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IntroductionSierra Leone has the world’s highest maternal mortality, partly due to low access to caesarean section. Limited data are available to guide improvement. In this study, we aimed to analyse the rate and mortality of caesarean sections in the country.MethodsWe conducted a retrospective study of all caesarean sections and all reported in-facility maternal deaths in Sierra Leone in 2016. All facilities performing caesarean sections were visited. Data on in-facility maternal deaths were retrieved from the Maternal Death Surveillance and Response database. Caesarean section mortality was defined as in-facility perioperative mortality.ResultsIn 2016, there were 7357 caesarean sections in Sierra Leone. This yields a population rate of 2.9% of all live births, a 35% increase from 2012, with district rates ranging from 0.4% to 5.2%. The most common indications for surgery were obstructed labour (42%), hypertensive disorders (25%) and haemorrhage (22%). Ninety-nine deaths occurred during or after caesarean section, and the in-facility perioperative caesarean section mortality rate was 1.5% (median 0.7%, IQR 0–2.2). Haemorrhage was the leading cause of death (73%), and of those who died during or after surgery, 80% had general anaesthesia, 75% received blood transfusion and 22% had a uterine rupture diagnosed.ConclusionsThe caesarean section rate has increased rapidly in Sierra Leone, but the distribution remains uneven. Caesarean section mortality is high, but there is wide variation. More access to caesarean sections for maternal and neonatal complications is needed in underserved areas, and expansion should be coupled with efforts to limit late presentation, to offer assisted vaginal delivery when indicated and to ensure optimal perioperative care.

Background Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task‐sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors. Methods All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non‐inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity. Results Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42). Conclusion Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task‐sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

Background: Ebola Virus Disease (EVD) has ravaged three countries in West Africa. The mortality rate is extremely high, and it is perceived not only as threat to all of Africa but to the entire world. There is no known treatment to date other than administration of convalescent blood or experimental monoclonal antibodies, which both often fail. Ozone therapy (OT) has been in clinical use for decades and has been found to have physiological effects, which should directly inactivate the virus itself, as well as modulate its damaging effects. We present the scientific background and the possibility of ozone therapy as a cure or prevention for EVD in five consecutive patients. Materials and Methods: Ozone therapy administration by a combination of direct intravenous gas administration, rectal gas administration and ozonized water was administered to three patients with known acute EVD, one with apparent acute infection, and one case of extremely high risk. Treatment was carried out for up to ten days despite fast total remission of symptoms. Vitamin C and glutathione supporting supplements were administered. Results: Four symptomatic patients, three with test positive EVD confirmation and one (who suffered Ebola contaminated needle stick contamination three days earlier) without lab confirmation all remitted symptoms within 2-4 days and fully recovered. All four ill cases had an immediate recovery course upon initiation of therapy. The single case of non-symptomatic high-risk exposure treated preventively did not develop symptoms. Conclusion: Ebola virus may have a very narrow window of redox infectivity capacity, which can be easily exploited with OT. OT may be a useful modality in EVD and other viral diseases and should be immediately studied to save lives that might otherwise be lost.

Background Malaria infection affects the immune response to some vaccines. As Ebola virus (EBOV) outbreaks have occurred mainly in malaria-endemic countries, we have assessed whether asymptomatic malaria affects immune responses to the 2-dose Ad26.ZEBOV, MVA-BN-Filo Ebola vaccine regimen. Methods In this sub-study of the EBOVAC-Salone Ebola vaccine trial in Sierra Leone, malaria microscopy was performed at the time of Ebola vaccination. Participants with symptomatic malaria were treated before vaccination. Ebola vaccine responses were assessed post-dose 1 (day 57) and post-dose 2 (day 78) by the EBOV glycoprotein FANG enzyme-linked immunosorbent assay (ELISA), and responses expressed as geometric mean concentrations (GMCs). Geometric mean ratios (GMRs) of the GMCs in malaria-positive versus malaria-negative participants were derived with 95% confidence intervals (CIs). Results A total of 587 participants were studied, comprising 188 adults (≥18 years) and 399 children (in age groups of 12–17, 4–11, and 1–3 years). Asymptomatic malaria was observed in 47.5% of adults and 51.5% of children on day 1. Post-dose 1, GMCs were lower in 1–3-year-old malaria-positive compared with malaria-negative children (age group–specific GMR, .56; 95% CI, .39–.81) but not in older age groups. Post-dose 2, there was no consistent effect of malaria infection across the different age groups but there was a trend toward a lower response (GMR, .82; 95% CI, .67–1.02). Conclusions The Ad26.ZEBOV, MVA-BN-Filo Ebola vaccine regimen is immunogenic in participants with asymptomatic malaria. Therefore, it is not necessary to screen for asymptomatic malaria infection prior to vaccination with this regimen.

IntroductionNurse-led triage, using the South African Triage Scale, was introduced to the emergency centre of the tertiary referral hospital in Freetown, Sierra Leone in early 2014 prior to the Ebola epidemic. The aim of this study was to measure the effectiveness of the process now that the country has been declared free of Ebola.MethodsThe study was conducted over a five-day consecutive period in the adult emergency centre of the main government teaching hospital in December 2015. The times from arrival to triage and medical assessment were recorded and compared for each triage category. We also assessed the inter-rater reliability of the process.Results111 patients were included during the study period. In terms of acuity, 6% were categorised as red, 27% were orange, 20% yellow and 47% green. Triage Early Warning Score was correctly calculated in 90% of cases and there was inter-rater agreement of colour code and triage category on 92% of occasions (k = 0.877, p < 0.001). Median time from triage to assessment was 15 min for red patients, 20 min for orange, 40 min for yellow and 72 min for green.DiscussionThe triage process is functioning effectively in the emergency centre after the Ebola epidemic and provides a reliable assessment of undifferentiated patients presenting to the hospital to ensure that they are seen in a timely manner based on acuity.

Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.