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This paper examines the dominant knowledge paradigms that have underpinned planning over time in Freetown, Sierra Leone and their implications for urban equality. Looking at the history of the informal settlement upgrading agenda, it presents this analysis through a historical mapping, outlining the knowledge paradigms that have informed planning approaches from the colonial era to the present day. It then outlines three strategic moments over the past 13 years, in which organized informal settlement residents and wider coalitions have mobilized diverse forms of knowledge. By engaging both with long-term trajectories and the intimacy of more recent experiences, it outlines what we refer to as the "slow anatomy of change" through which diverse knowledges have been consolidated. The paper offers reflections on the temporalities and geographies of change; the role of knowledge production as a historical site of power disparities; and what these strategies tell us about the negotiation of power and knowledge through planning towards urban equality. [ABSTRACT FROM AUTHOR]

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

Background: Lassa fever is a critical public health issue in Sierra Leone that demands appropriate health system responses and interventions to mitigate infections and reduce mortality. Methods: A qualitative study was conducted to delve into healthcare workers' experiences with Lassa fever management and interventions across diverse healthcare settings in Sierra Leone, including the Eastern Province and Freetown's Directorate of Health Security and Emergency (DHSE). Engaging ten key informants through purposive sampling, the study employed NVivo version 10 for a detailed thematic analysis using Query and Coding to systematically identify, classify, and organize key themes regarding knowledge, diagnostics, management roles, and community impact. Results: The findings indicate a well-informed healthcare workforce but highlight gaps in early detection, diagnostic accuracy, and procedural standardization. Concerns were raised about the potential overestimation of disease incidence due to improved diagnostics, suggesting a historical under-detection of Lassa fever. The analysis underscores the need for a multifaceted management approach, emphasizing international collaboration and culturally sensitive community engagement to effectively tackle the disease. A significant concern identified is the high mortality rate resulting from delayed referrals and communication challenges within the health system, leading to actionable recommendations for enhancing Lassa fever response strategies. The study's thematic analysis provides a nuanced understanding of the challenges and areas for improvement, emphasizing the critical role of healthcare professionals in combating Lassa fever. Conclusion: Combating Lassa fever in Sierra Leone demands an integrative strategy that extends beyond medical interventions to encompass educational and infrastructural enhancements. This research pays homage to the commitment of healthcare professionals, underscoring the importance of sustained support and recognition of their essential contributions to advancing Lassa fever management and interventions. [ABSTRACT FROM AUTHOR]

Packaged drinking water (PW) sold in bottles and plastic bags/sachets is widely consumed in low- and middle-income countries (LMICs), and many urban users in sub-Saharan Africa (SSA) rely on packaged sachet water (PSW) as their primary source of water for consumption. However, few rigorous studies have investigated PSW quality in SSA, and none have compared PSW to stored household water for consumption (HWC). A clearer understanding of PSW quality in the context of alternative sources is needed to inform policy and regulation. As elsewhere in SSA, PSW is widely consumed in Sierra Leone, but government oversight is nearly nonexistent. This study examined the microbiological and chemical quality of a representative sample of PSW products in Freetown, Sierra Leone at packaged water manufacturing facilities (PWMFs) and at points of sale (POSs). Samples of HWC were also analyzed for comparison. The study did not find evidence of serious chemical contamination among the parameters studied. However, 19% of 45 PSW products sampled at the PWMF contained detectable Escherichia coli (EC), although only two samples exceeded 10 CFU/100 mL. Concentrations of total coliforms (TC) in PSW (but not EC) increased along the supply chain. Samples of HWC from 60 households in Freetown were significantly more likely to contain EC and TC than PSW at the point of production (p<0.01), and had significantly higher concentrations of both bacterial indicators (p<0.01). These results highlight the need for additional PSW regulation and surveillance, while demonstrating the need to prioritize the safety of HWC. At present, PSW may be the least unsafe option for many households. [ABSTRACT FROM AUTHOR]

Objective: Tuberculosis (TB) is a leading cause of death globally, with approximately 1.5 million deaths in 2020. TB often coexists with chronic communicable and non-communicable diseases, but data to determine the extent of comorbid diseases are limited. In this study, we aimed to assess the prevalence of TB multimorbidity and its risk factors in a tertiary hospital in Sierra Leone. This is a cross-sectional study of 240 adults with microbiologically-confirmed TB at Connaught Hospital in Freetown, between March and May 2022. Logistic regression analysis was used to identify factors associated with TB multimorbidity. Results: The mean age of the patients was 37 years. More than two-thirds were males and about the same number had two or more chronic diseases. The most common were hypertension (47.9%) and diabetes (24.2%). Patients under 35 years of age were less likely to have TB multimorbidity (< 25 years: adjusted OR 0.07, 95%CI 0.01–0.6; 25–34 years: adjusted OR 0.2, 95%CI 0.01–0.9). We report a high prevalence of comorbid diseases among TB patients in the largest treatment center in Sierra Leone, with hypertension and diabetes being the most common. These findings support the current call for addressing comorbid non-communicable diseases in TB patients through integrated care. [ABSTRACT FROM AUTHOR]

It was in Freetown, Sierra Leone, that the malaria mosquito Anopheles coastalis, now known as Anopheles gambiae, was first discovered as the vector of malaria, in 1899. That discovery led to a pioneering vector research in Sierra Leone and neighbouring Liberia, where mosquito species were extensively characterized. Unfortunately, the decade long civil conflicts of the 1990s, in both countries, resulted in a stagnation of the once vibrant research on disease vectors. This paper attempts to fill in some of the gaps on what is now known of the distribution of the sibling species of the An. gambiae complex, and especially the An. coluzzii and An. gambiae s.s, formerly known as the An. gambiae molecular M and S forms respectively, in the cities of Freetown and Monrovia. [ABSTRACT FROM AUTHOR]

Introduction: Sarcoidosis is a multiorgan, multisystem chronic disease of unknown etiology and unpredictable course. Health status is reduced in sarcoidosis and assessing it is a difficult multitask effort due to many faces this disease might have. Recently, a new questionnaire for assessing health status in sarcoidosis was developed by a group of authors from England–King's Sarcoidosis Questionnaire (KSQ). The benefit of KSQ is the ability to develop the best care plan for the patient, as well as to differentiate the efficacy of the administered treatment. Objective: The aim of this study was to validate the KSQ in Serbian speaking population of sarcoidosis patients. The test itself is a modular, multi-organ health status measure for patients with sarcoidosis for use in clinic and the evaluation of therapies. The correlation of KSQ with different clinical course of sarcoidosis (acute vs chronic disease) and with the clinical outcome status (COS) in sarcoidosis was also investigated. Methods: A total of 159 biopsy positive sarcoidosis patients participated in this study. The average age of the participants was 49.67, majority was female (67.3%) and majority had only pulmonary form of sarcoidosis (71.7%). KSQ ‐ new disease-specific health status instrument, was compared with 5 other already existing instruments already used and validated in sarcoidosis (Saint George Respiratory Questionnaire- SGRQ, Daily Activity List -DAL, Fatigue Assessment Scale- FAS, Medical Research Council dyspnea scale–MRC, Borg Dyspnea Scale and 15D as general questionnaire. Results: KSQ has significant correlation with other quality of life questionnaires already used in sarcoidosis. Translated version of KSQ shows significant internal reliability, similar to the original KSQ. Serbian version of KSQ has significant correlation with different clinical course of sarcoidosis and with COS as well. The translated version of KSQ is reliable sarcoidosis specific instrument for assessing health status in these patients. [ABSTRACT FROM AUTHOR]

Introduction: Sickle cell disease (SCD) in pregnancy is associated with worse maternal and neonatal outcomes. There is limited available data describing the burden and outcomes of critically ill obstetric patients affected by SCD in low-income settings. Objectives: We aimed to define SCD burden and impact on mortality in critically-ill obstetric patients admitted to an urban referral hospital in Sierra Leone. We hypothesized that SCD burden is high and independently associated with increased mortality. Methods: We performed a registry-based cross-sectional study from March 2020 to December 2021 in the high-dependency unit (HDU) of Princess Christian Maternity Hospital PCMH, Freetown. Primary endpoints were the proportion of patients identified in the SCD group and HDU mortality. Secondary endpoints included frequency of maternal direct obstetric complications (MDOCs) and the maternal early obstetric warning score (MEOWS). Results: Out of a total of 497 patients, 25 (5.5%) qualified to be included in the SCD group. MEOWS on admission was not different between patients with and without SCD and SCD patients had also less frequently reported MDOCs. Yet, crude HDU mortality in the SCD group was 36%, compared to 9.5% in the non SCD group (P < 0.01), with an independent association between SCD group exposure and mortality when accounting for severity on admission (hazard ratio 3.40; 95%CI 1.57—7.39; P = 0.002). Patients with SCD had a tendency to longer HDU length of stay. Conclusions: One out of twenty patients accessing a HDU in Sierra Leone fulfilled criteria for SCD. Despite comparable severity on admission, mortality in SCD patients was four times higher than patients without SCD. Optimization of intermediate and intensive care for this group of patients should be prioritized in low-resource settings with high maternal mortality. [ABSTRACT FROM AUTHOR]

Ensuring a sustainable urban water supply for developing/low-income countries requires an understanding of the factors affecting water consumption and technical evidence of individual consumption which can be used to design an improved water demand projection. This paper compared dry and rainy season water sources available for consumption and the end-use volume by each person in the different income groups. The study used a questionnaire survey to gather household data for a total of 398 households, which was analysed to develop the relationship between per capita water consumption characteristics: Socio-economic status, demographics, water use behaviour around indoor and outdoor water use activities. In the per capita water consumption patterns of Freetown, a seasonal variation was found: In the rainy season, per capita water consumption was found to be about 7% higher than the consumption for the full sample, whilst in the dry season, per capita water consumption was almost 14% lower than the full survey. The statistical analysis of the data shows that the average per capita water consumption for both households increases with income for informal slum-, low-, middle- and high-income households without piped connection (73, 78, 94 and 112 L/capita/day) and with connection (91, 97, 113 and 133 L/capita/day), respectively. The collected data have been used to develop 20 statistical models using the multiple linear stepwise regression method for selecting the best predictor variable from the data set. It can be seen from the values that the strongest significant relationships of per capita consumption are with the number of occupants (R = −0.728) in the household and time spent to fetch water for use (R = −0.711). Furthermore, the results reveal that the highest fraction of end use is showering (18%), then bathing (16%), followed by toilet use (14%). This is not in agreement with many developing countries where toilet use represents the largest component of indoor end use. [ABSTRACT FROM AUTHOR]

Purpose: Brain tumors are diagnosed and classified manually and noninvasively by radiologists using Magnetic Resonance Imaging (MRI) data. The risk of misdiagnosis may exist due to human factors such as lack of time, fatigue, and relatively low experience. Deep learning methods have become increasingly important in MRI classification. To improve diagnostic accuracy, researchers emphasize the need to develop Computer-Aided Diagnosis (CAD) computational diagnostics based on artificial intelligence (AI) systems by using deep learning methods such as convolutional neural networks (CNN) and improving the performance of CNN by combining it with other data analysis tools such as wavelet transform. In this study, a novel diagnostic framework based on CNN and DWT data analysis is developed for the diagnosis of glioma tumors in the brain, among other tumors and other diseases, with T2-SWI MRI scans. It is a binary CNN classifier that treats the disease "glioma tumor" as positive and the other pathologies as negative, resulting in a very unbalanced binary problem. The study includes a comparative analysis of a CNN trained with wavelet transform data of MRIs instead of their pixel intensity values in order to demonstrate the increased performance of the CNN and DWT analysis in diagnosing brain gliomas. The results of the proposed CNN architecture are also compared with a deep CNN pre-trained on VGG16 transfer learning network and with the SVM machine learning method using DWT knowledge. Methods: To improve the accuracy of the CNN classifier, the proposed CNN model uses as knowledge the spatial and temporal features extracted by converting the original MRI images to the frequency domain by performing Discrete Wavelet Transformation (DWT), instead of the traditionally used original scans in the form of pixel intensities. Moreover, no pre-processing was applied to the original images. The images used are MRIs of type T2-SWI sequences parallel to the axial plane. Firstly, a compression step is applied for each MRI scan applying DWT up to three levels of decomposition. These data are used to train a 2D CNN in order to classify the scans as showing glioma or not. The proposed CNN model is trained on MRI slices originated from 382 various male and female adult patients, showing healthy and pathological images from a selection of diseases (showing glioma, meningioma, pituitary, necrosis, edema, non-enchasing tumor, hemorrhagic foci, edema, ischemic changes, cystic areas, etc.). The images are provided by the database of the Medical Image Computing and Computer-Assisted Intervention (MICCAI) and the Ischemic Stroke Lesion Segmentation (ISLES) challenges on Brain Tumor Segmentation (BraTS) challenges 2016 and 2017, as well as by the numerous records kept in the public general hospital of Chania, Crete, "Saint George". Results: The proposed frameworks are experimentally evaluated by examining MRI slices originating from 190 different patients (not included in the training set), of which 56% are showing gliomas by the longest two axes less than 2 cm and 44% are showing other pathological effects or healthy cases. Results show convincing performance when using as information the spatial and temporal features extracted by the original scans. With the proposed CNN model and with data in DWT format, we achieved the following statistic percentages: accuracy 0.97, sensitivity (recall) 1, specificity 0.93, precision 0.95, FNR 0, and FPR 0.07. These numbers are higher for this data format (respectively: accuracy by 6% higher, recall by 11%, specificity by 7%, precision by 5%, FNR by 0.1%, and FPR is the same) than it would be, had we used as input data the intensity values of the MRIs (instead of the DWT analysis of the MRIs). Additionally, our study showed that when our CNN takes into account the TL of the existing network VGG, the performance values are lower, as follows: accuracy 0.87, sensitivity (recall) 0.91, specificity 0.84, precision 0.86, FNR of 0.08, and FPR 0.14. Conclusions: The experimental results show the outperformance of the CNN, which is not based on transfer learning, but is using as information the MRI brain scans decomposed into DWT information instead of the pixel intensity of the original scans. The results are promising for the proposed CNN based on DWT knowledge to serve for binary diagnosis of glioma tumors among other tumors and diseases. Moreover, the SVM learning model using DWT data analysis performs with higher accuracy and sensitivity than using pixel values. [ABSTRACT FROM AUTHOR]

Flooding is a well-known extreme climate event affecting coastal settlements around the world. It is the principal climate-related disaster encountered by residents of Portee and Rukupa, coastal slums in Freetown, Sierra Leone. The impacts of floods in these slums have been exacerbated by the lack of effective control measures to address the disaster. One reason for this ineffectiveness is a lack of information about how households are ready to manage floods and the roles of community-based organisations (CBOs) in these events. Given this concern, this study examines household readiness and CBOs' roles in flood management in Portee and Rokupa using observation, purposive, and snowball sampling techniques to study 204 households and 12 CBOs. The results show that flood-related information in the community is mostly shared verbally among residents. In addition, most households claimed not to have received support amidst flood events, whereas CBOs within the area claimed the opposite. As such, we recommend that future studies look at household perceptions of vulnerability and willingness to take risk-reduction actions. This study encourages community members to strengthen intercommunity and organisational learning, feedback, and support systems and adopt a "no wait on the government principle" for flood management. [ABSTRACT FROM AUTHOR]

Consumption of water contaminated with heavy metals has serious health consequences and these include hypertension, kidney disease, cancer, anaemia, brain damage, etc. However, groundwater pollution with heavy metals may occur naturally or anthropogenically as a result of water-rock interaction, dumpsite leachate, agricultural activities, or sewage percolation. Therefore, the apportionment of the specific sources of heavy metals to groundwater is vital to prevent and control its pollution to groundwater. The present work assessed thirtyfour (34) groundwater samples from the vicinity of the Granvillebrook and Kingtom dumpsites, Freetown, Sierra Leone. The objective of the research was achieved by integrating geospatial, indexical, and multivariate statistical methods. The results showed that heavy metals such as Cu, Cr, Fe, and Mn exceeded the permissible levels in the majority of the groundwaters. As and Pb were below the detection level of the instrument in all the groundwaters analyzed. Seasonal variations revealed that the concentration of heavy metals is relatively higher in the dry season due to the effect of dilution. The heavy metal evaluation index and degree of contamination analyses respectively showed that 16.7 and 41.6% of the groundwaters in the Granvillebrook dumpsite are highly polluted by heavy metals. All the groundwater samples in the Kingtom dumpsites except well KW17 are unaffected by heavy metals. The principal component analysis showed that fuel combustion, brake abrasion, and discharge of municipal and industrial waste from the dumpsites are some of the anthropogenic sources that impact groundwater pollution in the study areas. The findings of this research revealed the urgent need to develop strategies to control and mitigate the occurrences of heavy metals and thus serve as a base for future research in the study areas. [ABSTRACT FROM AUTHOR]

Timber heritage sites are vulnerable to damage from moisture. Simple meteorological descriptions of climate need to be tuned to capture drivers that threaten heritage, including dimensional change, insect attack and mould growth. Global climate models often provide projections through to the end of the 21st century but need to be translated to a local level to reveal processes of deterioration at specific sites. Translation to a local level can be challenging and requires the use of local information from a range of sources. This translation is explored over a range of sites facing different climate pressures, including fungal and insect risk at Harmondsworth Great Barn, England; changes in humidity range, salt risk and algal growth in rural timber buildings in the Midwestern states, USA; wind-driven rain impacts on board houses in Freetown, Sierra Leone; and rainfall and humidity range on timber buildings among the tropical rainforests of the Amazon, Congo Basin and Southeast Asia. Evidence-based narratives provide a tool to incorporate a multiplicity of local information to enrich projections and the interpretation of the model output. These could build trust and aid decision-making based on future projections, which are inherently uncertain. [ABSTRACT FROM AUTHOR]

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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]

Deforestation affects local and regional hydroclimate through changes in heating and moistening of the atmosphere. In the tropics, deforestation leads to warming, but its impact on rainfall is more complex, as it depends on spatial scale and synoptic forcing. Most studies have focused on Amazonia, highlighting that forest edges locally enhance convective rainfall, whereas rainfall decreases over drier, more extensive, deforested regions. Here, we examine Southern West Africa (SWA), an example of “late-stage” deforestation, ongoing since 1900 within a 300-km coastal belt. From three decades of satellite data, we demonstrate that the upward trend in convective activity is strongly modulated by deforestation patterns. The frequency of afternoon storms is enhanced over and downstream of deforested patches on length scales from 16 to 196 km, with greater increases for larger patches. The results are consistent with the triggering of storms by mesoscale circulations due to landscape heterogeneity. Near the coast, where sea breeze convection dominates the diurnal cycle, storm frequency has doubled in deforested areas, attributable to enhanced land–sea thermal contrast. These areas include fastgrowing cities such as Freetown and Monrovia, where enhanced storm frequency coincides with high vulnerability to flash flooding. The proximity of the ocean likely explains why ongoing deforestation across SWA continues to increase storminess, as it favors the impact of mesoscale dynamics over moisture availability. The coastal location of deforestation in SWA is typical of many tropical deforestation hotspots, and the processes highlighted here are likely to be of wider global relevance. [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: 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]

After a decade of civil war and the 2014–2016 West African Ebola outbreak, Sierra Leone now faces the COVID-19 pandemic with a fragile health system. As was demonstrated during Ebola, preparedness is key to limiting a health crisis' spread and impact on health systems and ensuring continued care for vulnerable populations including people living with HIV (PLHIV). To assess COVID-19 preparedness and inform interventions to ensure continuity of HIV services at health facilities (HFs) and community service points (CSPs), we conducted site readiness assessments in Freetown, the epicenter of COVID-19 in Sierra Leone. Data were collected at nine high-volume HIV HFs and seven CSPs in April 2020, a month after COVID-19 was declared a pandemic. CSPs comprised three community drop-in centers providing HIV counseling and testing services as well as HIV prevention services (e.g., condoms and lubricants) for key and priority populations and four community-based support groups serving PLHIV. At the time of assessment, CSPs did not provide antiretroviral therapy (ART) but were considered potential sites for expansion of differentiated service delivery (DSD)—a client-centered approach to HIV care—in the context of COVID-19. Overall, 5/9 HFs had trained staff on use of personal protective equipment (PPE) and prevention of COVID-19 transmission. Most had access to masks (5/9) and gloves (7/9) for management of suspected/confirmed COVID-19 cases, and 4/9 HFs had triage procedures for isolation of suspected cases. Conversely, few CSPs had access to masks (2/7) or gloves (2/7) and no staff were trained on PPE use or COVID-19 transmission. 7/9 HFs had adequate ART stock for multi-month dispensing though few had procedures for (3/9) or had trained staff in providing DSD (2/9). Among CSPs where measures were applicable, 2/4 had procedures for DSD, 1/3 had staff trained on DSD and none had adequate ART stock. Identification of gaps in COVID-19 preparedness is a critical step in providing support for infection control and modified service delivery. Findings from this assessment highlight gaps in COVID-19 preparedness measures at sites supporting PLHIV in Sierra Leone and indicate CSPs may require intensive supervision and training to ensure HIV services are uninterrupted while minimizing COVID-19 risk, especially if used as sites to scale up DSD. [ABSTRACT FROM AUTHOR]

Background: Reports about child witchcraft are not uncommon in sub-Saharan Africa. In this study we approach child witchcraft as an idiom of distress. In an environment that may prohibit children from openly expressing distress, the shared imagery of witchcraft can provide a cultural idiom to communicate about psychosocial suffering. We used an ecological approach to study how some children in distressing circumstances come to a witchcraft confession, with the aim to set out pathways for mental health interventions. Methods: We employed rapid qualitative inquiry methodology, with an inductive and iterative approach, combining emic and etic perspectives. We conducted 37 interviews and 12 focus group discussions with a total of 127 participants in Freetown, Sierra Leone. Inductive analysis was used to identify risk and protective factors related to witchcraft accusations and confessions. Results: We identified risk and protective factors related to the individual child, the family, peer relations, teachers and other professionals in a child's life, traditional healers, pastors and the wider society. We found that in the context of a macrosystem that supports witchcraft, suspicions of witchcraft are formed at the mesosystem level, where actors from the microsystem interact with each other and the child. The involvement of a traditional healer or pastor often forms a tipping point that leads to a confession of witchcraft. Conclusions: Child witchcraft is an idiom of distress, not so much owned by the individual child as well as by the systems around the child. Mental health interventions should be systemic and multi-sectoral, to prevent accusations and confessions, and address the suffering of both the child and the systems surrounding the child. Interventions should be contextually relevant and service providers should be helped to address conscious and subconscious fears related to witchcraft. Beyond mental health interventions, advocacy, peacebuilding and legislation is needed to address the deeper systemic issues of poverty, conflict and abuse. [ABSTRACT FROM AUTHOR]

Background: Despite identification 50 years ago, the true burden of Lassa Fever (LF) across Africa remains undefined for reasons including research focus on hospitalised patients, lack of validated field-feasible tools which reliably identify past infection, and the fact that all assays require blood samples making large-scale surveys difficult. Designated a priority pathogen of epidemic potential requiring urgent research by the World Health Organisation, a better understanding of LF sero-epidemiology is essential to developing and evaluating new interventions including vaccines. We describe the first field testing of a novel species-neutral Double Antigen Binding Assay (DABA) designed to detect antibodies to LF in plasma and oral fluid. Methodology/Principal findings: Paired plasma and oral fluid were collected in Sierra Leone from survivors discharged from Kenema Government Hospital Lassa Fever Unit between 1980 and 2018, and from controls recruited in Freetown in 2019. Epidemiological sensitivity and specificity of the DABA measured against historical diagnosis in survivors and self-declared non-exposed controls was 81.7% (95% CI 70.7%– 89.9%) and 83.3% (72.7%- 91.1%) respectively in plasma, and 71.8% (60.0%– 81.9%) and 83.3% (72.7%– 91.1%) respectively in oral fluid. Antibodies were identified in people infected up to 15 years and, in one case, 40 years previously. Participants found oral fluid collection easy and painless with 80% happy to give an oral fluid sample regularly. Conclusions/Significance: Given the difficulties of assay validation in a resource-limited setting, including unexpected exposures and diagnostics of varying accuracy, the new assay performed well in both plasma and oral fluid. Sensitivity and specificity are expected to be higher when case/control ascertainment is more definitive and further work is planned to investigate this. Even at the performance levels achieved, the species-neutral DABA has the potential to facilitate the large-scale seroprevalence surveys needed to underpin essential developments in LF control, as well as support zoonotic investigations. Author summary: Lassa Fever (LF) is a life-threatening rodent-borne viral haemorrhagic disease of epidemic potential particularly affecting some West African communities. Although it is estimated to cause 100,000–300,000 infections and 5,000 deaths annually, the true burden of the disease in the community is not well understood since research has largely focussed on hospitalised cases (thought to account for ~15% of infections) because of the difficulty of identifying mild or asymptomatic cases in the community. Gaining a better understanding of LF epidemiology, particularly the exposure and immunity status of populations in countries where the virus is endemic in the rodent hosts, is critical to developing control measures including vaccines which can protect against disease and/or reduce risk of epidemic transmission. A key step is to be able to identify who has been previously infected by virus, and therefore likely immune, and who remains susceptible by examining the prevalence of antibodies to the virus in the community. However, to date all tests require blood to be drawn which can be problematic for community participation as well as risky for collectors. This study reports on a project to develop and validate an antibody test that can be used with an easy-to-give oral fluid sample. [ABSTRACT FROM AUTHOR]

Background: There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods: This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory 'Theory of Change' process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention's effectiveness For improving nursing in this pilot setting. Discussion: We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. Trial registration: Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021. [ABSTRACT FROM AUTHOR]

aiman Kanu,1,* Peter Bai James,2,3,* Abdulai Jawo Bah,2,4,5 John Alimamy Kabba,6 Musa Salieu Kamara,1 Christine Ellen Elleanor Williams,7 Joseph Sam Kanu81University of Sierra Leone Teaching Hospital Complex, Connaught Hospital, Freetown, Sierra Leone; 2Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; 3Australian Research Centre in Complementary and Integrative Medicine, School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Sydney, NSW 2007, Australia; 4Faculty of Basic Medical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; 5Institute for Global Health and Development, Queen Margaret University Edinburg, Musselburgh, Scotland, UK; 6Department of Pharmacy Administration and Clinical Pharmacy, Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, People's Republic of China; 7Sierra Leone–China Friendship Hospital, Ministry of Health and Sanitation, Freetown, Sierra Leone; 8Directorate of Disease Prevention and Control, Ministry of Health and Sanitation, Freetown, Sierra Leone*These authors contributed equally to this workCorrespondence: Peter Bai JamesFaculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra LeoneEmail jamepeb@yahoo.com Background: Healthcare workers (HCWs) are known to spearhead the fight against the COVID-19 pandemic. As such, their knowledge, attitude, and practice (KAP) toward coronavirus disease 2019 (COVID-19) are considered critical to the success of the current COVID-19 response efforts. This study aims to determine HCWs' KAP toward COVID-19 and assesses their perception of their healthcare facilities preparedness to respond appropriately to the ongoing COVID-19 pandemic in Sierra Leone. Methods: We conducted an online cross-sectional study among HCWs (n=516) between 1st May 2020 and 30th June 2020. We collected our data using a self-administered structured questionnaire via email and online social media platforms. We analyzed our data using descriptive statistics and regression analysis (p< 0.05). Results: Close to three-fourth of HCWs (n=375, 72.7%) were knowledgeable regarding COVID-19. Doctors were more knowledgeable than community health workers and laboratory technicians (AOR= 2.48, 95% CI: 1.16– 5.31, p=0.019) regarding COVID-19. Close to two-thirds of HCWs (n=301, 58.3%) HCWs show positive attitudes toward COVID-19. Being male (AOR=2.08, 95% CI: 1.36– 3.20, p=0.001) and directly involved in COVID-19 patient care (AOR=3.21, 95% CI: 1.88– 5.48, p< 0.001) were identified as predictors of positive attitude towards COVID-19. HCWs are generally adhering to COVID-19 safe practices with majority indicating that they regularly wash or sanitize their hands (n=510, 98.8%) and used facemask at point of care (n=499, 96.7%). Majority of HCWs are of the view that their healthcare facilities are ill-prepared to adequately respond to COVID-19 with majority (n= 400, 77.5%) of them stating that their facilities lack enough personal protective equipment. Conclusion: HCWs in Sierra Leone showed good knowledge, positive attitude and practice regarding COVID-19. However, HCWs are of the view that their healthcare facilities are ill-prepared to respond adequately to the COVID-19 outbreak. Health authorities and policymakers need to provide the necessary resources to allow HCWs to work in a safe environment. [ABSTRACT FROM AUTHOR]

Introduction: In public health emergencies, local media are important sources of information for the public. Not much is known about the professional and personal roles and experiences of Sierra Leonean journalists during the Ebola virus disease (EVD) outbreak between 2014–2015. Methods/Principal findings: This qualitative study is based on semi-structured interviews with 13 Sierra Leonean journalists based in urban Freetown and rural Waterloo in February and March 2016. The majority of the journalists worked for radio stations. The mostly male journalists represented national, regional and local radio stations. Transcripts of the interviews were analysed using thematic analysis. The analysis was inspired by previously reported journalist roles and agenda-setting theory, which state that the media filter what is happening, making a few core issues more salient. Sierra Leonean journalists shifted from being sceptical monitors in the beginning of the outbreak, to collaborative instructors towards the end. While they adapted to different roles, journalists struggled with their own fears for the virus, which hampered their work. They indicated that the training they received about Ebola helped them overcome their fear. Being trained gave a sense of security that helped them carry out their jobs. By turning into instructors, journalists stepped away from their journalistic professional detachment–potentially exacerbated by their personal experiences. Conclusion/Significance: The first months of the outbreak were marked by passive agenda-setting roles of Sierra Leonean journalists. It took several months before the outbreak became a core issue in local media. In health emergencies, efforts should be made to partner with local media to use their platforms for local, trusted journalists and leaders to disseminate public health messages. Whereas this might hamper journalists' credibility and can be challenging in areas with problematic press freedom, Sierra Leonean journalists experienced the outbreak as a driver of necessary change in their profession. Author summary: Local media are important sources of information for the public during a health emergency. However, not much is known about the roles and experiences of local journalists who have to report under extraordinary circumstances. In this qualitative study, we interviewed Sierra Leonean journalists who reported during the 2014–2015 Ebola outbreak. The thematic analysis shows that the journalists adapted different roles over the course of the outbreak. They went from being sceptical about the existence of an outbreak at the start to changing into instructors at the end of the outbreak. Journalists struggled with their own fear for the virus, which they could overcome through targeted training, that helped them identify safe practices of reporting in the field. Our results show that it is possible to effectively partner with local media to disseminate public health messages. This might be challenging in settings with problematic press freedom, but Sierra Leonean journalists actually felt that the outbreak helped improve their practices. [ABSTRACT FROM AUTHOR]

This article deconstructs a binary that has arisen between prisons as, on the one hand, 'total institutions' of exclusion and, on the other, 'carceral continuums' that incorporate marginalized urban livelihoods. The experiences of four inmates at Pademba Road, Freetown's male prison -- which accommodates inmates with sentences from one year to life -- illustrate that prisons belong in neither camp. Instead, inmates' unique responses to their imprisonment show that both a prison's continuity and its exclusionary mechanism are situational and gendered as crime, social standing, capital and agency coalesce. Following Michel de Certeau's examination of people's reappropriations of culture in everyday life, this article analyses how inmates' tactics to reinforce and bend prison walls work to either strengthen or undermine the carceral system's strategies and influence the prison's permeability. Inmates' embodied experiences allow for a nuanced understanding of the inside/ outside relationship of imprisonment and of the space between mobility and stasis, subjugation, embrace and resistance. [ABSTRACT FROM AUTHOR]

Background: Available data on antibiotic resistance in sub-Saharan Africa is limited despite its increasing threat to global public health. As there is no previous study on antibiotic resistance in patients with clinical features of healthcare-associated infections (HAIs) in Sierra Leone, research is needed to inform public health policies. Our study aimed to assess antibiotic resistance rates from isolates in the urine and sputum samples of patients with clinical features of HAIs. Methodology: We conducted a cross-sectional study of adult inpatients aged ≥18 years at Connaught Hospital, an urban tertiary care hospital in Freetown between February and June 2018. Results: Over the course of the study, we enrolled 164 patients. Risk factors for HAIs were previous antibiotic use (93.3%), comorbidities (58.5%) and age (≥65 years) (23.9%). Of the 164 samples, 89.6% were urine. Bacterial growth was recorded in 58.8% of cultured specimens; the type of specimen was an independent predictor of bacterial growth (p < 0.021). The most common isolates were Escherichia coli and Klebsiella pneumoniae; 29.2% and 19.0% in urine samples and 18.8% and 31.3% in sputum samples, respectively. The overall resistance rates were 58% for all extended-spectrum beta-lactamase (ESBL)-producing organisms, 13.4% for carbapenem-resistant non-lactose fermenting gram-negative bacilli, 8.7% for carbapenem-resistant Acinetobacter baumannii (CRAB) and 1.3% for carbapenem-resistant Enterobacteriaceae (CRE). There were no carbapenem-resistant P. aeruginosa (CRPA) isolates but all Staphylococcus aureus isolates were methicillin-resistant S. aureus. Conclusion: We demonstrated a high prevalence rate of ESBL-producing organisms which are a significant burden at the main tertiary hospital in Sierra Leone. Urgent action is needed to strengthen microbiological diagnostic infrastructure, initiate surveillance on antibiotic resistance and develop and implement policy framework on antibiotic stewardship. [ABSTRACT FROM AUTHOR]

We determine the fault geometry and kinematic slip models of the 2019 Mw 7.7 and 2000 Mw 8.0 earthquakes in Papua New Guinea using measurements from optical image correlation and teleseismic waveforms. The 2000 earthquake ruptured an extensive fault system over a distance of ~150 km including the entire 60‐km long onshore segment of the Weitin fault and its offshore continuation southeast of New Ireland. The northern portion of the onshore Weitin fault segment ruptured again in 2019. Most of the moment was released by a compact, shallow, high stress‐drop slip patch on the northwestern continuation of the Weitin fault in the Saint George Channel, which was brought closer to failure by the 2000 earthquake. The two ruptures overlap over about 20 km but in fact mostly complement each other. Large dynamic stresses may have driven the partial rerupture of the Weitin fault during the 2019 event. Plain Language Summary: The Weitin Fault runs across the southern tip of New Ireland, Papua New Guinea and marks the boundary between the Bismark and the Pacific plate with an interseismic slip rate of ~13 cm/year. On May 14, 2019, it produced a Mw 7.7 earthquake, which according to our optical image correlation results, ruptured the surface for over 30 km and slipped by up to 5 m in a left‐lateral sense. Optical image correlation measurements also show that a previous large earthquake, the Mw 8.0 event in 2000, had ruptured the entire 60‐km onshore segment of the same fault. We use the optical image correlation results and seismological records to produce slip models of the two events to understand how the earlier event may have affected the most recent one. The 2019 earthquake was an unusually compact high stress‐drop (~35 MPa) event, which ruptured an area that was brought closer to failure by the earlier 2000 earthquake but was energetic enough to propagate into the 2000 rupture area over 20 km. Key Points: We invert the rupture process for both of the 2019 Mw 7.7 and 2000 Mw 8.0 earthquakes by using optical images and teleseismic waveformsThe 2019 Mw 7.7 earthquake ruptured the northwestern continuation of the Weitin fault while the 2000 Mw 8.0 earthquake broke the southeast partThe 2019 Mw 7.7 earthquake was more probably driven by the dynamic stresses during the southward propagation of the rupture front [ABSTRACT FROM AUTHOR]

Over the past three decades, Sierra Leone has experienced two major humanitarian crises: an armed conflict (1991–2002) and an Ebola virus disease outbreak (2014–2015). In addition to these country-wide crises, the capital Freetown experienced a mudslide affecting thousands of people in 2017. In response to these emergencies, donors and aid organizations showed an increased interest in supporting and implementing mental health and psychosocial support interventions. Despite these efforts, the mental health infrastructure of the country remains frail. Specifically, systemic improvements in the implementation of evidence-based mental health care for children and adolescents appear to be lacking. In this article, the Interactive Systems Framework for Dissemination and Implementation is used as a tool to analyze issues related to the development of a sustainable, contextually relevant child and adolescent mental health-care delivery system. The author draws on her long-term experience as a child mental health specialist in Sierra Leone. Observations and hypotheses are tested and supplemented by formal and informal reports and national and international literature. The three systems described by the Interactive Systems Framework are explored in the context of Sierra Leone: (1) Synthesis and Translation, (2) Support, and (3) Delivery. Interaction between the three Systems is discussed as critical to the successful dissemination and implementation of interventions. Ample attention is given to contextual factors that are believed to be paramount to the development of child and adolescent mental health care in Sierra Leone. The article concludes with a reflection on the usefulness of the Interactive Systems Framework in the dissemination and implementation of child and adolescent mental health-care interventions in low-resource, postemergency settings. It is suggested that, in addition to funding and policies, the child and adolescent mental health system in Sierra Leone could benefit from the development of contextually relevant interventions, improvement of capacity-building efforts, and acknowledgment of the role of community-based practitioners in the delivery of services. Local mental health experts, especially those trained in child and adolescent mental health, should be empowered to work together with culturally competent expatriate professionals to improve child and adolescent mental health care in Sierra Leone. [ABSTRACT FROM AUTHOR]

Testing the globally popular grapevine rootstocks for affinity with new grape cultivars or tolerance potential to stress factors like drought is essential for districts where supplemental irrigation is more frequently needed due to the pressures of a global climate change. In this study, a seasonal evaluation of leaf gas exchange, leaf temperature, leaf greenness (chlorophyll content prediction) and vegetative development of Vitis vinifera L. cv. 'Prima' grafted to different rootstock genotypes having great variability in drought tolerance, were investigated. The experiment was conducted in a controlled experimental glasshouse on two-year-old soilless grown 'Prima' vines grafted on nine rootstocks [44-53 M, 5 BB, 140 Ru, Ramsey (Syn. Salt Creek), 99 R, Saint George (Syn. Rupestris du Lot), 41 B, 1613 C and 420 A]. A long-term deficit irrigation (DI) was imposed before bud break by reducing water supply to 40% of field capacity derived from concurrent measurements of water content of growth medium and maintained until the end of vegetation period. The rootstocks significantly modulated the physiology and vegetative growth of the scion cultivar in varying degrees according to their genetic features. Among them, 140 Ru rootstock found to be more prominent in terms of mitigating the adverse effect of water deficit on physiology and growth of the scion genotype 'Prima' as there were no significant difference between deficit and full irrigation treatments for most of parameters investigated. In general, the 'Prima' scion performed better when the rootstocks coming from V. berlandieri × V. rupestris pedigree rather than the others including V. berlendieri × V. riparia. [ABSTRACT FROM AUTHOR]

The author talks about his journey to Sierra Leone, two years after an Ebola outbreak devastated the country, in search of a rumored Ebola Museum. The author discusses the trip to the main campus of Njala University in Freetown in search of the museum, and being told that the museum, a brainchild of anthropologist Paul Richards, had been in the making for two years after having received funding but it was not yet operational and did not contain any artifacts.

Background: The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care. Methods: We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. “Effective HIV care” was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care. Results: 408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care. Conclusions: The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care. [ABSTRACT FROM AUTHOR]

Evidence to inform decontamination practices at Ebola holding units (EHUs) and treatment centres is lacking. We conducted an audit of decontamination procedures inside Connaught Hospital EHU in Freetown, Sierra Leone, by assessing environmental swab specimens for evidence of contamination with Ebola virus by RT-PCR. Swabs were collected following discharge of Ebola Virus Disease (EVD) patients before and after routine decontamination. Prior to decontamination, Ebola virus RNA was detected within a limited area at all bedside sites tested, but not at any sites distant to the bedside. Following decontamination, few areas contained detectable Ebola virus RNA. In areas beneath the bed there was evidence of transfer of Ebola virus material during cleaning. Retraining of cleaning staff reduced evidence of environmental contamination after decontamination. Current decontamination procedures appear to be effective in eradicating persistence of viral RNA. This study supports the use of viral swabs to assess Ebola viral contamination within the clinical setting. We recommend that regular refresher training of cleaning staff and audit of environmental contamination become standard practice at all Ebola care facilities during EVD outbreaks. [ABSTRACT FROM AUTHOR]

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

Hepatitis B (HBV) is a major public health threat in Sierra Leone. Pregnant women are disproportionately impacted, yet little is known about the epidemiology of HBV in this group. We conducted a cross-sectional study of pregnant women aged ≥16 years receiving antenatal care across 10 community health centers in Freetown from July to September 2021 to assess the prevalence and associated factors of HBsAg seropositivity. Logistic regression was used to identify the predictors of HBsAg seropositivity. In total, 394 pregnant women were screened. The mean age was 24.4 ± 4.9 years, 78.2% were married, and 47.2% were in the second trimester. Only 1% had received the HBV vaccine. The prevalence of HBsAg was 7.9%, while HIV was 5.8% and HIV/HBV co-infection was 0.3%. Regarding high-risk practices, 76.6% reported female genital circumcision, 41.9% ear piercing, 29.0% endorsed multiple sexual partners, and 23.6% reported sexually transmitted infections. In the logistic regression analysis, having a husband/partner with HBV (adjusted odds ratio (aOR): 6.54; 95% CI: [1.72–24.86]; p = 0.006) and residing in Central Freetown (aOR: 4.00; 95% CI: [1.46–11.00]; p = 0.007) were independently associated with HBsAg seropositivity. Our findings support the scaling up of HBV services to target pregnant women and their partners for screening and vaccination to help reduce mother-to-child transmission rates in Sierra Leone. [ABSTRACT FROM AUTHOR]

The article examines the role of West African urban locations like a city block in Monrovia in the conceptualization of postcolonial African cities. On the basis of the configuration of space, bodies, subjects and violence within specific locations in Freetown in Sierra Leone and Monrovia in Libera, these cities are best understood not in terms of destruction but as zones of excessive production. The most crucial element in the conceptualization is the organization of labor.

As the human population increases, land cover is converted from vegetation to urban development, causing increased runoff from precipitation events. Additional runoff leads to more frequent and more intense floods. In urban areas, these flood events are often catastrophic due to infrastructure built along the riverbank and within the floodplains. Sufficient data allow for flood modeling used to implement proper warning signals and evacuation plans, however, in least developed countries (LDC), the lack of field data for precipitation and river flows makes hydrologic and hydraulic modeling difficult. Within the most recent data revolution, the availability of remotely sensed data for land use/land cover (LULC), flood mapping, and precipitation estimates has increased, however, flood mapping in urban areas of LDC is still limited due to low resolution of remotely sensed data (LULC, soil properties, and terrain), cloud cover, and the lack of field data for model calibration. This study utilizes remotely sensed precipitation, LULC, soil properties, and digital elevation model data to estimate peak discharge and map simulated flood extents of urban rivers in ungauged watersheds for current and future LULC scenarios. A normalized difference vegetation index (NDVI) analysis was proposed to predict a future LULC. Additionally, return period precipitation events were calculated using the theoretical extreme value distribution approach with two remotely sensed precipitation datasets. Three calculation methods for peak discharge (curve number and lag method, curve number and graphical TR-55 method, and the rational equation) were performed and compared to a separate Soil and Water Assessment Tool (SWAT) analysis to determine the method that best represents urban rivers. HEC-RAS was then used to map the simulated flood extents from the peak discharges and ArcGIS helped to determine infrastructure and population affected by the floods. Finally, the simulated flood extents from HEC-RAS were compared to historic flood event points, images of flood events, and global surface water maximum water extent data. This analysis indicates that where field data are absent, remotely sensed monthly precipitation data from Integrated Multi-satellitE Retrievals for GPM (IMERG) where GPM is the Global Precipitation Mission can be used with the curve number and lag method to approximate peak discharges and input into HEC-RAS to represent the simulated flood extents experienced. This work contains a case study for seven urban rivers in Freetown, Sierra Leone. [ABSTRACT FROM AUTHOR]

Medication adherence is an essential step in the malaria treatment cascade. We conducted a qualitative study embedded within a randomized controlled trial comparing the adherence to the recommended dosing of two artemisinin-based combination therapies (ACT) to treat uncomplicated malaria in Freetown, Sierra Leone. This study explored the circumstances and factors that influenced caregiver adherence to the ACT prescribed for their child in the trial. In-depth interviews were conducted with 49 caregivers; all interviews were recorded, transcribed, and translated. Transcripts were coded and aggregated into themes, applying a thematic content approach. We identified four key factors that influenced optimal treatment adherence: (1) health system influences, (2) health services, (3) caregivers' experiences with malaria illness and treatment, and (4) medication characteristics. Specifically, caregivers reported confidence in the health system as facilities were well maintained and care was free. They also felt that health workers provided quality care, leading them to trust the health workers and believe the test results. Ease of medication administration and perceived risk of side effects coupled with caregivers' prior experience treating malaria influenced how medications were administered. To ensure ACTs achieve maximum effectiveness, consideration of these contextual factors and further development of child-friendly antimalarials are needed. [ABSTRACT FROM AUTHOR]

Focuses on the street art in Freetown, Sierra Leone celebrating the republic's 1992 revolution. Background information on the revolution; Overthrow of President J.S. Momoh by Captain Valetine Strasser's military coup; Institution of the new government, the National Provisional Ruling Council (NPRC); Information from the book `Sierra Leonean Heroes'; Themes of the patriotic art.