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Abstract Background On 5 November 2021, a fire incident following a tanker explosion occurred in the Wellington PMB Junction east of Freetown, Sierra Leone, injuring and killing people. WHO facilitated the deployment of international emergency medical teams (EMTs) to support the Ministry of Health (MoH) in providing care to the wounded in four hospitals. Objective In this study, we document Sierra Leone's experience managing the fire incident and the role of EMTs in responding to it. Method This is a cross-sectional After-Action Review (AAR) debrief of the response and deployment, including focus group discussion with WHO and MoH staff (n = 14) in a virtual workshop and document reviews on the response. The results thematically cover the event and the different agencies' responses and a review of EMTs' responses. Results At the onset of the emergency, the National Disaster Management Agency (NDMA) instituted a well-coordinated response mechanism in collaboration with the MoH and managed all response actions, such as medical services, informing partners and the public and coordinating all other agencies. WHO facilitated EMT deployments and mobilised medical supplies and equipment, while the MoH provided accommodation, logistics and coordination. The EMTs dispensed their functions with professionalism, adapted to the environment and available resources, and augmented the care the national health workers provided. They offered additional care: reconstructive surgery, pain management, palliative care, wound care, rehabilitation, physiotherapy and psychosocial counselling, which were initially inadequate at the onset of the disaster. 94 out of 157 patients were discharged home at the end. National clinicians acquired additional skills through the capacity-building activities of EMTs. The community appreciated the teams. Conclusion The government, partners and EMTs were important in the response and worked with speed and political acceptability using the context experience to provide surge support to the country. This experience brought to focus the idea of developing a national EMT in Sierra Leone, which would be useful to help respond even more swiftly. In collaboration with WHO, there is a need to institute further mechanisms to facilitate rapid response and quality-assured deployment of EMTs at regional and sub-regional levels and strengthen to support future responses.

Abstract Background Alcohol-based handrub (ABHR) is the gold standard for hand hygiene (HH) and is a cornerstone of infection prevention and control (IPC) strategies. However, several factors influence the efficient use of ABHR by health workers. This study evaluated the tolerability and acceptability of a locally produced ABHR product and HH behaviour among health workers. Methods A longitudinal hospital-based intervention study was conducted in accordance with the WHO’s standardized protocol for evaluating ABHR tolerability and acceptability (Method 1). Sixty health workers across 4 hospitals in Sierra Leone were observed over a 30-day period at three separate visits (days 1, 3–5, and 30) by trained observers. The outcomes of interest included skin tolerability and product acceptabilityevaluated using subjective and objective measures. Results Objective and subjective evaluations demonstrated strong skin tolerability and high acceptability with the product. At all three visits, the skin tolerability score assessed by trained observers was 4 (BMS = > 4 in ≥ 75%). The primary acceptability criteria increased up to 95% (colour) and 88% (smell) at visit 3 (BMS = > 4 in ≥ 50%). Despite high acceptability, the product’s drying effect remained low at 52% and 58% during visits 2 and 3, respectively (BMS = > 4 in ≥ 75%). There were positive HH behaviours (n = 53, 88%), with more than half (n = 38, 63%) of them exhibiting HH at almost every HH moment. The mean ABHR was notably high (76.1 ml, SD ± 35), especially among nurses (mean = 80.1 ml) and doctors (mean = 74.0 ml). Conclusion The WHO-formulated, locally produced ABHR was well tolerated and accepted by health workers. These findings support the continuous utilization of evidence-based, cost-effective hand hygiene interventions in resource-limited settings. High handrub consumption and frequent HH practices were noticeable HH behaviours. Further research is recommended to optimize product formulations for skin dryness and investigate the association between ABHR consumption and hand hygiene compliance.

Abstract Background All countries are required to implement International Health Regulations (IHR) through development and implementation of multi-year National Action Plans for Health Security (NAPHS). IHR implementation requires annual operational planning which involves several tools such as NAPHS, State Party Annual Report (SPAR), Joint External Evaluation (JEE) and WHO IHR Benchmarks tool. Sierra Leone has successfully improved IHR capacities across the years through successful annual operational planning using the above tools. We conducted a study to document and share the country’s unique approach to implementation of NAPHS. Methods This was an observational study where the process of implementing and monitoring NAPHS in Sierra Leone was observed at the national level from 2018 to 2021. Data was obtained through review and analysis of NAPHS annual operational plans, quarterly review reports and annual IHR assessment reports. Available data was supplemented by information from key informants. Qualitative data was captured as notes and analysed for various themes while quantitative data was analyzed mainly for means and proportions. Results The overall national IHR Joint External Evaluation self-assessment score for human health improved from 44% in 2018 to 51% in 2019 and 57% in 2020. The score for the animal sector improved from 32% in 2018 to 43% in 2019 and 52% in 2020. A new JEE tool with new indicators was used in 2021 and the score for both human and animal sectors declined slightly to 51%. Key enablers of success included strong political commitment, whole-of-government approach, annual assessments using JEE tool, annual operational planning using WHO IHR Benchmarks tool and real time online monitoring of progress. Key challenges included disruption created by COVID-19 response, poor health infrastructure, low funding and inadequate health workforce. Conclusion IHR annual operational planning and implementation using evidence-based data and tools can facilitate strengthening of IHR capacity and should be encouraged.

Objective Inappropriate use of antibiotics is a major driver of antibiotic resistance. A few studies conducted in Africa have documented that about half of hospitalised patients who receive antibiotics should not have received them. A few hospital-based studies that have been conducted in Sierra Leone have documented a high usage of antibiotics in hospitals. Therefore, we conducted a nationwide point prevalence survey on antibiotic use among hospitalised patients in Sierra Leone.Design We conducted a hospital-based, cross-sectional survey on the use of antibiotics using the WHO point prevalence survey methodology.Setting The study was conducted in 26 public and private hospitals that are providing inpatient healthcare services.Participants All patients admitted to paediatric and adult inpatient wards before or at 08:00 on the survey date were enrolled.Outcome measures Prevalence of antibiotic use, antibiotics Access, Watch and Reserve (AWaRe) categorisation, indication for antibiotic use prevalence and proportion of bacteria culture done.Results Of the 1198 patient records reviewed, 883 (73.7%, 95% CI 71.1% to 76.2%) were on antibiotics. Antibiotic use was highest in the paediatric wards (306, 85.7%), followed by medical wards (158, 71.2%), surgical wards (146, 69.5%), mixed wards (97, 68.8%) and lowest in the obstetrics and gynaecology wards (176, 65.7%). The most widely prescribed antibiotics were metronidazole (404, 22.2%), ceftriaxone (373, 20.5%), ampicillin (337, 18.5%), gentamicin (221, 12.1%) and amoxicillin (90, 5.0%). Blood culture was only done for one patient and antibiotic treatments were given empirically. The most common indication for antibiotic use was community-acquired infection (484, 51.9%) followed by surgical prophylaxis (222, 23.8%).Conclusion There was high usage of antibiotics in hospitals in Sierra Leone as the majority of patients admitted received an antibiotic. This has the potential to increase the burden of antibiotic resistance in the country. We, therefore, recommend the establishment of hospital antimicrobial stewardship programmes according to the WHO core components.

Background: Antimicrobial resistance (AMR) is a global public health concern that has the potential to reverse decades of progress aimed at decreasing morbidity and mortality attributed to infectious diseases. In 2019, ~5 million deaths were associated with AMR, of which 1.2 million were attributed to antibacterial-resistant infections. Healthcare facilities where antimicrobials are frequently used are high-risk settings for the selection and spread of resistant bacteria, and they further contribute to the increase in the burden of AMR. We have documented the prevalence and indication of antibiotic use in a tertiary-care referral hospital in Freetown, Sierra Leone. Methods: This point-prevalence survey was conducted at Connaught hospital, a tertiary-care hospital in Sierra Leone, in November 2021. The hospital offers a range of medical and surgical services through 25 units and has 16 wards with >300 beds. Data on patient-level antibiotic use, including indications for use, were extracted from medical records using WHO point-prevalence survey (PPS) forms that had been pretested and validated. Data collection was conducted in all the wards over a 10-day period by trained healthcare personnel. On the day of the survey, only the medical records of patients on admission before 8:00 a.m. on that day were included in the study. Data entry, cleaning, and analysis were conducted using the WHO PPS platform. Ethical approval was obtained. Results: In total, 87 patient records were included in the survey. Most (71%) were women, and the average age was 30.6 years. The prevalence of antibiotic use was 66%, and the average number of antibiotics prescribed to patients since admission was 2. The 5 most prescribed antibiotics were metronidazole, ceftriaxone, amoxicillin and clavulanic acid, ampicillin and cloxacillin, and azithromycin. The parenteral route of drug administration was the mainstay. The most frequent indications for antibiotic prescription were community-acquired infection and surgical prophylaxis. Blood-culture requests were not ordered before the initiation of antibiotic treatment. Conclusions: This study was the first study to be conducted in Connaught hospital using the WHO PPS methodology. The survey reports a high prevalence (60%) of antibiotic use, and most treatment was done empirically. This finding is contrary to the WHO recommendation of

ABSTRACT: Introduction: On November 20, 2019, the Sierra Leone International Health Regulations (IHR) National Focal Point was notified of an exported case of Lassa fever in The Netherlands, by a Dutch doctor who previously practiced in a rural hospital in Sierra Leone. This report describes the extent of the outbreak, possible sources of infection, and the outbreak response measures taken. Methods: Response measures implemented to control the outbreak included coordination across multiple countries and cities, outbreak investigation, active case finding, contact tracing and monitoring, laboratory investigation, and isolation and treatment of cases. Results: We report a hospital-associated outbreak that resulted in 3 confirmed cases (health workers) and 2 probable cases (patients). The case fatality rate was 60%, whereas the secondary attack rate was 14%. Two cases involved exportations to The Netherlands. Failure to detect the index case and poor adherence to infection prevention and control (IPC) protocols contributed to disease spread. Pregnancy status and nonspecific signs and symptoms of the index case contributed to failure in early case detection. Conclusions: Rapid activation of national and subnational incident management systems resulted in rapid outbreak control. We recommend regular training for clinicians on surveillance and IPC protocols and strengthening in-country Lassa virus diagnostic capacity.

Background In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two that were exported to the Netherlands. The outbreak tested multiple technical capacities in the International Health Regulations (2005) in a real-life setting. As such, an after action review (AAR) was undertaken as recommended by World Health Organization. We report on the findings of the AAR including best practices and lessons learnt. Methods A two stage review process was employed. The first stage involved national pillar level reviews for each technical pillar and one review of the district level response. The second stage brought together all pillars, including participants from the national and sub-national level as well as health sector partners. National guidelines were used as references during the deliberations. A standardized template was used to report on the key findings on what happened, what was supposed to happen, what went well and lessons learnt. Results This was a hospital associated outbreak that likely occurred due to a breach in infection prevention and control (IPC) practices resulting in three health workers being infected during a surgical operation. There was a delay in detecting the outbreak on time due to low index of suspicion among clinicians. Once detected, the outbreak response contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Notable gaps included delays in accessing local emergency funding and late distribution of IPC and laboratory supplies. Conclusions The incident management system worked optimally to contain this outbreak. The core technical gaps identified in surveillance, IPC and delay in deployment of resources should be addressed through systemic changes that can mitigate future outbreaks. Author summary The International Health Regulations (IHR) Monitoring and Evaluation Framework was developed by the World Health Organization to provide strategies to monitor and assess how countries are building their core public health capacities under IHR (2005). The framework has four components: annual reporting on IHR capacities (mandatory), Joint External Evaluation, simulation exercises and After Action Review (AAR). In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two deaths and two exported cases to the Netherlands. The outbreak tested multiple technical capacities in the IHR (2005) in a real-life setting. We therefore conducted an AAR to assess how well the country responded to the outbreak. This hospital associated outbreak likely occurred due to a breach in infection prevention and control (IPC) practices. The response launched after detection of the outbreak successfully contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Areas that needed improvement were clinicians’ knowledge on Lassa Fever, delays in accessing local emergency funding and late distribution of IPC and laboratory supplies.

Introduction: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in 2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. Methods: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0–25%), basic (25.1–50%), intermediate (50.1–75%), and advanced (75.1–100%). Results: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. Conclusions: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.

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

INTRODUCTION: West Africa is experiencing the largest ever reported Ebola outbreak. Over 20,000 people have been infected of which about 9000 have died. It is possible that lack of community understanding of the epidemic and lack of institutional memory and inexperienced health workers could have led to the rapid spread of the disease. In this paper, we share Uganda's experiences on how the capacity of health workers and other multidisciplinary teams can be improved in preparing and responding to Ebola outbreaks.Methods: Makerere University School of Public Health in collaboration with the Ministry of Health and the African Field Epidemiology Network (AFENET), trained health care workers and other multidisciplinary teams from six border districts of Uganda so as to increase their alertness and response capabilities towards Ebola. We used participatory training methods to impart knowledge and skills and guided participants to develop district epidemic response plans. Communities were sensitized about Ebola through mass media, IEC materials, and infection control and prevention materials were distributed in districts.Results: we trained 210 health workers and 120 other multidisciplinary team members on Ebola surveillance, preparedness and response. Evaluation results demonstrated a gain in knowledge and skills. Communities were sensitized about Ebola and Districts received person protective equipments and items for infection prevention. Epidemic Preparedness and Response plans were also developed.CONCLUSION: training of multidisciplinary teams improves the country's preparedness, alertness and response capabilities in controlling Ebola. West African countries experiencing Ebola outbreaks could draw lessons from the Uganda experience to contain the outbreak.