Search

Objectivesto evaluate the association of sex-and-gender-specific cardiovascular disease risk factors, their prevalence, and correlates among adults in Sierra Leone.Study designThis community-based cross-sectional study used a stratified multistage random sampling.Methodsthe survey was conducted in eight (8) selected randomized sub-zonal communities across the western urban area in Sierra Leone, with an included sampling of 2394 adults. The WHO stepwise approach for non-communicable diseases was utilized. Multivariable logistic regression was done to determine associations between demographic characteristics and cardiovascular risk factors.ResultsThe prevalence of hypertension (33.4% vs 37.4%, p=0.068), diabetes mellitus (7.4% vs 9.2%, p=0.101), overweight (32.3% vs 34.2%, p=0.323) and obesity (9.9% vs 10.2%, p=0.818) were higher among males in comparison to females. Body Mass Index (BMI) (25.0 ± 5.0 vs 24.6 ± 4.4, p = 0.029), waist circumference (WC) (93.6 ± 4.5 vs 80.0 ± 5.0, p < 0.001), triglyceride (1.7±0.35 vs 1.6±0.32, p=0.013), total cholesterol (5.1±0.77 vs 4.9±0.66, p < 0.001) and low HDL-C (1.28 ± 0.29 vs 1.3±0.24, p = 0.016) were significantly higher among females as compared to males. The odds of having dyslipidemia [OR = 1.339; 95% C.I: (1.101-1.629), p=0.003] and consuming alcohol [OR = 1.229; 95% C.I: (1.026-1.472),p=0.025] were higher among females. Women had 1.8 times greater odds [AOR=1.849; 95% C.I: (0.713 - 1.010),p=0.030] of being hypertensive, 1.4 times greater odds [AOR=1.441; 95% C.I: (1.176 - 1.765),p=p=0.037] of consuming alcohol compared to men. BMI, WC, and raised blood sugar had a strong correlation among women than men.ConclusionBeing female was associated with a high prevalence of cardiovascular health risks in Sierra Leone. This study emphasizes the importance of reducing the CVD burden among females through policies related to public health education and screening strategies.

This study is an evaluation of the first cohort of patients enrolled in an outpatient non-communicable disease clinic in Kono, Sierra Leone. In the first year, the clinic enrolled 916 patients. Eight months after the enrollment of the last patient, 53% were still active in care, 43% had been lost to follow-up (LTFU) and 4% had defaulted. Of the LTFU patients, 47% only came for the initial enrollment visit and never returned. Treatment outcomes of three patient groups [HTN only (n = 720), DM only (n = 51), and HTN/DM (n = 96)] were analyzed through a retrospective chart review. On average, all groups experienced reductions in blood pressure and/or blood glucose of approximately 10% and 20%, respectively. The proportions of patients with their condition controlled also increased. As NCDs remain underfunded and under-prioritized in low-income countries, the integrated program in Kono demonstrates the possibility of improving outpatient NCD care in Sierra Leone and similar settings.

ObjectiveThe aim of the study was to investigate the prevalence of cardiometabolic risk factors (CMRFs), target organ damage and its associated factors among adults in Freetown, Sierra Leone.DesignThis community-based cross-sectional study used a stratified multistage random sampling method to recruit adult participants.SettingThe health screening study was conducted between October 2019 and October 2021 in Western Area Urban, Freetown, Sierra Leone.ParticipantsA total of 2394 adults Sierra Leoneans aged 20 years, or more were enrolled.Outcome measureAnthropometric data, fasting lipid profiles, fasting plasma glucose, target organ damage, clinical profiles and demographic characteristic of participants were described. The cardiometabolic risks were further related to target organ damage.ResultsThe prevalence of known CMRFs was 35.3% for hypertension, 8.3% for diabetes mellitus, 21.1% for dyslipidemia, 10.0% for obesity, 13.4% for smoking and 37.9% for alcohol. Additionally, 16.1% had left ventricular hypertrophy (LVH) by electrocardiogram (ECG), 14.2% had LVH by 2D-Echo, and 11.4% had chronic kidney disease. The odds of developing ECG-LVH were higher with diabetes [OR = 1.255, 95% C.I. (0.822 - 1.916) and dyslipidaemia [OR = 1.449, 95% C.I. (0.834 - 2.518). The association factors for higher odds of LVMI by echo were dyslipidemia [OR = 1.844, 95% C.I (1.006-3.380)] and diabetes mellitus [OR =1.176, 95% C.I. (0.759-1.823)]. The odds of having CKD were associated with diabetes mellitus [OR =1.212, 95% CI (0.741-1.983)] and hypertension [OR =1.163, 95% CI (0.887-1.525)]. A low optimal cut-off point for ECG-LVH (male 24.5mm vs female 27.5mm) as a target organ damage was required to maximize sensitivity and specificity by a receiver operating characteristic (ROC) curve since the odds for LVH by ECG was low.ConclusionsThis study provides novel data-driven information on the burden of cardiometabolic risks and its association with preclinical target organ damage in a resource limited setting. It illustrates the need for interventions in improve cardiometabolic health screening and management among adults in Sierra Leoneans.Strengths and Limitations of the studyStrengthsA major strength of this study is its community-based design and the first study of its kind on a larger population in Sierra Leone.The study was statistically powered to produce results that are representative of adults in Sierra Leone.LimitationsThe study is limited as it could not conclude direct causality inference of risk factors and effect outcomes.Since some of the outcomes (fasting plasma glucose, HbA1c and fasting lipid profile) are limited by the reliance on single time point measurements, it may result in measurement errors and the potential of underestimating cardiometabolic risk factors.Chronic kidney disease (CKD) assessment by single serum creatinine without assessing for proteinuria, which also indicates the presence of CKD, will lead to underestimation of CKD.

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

ObjectivesTo assess the trends concerning utilisation of maternal and child health (MCH) services before, during and after the Ebola outbreak, quantifying the contribution of a reorganised referral system (RS).DesignA prospective observational study of MCH services.SettingPujehun district in Sierra Leone, 77 community health facilities and 1 hospital from 2012 to 2017.Main outcome measuresMCH utililization was evaluated by assessing: (1) institutional deliveries, Cesarean-sections, paediatric and maternity admissions and deaths, and major direct obstetric complications (MDOCs), at hospital level; (2) antenatal care (ANC) 1 and 4, institutional delivery and family planning, at community level. Contribution of a strengthened RS was also measured.ResultsAt hospital level, there is a significant difference between trends Ebola versus pre-Ebola for maternal admissions (7, 95% CI 4 to 11, pConclusionsA stronger health system compared with other districts in Sierra Leone and a strengthened RS enabled health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic.

Introduction Sierra Leone has the world’s highest maternal mortality, partly due to low access to caesarean section. Limited data are available to guide improvement. In this study, we aimed to analyse the rate and mortality of caesarean sections in the country. Methods We conducted a retrospective study of all caesarean sections and all reported in-facility maternal deaths in Sierra Leone in 2016. All facilities performing caesarean sections were visited. Data on in-facility maternal deaths were retrieved from the Maternal Death Surveillance and Response database. Caesarean section mortality was defined as in-facility perioperative mortality. Results In 2016, there were 7357 caesarean sections in Sierra Leone. This yields a population rate of 2.9% of all live births, a 35% increase from 2012, with district rates ranging from 0.4% to 5.2%. The most common indications for surgery were obstructed labour (42%), hypertensive disorders (25%) and haemorrhage (22%). Ninety-nine deaths occurred during or after caesarean section, and the in-facility perioperative caesarean section mortality rate was 1.5% (median 0.7%, IQR 0–2.2). Haemorrhage was the leading cause of death (73%), and of those who died during or after surgery, 80% had general anaesthesia, 75% received blood transfusion and 22% had a uterine rupture diagnosed. Conclusions The caesarean section rate has increased rapidly in Sierra Leone, but the distribution remains uneven. Caesarean section mortality is high, but there is wide variation. More access to caesarean sections for maternal and neonatal complications is needed in underserved areas, and expansion should be coupled with efforts to limit late presentation, to offer assisted vaginal delivery when indicated and to ensure optimal perioperative care. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

BACKGROUND From mid-2015, reproductive and child health interventions were integrated into a routine 6-month contact point: vitamin A supplementation, nutrition counseling with the mother's participation in the preparation of a complementary food, and confidential family planning counseling with provision of modern forms of contraceptives. By mid-2017, these services had reached 28% of health facilities nationwide. OBJECTIVE To evaluate awareness and uptake of modern contraception and complementary feeding practices. METHODS All health facilities were visited, and the health worker "in-charge" were interviewed to ascertain their training status and supply chains. Within each catchment, community mothers of children 6 to 23 months of age were interviewed. RESULTS Interviews were conducted with 321 "in-charges" and 670 mothers. Advantages and different types of contraception were understood by 99.0% of mothers, and 52.7% reported they were utilizing depot injections, hormonal implants, or oral contraceptive pills (45.1%, 34.6%, and 20.6% of users, respectively). Uptake was higher among Christians (62.1%) versus Muslims (48.6%) and among those with secondary/tertiary (61.5%) or primary education (60.5%) versus no education (43.3%) (P

Background A baseline survey in 2007–2008 found lymphatic filariasis (LF) to be endemic in Sierra Leone in all 14 districts and co-endemic with onchocerciasis in 12 districts. Mass drug administration (MDA) with ivermectin started in 2006 for onchocerciasis and was modified to add albendazole in 2008 to include LF treatment. In 2011, after three effective MDAs, a significant reduction in microfilaraemia (mf) prevalence and density was reported at the midterm assessment. After five MDAs, in 2013, mf prevalence and density were again measured as part of a pre-transmission assessment survey (pre-TAS) conducted per WHO guidelines. Methods For the pre-TAS survey, districts were paired to represent populations of one million for impact assessment. One sentinel site selected from baseline and one spot check site purposefully selected based upon local knowledge of patients with LF were surveyed per pair (two districts). At each site, 300 people over five years of age provided mid-night blood samples and mf prevalence and density were determined using thick blood film microscopy. Results are compared with baseline and midterm data. Results At pre-TAS the overall mf prevalence was 0.54% (95% CI: 0.36–0.81%), compared to 0.30% (95% CI: 0.19–0.47) at midterm and 2.6% (95% CI: 2.3–3.0%) at baseline. There was a higher, but non-significant, mf prevalence among males vs females. Eight districts (four pairs) had a prevalence of mf < 1% at all sites. Two pairs (four districts) had a prevalence of mf > 1% at one of the two sites: Koinadugu 0.98% (95% CI: 0.34–2.85%) and Bombali 2.67% (95% CI: 1.41–5.00%), and Kailahun 1.56% (95% CI: 0.72–3.36%) and Kenema 0% (95% CI: 0.00–1.21%). Conclusions Compared to baseline, there was a significant reduction of LF mf prevalence and density in the 12 districts co-endemic for LF and onchocerciasis after five annual LF MDAs. No statistically significant difference was seen in either measure compared to midterm. Eight of the 12 districts qualified for TAS. The other four districts that failed to qualify for TAS had historically high LF baseline prevalence and density and had regular cross-border movement of populations. These four districts needed to conduct two additional rounds of LF MDA before repeating the pre-TAS. The results showed that Sierra Leone continued to make progress towards the elimination of LF as a public health problem.

Background Onchocerciasis is endemic in 12 of the 14 health districts of Sierra Leone. Good treatment coverage of community-directed treatment with ivermectin was achieved between 2005 and 2009 after the 11-year civil conflict. Sentinel site surveys were conducted in 2010 to evaluate the impact of five annual rounds of ivermectin distribution. Methods In total, 39 sentinel villages from hyper- and meso-endemic areas across the 12 endemic districts were surveyed using skin snips in 2010. Results were analyzed and compared with the baseline data from the same 39 villages. Results The average microfilaridermia (MF) prevalence across 39 sentinel villages was 53.10% at baseline. The MF prevalence was higher in older age groups, with the lowest in the age group of 1–9 years (11.00%) and the highest in the age group of 40–49 years (82.31%). Overall mean MF density among the positives was 28.87 microfilariae (mf)/snip, increasing with age with the lowest in the age group of 1–9 years and the highest in the age group of 40–49 years. Males had higher MF prevalence and density than females. In 2010 after five rounds of mass drug administration, the overall MF prevalence decreased by 60.26% from 53.10% to 21.10%; the overall mean MF density among the positives decreased by 71.29% from 28.87 mf/snip to 8.29 mf/snip; and the overall mean MF density among all persons examined decreased by 88.58% from 15.33 mf/snip to 1.75 mf/snip. Ten of 12 endemic districts had > 50% reduction in MF prevalence. Eleven of 12 districts had ≥50% reduction in mean MF density among the positives. Conclusions A significant reduction of onchocerciasis MF prevalence and mean density was recorded in all 12 districts of Sierra Leone after five annual MDAs with effective treatment coverage. The results suggested that the onchocerciasis elimination programme in Sierra Leone was on course to reach the objective of eliminating onchocerciasis in the country by the year 2025. Annual MDA with ivermectin should continue in all 12 districts and further evaluations are needed across the country to assist the NTDP with programme decision making. Electronic supplementary material The online version of this article (10.1186/s40249-018-0410-y) contains supplementary material, which is available to authorized users.

Multilingual abstracts in the five official working languages of the United Nations. (PDF 483 kb)

We present a case of congenital lymphedema in a 7-year-old boy in Sierra Leone with active filarial infection and penile edema. The genital edema with onset at 6 months of age may have been due to a congenital abnormality in lymphatic drainage. Other possible causes of childhood lymphedema, including Milroy's disease, are discussed.

Based on regional CBM geological characteristics and drainage data of three typical Coalbed Methane (CBM) wells in the southern Qinshui Basin, history matching, productivity prediction and factor analysis of gas production control are conducted by using COMET3 reservoir modeling software. The results show that in the next 20 years, the cumulative and average daily gas production of the QN01 well are expected to be 800×104 m3 and 1141.1 m3/d, for the QN02 well 87×104 m3 and 1202.7 m3/d and 97.5×104 m3 and 133.55 m3/d for the QN03 well. Gas content and reservoir pressure are the key factors controlling gas production in the area; coal thickness, permeability and porosity are less important; the Langmuir volume, Langmuir pressure and adsorption time have relatively small effect. In the process of CBM recovery, the material source and driving force are the key features affecting gas productivity, while the permeation process is relatively important and the desorption process has some impact on gas recovery.

Ebola virus continues to cause considerable disease in West Africa, with an initial 70% associated mortality. This report shows improving survival at one center in Sierra Leone.

Background Schistosoma mansoni was moderately-highly endemic in the northeast of Sierra Leone. The national neglected tropical disease control program started mass drug administration (MDA) with praziquantel (PZQ) in six districts in 2009 targeting primary school children only. The effort was scaled-up to seven districts in 2010 targeting school aged children (SAC) and at-risk adults. A cross-sectional sentinel site survey was conducted in 2012 after three rounds of MDA to evaluate the impact of the national program. Methods Twenty-six (26) sentinel sites were randomly selected from the baseline mapping survey sites stratified according to the baseline prevalence into high, moderate or low endemic category. Fifty (50) school children (25 males and 25 females) were randomly selected per site. Fresh stool samples were examined in the field using the Kato Katz technique. The results were compared with the baseline data. Results Program coverage of 94.8%, 77.1% and 81.7% was reported in 2009, 2010 and 2011 respectively. Independent monitoring in 2011 showed program coverage of 83.9%, not significantly different from the reported result in the same year. The overall prevalence of S. mansoni was 16.3% (95% CI: 14.4-18.4%) and mean intensity was 18.98 epg (95% CI: 11.46-26.50 epg) in 2012, representing 67.2% and 85.9% reduction from the baseline respectively. The proportion of moderately and heavily infected children was 3.3% and 1.2%, a significant reduction from 18.2% and 8.8% at baseline respectively. Conclusions Sierra Leone has maintained effective MDA coverage with PZQ since 2009. Three rounds of MDA led to a significant reduction of S. mansoni infection in the country. In line with the significant progress made in controlling schistosomiasis, the national treatment strategy has been reviewed and MDA will be expanded to include school age children in low endemicity districts with the new national objective for the elimination of schistosomiasis. Sierra Leone is well on its way to eliminate schistosomiasis as a public health problem.

Background 1974–2005 studies across Sierra Leone showed onchocerciasis endemicity in 12 of 14 health districts (HDs) and baseline studies 2005–2008 showed lymphatic filariasis (LF) endemicity in all 14 HDs. Three integrated annual mass drug administration (MDA) were conducted in the 12 co-endemic districts 2008–2010 with good geographic, programme and drug coverage. Midterm assessment was conducted 2011 to determine impact of these MDAs on LF in these districts. Methodology/Principal Findings The mf prevalence and intensity in the 12 districts were determined using the thick blood film method and results compared with baseline data from 2007–2008. Overall mf prevalence fell from 2.6% (95% CI: 2.3%–3.0%) to 0.3% (95% CI: 0.19%–0.47%), a decrease of 88.5% (p = 0.000); prevalence was 0.0% (100.0% decrease) in four districts: Bo, Moyamba, Kenema and Kono (p = 0.001, 0.025, 0.085 and 0.000 respectively); and seven districts had reductions in mf prevalence of between 70.0% and 95.0% (p = 0.000, 0.060, 0.001, 0.014, 0.000, 0.000 and 0.002 for Bombali, Bonthe, Kailahun, Kambia, Koinadugu, Port Loko and Tonkolili districts respectively). Pujehun had baseline mf prevalence of 0.0%, which was maintained. Only Bombali still had an mf prevalence ≥1.0% (1.58%, 95% CI: 0.80%–3.09%)), and this is the district that had the highest baseline mf prevalence: 6.9% (95% CI: 5.3%–8.8%). Overall arithmetic mean mf density after three MDAs was 17.59 mf/ml (95% CI: 15.64 mf/ml–19.55 mf/ml) among mf positive individuals (65.4% decrease from baseline of 50.9 mf/ml (95% CI: 40.25 mf/ml–61.62 mf/ml; p = 0.001) and 0.05 mf/ml (95% CI: 0.03 mf/ml–0.08 mf/ml) for the entire population examined (96.2% decrease from baseline of 1.32 mf/ml (95% CI: 1.00 mf/ml–1.65 mf/ml; p = 0.000)). Conclusions/Significance The results show that mf prevalence decreased to, Author Summary Onchocerciasis studies across Sierra Leone between 1974 and 2005 showed that 12 of the 14 health districts (HDs) are endemic for onchocerciasis. Baseline lymphatic filariasis (LF) studies 2005–2008 showed that all 14 HDs of Sierra Leone are LF endemic. Three annual rounds of integrated mass drug administration (MDA) with ivermectin and albendazole 2008–2010 were conducted in the 12 HDs that are co-endemic for onchocerciasis and LF with good geographic, epidemiological drug (or programme) and drug coverage. A midterm evaluation study of mf prevalence and density was conducted in the 12 HDs in 2011. The hypothesis proposed for this study is that areas previously exposed to ivermectin treatment for onchocerciasis control may require less rounds of annual MDA to eliminate LF (i.e. reduce microfilaremia (mf) prevalence to

Neglected tropical diseases (NTDs) cause significant morbidity and mortality worldwide and impose a large economic burden on endemic countries [1]. In 2006, the United States Agency for International Development (USAID) founded the NTD Control Program to target five NTDs in African, Asian, and Latin American countries, namely, lymphatic filariasis (LF), onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH), and trachoma; the three targeted STH infections are ascariasis, hookworm, and trichuriasis. The NTD Control Program supported national NTD control and elimination programs' efforts to integrate and scale up delivery of preventive chemotherapy (PC) [2]. PC is the administration of safe, single-dose drugs, either alone or in combination, as a public health intervention against targeted NTDs. Administration is characterized by population-based diagnosis,population-based treatment,and implementation at regular intervals. PC can be delivered as universal chemotherapy (i.e., mass drug administration [MDA]), where the entire population of an area is targeted; targeted chemotherapy, where only high-risk groups (e.g., school age children) are targeted; or selective chemotherapy, where only screened individuals found or suspected to be infected are targeted [3]. Between October 2006 and March 2012, the program provided 589 million NTD treatments through the collaborative efforts of ministries of health, implementing partners, funders, and pharmaceutical donation programs. The implementation of integrated NTD programs at the full national scale remains an important objective in many endemic countries [4]–[8]. Several theoretical frameworks for integration have been proposed; most protocols stress the importance of long-term commitments and concerted efforts of partnerships to realize NTD control and elimination objectives [9]–[14]. However, there is currently a paucity of economic evidence on the costs of integrated PC delivery for NTDs, primarily due to the significant variation in program structures and operations [14]. Given the scarce resources and substantial costs associated with NTD control and elimination, there is therefore a need to accurately determine the cost of program implementation. It is also important to delineate funding commitments to ensure that additional assistance is used to complement available resources, rather than duplicate or replace previous efforts. To allow governments to more easily enumerate costs and funding commitments for NTD control and elimination, the NTD Control Program developed the Tool for Integrated Planning and Costing (TIPAC). The TIPAC, a versatile planning and costing instrument, is designed to be used by members of a NTD program at the national level. For countries with decentralized political structures, the TIPAC can also be implemented at a subnational administrative level. NTD program and financial managers are the primary users of the tool; the involvement of other personnel, including representatives from partner organizations and ministries of education, improves the accuracy and completeness of the TIPAC data. The TIPAC implementation process includes four main phases: Background data collection: country coordinators compile, review, and verify demographic, epidemiologic, and cost classification data. In countries where individual disease control programs are not integrated, this phase may generate fruitful discussions among stakeholders and stimulate collaboration on program planning, outreach, implementation, and monitoring. Data entry: a focal person appointed by the national program enters the planned activity costs. The national strategic plans for NTD control and elimination, also referred to as master plans, serve as the guiding documents for data entry. As the tool is populated, integration opportunities and areas of overlap and duplication are identified. After the costs are entered, stakeholder meetings are convened to identify drug and funding commitments. Finalization and approval: the entered data is reviewed by all stakeholders and approved for use by ministry of health representatives from the national NTD control and elimination program. Results application: the results can be used to inform and guide annual work plans, drug applications, donor coordination efforts, and advocacy and fundraising strategies. The TIPAC is able to convert the information in the tool for use during another funding year, thereby facilitating data entry in subsequent years. The aim of this feasibility study is to assess whether the TIPAC effectively informs and facilitates country program decision-making and the integration of program activities. This study presents excerpts from data collected in two African countries (Sierra Leone, fiscal year [FY] Oct. 2010–Sept. 2011, and Tanzania, FY Oct. 2010–Sept. 2011), one Asian country (Nepal, FY Jul. 2010–Jul. 2011), and one Latin American country (Haiti, FY Oct. 2011–Sept. 2012). The lessons learned from implementing the TIPAC in these four countries can guide the planning and costing of annual NTD control and elimination activities in other NTD-endemic countries.

Background In West Africa, the principal vectors of lymphatic filariasis (LF) are Anopheles species with Culex species playing only a minor role in transmission, if any. Being a predominantly rural disease, the question remains whether conflict-related migration of rural populations into urban areas would be sufficient for active transmission of the parasite. Methodology/Principal Findings We examined LF transmission in urban areas in post-conflict Sierra Leone and Liberia that experienced significant rural-urban migration. Mosquitoes from Freetown and Monrovia, were analyzed for infection with Wuchereria bancrofti. We also undertook a transmission assessment survey (TAS) in Bo and Pujehun districts in Sierra Leone. The majority of the mosquitoes collected were Culex species, while Anopheles species were present in low numbers. The mosquitoes were analyzed in pools, with a maximum of 20 mosquitoes per pool. In both countries, a total of 1731 An. gambiae and 14342 Culex were analyzed for W. bancrofti, using the PCR. Two pools of Culex mosquitoes and 1 pool of An. gambiae were found infected from one community in Freetown. Pool screening analysis indicated a maximum likelihood of infection of 0.004 (95% CI of 0.00012–0.021) and 0.015 (95% CI of 0.0018–0.052) for the An. gambiae and Culex respectively. The results indicate that An. gambiae is present in low numbers, with a microfilaria prevalence breaking threshold value not sufficient to maintain transmission. The results of the TAS in Bo and Pujehun also indicated an antigen prevalence of 0.19% and 0.67% in children, respectively. This is well below the recommended 2% level for stopping MDA in Anopheles transmission areas, according to WHO guidelines. Conclusions We found no evidence for active transmission of LF in cities, where internally displaced persons from rural areas lived for many years during the more than 10 years conflict in Sierra Leone and Liberia., Author Summary There have been many arguments regarding the implementation of Mass Drug Administration (MDA) activities for elephantiasis control in urban areas, and especially in countries where the disease is mostly found in rural settings. Blanket MDA in implementation units in big cities, may be costly and unnecessary, without evidence for active transmission in urban areas. Over 1 million people were treated in Freetown during the first MDA carried out in 2010. This represents hundreds of thousands dollars that may serve a better use in reducing the impact of elephantiasis in areas with established on-going transmission. This study was conducted to assess the evidence of transmission of elephantiasis in urban areas, as a result of rural to urban migration in West African countries that have experienced civil wars, and the displacement of people from rural to urban areas. The results showed that the main mosquitoes transmitting elephantiasis are in numbers not enough to support transmission. Testing of individuals also showed very few people to have infection. Together, the results show that elephantiasis infection in the urban areas, where the study was conducted, is not enough to justify the need for MDA in the national capitals. This study represents a strategy that can be adopted in many countries, to inform the decision for undertaking MDA activities in cities.

Background Since 2007 Sierra Leone has conducted mass drug administration (MDA) for the elimination of lymphatic filariasis (LF) implemented by unpaid community health volunteers (CHVs). Other health campaigns such as Mother and Child Health Weeks (MCHW) pay for services to be implemented at community level and these persons are then known as community health workers (CHWs). In 2010, the LF MDA in the 12 districts of the Southern, Northern and Eastern Provinces un-expectantly coincided with universal distribution of Long Lasting Insecticide Treated Nets (LLITNs) during the MCHW. In-process monitoring of LF MDA was performed to ensure effective coverage was attained in hard to reach sites (HTR) in both urban and rural locations where vulnerable populations reside. Methods Independent monitors interviewed individuals eligible for LF MDA and tallied those who recalled having taken ivermectin and albendazole, calculated program coverage and reported results daily by phone. Monitoring of coverage in HTR sites in the 4 most rapidly urbanizing towns was performed after 4 weeks of LF MDA and again after 8 weeks throughout all 12 districts. End process monitoring was performed in randomly selected HTR sites not previously sampled throughout all 12 districts and compared to coverage calculated from the pre-MDA census and reported treatments. Results Only one town had reached effective program coverage (≥80%) after 4 weeks following which CHWs were recruited for LF MDA in all district headquarter towns. After 8 weeks only 4 of 12 districts had reached effective coverage so LF MDA was extended for a further month in all districts. By 12 weeks effective program coverage had been reached in all districts except Port Loko and there was no significant difference between those interviewed in communities versus households or by sex. Effective epidemiological coverage (≥65%) was reported in all districts and overall was significantly higher in males versus females. Conclusions The challenges to LF MDA included the late delivery in country of ivermectin, the availability and motivation of unpaid CHVs, concurrent LLITN distribution and the MCHW, remuneration for CHWs, rapid urbanization and employment seeking population migrations. 'In process' monitoring ensured modifications of LF MDA were made in a timely manner to ensure effective coverage was finally attained even in HTR locations.

Background Lymphatic filariasis elimination programs are based upon preventative chemotherapy annually in populations with prevalence more than or equal to 1%. The goal is to treat 80% of the eligible, at risk population yearly, for at least 5 years, in order to interrupt transmission and prevent children from becoming infected. This level of coverage has been a challenge in urban settings. Assessing the coverage in a rapidly growing urban/non-rural setting with inadequate population data is also problematic. In Sierra Leone, a 5-day preventative chemotherapy campaign was carried out in the Western Area including the capital: Freetown. An intensive, social mobilization strategy combined traditional and modern communication channels. To aid dissemination of appropriate information Frequently Asked Questions were developed and widely circulated. The population of the Western Area has grown faster than projected by the 2004 National Census due to the post-war settlement of internally displaced persons. As a reliable denominator was not available, independent monitoring was adapted and performed "in process" to aid program performance and "end process" to assess final coverage. Results In 5 days 1,104,407 eligible persons were treated. Using the projected population from the 2004 census this figure represented coverage of 116% in the Urban Western Area and 129% in the Rural Western Area. Independent monitors interviewed a total of 9,253 persons during the 2 End Process days representing 1% of the projected population. Of these, 85.8% recalled taking both ivermectin and albendazole (Urban: 85.2%, Rural: 87.1%). No serious adverse drug reactions were reported. Conclusion The paper presents the key elements of success of the social mobilization and implementation strategy and describes the independent monitoring used to estimate final coverage in this urban/non-rural setting where the current population size is uncertain. This implementation strategy and Independent Monitoring tool could be useful in similar, rapidly growing cities implementing lymphatic filariasis elimination programs.