INTRODUCTION:Bypassing refers to a person's decision to seek care at a healthcare facility that is not the nearest one of its type to the person's home.METHODS:This study examined inpatient care facility bypassing in urban Bo, Sierra Leone using data from 1,980 women with children 15 years of age and younger who were interviewed in 2010-2011. The locations of residential structures and hospitals were identified using a geographic information system (GIS), and the road distances from participating households to the nearest and preferred inpatient care facilities were measured.RESULTS:Nine inpatient care facilities serve Bo residents, but more than 70% of the participating women reported that the city's main public hospital (Bo Government Hospital), located in the city center, was their preferred inpatient care provider. Participants resided within a median distance of 0.9 km (Interquartile range (IQR): 0.6, 1.8) from their closest inpatient facility, but they would travel a median distance of 2.4 km (IQR: 1.0, 3.3) to reach their preferred providers. About 87% of the women would bypass their nearest inpatient care facility to access care at a preferred provider. Bypassing rates were similar for various demographic and socioeconomic groups, but higher for women living farther from the city center.CONCLUSION:Although Bo has a diverse healthcare marketplace, access to affordable advanced care options is limited. Most women in Bo would choose to bypass facilities nearer to their homes to seek the low-cost and comprehensive care offered by Bo Government Hospital.

To examine the diversity of the health-care providers in urban Bo, Sierra Leone, identify the types of health-care facilities preferred by women for fevers, and analyze the road network distances from homes to preferred health-care providers. A population-based random sampling method was used to recruit 2419 women from Bo. A geographic information system was used to measure the road distance from each woman’s home to her preferred provider. Preferred health-care providers for acute febrile illnesses (commonly referred to as “malaria” in the study communities) were hospitals (62.3 %), clinics (12.6 %), and pharmacies (12.4 %). Participants lived a median distance of 0.6 km from the nearest provider, but on average each woman lived 2.2 km one-way from her preferred provider. Women living farther from the city center had preferred providers significantly farther from home than women living downtown. 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.

BACKGROUND:This analysis examined how the proportion of children less than 5-years-old who slept under a bed net the previous night changed during and after a national long-lasting insecticidal net (LLIN) distribution campaign in Sierra Leone in November-December 2010.METHODS:A citywide cross-sectional study in 2010-2011 interviewed the caregivers of more than 3000 under-five children from across urban Bo, Sierra Leone. Chi squared tests were used to assess change in use rates over time, and multivariate regression models were used to examine the factors associated with bed net use.RESULTS:Reported rates of last-night bed net use changed from 38.7 % (504/1304) in the months before the LLIN campaign to 21.8 % (78/357) during the week of the campaign to 75.3 % (1045/1387) in the months after the national campaign. The bed net use rate significantly increased (p < 0.01) from before the campaign to after the universal LLIN distribution campaign in all demographic, socioeconomic, and health behaviour groups, even though reported use during the campaign dropped significantly.CONCLUSION:Future malaria prevention efforts will need to promote consistent use of LLINs and address any remaining disparities in insecticide-treated bed net (ITN) use.

Human health depends on reliable access to safe drinking water, but in many developing countries only a limited number of wells and boreholes are available. Many of these water resources are contaminated with biological or chemical pollutants. The goal of this study was to examine water access and quality in urban Bo, Sierra Leone. A health census and community mapping project in one neighborhood in Bo identified the 36 water sources used by the community. A water sample was taken from each water source and tested for a variety of microbiological and physicochemical substances. Only 38.9% of the water sources met World Health Organization (WHO) microbial safety requirements based on fecal coliform levels. Physiochemical analysis indicated that the majority (91.7%) of the water sources met the requirements set by the WHO. In combination, 25% of these water resources met safe drinking water criteria. No variables associated with wells were statistically significant predictors of contamination. This study indicated that fecal contamination is the greatest health risk associated with drinking water. There is a need to raise hygiene awareness and implement inexpensive methods to reduce fecal contamination and improve drinking water safety in Bo, Sierra Leone.

The tet(X) gene encodes a flavin-dependent monooxygenase that confers resistance to all clinically relevant tetracycline antibiotics including tigecycline. It has only previously been identified in environmental and non-human pathogenic bacteria. To investigate levels of multidrug resistance in Bo, Sierra Leone, a molecular epidemiological study was conducted using an antimicrobial resistance determinant microarray (ARDM), PCR and DNA sequencing. The study found that 21% of isolates from Mercy Hospital (Bo, Sierra Leone) were tet(X)-positive, all of which originated from urinary specimens. Use of molecular epidemiological surveillance tools has provided the first evidence of tet(X)-containing multidrug-resistant Gram-negative hospital isolates in a hospital in Sierra Leone.

ABSTRACT We 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.

BACKGROUND:Resource-limited tropical countries are home to numerous infectious pathogens of both human and zoonotic origin. A capability for early detection to allow rapid outbreak containment and prevent spread to non-endemic regions is severely impaired by inadequate diagnostic laboratory capacity, the absence of a "cold chain" and the lack of highly trained personnel. Building up detection capacity in these countries by direct replication of the systems existing in developed countries is not a feasible approach and instead requires "leapfrogging" to the deployment of the newest diagnostic systems that do not have the infrastructure requirements of systems used in developed countries.METHODS:A laboratory for molecular diagnostics of infectious agents was established in Bo, Sierra Leone with a hybrid solar/diesel/battery system to ensure stable power supply and a satellite modem to enable efficient communication. An array of room temperature stabilization and refrigeration technologies for reliable transport and storage of reagents and biological samples were also tested to ensure sustainable laboratory supplies for diagnostic assays.RESULTS:The laboratory demonstrated its operational proficiency by conducting an investigation of a suspected avian influenza outbreak at a commercial poultry farm at Bo using broad range resequencing microarrays and real time RT-PCR. The results of the investigation excluded influenza viruses as a possible cause of the outbreak and indicated a link between the outbreak and the presence of Klebsiella pneumoniae.CONCLUSIONS:This study demonstrated that by application of a carefully selected set of technologies and sufficient personnel training, it is feasible to deploy and effectively use a broad-range infectious pathogen detection technology in a severely resource-limited setting.

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.

As of April 2010, all maternity care at government healthcare facilities in Sierra Leone is provided at no cost to patients. In late 2010, we conducted a community health census of 18 sections of the city of Bo (selected via randomized cluster sampling from 68 total sections). Among the 3421 women with a history of pregnancy who participated in the study, older women most often reported having a history of both home and hospital deliveries, while younger women showed a preference for hospital births. The proportion of lastborn children delivered at a healthcare facility increased from 71.8% of offspring 1014 years old to 81.1% of those one to nine years old and 87.3% of infants born after April 2010. These findings suggest that the new maternal healthcare initiative has accelerated an existing trend toward a preference for healthcare facility births, at least in some urban parts of Sierra Leone.

Multiplexed microbial diagnostic assays are a promising method for detection and identification of pathogens causing syndromes characterized by nonspecific symptoms in which traditional differential diagnosis is difficult. Also such assays can play an important role in outbreak investigations and environmental screening for intentional or accidental release of biothreat agents, which requires simultaneous testing for hundreds of potential pathogens. The resequencing pathogen microarray (RPM) is an emerging technological platform, relying on a combination of massively multiplex PCR and high-density DNA microarrays for rapid detection and high-resolution identification of hundreds of infectious agents simultaneously. The RPM diagnostic system was deployed in Sierra Leone, West Africa in collaboration with Njala University and Mercy Hospital Research Laboratory located in Bo. We used the RPM-Flu microarray designed for broad-range detection of human respiratory pathogens, to investigate a suspected outbreak of avian influenza in a number of poultry farms in which significant mortality of chickens was observed. The microarray results were additionally confirmed by influenza specific real-time PCR. The results of the study excluded the possibility that the outbreak was caused by influenza, but implicated Klebsiella pneumoniae as a possible pathogen. The outcome of this feasibility study confirms that application of broad-spectrum detection platforms for outbreak investigation in low-resource locations is possible and allows for rapid discovery of the responsible agents, even in cases when different agents are suspected. This strategy enables quick and cost effective detection of low probability events such as outbreak of a rare disease or intentional release of a biothreat agent.

Hybrid power systems have the capability to incorporate significant renewable energy penetration for a small autonomous system while still maintaining reliable grid stability. While there are many papers covering the optimization of component size and dispatch strategy, far fewer papers contain experimental performance data from hybrid systems. Mercy Hospital in Bo, Sierra Leone is converting their power system into a photovoltaic (PV)-diesel hybrid system, thus providing an opportunity to examine the change in system performance before, during, and after the conversion. Due to the seasonal availability of electric power in Sierra Leone, two datasets representing two distinct load profiles are analyzed: Wet Season and Dry Season. The difference in generation efficiency, cost per kW h, generator runtime, and fuel consumption are calculated between a diesel-only generation baseline and the recorded hybrid system performance. The results indicated that the hybrid system significantly reduces operation costs; approximately 37% less during Dry Season and 64% reduction in the Wet Season than a diesel-only generator serving the same load. Published by Elsevier Ltd.

BACKGROUND:Spatial 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.RESULTS:The 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.CONCLUSIONS:The 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.