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BackgroundSpatial epidemiology is useful but difficult to apply in developing countries due to the low availability of digitized maps and address systems, accurate population distributions, and computational tools. A community-based mapping approach was used to demonstrate that participatory geographic information system (PGIS) techniques can provide information helpful for health and community development.ResultsThe PGIS process allowed for the rapid determination of sectional (neighborhood) boundaries within the city of Bo, Sierra Leone. When combined with data about hospital laboratory visits, a catchment area for one hospital in Bo could be established. A survey of households from within the catchment area determined that the average population per household (about 6 individuals) was similar to that found in the 2004 census. However, we also found that the average house was inhabited by more than one household, for an average of 17.5 inhabitants per residential building, which is critical information to know when estimating population size using remote imagery that can detect and enumerate buildings.ConclusionsThe methods developed in this paper serve as a model for the involvement of communities in the generation of municipal maps and their application to community and health concerns.

fWe describe the results of a molecular epidemiological survey of 15 carbapenemase-encoding genes from a recent collection of clinical isolates from Mercy Hospital in Bo, Sierra Leone. The most salient findings revealed that (i) 60% of the isolates harbored multiple carbapenemase genes; (ii) the bla DIM-1 gene, which has previously only been reported in The Netherlands, is also circulating in this environment; and (iii) bla OXA-51-like and bla OXA-58 genes, which were thought to reside exclusively in Acinetobacter species, can also be found in members of the Enterobacteriaceae. Carbapenem antibiotics are currently the most potent ␤-lactam antibiotics clinically available and are used as a last resort to treat infections caused by multidrug-resistant Gram-negative pathogens. The significance and usage of this family of antibiotics have risen dramatically over the last decade, especially in hospital settings, due to the global spread and increasing prevalence of bacterial pathogens that harbor extended-spectrum ␤-lactamase genes that confer resistance to all ␤-lactam compounds except for carbapenems (1). Not surprisingly, the positive selection pressure provided by the increased usage of carbapenems has resulted in the emergence and expansion of carbapenem resistance in a number of common nosocomial pathogenic species (1).Carbapenem resistance is mediated mostly by ␤-lactamase enzymes that are capable of hydrolyzing carbapenem compounds (carbapenemases) and often differ in host microorganism range, substrate specificity, and ␤-lactamase inhibitor sensitivity (2, 3). Furthermore, carbapenemases are frequently found in pathogenic strains that contain additional genetic determinants that confer resistance to aminoglycosides, tetracyclines, ␤-lactams, and fluoroquinolones and can result in intractable infections with high mortality rates (4, 5). The spread of Ambler class A, B, and D carbapenemase genes, which were encountered only rarely less than 2 decades ago, has been facilitated by conjugative plasmids, transposons, and integrons to such an extent that carbapenemase genes have now been reported worldwide (2). Despite this fact and the clinical impact of these genes, the true incidence and prevalence of carbapenem resistance and carbapenemase genes are still unknown, as many countries do not track and report antibiotic resistance rates; this is particularly true in many African countries (1).To better understand the level, distribution, and evolution of multidrug resistance in environments that currently lack a national antibiotic stewardship policy, we initiated a molecular epidemiology surveillance program at Mercy Hospital in Bo, Sierra Leone. The preliminary evidence, obtained using an antimicrobial resistance determinant microarray as a screening tool (6), indicated the presence of class B metallo-␤-lactamase (MBL) and class D carbapenem-hydrolyzing ␤-lactamase (CHDL) genes in this environment. In this study, we utilized PCR and DNA sequencing to target 15 carbapenemase genes (bla , bla , bla OXA-48 ,

The factors that influence the selection of a healthcare provider once the decision to seek care has been made can be summarized using a triad of cost, location and reputation. The goal of this study was to identify which of these factors is the primary consideration when women in urban Bo, Sierra Leone, select a healthcare provider for themselves or their children. We interviewed 1091 mothers during a household census of two neighbourhoods of Bo in April 2010. Reputation was the top consideration for about half of the women, cost was the second most common priority, and the location of the healthcare facility was the primary consideration for less than 7% of the participants. The majority of women said they would select a new provider if cost was not a barrier. Socioeconomic characteristics were not significant predictors of whether cost, location or reputation was selected as the highest-ranked consideration. This evidence for the importance of reputation in healthcare decision-making even in low-resource areas highlights the need for health systems to address issues of quality and responsiveness, and not just cost, in order to increase access to and utilization of health services.

The diverse health-care marketplace in Bo allows women to select clinical facilities from across the city. Most women prefer a malaria care provider farther from home than they could comfortably walk when ill.