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Ridout AE, Moses FL, Herm-Singh S, Turienzo CF, Seed PT, Goodhart V, Vousden N, Sam B, Momoh M, Kamara D, Kuhrt K, Samura S, Beoku-Betts C, Hurrell A, Bramham K, Kenneh S, Smart F, Chappell L, Sandall J, Shennan A. CRADLE-5: a stepped-wedge type 2 hybrid implementation-effectiveness cluster randomised controlled trial to evaluate the real-world scale-up of the CRADLE Vital Signs Alert intervention into routine maternity care in Sierra Leone-study protocol. Trials 2023; 24:590. [PMID: 37723530 PMCID: PMC10506317 DOI: 10.1186/s13063-023-07587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The CRADLE Vital Signs Alert intervention (an accurate easy-to-use device that measures blood pressure and pulse with inbuilt traffic-light early warning system, and focused training package) was associated with reduced rates of eclampsia and maternal death when trialled in urban areas in Sierra Leone. Subsequently, implementation was successfully piloted as evidenced by measures of fidelity, feasibility and adoption. The CRADLE-5 trial will examine whether national scale-up, including in the most rural areas, will reduce a composite outcome of maternal and fetal mortality and maternal morbidity and will evaluate how the CRADLE package can be embedded sustainably into routine clinical pathways. METHODS CRADLE-5 is a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care across eight rural districts in Sierra Leone (Bonthe, Falaba, Karene, Kailahun, Koinadugu, Kono, Moyamba, Tonkolili). Each district will cross from control to intervention at six-weekly intervals over the course of 1 year (May 2022 to June 2023). All women identified as pregnant or within six-weeks postpartum presenting for maternity care in the district are included. Primary outcome data (composite rate of maternal death, stillbirth, eclampsia and emergency hysterectomy) will be collected. A mixed-methods process and scale-up evaluation (informed by Medical Research Council guidance for complex interventions and the World Health Organization ExpandNet tools) will explore implementation outcomes of fidelity, adoption, adaptation and scale-up outcomes of reach, maintenance, sustainability and integration. Mechanisms of change and contextual factors (barriers and facilitators) will be assessed. A concurrent cost-effectiveness analysis will be undertaken. DISCUSSION International guidance recommends that all pregnant and postpartum women have regular blood pressure assessment, and healthcare staff are adequately trained to respond to abnormalities. Clinical effectiveness to improve maternal and perinatal health in more rural areas, and ease of integration and sustainability of the CRADLE intervention at scale has yet to be investigated. This trial will explore whether national scale-up of the CRADLE intervention reduces maternal and fetal mortality and severe maternal adverse outcomes and understand the strategies for adoption, integration and sustainability in low-resource settings. If successful, the aim is to develop an adaptable, evidence-based scale-up roadmap to improve maternal and infant outcomes. TRIAL REGISTRATION ISRCTN 94429427. Registered on 20 April 2022.
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Affiliation(s)
- Alexandra E Ridout
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Francis L Moses
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Cristina Fernandez Turienzo
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Nicola Vousden
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Betty Sam
- Welbodi Partnership, Freetown, Sierra Leone
| | - Mariama Momoh
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Katy Kuhrt
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Sorie Samura
- National Emergency Medical Service, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Candace Beoku-Betts
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Alice Hurrell
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Kate Bramham
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Sartie Kenneh
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Francis Smart
- Reproductive Health and Family Planning, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Lucy Chappell
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
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Syed U, Kinney MV, Pestvenidze E, Vandy AO, Slowing K, Kayita J, Lewis AF, Kenneh S, Moses FL, Aabroo A, Thom E, Uzma Q, Zaka N, Rattana K, Cheang K, Kanke RM, Kini B, Epondo JBE, Moran AC. Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes. Front Glob Womens Health 2022; 3:909991. [PMID: 36299801 PMCID: PMC9589433 DOI: 10.3389/fgwh.2022.909991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.
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Affiliation(s)
- Uzma Syed
- World Health Organization, Geneva, Switzerland
| | - Mary V. Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | | | - Karin Slowing
- Pan American Health Organization, Guatemala City, Guatemala
| | - Janet Kayita
- World Health Organization, Freetown, Sierra Leone
| | | | - Sartie Kenneh
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | | | - Ellen Thom
- World Health Organization, Islamabad, Pakistan
| | - Qudsia Uzma
- World Health Organization, Islamabad, Pakistan
| | - Nabila Zaka
- World Health Organization, Islamabad, Pakistan
| | - Kim Rattana
- National Maternal and Child Health Centre, Phnom Penh, Cambodia
| | | | - Robert M. Kanke
- World Health Organization, Kinshasa, Democratic Republic of Congo
| | - Brigitte Kini
- World Health Organization, Kinshasa, Democratic Republic of Congo
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Mansaray AHD, Yankson DPY, Johnson RAB, Moses FL, Kanu JS, Kamara IF, Zachariah R, Kumar AMV, Selvaraj K. Bacterial Isolates and Antibiotic Resistance of Escherichia coli Isolated from Fresh Poultry Excreta Used for Vegetable Farming in Freetown, Sierra Leone. Int J Environ Res Public Health 2022; 19:ijerph19095405. [PMID: 35564800 PMCID: PMC9100810 DOI: 10.3390/ijerph19095405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/28/2022] [Accepted: 04/13/2022] [Indexed: 01/13/2023]
Abstract
The transfer of antibiotic resistance from animals to humans is of concern in recent times. One potential source of such transfer is the untreated poultry excreta used as manure in farming. We aim to identify bacterial isolates and antibiotic susceptibility patterns of Escherichia coli in poultry excreta in Sierra Leone. This was a cross-sectional study of fresh poultry excreta samples collected from four commercial poultry sites in Freetown, Sierra Leone, from June−September 2021. Bacterial isolates were tested against eight antibiotics using established standards. Of 100 samples, 93 showed Escherichia coli (93%): of those, eight isolates also had Salmonella (8%). E. coli was 100% resistant to all three ‘Watch’ drugs (erythromycin, cefoxitin and streptomycin) and tetracycline. E. coli was least resistant to ampicillin (12%), followed by chloramphenicol (35%). The prevalence of multidrug resistance was 95.6%. Multiple antibiotic resistance index ranged from 0.5−0.7 (optimal < 0.2), indicating high prior exposure to antibiotics in these poultries. Such high levels of resistance in E. coli isolated from poultry excreta could pose a serious threat to humans. We recommend (i) routine surveillance to monitor antibiotic resistance in poultry excreta, (ii) using poultry excreta as manure only after treatment and (iii) restricting the use of antibiotics as prophylactics and growth promoters in poultry feeds.
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Affiliation(s)
- Alie H. D. Mansaray
- Senior Agriculture Officer, Crops Division, Ministry of Agriculture and Forestry, West Wing, Youyi Building, Brookfields, Freetown 00232, Sierra Leone; (D.P.Y.Y.); (R.A.B.J.)
- Correspondence: ; Tel.: +232-78-422976
| | - Dennis P. Y. Yankson
- Senior Agriculture Officer, Crops Division, Ministry of Agriculture and Forestry, West Wing, Youyi Building, Brookfields, Freetown 00232, Sierra Leone; (D.P.Y.Y.); (R.A.B.J.)
| | - Raymonda A. B. Johnson
- Senior Agriculture Officer, Crops Division, Ministry of Agriculture and Forestry, West Wing, Youyi Building, Brookfields, Freetown 00232, Sierra Leone; (D.P.Y.Y.); (R.A.B.J.)
| | - Francis L. Moses
- Directorate of Reproductive and Child Health, Ministry of Health and Sanitation, Youyi Building, Brookfields, Freetown 00232, Sierra Leone;
- Faculty of Basic Medical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown 00232, Sierra Leone
| | - Joseph Sam Kanu
- National Disease Surveillance Program, Ministry of Health and Sanitation, Sierra Leone National Public Health Emergency Operations Centre, Cockerill, Wilkinson Road, Freetown 00232, Sierra Leone;
- Department of Community Health, Faculty of Clinical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown 00232, Sierra Leone
| | - Ibrahim Franklyn Kamara
- World Health Organization, 21A-B Riverside, Off King Harman Road Freetown, Freetown 00232, Sierra Leone; or
| | - Rony Zachariah
- Special Program for Research and Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland;
| | - Ajay M. V. Kumar
- International Union against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France;
- International Union against Tuberculosis and Lung Disease, South-East Asia Office, C-6 Qutub Institutional Area, New Delhi 110016, India
- Yenepoya Medical College, Yenepoya (Deemed to be University), University Road, Deralakatte, Mangalore 575018, India
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Mahto M, Chaudhary M, Shah A, Show KL, Moses FL, Stewart AG. High antibiotic resistance and mortality with Acinetobacter species in a tertiary hospital, Nepal. Public Health Action 2021; 11:13-17. [PMID: 34778010 DOI: 10.5588/pha.21.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Nepal Mediciti Hospital, Bhainsepati, Lalitpur, Nepal. OBJECTIVES To determine antimicrobial resistance patterns, and the number and proportion of multidrug-resistant (MDR-) and extensively drug-resistant (XDR-) cases among all patients with Acinetobacter isolates between September 2018 and September 2019. DESIGN This was a hospital laboratory-based, cross-sectional study. RESULTS Acinetobacter spp. (n = 364) were more common in respiratory (n = 172, 47.3%) and invasive samples such as blood, body fluids (n = 95, 26.1%). Sensitivity to AWaRe (Access, Watch and Reserve) Group antibiotics (tigecycline, polymyxin B, colistin) remained high. MDR (resistance to at least three classes of antimicrobial agents) (n = 110, 30.2%) and XDR (MDR plus carbapenem) (n = 87, 23.9%) isolates were most common in the Watch Group of antibiotics and found in respectively 99 (31.0%) and 78 (24.5%) patients (n = 319). Infected patients were more likely to be aged >40 years (n = 196, 61.4%) or inpatients (n = 191, 59.9%); 76 (23.8%) patients had an unfavourable outcome, including death (n = 59, 18.5%). CONCLUSION A significant proportion of MDR and XDR isolates was found; nearly one patient in five died. Robust hospital infection prevention and control measures (particularly for respiratory and invasive procedures) and routine surveillance are needed to reduce infections and decrease the mortality rate. Tigecycline, polymyxin B and colistin should be cautiously used only in MDR and XDR cases.
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Affiliation(s)
- M Mahto
- Nepal Mediciti Hospital, Bhainsepati, Lalitpur, Nepal
| | - M Chaudhary
- Nepal Mediciti Hospital, Bhainsepati, Lalitpur, Nepal
| | - A Shah
- Kist Medical College and Teaching Hospital, Nepal
| | - K L Show
- Department of Medical Research, Yangon, Myanmar
| | - F L Moses
- Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone.,College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - A G Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, UK
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Mahto M, Shah A, Show KL, Moses FL, Stewart AG. Pseudomonas aeruginosa in Nepali hospitals: poor outcomes amid 10 years of increasing antimicrobial resistance. Public Health Action 2021; 11:58-63. [PMID: 34778017 DOI: 10.5588/pha.21.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To determine antimicrobial resistance patterns and prevalence of multi- (MDR, i.e., resistant to ⩾3 classes of antimicrobial agents) and extensively (XDR, i.e., resistant to ⩾3, susceptible to ⩽2 groups of antibiotics) drug-resistant strains of Pseudomonas aeruginosa. METHODS This was a cross-sectional study conducted in Nepal Mediciti Hospital, Lalitpur, Nepal, using standard microbiological methods with Kirby Bauer disc diffusion to identify antimicrobial susceptibility. RESULTS P. aeruginosa (n = 447) were most frequently isolated in respiratory (n = 203, 45.4%) and urinary samples (n = 120, 26.8%). AWaRe Access antibiotics showed 25-30% resistance, Watch antibiotics 30-55%. Susceptibility to AWaRe Reserve antibiotics remains high; however, 32.8% were resistant to aztreonam. Overall, 190 (42.5%) were MDR and 99 (22.1%) XDR (first Nepali report) based on mainly non-respiratory samples. The majority of infected patients were >40 years (n = 229, 63.2%) or inpatients (n = 181, 50.0%); 36 (15.2%) had an unfavourable outcome, including death (n = 25, 10.5%). Our larger study showed a failure of improvement over eight previous studies covering 10 years. CONCLUSION Antibiotic resistance in P. aeruginosa occurred to all 19 AWaRe group antibiotics tested. Vulnerable patients are at significant risk from such resistant strains, with a high death rate. Sustainable and acceptable antibiotic surveillance and control are urgently needed across Nepal, as antimicrobial resistance has deteriorated over the last decade.
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Affiliation(s)
- M Mahto
- Nepal Mediciti Hospital, Lalitpur, Nepal
| | - A Shah
- Kist Medical College and Teaching Hospital, Lalitpur, Nepal
| | - K L Show
- Department of Medical Research, Yangon, Myanmar
| | - F L Moses
- Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone.,College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - A G Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, UK
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Yadav SK, Agrawal SK, Singh SK, Giri A, Singh GK, Ghimire R, Stewart AG, Show KL, Moses FL. Antimicrobial resistance in neonates with suspected sepsis. Public Health Action 2021; 11:6-12. [PMID: 34778009 PMCID: PMC8575386 DOI: 10.5588/pha.21.0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022] Open
Abstract
SETTING Nobel Medical College and Teaching Hospital, Biratnagar, Nepal. OBJECTIVE To determine the pattern of antimicrobial resistance and hospital exit outcomes in neonates with suspected sepsis in a tertiary neonatal intensive care unit (NICU). DESIGN This hospital-based cohort study was conducted to follow patients from January to December 2019. All identified cases of suspected sepsis were enlisted from hospital records. RESULTS Sepsis was suspected in 177 (88%) of the 200 cases admitted in the NICU; 52 (29%) were culture-positive. Pseudomonas was the predominant organism isolated (n = 40; 78%), followed by coagulase negative staphylococcus (n = 12, 23%). Nine (17%) of the 52 isolates were resistant to the Access and Watch group of antibiotics, including some resistance to Reserve group drugs such as imipenem and linezolid. Most treated cases (n = 170, 96%) improved, although 7 (4%) left against medical advice. CONCLUSION Most of the pathogens were resistant to WHO Access and Watch antibiotics and occasional resistance was observed to Reserve group drugs. Most sepsis was caused by Gram-negative bacilli. Improving turnaround times for antibiotic sensitivity testing using point-of-care testing, and a greater yield of culture-positive results are needed to enhance the management of neonatal sepsis.
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Affiliation(s)
- S K Yadav
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - S K Agrawal
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - S K Singh
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - A Giri
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - G K Singh
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - R Ghimire
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - A G Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, UK
| | - K L Show
- Department of Medical Research, Yangon, Myanmar
| | - F L Moses
- Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Moses FL, Tamang D, Denisiuk O, Dumbuya U, Hann K, Zachariah R. Management of malaria in children with fever in rural Sierra Leone in relation to the 2014-2015 Ebola outbreak. Public Health Action 2017; 7:S22-S26. [PMID: 28744435 DOI: 10.5588/pha.16.0085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/12/2016] [Indexed: 11/10/2022] Open
Abstract
Setting: Sixty-eight primary health facilities, Koinadugu District, rural Sierra Leone. Objectives: Sierra Leone, a country with one of the highest burdens of malaria, was severely affected by the 2014-2015 Ebola virus disease outbreak. In under-five children, we compared trends in the completeness of malaria reports sent to the district office during the pre-Ebola, Ebola and post-Ebola periods, including the number of children with reported fever, malaria diagnostic testing performed and treatment for malaria initiated with artemisinin-based combination therapy (ACT). Design: A cross-sectional study. Results: Of 1904 expected malaria reports, 1289 (68%) were received. Completeness of reporting was 61% pre-Ebola, increased to 88% during the outbreak and dropped to 44% post-Ebola (P = 0.003). Total malaria testing (n = 105 558) exceeded the number of fever cases (n = 105 320). Pre-Ebola, 75% (n = 43 245) of all reported fever cases received malaria treatment, dropping to 34% (n = 50 453) during the Ebola outbreak. Of 36 804 confirmed malaria cases during Ebola, 17 438 (47%) were treated, significantly fewer than in the pre-Ebola period (96%, P < 0.001). Of the fever cases, 95% in both the pre- and post-Ebola periods received ACT, a rate that increased to 99% during the Ebola outbreak. Conclusion: Pre-existing gaps in malaria reporting worsened after the Ebola outbreak. Reassuringly, malaria testing matched fever cases, although only half of all confirmed cases received treatment during the outbreak, possibly explained by outbreak-related operational difficulties. These findings could be useful to guide health systems strengthening and recovery.
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Affiliation(s)
- F L Moses
- Koinadugu District Health Management Team, Ministry of Health and Sanitation, Koinadugu, Sierra Leone
| | - D Tamang
- International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India
| | - O Denisiuk
- Alliance for Public Health, Kiev, Ukraine
| | - U Dumbuya
- Koinadugu District Health Management Team, Ministry of Health and Sanitation, Koinadugu, Sierra Leone
| | - K Hann
- Partners in Health, Freetown, Sierra Leone
| | - R Zachariah
- Médecins Sans Frontières, Medical Department, Operational Centre Brussels, Luxembourg
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