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The paper examines the health system’s response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013–16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients’ experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients’ livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

Objectives To assess the feasibility, repeatability, validity and responsiveness of the EQ-5D-3L in Krio for patients with stroke in Sierra Leone, the first psychometric assessment of the EQ-5D-3L to be conducted in patients with stroke in Sub Saharan Africa. Methods A prospective stroke register at two tertiary government hospitals recruited all patients with the WHO definition of stroke and followed patients up at seven days, 90 days and one year post stroke. The newly translated EQ-5D-3L, Barthel Index (BI), modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS), a measure of stroke severity, were collected by trained researchers, face to face during admission and via phone at follow up. Feasibility was assessed by completion rate and proportion of floor/ceiling effects. Internal consistency was assessed by inter item correlations (IIC) and Cronbach’s alpha. Repeatability of the EQ-5D-3L was examined using test–retest, EQ-5D-3L utility scores at 90 days were compared to EQ-5D-3L utility scores at one year in the same individuals, whose Barthel Index had remained within the minimally clinical important difference. Known group validity was assessed by stroke severity. Convergent validity was assessed against the BI, using Spearman’s rho. Responsiveness was assessed in patients whose BI improved or deteriorated from seven to 90 days. Sensitivity analyses were conducted using the UK and Zimbabwe value sets, to evaluate the effect of value set, in a subgroup of patients with no formal education to evaluate the influence of patient educational attainment, and using the mRS instead of the BI to evaluate the influence of utilising an alternative functional scale. Results The EQ-5D-3L was completed in 373/460 (81.1%), 360/367 (98.1%) and 299/308 (97.1%) eligible patients at seven days, 90 days and one year post stroke. Missing item data was low overall, but was highest in the anxiety/depression dimension 1.3% (5/373). Alpha was 0.81, 0.88 and 0.86 at seven days, 90 days and one year post stroke and IIC were within pre-specified ranges. Repeatability of the EQ-5D-3L was moderate to poor, weighted Kappa 0.23–0.49. EQ-5D-3L utility was significantly associated with stroke severity at all timepoints. Convergent validity with BI was strong overall and for shared subscales. EQ-5D-3L was moderately responsive to both improvement Cohen’s D 0.55 (95% CI:0.15—0.94) and deterioration 0.92 (95% CI:0.29—1.55). Completion rates were similar in patients with no formal education 148/185 (80.0%) vs those with any formal education 225/275 (81.8%), and known group validity for stroke severity in patients with no formal education was strong. Using the Zimbabwe value set instead of the UK value set, and using the mRS instead of the BI did not change the direction or significance of results. Conclusions The EQ-5D-3L for stroke in Sierra Leone was feasible, and responsive including in patients with no formal education. However, repeatability was moderate to poor, which may be due to the study design, but should add a degree of caution in the analysis of repeated measures of EQ-5D-3L over time in this population. Known group validity and convergent validity with BI and mRS were strong. Further research should assess the EQ-5D in the general population, examine test–retest reliability over a shorter time period and assess the acceptability and validity of the anxiety/depression dimension against other validated mental health instruments. Development of an EQ-5D value set for West Africa should be a research priority.

Background Stroke is a leading cause of disability and mortality globally. Despite growing awareness of the stroke epidemic, there is limited understanding of the lived experiences and perspectives of stroke care within resource-constrained health systems. This study explored the experiences and perspectives of stroke survivors, primary caregivers and healthcare providers on stroke care in Sierra Leone. Methods This qualitative descriptive study involved face-to-face semi-structured interviews with stroke survivors, informal caregivers, and healthcare providers between December 2020 and August 2021 in Sierra Leone. We purposively sampled participants to capture diverse experiences across the care continuum. Data were analysed thematically using a constant comparative approach and interpretative phenomenological analysis, triangulating perspectives across participant groups. Results Five interconnected themes emerged and are grouped into three categories: (1) Health-seeking behaviour: delayed hospital presentation, financial burden and out-of-pocket costs; (2) Health service delivery: hospital care experiences, access to and continuity of physiotherapy and; (3) Perceived impact and recommendation: recommendations for systemic improvements. Stroke survivors and caregivers reported a lack of knowledge of stroke symptoms, considering traditional treatment or religious consultation as the first point of contact, resulted in considerable delay in seeking hospitalisation. Other major barriers were related to challenges in accessing physiotherapy services and the financial hardship associated with stroke care. The dependence of stroke survivors on their caregivers as a result of staffing shortages and frequent communication breakdowns was frequently reported during hospitalisation. National health policies on stroke care, dedicated stroke units, community physiotherapy programmes and funding support were recommended. Conclusion Stroke care in Sierra Leone is limited by systemic barriers that include infrastructure, cost, and accessibility. To bridge these gaps, community-based stroke education, health insurance schemes, workforce stroke-care training, and organised stroke-care delivery are needed. These results offer actionable recommendations for improving stroke care and service delivery in resource-constrained settings.

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.

IntroductionThe COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone.MethodsMixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student’s t-test. Qualitative data were analysed using thematic analysis.ResultsFrom Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship.ConclusionThe study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

ObjectivesTo study the mortality of patients with COVID-19 in Sierra Leone, to explore the factors associated with mortality during the COVID-19 pandemic and to highlight the complexities of treating patients with a novel epidemic disease in a fragile health system.Study designA prospective single-centre cohort study. Data were extracted from paper medical records and transferred onto an electronic database. Specific indicators were compared between survivors and non-survivors, using descriptive statistics in Stata V.17.Study settingThe infectious diseases unit (IDU) at Connaught Hospital in Freetown, Sierra LeoneParticipantsParticipants were all patients admitted to the IDU between March and July 2020.Aims of studyThe primary outcome of the study was to examine the all-cause mortality of hospitalised patients with suspected COVID-19 in Sierra Leone and the secondary outcome measures were to examine factors associated with mortality in patients positive for COVID-19.Results261 participants were included in the study. Overall, 41.3% of those admitted to the IDU died, compared with prepandemic in-hospital mortality of 23.8%. Factors contributing to the higher mortality were COVID-19 infection (aOR 5.61, 95% CI 1.19 to 26.30, p=0.02) and hypertension (aOR 9.30, 95% CI 1.18 to 73.27, p=0.03)ConclusionsThis study explores the multiple factors underpinning a doubling in facility mortality rate during the COVID-19 pandemic in Sierra Leone . It provides an insight into the realities of providing front-line healthcare during a pandemic in a fragile health system.

IntroductionStroke is now the second leading cause of adult death in Sub-Saharan Africa. Developed in dialogue with stroke survivors and caregivers in Sierra Leone, this will be the first study to explore the experience of stroke as well as the perceptions of the barriers and facilitators to accessing stroke care among stroke survivors, informal caregivers and healthcare providers. Findings will inform future stroke research and care in Sierra Leone.Methods and analysisA cross-sectional qualitative study employing semistructured interviews that will be audiorecorded, translated, transcribed and coded.SettingFreetown, Sierra Leone.ParticipantsInterviews with a purposive sample of stroke survivors, informal caregivers and healthcare providers.AnalysisInterviews will be coded by two authors and inductively analysed using thematic analysis.Ethics and disseminationThis study has received ethical approval from the Sierra Leone Ethics and Scientific Review Committee (8 December 2020) and the KCL Biomedical & Health Sciences, Dentistry, Medicine and Natural & Mathematical Sciences Research Ethics Subcommittee (reference: HR-20/21-21050). The findings of the study and learning in terms of the process of coproduction and involvement of stroke survivors will be disseminated via peer-reviewed publications, conferences, media and lay reports.

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.

IntroductionSierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.MethodsWe collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.ResultsAt the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%.ConclusionNEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.

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.