free Healthcare Initiative through a pharmacy and supply chain intervention: Partners in Health's experience in rural Sierra Leone

Abstract Background To improve high maternal and under-5 mortality—among the worst globally—Sierra Leone's Ministry of Health and Sanitation (MOHS) enacted the Free Healthcare Initiative in 2010. Under this initiative, pregnant and lactating women and children aged younger than 5 years receive medical treatment and essential medicines free of charge at public facilities. However, the availability of medicines remains inconsistent, which results in patients paying for medicines and an undermining of the quality of care and trust in the health-care system. These gaps between services and medicines promised under the Free Healthcare Initiative and actual resources delivered worsened during the 2013–15 Ebola epidemic, which strained an already weak health-care system. Here, we describe an approach to strengthen pharmacy and supply chain systems to improve access to essential medicines at a district hospital in Sierra Leone. Methods In 2015, Partners In Health undertook a gap analysis to understand the barriers to drug availability for patients eligible for the Free Healthcare Initiative at Koidu Government Hospital (KGH). A multidisciplinary task force identified priorities and created a partnership with the MOHS. Partners In Health's Director of Pharmacy led meetings with hospital management, shadowed clinical staff, and performed an inventory of drugs and medical supplies. Findings The gap analysis revealed challenges in the areas of human resources, infrastructure, storage, and information systems. The results led to the following interventions: decentralisation of medication distribution from hospital to ward level; the hiring of four pharmacy technicians; expansion of central warehousing; and implementation of electronic reporting tools to improve consumption data. MOHS pharmacy staff were mentored to improve feedback mechanisms between central and district levels. Between November, 2015, and August, 2016, these changes resulted in nearly 100% availability of essential drugs—with 80% provided via the strengthened MOHS system—and elimination of out-of-pocket expenses for patients. Additionally, trust in the public health-care system has improved: compared with a 2012 and 2013 pre-Ebola baseline at KGH, paediatric and maternity admissions have increased by 47%, with a 95% increase in hospital-based deliveries. Interpretation The success of the Free Healthcare Initiative is rooted in its shared ownership with the MOHS and the integration of central-level and district-level information systems. The approach described here could be used to guide new interventions to strengthen pharmacy supply chains elsewhere in Sierra Leone and other low-resource settings. Funding Partners In Health, Sierra Leone.

Interagency technical consultation on improving mortality reporting in Sierra Leone: meeting report

By the end of the Ebola epidemic, death reporting in Sierra Leone (SL) became more acceptable amongst local populations, with nearly all deaths being reported to the Ebola hot line alert centers. To continue the positive momentum generated by the epidemic, the Sierra Leone Ministry of Health and Sanitation (MoHS) and the US Centers for Disease Control and Prevention (CDC) organized and conducted the two-day Inter-agency Consultations on Improving Mortality Reporting in Sierra Leone (Consultations). In conjunction with the Consultations, participants were also offered a one-day, in-person training on the major components, characteristics, and uses of a national Civil Registration and Vital Statistics (CRVS) system. To understand processes used by governmental and non-governmental organizations in collection of death data before and during the Ebola epidemic, and to develop recommendations on improving death reporting and CRVS in Sierra Leone. The Inter-agency Consultations were conducted in person over two days in October, 2015. Real-time notes were kept by CDC staff for later abstraction and summarizing. Presenters agreed to share their materials (usually PowerPoint presentations) and approved the summaries. Challenges to implementation and suggestions for improving death reporting were drawn from the presentations and from anonymous suggestions collected at the end of each of three days of the Consultations. The Consultations attracted more than 80 participants from 28 Sierra Leone governmental, business, and other non-governmental organizations. Over the course of 18 presentations, participants presented and discussed the ways deaths were reported before and during the Ebola epidemic and ways in which the CRVS in Sierra Leone might be improved. The presentations made clear the need to improve death reporting in order to improve the health status of Sierra Leone. Many presenters and participants discussed the challenges to improvements, including lack of infrastructure and country diversity. In addition, participants generally agreed upon the need for improving the government’s understanding of the benefits of death reporting at multiple levels: from local chiefdom authorities and councils to the community and individual families. Despite the many challenges identified, all participants stressed the need for modernizing and improving death registration in Sierra Leone. The recommendations from the presentations and notes collected at the end of each day can be categorized within the following five domains: capacity building (organizational, staffing, infrastructure, policies, guidelines and tools), awareness and sensitization (including strategies to use best practices and emerging technologies), political will (governmental support and prioritization), funding (providing resources to achieve sustainability), and monitoring and evaluation (developing charts of existing death reporting pathways and identifying challenges).

Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone.

A central pillar in the response to the 2014 Ebola virus disease (EVD) epidemic in Sierra Leone was the role of Ebola Holding Units (EHUs). These units isolated patients meeting a suspect case definition, tested them for EVD, initiated appropriate early treatment and discharged negative patients to onward inpatient care or home. Positive patients were referred to Ebola Treatment Centres. We aimed to estimate the risk of nosocomial transmission within these EHUs. We followed up a cohort of 543 patients discharged with a negative EVD test from five EHUs in the Western Area, Sierra Leone, and examined all line-listed subsequent EVD tests from any facility in the Western Area to see whether the patient was retested within 30 days, matching by name, age and address. We defined possible readmissions as having the same name and age but uncertain address, and confirmed readmissions where name, age and address matched. We found a positive readmission rate of 3.3% (18 cases), which included 1.5% confirmed readmissions (8 cases) and 1.8% possible readmissions (10 cases). This is lower than rates previously reported. We cannot ascertain whether EVD was acquired within the EHUs or from re-exposure in the community. No demographic or clinical variables were identified as risk factors for positive readmission, likely due to our small sample size. These findings support the EHU model as a safe method for isolation of suspect EVD patients and their role in limiting the spread of EVD.

Notes from the Field: Ebola Virus Disease Response Activities During a Mass Displacement Event After Flooding--Freetown, Sierra Leone, September-November, 2015.

Since the start of the Ebola virus disease (Ebola) outbreak in West Africa, Sierra Leone has reported 8,706 confirmed Ebola cases and 3,956 deaths. During September 15-16, 2015, heavy rains flooded the capital, Freetown, resulting in eight deaths, home and property destruction, and thousands of persons in need of assistance. By September 27, approximately 13,000 flood-affected persons registered for flood relief services from the government. On September 17, two stadiums in Freetown were opened to provide shelter and assistance to flood-affected residents; a total of approximately 3,000 persons stayed overnight in both stadiums (Sierra Leone Ministry of Health and Sanitation, personal communication, September 2015). On the same day the stadiums were opened to flood-affected persons, the Ministry of Health and Sanitation (MoHS) and Western Area Ebola Response Center (WAERC) staff members from CDC, the World Health Organization (WHO), and the African Union evaluated the layout, logistics, and services at both stadiums and identified an immediate need to establish Ebola response activities. The patient in the last Ebola case in the Western Area, which includes Freetown, had died 37 days earlier, on August 11; however, transmission elsewhere in Sierra Leone was ongoing, and movement of persons throughout the country was common.