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In sub-Saharan Africa, extreme poverty highlights the tension between development aid and the environment. Foreign aid is considered one of the most important factors affecting forest health in this region. Although many studies have empirically examined the effects of different kinds of foreign aid on forests, few have investigated the potential impact of agricultural aid. This study investigated the causal effects of agricultural aid on forests in Sierra Leone, a country that relies heavily on agricultural products. We constructed a fine-grained (16-day) indicator of forest growth from 2001 to 2015 by combining remotely sensed data of land cover and the Normalized Difference Vegetation Index. The high frequency of forest growth data enables us to trace the dynamic causal process. To reduce the confounding effects of heterogeneity, we applied a difference-in-difference design with data at the sub-national level to estimate the causal effect. This study provides robust empirical evidence that foreign agricultural aid harms forests both in the short term (i.e., 16 days) and long term (i.e., years) in Sierra Leone. Agricultural aid projects with agricultural development as their primary objective or aid projects without specific objectives lead to the highest levels of forest degradation. [ABSTRACT FROM AUTHOR]

This study has analysed the determinants of child undernutrition and mortality in Sierra Leone with the objective of identifying key predictors to advise policy. It utilises the country's Demographic and Health Survey 2008. The estimation of the empirical model employs a seemingly unrelated regression (SUR) technique and probit framework. The predictors of undernutrition found most significant are: mothers' education; housing environment measured by household density, accommodation capacity and sanitary condition; regional development differentials; having vegetables in the diet for mothers and children; and immunization. The predictors found significant for tackling mortality are: mothers' education; household density; recognition of gendered differential needs for children; nutritional deficiency; micronutrient supplement; and postnatal care. The policy simulations demonstrate that focusing policy on these factors could immensely help address child growth problems in the country. More particularly, the paper suggests the need for a greater focus on supporting mothers' education and strengthening public health in childcare management. That, while modern medicine is always crucial, it can be perceived only as bolstering good natural practices in caring for children. It is noted that children that are chronically undernourished can resist episodic sources of undernutrition more strongly than those that have not been undernourished before. This supports the argument that while 'vulnerability' and 'poverty' are closely related concepts, they are separable from a static and dynamic point of view; the former measures the probability of becoming poor due to exposure to shocks even if one is currently better-off, or the probability of becoming poorer for those that are already poor. Child wasting appears closer to vulnerability than stunting, which is mainly noted with those already in poverty. Therefore, policies should target both urban and rural settlers--the former are characterised in this study by higher incidence of child wasting (acute undernutrition) while the latter are characterised by higher incidence of stunting (chronic undernutrition). The study does not find any strict linearity in the expectation of the distribution and dynamics of the effects of nutritional deficiency and morbid episodes across the socioeconomic groups analysed, thereby evincing the need for careful policy targeting. The four regions of the country should be evaluated carefully in policy targeting processes, given that there are urban poverty pockets as well as rural poverty pockets. [ABSTRACT FROM AUTHOR]

Primary eye care (PEC) is a vital component of primary healthcare (PHC) and is the cornerstone for the progress towards universal eye health coverage. While the concept of PEC is not new, with the increased focus of the global eye-health agenda on equity and people-centred care, it is critical to review experiences of delivering PEC in low- and middle-income countries and to identify common lessons learnt. This commentary builds on the available evidence and focuses specifically on three recently published evaluations of PEC in Sightsavers-supported programmes in Tanzania, Sierra Leone and Pakistan. It argues that systems thinking is critical in the delivery of PEC interventions, as only this approach can ensure that the integration of PEC into PHC is delivered in a comprehensive, coherent and sustainable way. [ABSTRACT FROM AUTHOR]

The UN-imposed sanctions on Sierra Leone began in 1997 after the Revolutionary United Front (RUF) led a coup that forced newly elected president Ahmad Tejan Kabbah into exile. Alongside its peacemaking efforts, the UN Security Council explicitly supported the reinstatement of Kabbah, and its sanctions targeted the RUF by limiting travel and banning the trade of arms, petroleum, and diamonds. This article analyzes whether and how UN sanctions pushed the RUF to negotiate, accept, and implement agreements mediated by the Economic Community of West African States and the UN. Its findings are drawn from the qualitative analysis of official documents, memoirs, and interviews with key negotiators. It adds to the inclusion debate in peace mediation literature by discussing whether the coordinated use of sanctions and mediation can resolve the difficulties inherent in including veto players in peace negotiations. [ABSTRACT FROM AUTHOR]

The neoclassical growth model has emphasised the importance of technology shocks, which supposedly affect macroeconomic variables' heterogeneously in a small open economy like Sierra Leone. Using a Bayesian DSGE methodology for a non-linear model, we found that investment-specific technological shock partly explains business cycle fluctuations in Sierra Leone. Moreover, the analysis indicates that technology shock on output, capital, and consumption is more persistent than that of interest rate. The key implication is that technological innovation is crucial for long-term steady-state growth in Sierra Leone. The results also partly confirm the neoclassical growth model prediction - that is, in the long run, productivity growth is driven only by technological progress. The model specified for this research is largely inward-looking, with a minimal role for the Bank of Sierra Leone to influence investment in technology-related investment directly. Despite this limitation and more so given the fact that the DSGE modelling concept is quite a new venture at the BSL, thoughts have been given to enhance the model's future capabilities to incorporate both the monetary bloc and external blocs to fully assess the impact of technological shock's transmission in the entire economy in future research. [ABSTRACT FROM AUTHOR]

Recently developed methods for the non-parametric estimation of Hawkes point process models facilitate their application for describing and forecasting the spread of epidemic diseases. We use data from the 2014 Ebola outbreak in West Africa to evaluate how well a simple Hawkes point process model can forecast the spread of Ebola virus in Guinea, Sierra Leone, and Liberia. For comparison, SEIR models that fit previously to the same data are evaluated using identical metrics. To test the predictive power of each of the models, we simulate the ability to make near real-time predictions during an actual outbreak by using the first 75% of the data for estimation and the subsequent 25% of the data for evaluation. Forecasts generated from Hawkes models more accurately describe the spread of Ebola in each of the three countries investigated and result in a 38% reduction in RMSE for weekly case estimation across all countries when compared to SEIR models (total RMSE of 59.8 cases/week using SEIR compared to 37.1 for Hawkes). We demonstrate that the improved fit from Hawkes modeling cannot be attributed to overfitting and evaluate the advantages and disadvantages of Hawkes models in general for forecasting the spread of epidemic diseases. [ABSTRACT FROM AUTHOR]

How did "science," once a term used to refer to universal knowledge, come to be applied to the epistemic practices of particular civilizational and racial groups? This essay approaches this question by examining the life and writings of John Augustus Abayomi Cole, a Sierra Leonean medical practitioner and public intellectual who in the late nineteenth century used the term "science" to describe African knowledge systems. Cole's writing on science in Africa was explicitly anti-imperial and grounded in a critique of the "materialism" of European society. While reminding Africa's European conquerors of the folly of their civilizing mission, Cole at the same time urged the "Europized" elite of Sierra Leone's capital of Freetown to adapt themselves to African spiritual and scientific life. The essay argues that marginal intellectuals like Cole, whose thought was shaped by several interlocking local and intercontinental forces, were instrumental in generating the concept of civilization-specific science. [ABSTRACT FROM AUTHOR]

The 2014-2016 West African Ebola outbreak is often cited as a watershed moment for the social science of epidemics. Anthropologists played a key role in clarifying the social, economic and political dimensions of the epidemic, highlighting both how outbreak control measures were disrupting social practices and how they could be adapted to reflect local realities and experiences. Whilst undoubtedly significant, this narrative of anthropology's successful integration risks obscuring the fraught position of the anthropologist within the Ebola response. Taking debates about public anthropology and the balance of action and critique as a starting point, we offer reflexive considerations from our work in the Ebola vaccine trials in Sierra Leone. We look at the involvement of social scientists in HIV clinical trials, which led to the inclusion of a social science component in the Ebola trials, through to the everyday discussions on how to integrate ethnographic insights into the running of operations. In so doing, we highlight the importance of foregrounding participants' and communities' voices, and confront what gets lost in translation. Keeping this tension in focus, we consider the consequences of this complex position for the possibility of a 'critically embedded' anthropology of clinical research in health emergencies. [ABSTRACT FROM AUTHOR]

Background: Malaria is endemic to sub-Saharan African countries. Mass and routine distribution, promotion, and use of ITNs are critical components of malaria prevention programmes. Correct and consistent use of insecticide-treated mosquito nets (ITN) is an effective strategy for malaria prevention. To extend bed-net lifespan, the World Health Organization recommends folding or tying up ITNs when they are not in use. This study analyses factors associated with net care practices in three African countries. Methods: Researchers collected household data nationwide in Côte d'Ivoire, from the North and Far North regions of Cameroon, and from Port Loko and Bo districts in Sierra Leone, between 2018 and 2019. The dependent variable was respondents reporting that they fold or tie up their nets. The study adjusted for selected sociodemographic, ideational (psychosocial), and household variables using multilevel models. The analysis was limited to women of reproductive age and their male spouses/partners from households with at least one ITN: 2,940 respondents in Cameroon, 6,105 in Côte d'Ivoire, and 2,730 in Sierra Leone. Results: Among respondents, 50.2% in Cameroon, 52.0% in Côte d'Ivoire and 75.6% in Sierra Leone reported folding or tying up their net when it was not in use. In all three countries, the data showed significant clustering at both household and community levels, indicating the influence of factors operating at these levels on net-care behaviour. The odds of reporting the behaviour varied significantly by geographic unit in each country. Consistent use of nets was strongly correlated with net-care behaviour. Furthermore, five ideational variables were positively associated with the outcome behaviour in all three countries: positive attitude towards net care, perceived susceptibility for malaria, response-efficacy of ITNs, perceived self-efficacy for net use, and the perception that net use was a community norm. Additional significant ideational variables included positive attitudes towards net use (Cameroon and Côte d'Ivoire), perceived severity of malaria (Côte d'Ivoire), and interpersonal communication about malaria (Côte d'Ivoire). Conclusions: The study identified ideational variables associated with recommended net-care practice. Programme efforts designed to promote net-care practices and extend average lifespan of ITNs may be more effective if they emphasize positive attitudes towards net care, perceived susceptibility of malaria infection, response-efficacy of ITNs, perceived self-efficacy for net use, and promote net-care behaviour as a positive community norm. [ABSTRACT FROM AUTHOR]

Background: Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross's Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services.Methods: We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants "very comfortable" with course skills using paired Student's t-tests and McNemar's exact tests, respectively.Results: We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were "very comfortable" performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19.Conclusions: This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale. [ABSTRACT FROM AUTHOR]

Postwar governance reform in Sierra Leone is gradually creating a public space conducive to free expression. Youths, who for long did not have much say in governance, consider this an opportunity to make known their views and influence political decisions. This is evident in the singing of pop songs by urban youths, which cry down ethnicity, corruption, injustice, and bad governance in general. Enjoying the space created for free expression is, however, not without challenges, many of which spring from the irresponsible exercise of this right without taking into consideration the rights of others or the stability of the state. There is also the apparent lack of political will to keep this space open and free of manipulation. [ABSTRACT FROM AUTHOR]

Copyright of Africa Spectrum is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Information about several papers discussed at a conference held November 1-3, 2010 sponsored by the Danish Institute for International Studies on the issue of justice, security and international law. The topics include the link of the decentralization of power with the justice system in Sierra Leone. Information on the legal pluralism and the relationship between local power and the decentralized authority is also presented.

Abstract: Until now, no satisfactory geodynamic model has been delivered concerning the three main West African orogens: Panafrican 1 (Bassaride belt), Panafrican 2 (Rokelide belt) and Hercynian (Mauritanide belt). However, since the last synthetic paper (), new geological, geophysical and geochronological data, from the Moroccan Sahara to Sierra Leone, allow us to propose a new geodynamical model. It includes the two Panafrican events in a single model very similar to the present western Pacific margin. An old “West African Neoproterozoic ocean” (WANO) was limited by a set of island arcs separated from the West African craton by a series of “back arc basins”. The closure of this first round of back arc basins around 650 Ma led to the Bassaride belt (Panafrican 1). Then the WANO was subducting underneath the island arcs (between 650 and 550 Ma) meanwhile a new generation of “back arc basins” opened to the east between the arcs and the craton margin. The closure of the WANO and associated island arcs and back arc basins (550 to 500 Ma) led to the Rokelide belt (Panafrican 2). The Hercynian structures involving a Palaeozoic cover (made with continental material) associated to a “greeenschist facies” metamorphism is ascribed to an intracontinental belt. [Copyright &y& Elsevier]

Improving 'access to justice for the poor' features high on justice sector reform agendas in post conflict sub-Saharan Africa. This results in increased attention for the role of customary structures of dispute resolution at the grassroots. At the same time, it raises the challenge to address possible areas of tension between customary justice and human rights. Based on a case study in Sierra Leone, this article explores the scope, reach and limits of interventions that aim at promoting human rights within customary justice. The paper shows that the latter is multi-layered, including different actors and approaches for the maintenance of local order, with some forums adjudicating according to customary rules and others favoring mediation and the achievement of a negotiated solution. It argues that most interventions tend to focus on official customary justice providers and the identification of customary rules, while ignoring or at best indirectly targeting non- official actors and practices. It concludes that more attention is needed to plurality in customary justice, both in terms of the multiplicity of actors that play a role at grassroots level, the different approaches they follow for the resolution of conflicts, and the particular challenges and opportunities they present for the promotion of human rights locally. [ABSTRACT FROM AUTHOR]

This paper is a critical examination of women's roles in the West African civil conflicts of Liberia, Sierra Leone, and Cote d'Ivoire. Our epistemological point of departure is that women perform significant combat roles in war situations. Scholars/analysts have focused on women as solely victims of wars, but this study presents a framework that distances itself from this view and presents information on the wide variety of women's involvement in conflicts. Thus, whilst the public life of politics that comprises war-making decision is being dictated by men, women are involved in many other roles in the field. Consequently, this study addresses the following research conundrums: What factors explain the increased 'feminization of the militarization process' associated with conflicts in West Africa? Are women voluntary partners in war or are they reluctant actors being manipulated by ruthless army officers/warlords? What are the implications of women's active involvement in conflicts for the future development of women in these countries under focus, and society at large? What are the current and prospective roles of women in mediation and post-conflict peacebuilding? [ABSTRACT FROM AUTHOR]

The civil conflict in Sierra Leone (1991-2001) caused a dramatic increase in the population of Freetown. This population increase overstretched housing facilities, leading to the creation of camps and many squatter settlements with poor sanitation practices. Overcrowding has become a serious concern in light of the acute water shortage that struck Freetown in May and June 2006. Some of the numerous small water bodies that could have been used to augment the public water supply were contaminated by the disposal of solid and industrial waste and poor sewage management. Improper disposal practices have a direct impact on public health. This paper recommends addressing the policy gap, establishing clear threshold criteria for all water bodies and wastewater discharge, and integrating the above issues in the ongoing review process of draft water sanitation policy. Public education of the negative consequences of poor waste management practices on water quality and public health can also positively affect general sanitation practices [ABSTRACT FROM AUTHOR]

This paper uses a case-study approach to describe how organizational characteristics may influence program outcomes in humanitarian aid situations. Organizational structure and human resource management are discussed as organizational factors that influence the vulnerabilities of clients and employees. Interview and archival data from a program on reintegrating refugee and internally displaced women and girl survivors of sexual violence in Sierra Leone and observations based on the author's experience with the organization provides a relevant basis for isolating the firm as an important context within which refugee programs are embedded. [ABSTRACT FROM AUTHOR]

The article presents a paper on how the displaced youth in Sierra Leone heal their trauma from the violence and displacement caused by the country's civil war. The healing is facilitated by a deliverance ministry of Pentecostal churches and centers. The ministry helps the populace, particularly the youth, in giving them a sense of belonging with the end that they may live normal lives.

Copyright of Anthropologica is the property of CASCA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Postwar countries in Africa are among the poorest. In the countries of the Mano River region (Liberia, Sierra Leone) agrarian injustice emerges as a major cause of both poverty and conflict. Serious efforts are needed to improve the labour, land and property rights of rural women and young people if the long-term causes of these conflicts are to be mitigated and agricultural development opportunities enhanced. [ABSTRACT FROM AUTHOR]

This study assesses the nexus between credit risks and performance of commercial banks in Sierra Leone using data collected from the Bank of Sierra Leone (BSL) on relevant Financial Soundness Indicators like ROA, Bank Liquidity, NPL, and Credit over the 2008Q1-2018Q4 period. Evidence from (unbalanced) panel data estimation within the fixed effects model shows that the fragility of the banking system stems from high NPLs. We further provide evidence that a low productive base in the domestic economy influences the state of high NPLs in the banking system. The study revealed the need for collaboration between the research arm of monetary policy and financial stability departments in a bid to monitor risk in the financial system, which the entire banking system experienced around 2015-2017 that resulted in stringent measures adopted by the BSL to rescue the two state–own commercial banks. Equally, vigilant approaches should be explored by the BSL authority that leads to (positive) structural changes in banks’ approach to improving efficiency while at the same time minimizing continued risks to high NPLs and many more. The study finally recommends that ROA and ROE be adopted as independent indicators by the regulatory authorities to effectively monitor performances across the banking industry, as this would help monitor unexpected shocks in the banking system. [ABSTRACT FROM AUTHOR]

The morphosyntactic development of Atlantic creoles, including Krio, an English-based creole in Sierra Leone, is a highly debated issue, with the controversy centering on the extent of the influence of the properties of substrate West African languages, if any, on the development of Krio morphosyntax. Contrary to proposals that creoles (including Krio) tend to exhibit basic, universal, simplistic, and transparent grammar, this paper presents evidence of substratal influence on the morphosyntactic properties of Krio. The properties of three morphosyntactic structures--focused constructions, verb serialization, and complementation--are examined and evidence is provided for an intricate and productive system of morphosyntactic operations that sometimes generate structures of a regional rather than a universal orientation. In addition, these are linguistically marked structures that are extremely difficult to account for under proposed universal unmarked principles of grammar as currently stipulated. [ABSTRACT FROM AUTHOR]

Background: Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior. Methods: This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data. Results: The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions. Conclusion: This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital). [ABSTRACT FROM AUTHOR]

Introduction: Currently, there are no data on prevalence and associated risk factors of chronic kidney disease (CKD) among patients with hypertension in rural Sierra Leone. Purpose: To estimate the prevalence and associated risk factors of CKD in rural Sierra Leone. Patients and Methods: A cross-sectional study of hypertension patients aged between 18 and 75 years attending a non-communicable disease clinic at Koidu Government Hospital, Kono District, Sierra Leone was conducted between February and December 2020. Using systematic random sampling, a structured questionnaire, which comprised of questions on social demographic characteristics and past and current clinical history, was administered followed by measurement of creatinine and urinary protein and glucose. Estimated glomerular filtration rate (eGFR) was estimated using CKD-epidemiology formula without race as a factor. Baseline eGFR between 60– 89 min/mL/1.73m2 and < 60 min/mL/1.73m2 defined reduced eGFR and renal impairment, respectively. Estimated GFR less than 60 min/mL/1.73m2 measured two times at least 3 months apart was used to define CKD. Results: Ninety-six percent (n = 304) patients out of 317 patients were included in the study. Among all included patients, only 3.9% (n = 12) had eGFR of 90 min/mL/1.73m2 and above. The prevalence of renal impairment and CKD was 52% (158/304, CI 46.2– 57.7) and 29.9% (91/304, CI 24.8– 34.5), respectively. In adjusted logistic regression analysis, currently taking herbal medications as treatment of hypertension (OR 4.11 (CI 1.14– 14.80), p = 0.03) and being overweight and/or obese (OR 2.16 (CI 1.24– 3.78), p < 0.001) was associated with CKD. Additionally, receiving some education was associated with a 48% (OR 0.52 (CI 0.29– 0.91), p = 0.02) reduced likelihood of CKD. Conclusion: The prevalence of renal impairment and CKD is high among hypertensive patients in rural Sierra Leone. CKD was associated with current history of taking herbal medications and being overweight and/or obese. Additionally, CKD was associated with reduced likelihood in patients who received some education. [ABSTRACT FROM AUTHOR]

Copyright of Review of African Political Economy is the property of Review of Political Economy (ROAPE) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Deficits in global oral health care are paramount, and complications of odontogenic infections constitute a considerable global health problem, particularly in low-income countries. A high mortality rate has been observed for patients who have been admitted with complicated odontogenic infections to our facilities in Tonkolili District, Sierra Leone, although exact data have not been published yet. Data regarding who in this region is at risk and why are lacking. Objective: The Dental Abscess Study (DELAY) aims to prospectively investigate morbidity and mortality from complicated dental abscesses and to analyze patients’ characteristics and microbial findings to examine predisposing factors for poor outcomes. In particular, the incidence and the clinical and microbial characteristics of complicated odontogenic infections, as well as the sociodemographic data and comorbidities of affected patients, will be studied to develop improved management algorithms based on circumstance-specific factors. Methods: Patients who present with complicated dental infections requiring hospital admission in Masanga Hospital or Lion Heart Medical Centre will be consecutively selected for possible inclusion in the study (starting on September 4, 2021) over a study period of 1 year, and individual routine follow-ups will be conducted at least 3 months after discharge. The results of standardized questionnaires will be obtained, and clinical measurements as well as medical photos will be taken. Standard laboratory tests (eg, full blood count and HIV status tests) will be performed, and pus specimens will be examined. Local treatment guidelines will be adhered to, and data on medical and surgical treatment as well as data on outcomes will be collected. The study results will be reported according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Routine follow-ups will take place at 1 and 3 months postdischarge. Results: The DELAY protocol was endorsed by the Masanga Medical Research Unit’s Scientific Review Committee on June 16, 2021, and ethical approval was granted on July 5, 2021, by the Sierra Leone National Ethics Committee. The funding of the budgeted study costs was approved by Dental Health International Netherlands in August 2021. The projected start date of data collection was September 4, 2021, and the study period will most likely last for 1 year. As such, data collection is expected to be complete in November 2022. Conclusions: The aim of our prospective observational cohort study is to gain more knowledge about complicated odontogenic infections in Tonkolili District, Sierra Leone, to further improve treatment strategies. [ABSTRACT FROM AUTHOR]

Background: Surgical logbooks are a commonly used tool for quality assurance of surgical training. Electronic logbooks are increasingly applied in low-resource settings, but there is limited research on their quality. The aim of this study is to evaluate the quality of an app-based surgical e-logbook system shortly after its implementation in a low-income country and to identify potential areas of improvement for the system. Methods: Entries in the e-logbook system were cross-checked with hospital records and categorized as matched or overreported. Moreover, the hospital records were checked for underreported procedures. Additionally, semi-structured interviews were conducted with users of the e-logbook system. Results: A total of 278 e-logbook database entries and 379 procedures in the hospital records from 14 users were analyzed. Matches were found in the hospital records for 67.3% of the database entries. Moreover, 32.7% of the database entries were overreported and 50.7% of the procedures in the hospital records were underreported. A previous study of an analog surgical logbook system in the same setting estimated that 73.1% of the entries were matches or close matches. Interviews with 12 e-logbook users found overall satisfaction but also identified potential areas of improvement, including the need for more training in the use of the system, modifications to improve user-friendliness, and better access to the necessary technology. Conclusions: A reliable documentation system is necessary to evaluate the quality of health workforce training. The early evaluation of a surgical e-logbook system in a low-income country showed that the collected data should be approached with caution. The quantitative analysis suggests that the e-logbook system needs to be improved in terms of accuracy. In interviews, users reported that digitalization of the logbook system was a much-needed innovation but also identified important areas of improvement. Recognition of these aspects at an early stage facilitates guidance and adjustment of further implementation and might improve the accuracy of the system. [ABSTRACT FROM AUTHOR]

Background: During the 2014-15 Ebola Virus Disease (EVD) epidemic, thousands of people in Sierra Leone were infected with the devastating virus and survived. Years after the epidemic was declared over, stigma toward EVD survivors and others affected by the virus is still a major concern, but little is known about the factors that influence stigma toward survivors. This study examines how key personal and ecological factors predicted EVD-related stigma at the height of the 2014-2015 epidemic in Sierra Leone, and the personal and ecological factors that shaped changes in stigma over time.Methods: Using three waves of survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines factors associated with self-reported personal stigma toward Ebola survivors (11 items, α = 0.77) among 1008 adults (74.6% retention rate) from 63 census enumeration areas of the Western Rural and Western Urban districts of Sierra Leone. Participants were randomly sampled at the height of the EVD epidemic and followed up as the epidemic was waning and once the epidemic had been declared over by the WHO. Three-level mixed effects models were fit using Stata 16 SE to examine cross-sectional associations as well as predictors of longitudinal changes in stigma toward EVD survivors.Results: At the height of the EVD epidemic, female sex, household wealth, post-traumatic stress, EVD-related fear and perceived infection risk are a few of the factors which predicted higher levels of stigma toward survivors. On average, stigma toward EVD survivors decreased significantly as the epidemic declined in Sierra Leone, but female sex, EVD fear, and risk perceptions predicted a slower rate of change.Conclusion: This study identified key individual and psychosocial characteristics which may predict higher levels of stigma toward infectious disease survivors. Future studies should pursue a better understanding of how personal characteristics and perceptions, including psychosocial distress, fear, and perceived infection risk serve as pathways for stigma in communities affected by infectious disease. [ABSTRACT FROM AUTHOR]

Background: Teenage pregnancy remains high with low contraceptive prevalence among adolescents (aged 15-19 years) in Sierra Leone. Stakeholders leverage multiple strategies to address the challenge. Mobile technology is pervasive and presents an opportunity to reach young people with critical sexual reproductive health and family planning messages. Objective: The objectives of this research study are to understand how mobile health (mHealth) is used for family planning, understand phone use habits among young people in Sierra Leone, and recommend strategies for mobile-enabled dissemination of family planning information at scale. Methods: This formative research study was conducted using a systematic literature review and focus group discussions (FGDs). The literature survey assessed similar but existing interventions through a systematic search of 6 scholarly databases. Cross-sections of young people of both sexes and their support groups were engaged in 9 FGDs in an urban and a rural district in Sierra Leone. The FGD data were qualitatively analyzed using MAXQDA software (VERBI Software GmbH) to determine appropriate technology channels, content, and format for different user segments. Results: Our systematic search results were categorized using Grading of Recommended Assessment and Evaluation (GRADE) into communication channels, audiovisual messaging format, purpose of the intervention, and message direction. The majority of reviewed articles report on SMS-based interventions. At the same time, most intervention purposes are for awareness and as helpful resources. Our survey did not find documented use of custom mHealth apps for family planning information dissemination. From the FGDs, more young people in Sierra Leone own basic mobile phones than those that have feature capablilities or are smartphone. Young people with smartphones use them mostly for WhatsApp and Facebook. Young people widely subscribe to the social media--only internet bundle, with the cost ranging from 1000 leones (US $0.11) to 1500 leones (US $0.16) daily. Pupils in both districts top-up their voice call and SMS credit every day between 1000 leones (US $0.11) and 5000 leones (US $0.52). Conclusions: mHealth has facilitated family planning information dissemination for demand creation around the world. Despite the widespread use of social and new media, SMS is the scalable channel to reach literate and semiliterate young people. We have cataloged mHealth for contraceptive research to show SMS followed by call center as widely used channels. Jingles are popular for audiovisual message formats, mostly delivered as either push or pull only message directions (not both). Interactive voice response and automated calls are best suited to reach nonliterate young people at scale. [ABSTRACT FROM AUTHOR]

Background: Malnutrition rates in Sierra Leone are among the highest in the world. However, policy-makers do not always recognise the fight against malnutrition as a policy priority to ensure the healthy human capital needed to fight poverty and achieve sustained positive economic growth. Objective: The analysis presented here was conducted by an intersectoral and inter-agency group of Sierra Leonean senior policy advisors to quantify some of the potential human and economic benefits of improved policies and programmes to reduce malnutrition. Findings: The analysis revealed that 46% of child deaths in Sierra Leone are attributable to malnutrition, the single greatest cause of child mortality in the country. In the absence of adequate policy and programme action, malnutrition will be the underlying cause of an estimated 74 000 child deaths over the next five years. The analysis also revealed that if current levels of iodine deficiency remain unchanged over the next five years, 252 000 children could be born with varying degrees of mental retardation as a result of intrauterine iodine deficiency. Finally, the analysis showed that, in the absence of adequate policy and programme action to reduce the unacceptable rates of anaemia in women, the monetary value of agricultural productivity losses associated with anaemia in the female labour force over the next five years will exceed $94.5 million. Conclusion: Sustained investment in nutrition in Sierra Leone could bring about enormous human and economic benefits to develop the social sector, revitalise the economy, and attain the poverty reduction goals that Sierra Leone has set forth. [ABSTRACT FROM AUTHOR]

Background: Stringent infection control requirements at Ebola treatment centers (ETCs), which are specialized facilities for isolating and treating Ebola patients, create substantial challenges for recording and reviewing patient information. During the 2014-2016 West African Ebola epidemic, paper-based data collection systems at ETCs compromised the quality, quantity, and confidentiality of patient data. Electronic health record (EHR) systems have the potential to address such problems, with benefits for patient care, surveillance, and research. However, no suitable software was available for deployment when large-scale ETCs opened as the epidemic escalated in 2014.Objective: We present our work on rapidly developing and deploying OpenMRS-Ebola, an EHR system for the Kerry Town ETC in Sierra Leone. We describe our experience, lessons learned, and recommendations for future health emergencies.Methods: We used the OpenMRS platform and Agile software development approaches to build OpenMRS-Ebola. Key features of our work included daily communications between the development team and ground-based operations team, iterative processes, and phased development and implementation. We made design decisions based on the restrictions of the ETC environment and regular user feedback. To evaluate the system, we conducted predeployment user questionnaires and compared the EHR records with duplicate paper records.Results: We successfully built OpenMRS-Ebola, a modular stand-alone EHR system with a tablet-based application for infectious patient wards and a desktop-based application for noninfectious areas. OpenMRS-Ebola supports patient tracking (registration, bed allocation, and discharge); recording of vital signs and symptoms; medication and intravenous fluid ordering and monitoring; laboratory results; clinician notes; and data export. It displays relevant patient information to clinicians in infectious and noninfectious zones. We implemented phase 1 (patient tracking; drug ordering and monitoring) after 2.5 months of full-time development. OpenMRS-Ebola was used for 112 patient registrations, 569 prescription orders, and 971 medication administration recordings. We were unable to fully implement phases 2 and 3 as the ETC closed because of a decrease in new Ebola cases. The phase 1 evaluation suggested that OpenMRS-Ebola worked well in the context of the rollout, and the user feedback was positive.Conclusions: To our knowledge, OpenMRS-Ebola is the most comprehensive adaptable clinical EHR built for a low-resource setting health emergency. It is designed to address the main challenges of data collection in highly infectious environments that require robust infection prevention and control measures and it is interoperable with other electronic health systems. Although we built and deployed OpenMRS-Ebola more rapidly than typical software, our work highlights the challenges of having to develop an appropriate system during an emergency rather than being able to rapidly adapt an existing one. Lessons learned from this and previous emergencies should be used to ensure that a set of well-designed, easy-to-use, pretested health software is ready for quick deployment in future. [ABSTRACT FROM AUTHOR]

Background: This paper discusses the establishment of a clinical trial of an Ebola vaccine candidate in Kambia District, Northern Sierra Leone during the epidemic, and analyses the role of social science research in ensuring that lessons from the socio-political context, the recent experience of the Ebola outbreak, and learning from previous clinical trials were incorporated in the development of community engagement strategies. The paper aims to provide a case study of an integrated social science and communications system in the start-up phase of the clinical trial.Methods: The paper is based on qualitative research methods including ethnographic observation, interviews with trial participants and key stakeholder interviews.Results: Through the case study of EBOVAC Salone, the paper suggests ways in which research can be used to inform communication strategies before and during the setting up of the trial. It explores notions of power, fairness and trust emerging from analysis of the Sierra Leonean context and through ethnographic research, to reflect on three situations in which social scientists and community liaison officers worked together to ensure successful community engagement. Firstly, a section on "power" considers the pitfalls of considering communities as homogeneous and shows the importance of understanding intra-community power dynamics when engaging communities. Secondly, a section on "fairness" shows how local understandings of what is fair can help inform the design of volunteer recruitment strategies. Finally, a section on "trust" highlights how historically rooted rumours can be effectively addressed through active dialogue rather than through an approach focused on correcting misinformation.Conclusion: The paper firstly emphasises the value of social science in the setting up of clinical trials, in terms of providing an in depth understanding of context and social dynamics. Secondly, the paper suggests the importance of a close collaboration between research and community engagement to effectively confront political and social dynamics, especially in the context of an epidemic. [ABSTRACT FROM AUTHOR]

With the general closure of universities and schools in Sierra Leone due to the COVID-19 pandemic, digital learning has become a credible alternative to maintain students in educational, training, and research links. The study responds to three primary questions: 1) Which digital learning modalities have shown to be most effective for providing continuity in learning amid temporary or permanent school closures? 2) Which digital learning modalities are promising for their use but evidence for their use evidence about them is still lacking? 3) What are the challenges and considerations when planning for and implementing digital learning? The study utilised qualitative research methods: interviews, focus group discussions, qualitative survey, and document reviewing. A stratified sample of 260 participants (161 male and 99 female) was randomly drawn from teachers, education officials, and information technology experts. This paper provides snapshots of the different distance learning initiatives and programs that have been implemented, including the promises they offer.

Background: Vaccine hesitancy is a complex, contested social phenomenon and existing research highlights the multifaceted role of trust in strengthening vaccine confidence. However, understanding public engagement with vaccination through the lens of (mis)trust requires more contextual evidence on trust's qualitative determinants. This includes expanding the geographic focus beyond current studies' focus on High Income Countries. Furthermore, obstacles remain in effectively integrating social science findings in the design of vaccine deployment strategies, and in ensuring that those who implement interventions and are affected by them are directly involved in producing knowledge about vaccination challenges. Methods: We piloted a community-led ethnographic approach, training Community Health Workers (CHWs) in Kambia District, Sierra Leone, in qualitative social science methods. Methods included participant observation, participatory power mapping and rumour tracking, focus group discussions and key stakeholder interviews. CHWs, with the support of public health officials and professional social scientists, conducted research on vaccination challenges, analysed data, tested new community engagement strategies based on their findings and elicited local perspectives on these approaches. Results: Our findings on vaccine confidence in five border communities highlighted three key themes: the impact of prior experiences with the health system on (mis)trust; relevance of livelihood strategies and power dynamics for vaccine uptake and access; and the contextual nature of knowledge around vaccines. Across these themes, we show how expressions of trust centered on social proximity, reliability and respect and the role of structural issues affecting both vaccine access and confidence. The pilot also highlighted the value and practical challenges to meaningfully co-designed research. Conclusion: There is scope for broader application of a community-led ethnographic approach will help redesign programming that is responsive to local knowledge and experience. Involving communities and low-cadre service providers in generating knowledge and solutions can strengthen relationships and sustain dialogue to bolster vaccine confidence. [ABSTRACT FROM AUTHOR]

Background: Chronic wounds pose a significant healthcare burden in low- and middle-income countries. Buruli ulcer (BU), caused by Mycobacterium ulcerans infection, causes wounds with high morbidity and financial burden. Although highly endemic in West and Central Africa, the presence of BU in Sierra Leone is not well described. This study aimed to confirm or exclude BU in suspected cases of chronic wounds presenting to Masanga Hospital, Sierra Leone. Methodology: Demographics, baseline clinical data, and quality of life scores were collected from patients with wounds suspected to be BU. Wound tissue samples were acquired and transported to the Swiss Tropical and Public Health Institute, Switzerland, for analysis to detect Mycobacterium ulcerans using qPCR, microscopic smear examination, and histopathology, as per World Health Organization (WHO) recommendations. Findings: Twenty-one participants with wounds suspected to be BU were enrolled over 4-weeks (Feb-March 2019). Participants were predominantly young working males (62% male, 38% female, mean 35yrs, 90% employed in an occupation or as a student) with large, single, ulcerating wounds (mean diameter 9.4cm, 86% single wound) exclusively of the lower limbs (60% foot, 40% lower leg) present for a mean 15 months. The majority reported frequent exposure to water outdoors (76%). Self-reports of over-the-counter antibiotic use prior to presentation was high (81%), as was history of trauma (38%) and surgical interventions prior to enrolment (48%). Regarding laboratory investigation, all samples were negative for BU by microscopy, histopathology, and qPCR. Histopathology analysis revealed heavy bacterial load in many of the samples. The study had excellent participant recruitment, however follow-up proved difficult. Conclusions: BU was not confirmed as a cause of chronic ulceration in our cohort of suspected cases, as judged by laboratory analysis according to WHO standards. This does not exclude the presence of BU in the region, and the definitive cause of these treatment-resistance chronic wounds is uncertain. Author summary: Chronic wounds constitute a significant surgical burden to low- and middle-income countries; however, their aetiology often remains poorly understood. This study improves our understanding of wound aetiology through tissue analysis of chronic leg wounds suspected to be caused by Buruli ulcer (BU). BU is a neglected tropical disease caused by infection with Mycobacterium ulcerans, and remains severely under-researched. There is a lack of testing facilities in regions surrounding endemic countries which makes prevalence difficult to determine, with a particular paucity of data from Sierra Leone (SL). This study identified twenty-one patients with wounds suspected to be caused by BU who presented to Masanga Hospital (Tonkonili District, Sierra Leone) between February and March 2019. Tissue samples were acquired from the wounds and transported to a European tropical health laboratory for analysis. Significant bacterial loads were demonstrated in the samples. However, the gold-standard molecular tests recommended by World Health Organisation (WHO) revealed no cases of BU. These results suggest that BU is not a major cause of chronic wounds in the Northern Province of Sierra Leone. Our conclusions cannot necessarily be generalised to other regions of Sierra Leone, therefore further studies in other geographical districts are required. [ABSTRACT FROM AUTHOR]

Background: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. Methods: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. Results: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04–1.15)), add salt at the Table (OR 1.88 (1.82–1.94)), eat salty snacks (OR 2.00 (1.94–2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12–1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20–1.27)) or consume salty snacks (OR 1.35 (1.31–1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. Conclusion: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation. [ABSTRACT FROM AUTHOR]

Background: Undernutrition accounts for at least 50% of the annual global under-five mortality burden. Although disparities in the childhood stunting between urban and rural areas in Sierra Leone have been documented, information on factors associated with these differences is lacking. We aimed to determine rural-urban correlates of stunting among children under the age of 5 in Sierra Leone. Methods: We analyzed data from 2019 Sierra Leone demographic and health survey (SLDHS) focusing on under-five children. We conducted multivariable logistic regression to examine rural-urban factors associated with childhood stunting. Results: Prevalence of stunting was 31.6% (95% CI 29.8-33.2) in rural areas and 24.0% (95% CI 21.6-26.1) in urban areas. Within the rural areas, children of stunted mothers (aOR = 2.37; 95% CI 1.07-5.24, P <.05), younger mothers aged 15 to 19 years (aOR = 2.08; 95% CI 1.17-3.69, P <.05), uneducated mothers (aOR = 1.87; 95% CI 1.28-2.71, P <.01), as well as older children (24-59 months) (aOR = 1.83; 95% CI 1.48-2.27, P <.001), and boys (aOR = 1.37; 95% CI 1.12-1.66, P <.01) were more likely to be stunted compared to those of non-stunted, older, post-primary education mothers and those who were less than 24 months and girls respectively. While urban children whose fathers had lower education (aOR = 1.94; 95% CI 1.10-3.42, P <.05), whose mothers were more parous (para 2-4) (aOR = 1.74; 95% CI 1.03-2.95, P <.05), and boys (aOR = 1.48; 95% CI 1.06-2.08, P <.05) were more likely to be stunted compared to their counterparts with fathers that had tertiary education, mothers of low parity and girls, respectively. Conclusions: Stunting is more prevalent in the rural areas compared to the urban areas. Sex of the child was the only significant factor in both rural and urban areas. Our study findings suggest that programs designed to reduce stunting should aim for integrated yet context specific interventions in rural and urban areas. [ABSTRACT FROM AUTHOR]

Background: Research is urgently needed to reduce the morbidity and mortality of Lassa fever (LF), including clinical trials to test new therapies and to verify the efficacy and safety of the only current treatment recommendation, ribavirin, which has a weak clinical evidence base. To help establish a basis for the development of an adaptable, standardised clinical trial methodology, we conducted a systematic review to identify the clinical characteristics and outcomes of LF and describe how LF has historically been defined and assessed in the scientific literature. Methodology: Primary clinical studies and reports of patients with suspected and confirmed diagnosis of LF published in the peer-reviewed literature before 15 April 2021 were included. Publications were selected following a two-stage screening of abstracts, then full-texts, by two independent reviewers at each stage. Data were extracted, verified, and summarised using descriptive statistics. Results: 147 publications were included, primarily case reports (36%), case series (28%), and cohort studies (20%); only 2 quasi-randomised studies (1%) were found. Data are mostly from Nigeria (52% of individuals, 41% of publications) and Sierra Leone (42% of individuals, 31% of publications). The results corroborate the World Health Organisation characterisation of LF presentation. However, a broader spectrum of presenting symptoms is evident, such as gastrointestinal illness and other nervous system and musculoskeletal disorders that are not commonly included as indicators of LF. The overall case fatality ratio was 30% in laboratory-confirmed cases (1896/6373 reported in 109 publications). Conclusion: Systematic review is an important tool in the clinical characterisation of diseases with limited publications. The results herein provide a more complete understanding of the spectrum of disease which is relevant to clinical trial design. This review demonstrates the need for coordination across the LF research community to generate harmonised research methods that can contribute to building a strong evidence base for new treatments and foster confidence in their integration into clinical care. Author summary: Clinical research in difficult-to-study infectious diseases such as Lassa fever is challenging. Only one controlled clinical trial has been conducted to assess the safety and efficacy of therapeutic interventions for Lassa fever (LF). Further research to test new and repurposed therapies is needed and should be supported by a methodological framework in which clinical trials can be consistently conducted for LF. To establish a basis for a standardised clinical trial methodology, we carried out a systematic review to identify the clinical characteristics and outcomes of LF and describe how LF has historically been defined and assessed in the scientific literature. Our data corroborates the current characterisation of LF, and also highlights a broader range of other general symptoms that characterise the onset of LF, such as gastrointestinal illness and other nervous system and musculoskeletal disorders that are not commonly included as indicators of LF. These findings, however, should be tempered by the lack of systematic assessment and reporting of presenting signs and symptoms, their evolution following treatment, and outcomes at discharge in the historic literature. It is therefore evident that a standardised set of data variables and outcome measures should be developed and incorporated into future trials and reported to accelerate collective knowledge. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is the second most common cause of adult death in Africa. This study reports the demographics, stroke types, stroke care and hospital outcomes for stroke in Freetown, Sierra Leone. Methods: A prospective observational register recorded all patients 18 years and over with stroke between May 2019 and April 2020. Stroke was defined according to the WHO criteria. Pearson's chi-squared test was used to examine associations between categorical variables and unpaired t -tests for continuous variables. Multivariable logistic regression, to explain in-hospital death, was reported as odds ratios (ORs) and 95% confidence intervals. Results: Three hundred eighty-five strokes were registered, and 315 (81.8%) were first-in-a-lifetime events. Mean age was 59.2 (SD 13.8), and 187 (48.6%) were male. Of the strokes, 327 (84.9%) were confirmed by CT scan. Two hundred thirty-one (60.0%) were ischaemic, 85 (22.1%) intracerebral haemorrhage, 11 (2.9%) subarachnoid haemorrhage and 58 (15.1%) undetermined stroke type. The median National Institutes of Health Stroke Scale on presentation was 17 [interquartile range (IQR) 9–25]. Haemorrhagic strokes compared with ischaemic strokes were more severe, 20 (IQR 12–26) vs. 13 (IQR 7–22) (p < 0.001), and occurred in a younger population, mean age 52.3 (SD 12.0) vs. 61.6 (SD 13.8) (p < 0.001), with a lower level of educational attainment of 28.2 vs. 40.7% (p = 0.04). The median time from stroke onset to arrival at the principal referral hospital was 25 hours (IQR 6–73). Half of the patients (50.4%) sought care at another health provider prior to arrival. One hundred fifty-one patients died in the hospital (39.5%). Forty-three deaths occurred within 48 hours of arriving at the hospital, with median time to death of 4 days (IQR 0–7 days). Of the patients, 49.6% had ≥1 complication, 98 (25.5%) pneumonia and 33 (8.6%) urinary tract infection. Male gender (OR 3.33, 1.65–6.75), pneumonia (OR 3.75, 1.82–7.76), subarachnoid haemorrhage (OR 43.1, 6.70–277.4) and undetermined stroke types (OR 6.35, 2.17–18.60) were associated with higher risk of in-hospital death. Discussion: We observed severe strokes occurring in a young population with high in-hospital mortality. Further work to deliver evidence-based stroke care is essential to reduce stroke mortality in Sierra Leone. [ABSTRACT FROM AUTHOR]

A suspended particulate matter distribution against a hydrographical background was studied at the oceanographic transect across the equatorial Atlantic in the year 2000. An area of abnormally high suspended matter volume concentrations was found above the Sierra Leone Rise in the entire water column (eastern part of the transect). The suggested explanation for the anomaly is based on the ballast hypothesis whereby solid particles are incorporated as ballast into suspended biogenic aggregates, leading to increased velocities of sinking. This occurs within the Northwest African upwelling area, where the plankton exposed to the Saharan dust abundance form a significant number of aggregates, which are later transported equatorward via the Canary Current. An intermediate nepheloid layer associated with the Deep Western Boundary Current was recorded from the South American Slope at depths of 3200–3700 to 4300 m above the Para Abyssal Plain. Antarctic Bottom Water enriched in suspended matter was found mostly in the troughs at 40–41 ∘ W. It was detached from the bottom, coinciding with the core of the flow due to the bottom rise "dam" located up-stream. The grain size of particles along the entire transect has a polymodal distribution with 2–4 and 8–13 µm modes. The registered rise in percentage in some parts of the transect of the 7–21 µm sized particles suggests the presence of the well-known coarse mode (20–60 µm) formed by aggregation of transparent exopolymer particles (mucus). [ABSTRACT FROM AUTHOR]

Introduction: Sierra Leone has one of the highest burdens of febrile illnesses in the world. As the incidence of malaria diminishes, a better understanding of the spectrum of etiological agents was important for accurate diagnosis and empirical treatment of febrile illness. Methods: Blood, nasopharyngeal, and fecal specimens were collected from febrile patients for serological, molecular detection, and microbiologic culture to identify potential pathogens. Results: For this prospective study, 142 febrile patients were enrolled. The prevalence of malaria was higher in children aged 5–15 years old (P = 0.185) and adults (P = 0.018). Acute respiratory infection (ARI) presented more commonly in the under 5 years old group (P = 0.009). For diarrhea, all children groups (P = 0.024) were predominant. A total of 22.5% of the febrile patients had malaria infection, 19.7% had typhoid infection, and 2.8% were coinfected with malaria and typhoid. ARI was the most common causes of fever, accounting for 31.7% of patients, influenza A virus, Mycoplasma pneumoniae, and five other respiratory pathogens were found. Diarrhea accounted for 16.2%, and seven kinds of diarrhea bacteria were isolated. Hepatitis B accounted for 8.5%, including five cases of spontaneous bacterial peritonitis, and ascites smear staining were both Gram-negative bacteria. Tuberculous encephalitis, parasitic diseases (ascaris and filariasis), and skin infection caused by Staphylococcus aureus accounted for 0.7%, 2.1%, and 0.7%, respectively. Conclusions: Evidence of a wide spectrum of febrile etiological agents other than malaria was identified. The spread of malaria rapid diagnostic tests (RDTs) out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. Antibiotics against Gram-negative bacteria are helpful for empirical treatment. Plain Language Summary: Sierra Leone has one of the highest burdens of febrile illnesses in the world. Evidence of a wide spectrum of febrile pathogens other than malaria has been proven in this study. We considered that the etiology of febrile patients was closely related to local geography, heredity, immune features, economic industry, living habits, air pollution, medical and health conditions, and this was fully analyzed and discussed. The screening process used in this study can further simplify and identify the etiological agents of fever in more than 70% of the study population. This laid the foundation for the establishment of a more simplified and efficient diagnosis and treatment process in the local area. We also found the characteristics of age distribution of different febrile diseases. Children were an important susceptible population to fever. This study indicated the importance of reliable diagnostic tests for febrile pathogens and provided the necessary information for RDT requirements. The spread of malaria RDTs out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. For empirical treatment, antimalarial treatment was still targeted at falciparum malaria in Sierra Leone. Antibiotics against Gram-negative bacteria contributed to the empirical treatment of febrile diseases. For patients with acute respiratory tract infection, Gram-positive coccal antibiotics could be candidates for treatment. In addition, systematic and professional treatment of liver diseases should be promoted to reduce infection complications. [ABSTRACT FROM AUTHOR]

Background: In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.Methods: A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the 'International Caries Classification and Management System (ICCMS)' tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.Results: To meet the needs of a single year-group of childrens' needs, an average of 163 DTs (range: 133-188) would be required to deliver Conventional care (CC); 39 DTs (range: 30-45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38-68); and 27 DTs (range: 25-32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565-6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255-1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590-2236) for more extended Surgical and Preventive care (S5&6P) (range 1590-2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016-1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251-488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586-1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.Conclusion: The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel. [ABSTRACT FROM AUTHOR]

Background: The 2014-2015 Ebola epidemic in West Africa became a humanitarian crisis that exposed significant gaps in infection prevention and control (IPC) capacity in primary care facilities in Sierra Leone. Operational partners recognized the national gap and rapidly scaled-up an IPC training and infrastructure package. This prompted us to carry out a mixed-methods research study which aimed to evaluate adherence to IPC practices and understand how to improve IPC at the primary care level, where most cases of Ebola were initially presenting. The study was carried out during the national peak of the epidemic.Discussion: We successfully carried out a rapid response research study that produced several expected and unexpected findings that were used to guide IPC measures during the epidemic. Although many research challenges were similar to those found when conducting research in low-resource settings, the presence of Ebola added risks to safety and security of data collectors, as well as a need to balance research activities with the imperative of response to a humanitarian crisis. A participatory approach that attempted to unify levels of the response from community upwards helped overcome the risk of lack of trust in an environment where Ebola had damaged relations between communities and the health system.Conclusion: In the context of a national epidemic, research needs to be focused, appropriately resourced, and responsive to needs. The partnership between local academics and a humanitarian organization helped facilitate access to study sites and approvals that allowed the research to be carried out quickly and safely, and for findings to be shared in response forums with the best chance of being taken up in real-time. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B virus (HBV) is a major global health problem. Although sub-Saharan Africa has a high proportion of the global burden of HBV, the epidemiology and clinical features of HBV in this region are poorly characterized, and access to diagnostic and treatment services remain limited.Methods: We conducted a retrospective study of HBV-infected children and adults of all age groups who were evaluated at public and private health facilities in Freetown, Sierra Leone between January 2017 and January 2019. We assessed their clinical presentation, HBV sero-markers, stages of liver disease, prevalence of cirrhosis by non-invasive tools, and the proportion of treatment eligible patients using the criteria recommended by the World Health Organization's 2015 treatment guidelines for HBV. Logistic regression was used to identify predictors of liver cirrhosis.Results: 163 HBV patients included in the study, with mean age 32.6 years and 65.0% (106) being males. Most (84.0%) were asymptomatic at presentation. The majority (69.9%) were classified as having HBeAg-negative chronic infection (or inactive HBsAg carrier phase), 24.5% were in the HBeAg-negative immune active phase, 3.1% had HBeAg positive hepatitis, and 2.5% were HBsAg negative. The median Aspartate aminotransferase to Platelet Ratio (APRI) and Fibrosis-4 (FIB-4) scores were 0.37 and 0.80, respectively. The prevalence of cirrhosis was 7.6% and 6.2%, estimated by the APRI and FIB-4 scores, respectively. About 20.0% of patients were eligible for treatment with antiviral agents. Based on APRI scores, the presence of any symptom [adjusted odds ratio (aOR) 20.0, 95% confidence interval (CI) (4.1-85.9); p < 0.001], elevated direct bilirubin [aOR 12.1, 95% CI (1.9-63.0); p = 0.003], and elevated total bilirubin [aOR 16.1, 95% CI (3.2-80.8); p = 0.001] were independent predictors of cirrhosis.Conclusion: Although most patients with HBV infection were asymptomatic, the prevalence of liver cirrhosis and proportion of patients requiring antiviral treatment were substantial. This small study from a hyperendemic setting in Sierra Leone suggests that routine population-based screening may increase early detection and linkage of HBV patients to care before development of complications. Larger studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

With increased upstream withdrawal of Ganga waters for irrigation and urban industrial uses, Ganga's dry season flow is declining. The heavily populated but marginalised north Indian State of Bihar with itscapital at Patna expects the Union government in Delhi to curb the appetite of upstream States; but Delhi's water bureaucracy, having grown within a culture of 'construction' rather than 'water management',is reluctant to do so. Adding to Patna's anxiety is a new fear in the form of the 1996 Farakka Treaty between India and Bangladesh, an international obligation that Patna fears will further curtail its water rights. Delhi, however, is able to placate Patna with promises of aKosi High Dam in Nepal on the major tributary of the Ganga closest to Bihar. Because both bureaucracies belong to a social solidarity of hierarchic procedures that would make similar technological choices, Patna is pacified. On the other hand, activist groups in Bihar belonging to a different solidarity, that of egalitarian equity, point to the dismal consequences of past technological choices (embankments) onthe land and its poor and continue to oppose this new choice as well. The hierarchic discourse between Patna and Delhi, however, filters out this activist critique and pursues a business-as-usual program ofnew high dam construction. The purpose of this paper is to examine the institutional background behind such rigid, single-mission policies and the costly surprises and impasse they are prone to. The paper argues that sagaciously providing space for constructive engagement among differing perspectives of the state, market and civil society on Bihar's water problems may minimize this risk. [ABSTRACT FROM AUTHOR]

Background: The West African Ebola epidemic of 2013–2016 killed nearly 4,000 Sierra Leoneans and devastated health infrastructure across West Africa. Changes in health seeking behavior (HSB) during the outbreak resulted in dramatic underreporting and substantial declines in hospital presentations to public health facilities, resulting in an estimated tens of thousands of additional maternal, infant, and adult deaths per year. Sierra Leone's Kenema District, a major Ebola hotspot, is also endemic for Lassa fever (LF), another often-fatal hemorrhagic disease. Here we assess the impact of the West African Ebola epidemic on health seeking behaviors with respect to presentations to the Kenema Government Hospital (KGH) Lassa Ward, which serves as the primary health care referral center for suspected Lassa fever cases in the Eastern Province of Sierra Leone. Methodology/Principal findings: Presentation frequencies for suspected Lassa fever presenting to KGH or one of its referral centers from 2011–2019 were analyzed to consider the potential impact of the West African Ebola epidemic on presentation patterns. There was a significant decline in suspected LF cases presenting to KGH following the epidemic, and a lower percentage of subjects were admitted to the KGH Lassa Ward following the epidemic. To assess general HSB, a questionnaire was developed and administered to 200 residents from 8 villages in Kenema District. Among 194 completed interviews, 151 (78%) of respondents stated they felt hospitals were safer post-epidemic with no significant differences noted among subjects according to religious background, age, gender, or education. However, 37 (19%) subjects reported decreased attendance at hospitals since the epidemic, which suggests that trust in the healthcare system has not fully rebounded. Cost was identified as a major deterrent to seeking healthcare. Conclusions/Significance: Analysis of patient demographic data suggests that fewer individuals sought care for Lassa fever and other febrile illnesses in Kenema District after the West African Ebola epidemic. Re-establishing trust in health care services will require efforts beyond rebuilding infrastructure and require concerted efforts to rebuild the trust of local residents who may be wary of seeking healthcare post epidemic. Author summary: The West African Ebola epidemic of 2013–2016 killed nearly 4,000 Sierra Leoneans and devastated health infrastructure. There is limited information regarding the effects of the epidemic on health seeking behavior. Lassa fever is clinically similar to Ebola and is prevalent in Kenema District, located in the Eastern Province of Sierra Leone. There was a significant decline in the number of individuals seeking care for suspected Lassa fever following the epidemic. Responses to a questionnaire completed by 194 Sierra Leonean residents suggested that confidence in the healthcare system was not fully restored. Cost was identified as a major deterrent to seeking healthcare. Additional community sensitization is needed to convey the need, and importance, of seeking care for Lassa fever. [ABSTRACT FROM AUTHOR]

Background: Following the West African Ebola virus disease (EVD) outbreak of 2013–2016 and more recent EVD outbreaks in the Democratic Republic of Congo, thousands of EVD survivors are at-risk for sequelae including uveitis, which can lead to unremitting inflammation and vision loss from cataract. Because of the known risk of Ebola virus persistence in ocular fluid and the need to provide vision-restorative, safe cataract surgery, the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) Study was implemented in Sierra Leone. During implementation of this multi-national study, challenges included regulatory approvals, mobilization, community engagement, infection prevention and control, and collaboration between multiple disciplines. In this report, we address the multifacted approach to address these challenges and the impact of implementation science research to address an urgent clinical subspecialty need in an outbreak setting. Methodology/Principal findings: Given the patient care need to develop a protocol to evaluate ocular fluid for Ebola virus RNA persistence prior to cataract surgery, as well as protocols to provide reassurance to ophthalmologists caring for EVD survivors with cataracts, the EVICT study was designed and implemented through the work of the Ministry of Health, Sierra Leone National Eye Programme, and international partnerships. The EVICT study showed that all 50 patients who underwent ocular fluid sampling at 19 and 34 months, respectively, tested negative for Ebola virus RNA. Thirty-four patients underwent successful cataract surgery with visual acuity improvement. Here we describe the methodology for study implementation, challenges encountered, and key issues that impacted EVD vision care in the immediate aftermath of the EVD outbreak. Key aspects of the EVICT study included defining the pertinent questions and clinical need, partnership alignment with key stakeholders, community engagement with EVD survivor associations, in-country and international regulatory approvals, study site design for infection prevention and control, and thorough plans for EVD survivor follow-up care and monitoring. Challenges encountered included patient mobilization owing to transportation routes and distance of patients in rural districts. Strong in-country partnerships and multiple international organizations overcame these challenges so that lessons learned could be applied for future EVD outbreaks in West and Central Africa including EVD outbreaks that are ongoing in Guinea and Democratic Republic of Congo. Conclusions/Significance: The EVICT Study showed that cataract surgery with a protocol-driven approach was safe and vision-restorative for EVD survivors, which provided guidance for EVD ophthalmic surgical care. Ophthalmologic care remains a key aspect of the public health response for EVD outbreaks but requires a meticulous, yet partnered approach with international and local in-country partners. Future efforts may build on this framework for clinical care and to improve our understanding of ophthalmic sequelae, develop treatment paradigms for EVD survivors, and strengthen vision health systems in resource-limited settings. [ABSTRACT FROM AUTHOR]