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AbstractUpdatesThis is the fourteenth and final version of this living guideline published in The BMJ.It replaces earlier versions, available as data supplements. The WHO continues to update the guideline, and readers should refer to their website and the MAGICapp version of the guideline for the latest version.Clinical questionWhat is the role of drugs in the treatment of patients with covid-19?ContextThe evidence base for therapeutics for covid-19 has evolved with numerous randomised controlled trials (RCTs) completed since the inception of the pandemic. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics.What is new?The fourteenth and final BMJ version of the guideline was published on November 10 2023. At that time, the guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication was also changed; recommendations were ordered by severity of covid-19.About this guidelineThis living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. This version and previous versions were published in The BMJ. Updates after 2023 will continue to be available on the WHO website and via MAGICapp. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact.

Background Following the Ebola outbreak in Sierra Leone, the post-Ebola recovery investments in Wellbody Clinic and Koidu Government Hospital provide an opportunity to conduct a more focused examination of facility-level maternal health services and outcomes in the context of COVID-19 pandemic. This study aimed to describe the use of maternal healthcare services and outcomes in these health facilities before, during, and after the COVID-19 pandemic. Methods The study involved analysis of routine programme data (March 2019 to February 2022) from two public health facilities supported by Partners In Health Sierra Leone: Koidu Government Hospital and Wellbody Clinic. Aggregated and de-identified secondary data was abstracted using a standardized tool. Descriptive statistics and bivariable negative binomial regression were used to assess the association between time periods ( pre-COVID-19 period [March 2019 to February 2020], during COVID-19 emergency period [March 2020 to February 2021], after COVID-19 emergency period [March 2021 to February 2022) and outcomes (antenatal care visit and facility deliveries). Results The study analyzed 3,204 fourth antenatal care visits and 7,369 deliveries over 36 months at both health facilities. The fourth antenatal care visits (from 947 to 920) and facility deliveries (from 2309 to 2221) decreased during COVID-19 compared to pre-COVID-19. However, maternal (from 32 to 23) and neonatal (36 to 26) deaths declined during COVID-19 compared to the pre-COVID-19 period at Koidu Government Hospital. Regression analysis showed that relative to the period of COVID-19 emergency period, there were no observable difference in the rate of fourth antenatal care visits in the pre-COVID-19 period [IRR = 1.02, 95%CI: 0.61, 1.72] and during the post-COVID-19 emergency period [IRR = 1.45, 95%CI: 0.87, 2.42]. Relative to the COVID-19 emergency period, there was also no difference observed in maternal deliveries: pre-COVID-19 [IRR = 1.03, 95%CI: 0.69, 1.56] and post-COVID-19 emergency [IRR = 1.28, 95%CI: 0.85, 1.92]. Conclusion In Sierra Leone, the resources and efforts directed to the post-Ebola recovery strategy were tested during and after the COVID-19 pandemic. Our study demonstrates the resilience of maternal and neonatal services in two healthcare facilities in a less-affected region of Sierra Leone, to the anticipated disruptions due to the COVID-19 pandemic.

The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospital's Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3–4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. None.

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

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.

The chapter in the book describing how the group managed to set up a laboratory in the hospital of Ngaliema in Kinshasa, and the following ones in which the author describes the challenge of analysing samples and detecting antibodies against Ebola virus in difficult and uncomfortable settings, can be applied to our need to build isolation units to manage suspected cases of Ebola virus disease in the main hospitals in Sierra Leone-hospitals that did not even have a reliable supply chain of gloves and lacked other basic personal protective equipment. The construction that van der Groen describes made with a few blocks of concrete and rudimentary furniture accompanied by a simple basic generator was similar to our experience of refurbishing an emergency department in Connaught hospital with the few pieces of equipment we could find in the storerooms of the facility: several old beds, pieces of plastic to work as...

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

This study reports on the prevalence and risk factors of chronic HBV among health care workers (HCWs) in a rural secondary hospital in Sierra Leone. Additionally, data on the uptake of HBV vaccination among negatively tested HCWs and on the linkage to care among positively tested HCWs are presented. In December 2019, 781 HCWs were invited to a screening and vaccination campaign at Koidu Government Hospital in Kono District. For each HCW, demographic information and data on their HBV risk history were captured, followed by a hepatitis B surface antigen (HBsAg) test. HCWs with a negative test result were offered an HBV vaccine on the same day, after one and six months. HCWs that were HBsAg positive were linked to a free HBV clinic. In total, 80% (632) of HCWs were screened. Among the screened, 97% had never received an HBV vaccine and 10.3% (n = 65) had chronic HBV. The following characteristics were associated with being HBsAg positive: aged less than 30 years old (aOR 2.17, CI 1.16–4.03, p = 0.01), male gender (aOR 2.0, CI 1.06–3.78, p = 0.03), working experience of 1–4 years (aOR 3.99, CI 1.15–13.73, p = 0.03) and over 9 years (aOR 6.16, CI 1.41–26.9, p = 0.02). For HBsAg-negative HCWs (n = 567), 99.8% (n = 566), 97.5% (n = 553) and 82.7% (n = 469) received their first, second and third dose of the vaccine, respectively. For HBsAg-positive HCWs (n = 65), 73.9% (n = 48) were successfully linked to an HBV clinic for further care. Most HCWs are unvaccinated for HBV, and the HBV prevalence amongst this at-risk group is high. Uptake of vaccination and linkage to care was successful.

The Ebola virus disease epidemic in West Africa has infected 28 457 people and claimed more than 11 000 lives. Many more people may have died from the indirect effects of the epidemic and closure of normal health-care facilities. Unlike other facilities in West Africa, the emergency department in Connaught Hospital, Freetown, Sierre Leone, protected by an onsite Ebola holding unit, continued to provide emergency care throughout the outbreak. We aimed to assess the effect of the outbreak on emergency department attendance and presentation. We also analysed emergency care capacity across Freetown. Attendance data from the emergency department and Ebola holding unit at Connaught Hospital were collected from June 1, 2014, to June 1, 2015. Severity of presentation was derived from South African Triage Score (SATS) assigned at first presentation to the emergency department. A mean severity score was calculated by dividing the number of presentations with a SATS of 1–2 by the total number of presentations. Local prevalence of the disease was counted as RT-PCR positive cases at the Ebola holding unit. Emergency care capacity was assessed at the seven principal hospitals in Freetown in May, 2013, and in April, 2015, with a standardised tool, the Emergency Care Capacity Score (ECCS), specifically designed for the low-income setting. All data were collected in Excel (2013). Stata (version 13) was used for statistical analysis. 8935 patients presented to the emergency department; mean attendance was 172 patients per week (95% CI 153–191), with attendance varying from 41 patients in the week beginning July 28, 2014, to 284 patients in the week beginning May 11, 2015. Emergency department attendance had a negative correlation with local prevalence of Ebola virus disease (r=–0·640, p<0·0001) (appendix). The proportion of severe cases also varied from a peak of 26·5% in week 40 of 2014 (a period of high local prevalence, 74·6%) to 3·2% in week 28 of 2014 before any case had occurred in Freetown. The mean severity of presentation was 11·9% (95% CI 10·3–13·4). The ECCS was reduced across all domains except the systems domain (appendix). Total ECCS for all seven hospitals decreased by 10% from 2013 to 2015, and all facilities showed a decrease in their individual ECCS score. The reduction in attendance probably demonstrates both a change in health-seeking behaviour—ie, great public fear of hospitals because of the perceived risk of nosocomial transmission of the virus—and a reduction in access to care. The decrease in emergency care capacity was expected and reflects the closure of many health services other than those for Ebola virus disease. Overall, this is an important case study of the impact of an infectious disease outbreak on a tertiary referral hospital in a low-income setting. None.

The Corona Virus Disease 2019 (COVID-19) pandemic has rapidly spread in Africa, with a total of 474,592 confirmed cases by 11 July 2020. Consequently, all policy makers and health workers urgently need to be trained and to access the most credible information to contain and mitigate its impact. While the need for rapid training and information dissemination has increased, most of Africa is implementing public health social and physical distancing measures. Responding to this context requires broad partnerships and innovative virtual approaches to disseminate new insights, share best practices, and create networked communities of practice for all teach, and all learn. The World Health Organization (WHO)-Africa region, in collaboration with the Extension for Community Health Outcome (ECHO) Institute at the University of New Mexico Health Sciences Center (UNM HSC), the West Africa college of nurses and the East Central and Southern Africa college of physicians, private professional associations, academia and other partners has embarked on a virtual training programme to support the containment of COVID-19. Between 1 April 2020 and 10 July 2020, about 7,500 diverse health professionals from 172 locations in 58 countries were trained in 15 sessions. Participants were from diverse institutions including: central ministries of health, WHO country offices, provincial and district hospitals and private medical practitioners. A range of critical COVID-19 preparedness and response interventions have been reviewed and discussed. There is a high demand for credible information from credible sources about COVID-19. To mitigate the \"epidemic of misinformation\" partnerships for virtual trainings and information dissemination leveraging existing learning platforms and networks across Africa will augment preparedness and response to COVID-19.