mhGAP Training 2018

As his placement with KSLP comes to end, Mental Health Volunteer Tarik Endale reflects on the recent mhGAP training which was supported by colleagues from KSLP and Handicap International.

Support for this project was received from Advancing Partners & Communities, a programme funded by the United States Agency for International Development through JSI Research & Training Institute.

 

Mental, neurological, and substance use (MNS) disorders are a serious public health concern, making up 13% of the global burden of disease1. Despite accounting for the same proportion of disease burden as cardiovascular disease, mental health routinely receives less than 1% of development aid funding and government health spending, if there is a dedicated budget line for it at all2. In addition to a lack of funding, low- and middle-income countries have scarce and unequally distributed specialist mental health professionals3. In Sierra Leone, this amounts to 2 psychiatrists based in Freetown and 20 mental health nurses dispersed across the district hospitals for a population of 7 million people. King’s Sierra Leone Partnership has been supporting this small but dedicated workforce. However, the scarcity of mental health specialists means that over 98% of people with serious mental disorders in Sierra Leone still do not receive the care they need4.

That’s why last week the KSLP Mental Health Team ran an mhGAP training week for 22 Community Health Officers (CHOs) representing 11 different districts across the country. mhGAP, or the Mental Health Gap Action Program, was launched by the World Health Organization (WHO) in 2010 in order to enable non-specialists in primary healthcare to detect, treat, and when necessary, refer people with priority MNS disorders5. CHOs are often in-charge of Peripheral Health Units in Sierra Leone, making them an ideal cadre of health workers to serve as catalysts for change at the primary healthcare level.


In collaboration with Hege Lind of Handicap International, Dr. Abdul Jalloh from Sierra Leone Psychiatric Hospital, and Mental Health Nurses Jennifer Duncan (Connaught Hospital) and Richard Fatoma (34 Military Hospital), CHOs received training on using the mhGAP Intervention Guide to assess and manage depression, psychosis, child and adolescent mental health, epilepsy, substance use disorders, dementia, self-harm/suicide, and other mental health complaints such as PTSD. Interactive presentations, discussions, videos, and roleplays were used throughout the week to strengthen understanding of concepts, practice clinical skills, and explore topics such as stigma and discrimination, human rights, and local expressions and understandings of distress and mental illness. The CHOs were also given an opportunity to spend a morning at either Connaught or 34 Military Hospital practicing their newly acquired clinical assessment skills.

I’m happy to say that following the training, participant scores on the pre- and post-training test increased significantly. Participants reported that the week was highly relevant and helpful to their work, with feedback that they learned “how to take a full history for mental health and how to treat different mental health disorders”, “good communication skills and psychoeducation skills”, and the importance of “giving more time for mental health patients”. Many talked about carrying out community sensitization work in the future to decrease stigma around mental illness and showed interest in further training, even going as far to say they would like to get a diploma in mental health once it becomes available to them in the future. The CHOs expressed interest in working more closely with their district mental health nurses and were given contact information to get in touch with them as well as with the Sierra Leone Psychiatric Hospital.


Mental Health Nurses at the secondary level of healthcare serve as the backbone of the country’s mental health system. But with the new Mental Health Policy and Strategic plan on the horizon, CHOs will play an increasingly important role in reducing the mental health treatment gap in Sierra Leone by increasing the availability of services at the primary healthcare level. Spending the past week with this highly engaged group of CHOs gives us a great deal of hope that, with the right support, they will play their part in improving mental health in Sierra Leone well.

As ever, many thanks to our supporters – this project is funded by USAID and supported by JSI.

  1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry. 2016 Feb 1;3(2):171-8.
  2. Mackenzie J, Kesner C. Mental health funding and the SDGs: what now and who pays. ODI. 2016.
  3. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, Sridhar D, Underhill C. Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet. 2007 Sep 29;370(9593):1164-74.
  4. Alemu W, Funk M, Gakurah T, Bash-Taqi D, Bruni A, Sinclair J, Kobie A, Muana A, Samai M & J E. WHO profile on mental health in development (WHO proMIND): Sierra Leone. Geneva: WHO. 2012.
  5. Dua T, Barbui C, Clark N, Fleischmann A, Poznyak V, van Ommeren M, Yasamy MT, Ayuso-Mateos JL, Birbeck GL, Drummond C, Freeman M. Evidence-based guidelines for mental, neurological, and substance use disorders in low-and middle-income countries: summary of WHO recommendations. PLoS Medicine. 2011 Nov 15;8(11):e1001122.

PTC Comes to Connaught

Over the past few months, the KSLP team have been working with Connaught Hospital and COMAHS to bring Primary Trauma Care courses to Sierra Leone for the first time.

Here, our Anaesthetics Volunteer Caroline outlines the importance of the PTC courses for improving delivery of care.


We are very pleased to announce completion of the very first Primary Trauma Care (PTC) courses with training of trainers at Connaught Hospital, Freetown!

The PTC Foundation is a non-profit organization which exists to prevent death and disability due to injury in developing countries, where the burden of trauma is high and can have devastating implications for individuals, communities and societies.1

Set up by clinicians in 1996, and delivered in more than 70 countries around the world, the two-day PTC course trains frontline doctors and health professionals in a systematic approach to emergency assessment and management of severely injured patients. Designed specifically for the low-income setting, PTC focuses on utilising the equipment and facilities available in the local context, and can therefore be delivered almost anywhere.

In turn, by training local trainers, PTC empowers countries where the need is greatest, to train their own staff in a way that is “appropriate, adaptable, affordable, sustainable”2.

In 2016 it was found that trauma accounts for 68% of adult surgical admissions, and nearly one third of paediatric admissions to Connaught Hospital. At the same time, a gap in staff training and knowledge was identified, generating enthusiasm for formalised trauma education.

Our aim is to deliver multi-disciplinary training promoting a team approach to trauma, to complement requirements of the postgraduate surgical residency programme at Connaught, and to disseminate knowledge to more rural centres via junior doctors rotating through the teaching hospitals complex.

With eleven new and enthusiastic local instructors including six surgical residents, two medical officers, two trauma nurses and one nurse anaesthetist, participant feedback highlighted the benefits of multi-disciplinary working. A third course was run exclusively by our new instructor team in July, and attended by doctors, trauma, triage and surgical nurses, and the hospital’s referral coordinator. We are proud to have supported the training of a total of 66 staff since April!

We would like to thank our donors, Johnson & Johnson’s Africa Grants Programme (AGP), managed through the Tropical Health and Education Trust (THET) for funding this course as part of a wider project aiming to implement structured trauma care and improve surgical safety at Connaught Hospital, Freetown. Without them such training would not be possible.

Many thanks to Connaught Hospital and The College of Medicine and Allied Health Sciences (COMAHS) for hosting this course. We would like to thank the Department of Surgery for their motivation to improve trauma care and bring PTC to Sierra Leone. We are grateful to the trauma, surgical, intensive care, operating theatre and anaesthesia nursing teams for their enthusiasm, involvement and drive to widen training opportunities for nurses at Connaught Hospital. Acknowledgements to the Royal College of Anaesthetists (UK), for supporting the course director’s position.

References

  1.  Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG. Injuries: the neglected burden in developing countries. Bulletin of the World Health Organization2009;87:246-246. doi: 10.2471/BLT.08.052290
  2. The Primary Trauma Care Foundation. Accessed online: https://www.primarytraumacare.org/

World Clubfoot Day 2018

 Last week (June 3rd) was World Clubfoot Day and our physiotherapy volunteer Sophie Bright went along to join the celebrations in Freetown.
The Sierra Leone National Clubfoot Programme (SLNCP) is kindly supported by the government of the Isle of Man, and you can find more information here: http://slclubfoot.org/

 

The National Rehabilitation Centre, Freetown, dressed for the Ceremony.

This week, the Sierra Leone National Clubfoot Programme (SLNCP), celebrated World Clubfoot Day. Clubfoot is a deformity in which a child’s foot is turned inward, often so severely that they struggle to walk. The SLNCP, supported by the Ministry of Health and Sanitation, the Government of the Isle of Man, KSLP and Mobility Outreach International, provide free treatment to children in Sierra Leone born with Clubfoot. They have 6 clinics across the country, which treat children using Ponsetti treatment, and counsel parents through the process.

Staff and beneficiaries from each of the 6 clinic areas (Bo, Kenema, Freetown, Makeni, Port Loko and Kono), travelled to Freetown to unite in celebrating World Clubfoot Day 2018. Members of staff from the Ministry of Health and local organisations who had expressed interest in partnership working, were invited to participate.

Children at various stages of their treatment, from casting through to discharge, came along to demonstrate how Ponsetti treatment progresses, and to support each other.

Posters of success stories displayed at the venue entrance.

The caregivers of some discharged patients gave thanks to the SLNCP. They encouraged other parents to continue with the Ponsetti treatment, and asked all to continue supporting the programme.

A mother provides a testimony to the success of the programme.
The Minister of Public Health, addresses the Audience. Two local television and radio networks, capture the moment.

The SLNCP is a programme under the Ministry of Health and Sanitation. While it has historically had support from NGOs, the programme strives towards independence and full absorption within the Ministry. Talking on the issue, the Director of Primary Health Care stated:

“I want to assure people here that the Ministry is going to do all it can, within its powers, to ensure that the programme that  you have embarked on is sustained. And, I believe that with the co-ordinator and the programme manager, and the directorate, we will be sitting down to be doing proper planning and budgeting for the forthcoming years”.

Care-givers of children who have now fully completed their treatment, receive certificates.

Although a technically simple and non-invasive procedure, completing the Ponsetti treatment is a lengthy process, that requires dedication from parents and children. As a small token of appreciation for their commitment, certificates were given to those who have now successfully finished treatment. All were also given a SLNCP t-shirt, with details of the Clinic locations, so that they can spread the word in their communities.

If left untreated, children with clubfoot struggle even to walk. It therefore seemed fitting that the best way to celebrate freedom from Clubfoot for these families, was to host one big celebratory dance!

Children, their parents and the Clinic Staff dancing to some Sierra Leone hits.

Once again, we could like to thank the Isle of Man government for their contributions to the SLNCP programme and the difference they have made to the lives of many families in Sierra Leone.

World Malaria Day at Connaught

25th April is World Malaria Day. In this blog, Rosie (Labs Volunteer) and Lisa (Implementation Coordinator) provide insight into why continued work on malaria is so important, and how KSLP (supported by Comic Relief) are contributing to the fight against this disease.

 

Malaria claims the life of at least 1 child every 2 minutes globally, and despite extensive international efforts it remains a major cause of mortality, with approximately 90% of malaria-related deaths occurring in children under 5 years old. Other at-risk groups include pregnant women and immunocompromised persons.

You have probably heard of it, but what exactly is malaria?

Malaria is a life-threatening disease caused by parasites that are transmitted person to person through the bites of infected mosquitos. The infected Anopheles mosquitoes typically bite at night and breed in shallow puddles of water.

What are the symptoms?

Symptoms can be very non-specific but can include fevers, shaking chills, headaches, muscle aches, nausea, vomiting and diarrhoea. Left untreated it may cause kidney failure, seizures, mental confusion, comas and death.

How does malaria affect Sierra Leone?

In Sierra Leone, the WHO estimated there were around ~2,000,000 malaria cases and ~7,000 deaths in 2016.

Evidence has shown malaria can slow economic growth by ~1% annually. Education is also hit, with approximately 60% of school age children impaired by absenteeism due to malaria in endemic areas.

But wait, there is some good news!

In 2015, all countries in the WHO European Region reported, for the first time, reported zero indigenous cases of malaria (down from 90,000 cases in 1995). From 2007-2015, Armenia, Maldives, Morocco, Turkmenistan and United Arab Emirates also all became certified malaria-free by WHO.

Future WHO malaria elimination targets aim to add at least 10 countries to this malaria-free list by 2020, at least 20 by 2025 & at least 35 by 2030.  This gives us the evidence and hope that it is possible to beat malaria, not just in Sierra Leone, but globally!

What is being done by KSLP to reduce the burden of malaria in Sierra Leone?

In September 2017, a project began between King’s Sierra Leone Partnership, University of Sierra Leone Teaching Hospitals Complex-Connaught and the Ministry of Health’s National Malaria Programme, to improve malaria management at the hospital level called: ‘Strengthening Health systems to Improve Fever management (SHIFT)’.

The project began with a 6-month baseline assessment that used a combination of quantitative (clinical audit and healthcare worker surveys) and qualitative (process mapping, focus groups, key informant interviews, and patient observations) methods to comprehensively understand the barriers to providing high quality malaria care in hospital. The baseline findings are now being used to inform and design project interventions, aimed at improving hospital service provision, staff knowledge, and data management with regards to malaria management.

A rapid diagnostic test (RDT) in action

KSLP, Connaught and the NMCP have collaborated to integrate malaria rapid diagnostic tests (RDT) into the hospital as a standard service since March 2018. These free tests provide patients with a quick malaria result (within 20 minutes) and if positive, the patient can obtain a prescription for free malaria treatment. We hope the introduction of RDTs (as well as new automatic haematology and biochemistry analysers!), will help lighten the manual workload for laboratory staff, providing more opportunity for on the job learning, and blood film preparation, staining and examination under the microscope.

RDTs are undoubtedly a great resource, however microscopic diagnosis is the global gold standard. It enables both quantification of parasites in the blood, as well as, species differentiation therefore providing essential epidemiological data. Going forward the project will continue to build capacity within the laboratory, focusing on the quality and turn-around-time for all malaria diagnostics.

Additional current project efforts include developing standard operating procedures and diagnostic and management protocols (including job aids) to align care with NMCP guidelines and strengthening the malaria data management in the Accident and Emergency (A&E), Laboratory, Pharmacy, Surveillance, and Monitoring and Evaluation departments. Each of the project elements link with the hospital’s quality improvement committee to coordinate multidisciplinary learning and service evaluation review.

In subsequent months the project aims to further harmonize the hospital data continuity through the integration of a simple electronic data collection and information system.  The interventions also include a training and mentorship programme for healthcare workers on malaria diagnosis and management.

How will this project help others in Sierra Leone outside of Connaught?

At the project’s conclusion, baseline assessment and implementation toolkits will be developed to support the replication of the project’s successes. Ministry of Health officials will then support the dissemination of these toolkits to other national hospitals!

 

Physiotherapy in Sierra Leone

In this blog, our Physiotherapy Coordinator Sophie Bright outlines the importance of improving access to treatments which can greatly increase quality of life for individuals with a range of conditions.

 

If you were to break your arm, would you consider yourself disabled?

Maybe not. Maybe you would expect to be treated in a hospital, your arm to heal, and your life to continue normally afterward.

However, what if you couldn’t access a hospital because you lived so far away, or you couldn’t afford to pay for your treatment? What if because of inadequate treatment, the break didn’t heal, and you couldn’t use your arm? What if those around you see your disfigurement, and avoid you out of fear? Would you now consider yourself disabled?

People living in Low and Middle-Income countries (LMICs), like Sierra Leone, are not only at high risk of encountering injury, illness and disease because of poverty, but are also much more likely to end up with a resulting disability. Around 15% of people globally have disability, but 80% of these live in LMICs.

Living with a disability not only impacts on the individual themselves, but also on those around them. In Sierra Leone, there is no social system to provide care at home, so families must take on this role if it is needed. If a parent is disabled, their children may have to leave education to work and support the family. As a result, a cycle of poverty, impairment and disability is maintained.

Reducing disability in Sierra Leone is therefore immensely important, and I admit that the scale of the task was initially daunting when I joined KSLP in November 2017. However, my Sierra Leonean physiotherapy colleagues are incredibly dedicated, and so together we are already taking positive steps towards this.

Sophie (back) pictured with attendees of the Stroke Training Day for physiotherapy assistants, ward nurses and dieticians at Connaught.

One key aspect of my role has been to support the Sierra Leone National Clubfoot Programme (SLNCP), through a grant supplied from the Isle of Man. Clubfoot is a congenital condition causing a baby’s feet to turn inward which, if left untreated, can cause immobility. However, it can be fully corrected with a simple manipulation, casting and bracing protocol – usually completed by 3 years of age.   The SLNCP has been treating clubfoot successfully for several years, and it is fantastic to see the progress made by children they have worked with. However, now that they have functioning clinics, it is essential that they have effective monitoring and evaluation systems in place, to ensure their sustainability. Since November, we have therefore collaborated on improving clinic data collection and interpretation at a local level. We have also reviewed methods for clinic evaluation, to ensure continued professional development and support of staff.

Another aspect of my role is to help improve access to Physiotherapy for all patients who need it, regardless of their age, diagnosis or socio-economic standing. The Ministry of Health and Sanitation currently employs only 5 Sierra Leonean Physiotherapists, supported by a small number of ‘mid-level therapists’ and nursing staff (many of whom volunteer). As a result, it is extremely challenging to reach all those needing rehabilitation, especially in rural areas. To address this, we are also supporting the leadership of the National Physiotherapy and Rehabilitation Programme in the Ministry of Health and Sanitation. We are mapping the services that are available (including private and NGO centres) to identify the most significant resource gaps, and redeploying staff where appropriate. We are also assisting the Sierra Leone Physiotherapy Association to develop an in-country BSc., to address the increasing demand for qualified physiotherapists. Finally, through collaborating with the Ministry we aim to ensure that rehabilitation remains a priority of theirs, so that these graduates will secure employment.

Additionally, whilst there remains a dearth of trained physiotherapists, we are encouraging other members of the healthcare team to integrate some rehabilitation in to their role. For example, stroke is one of the most commonly seen conditions in Connaught hospital, and patients who suffer from stroke are often left with severe impairments. Their optimal window for recovery is in the first few months post-stroke, however presently ward patients often do not receive physiotherapy until much later, if at all. Therefore, we have been training ward staff in fundamental principles of stroke rehabilitation, such as how to facilitate functional activity and prevent secondary complications.

Whilst it will never be possible to eradicate illness and disease, it is possible to reduce the burden of this on an individual, and to improve greatly their quality of life. This goal is driven by the unwavering dedication of the local team, making it an incredible time to be working with KSLP in the field of rehabilitation.

Pioneering enhanced hospital referral coordination in Sierra Leone

Our Hospital Performance Monitor volunteer, Lucy Hartshorn, describes her experience working as part of the referral coordination team, funded by USAID through JSI Research & Training Institute’s Advancing Partners & Communities project.

 

 

At the beginning of October last year, the Sierra Leone Ministry of Health launched a new national referral system, building on successful elements of previous Ebola survivor-targeted efforts, to support broader access to health services for the population of Sierra Leone. Critical to this system are the 17 KSLP-supported referral coordinators. A new cadre of specialist health workers, the referral coordinators are based in each district’s government secondary hospital and in the specialist, tertiary hospitals in Freetown. They use their clinical backgrounds to support incoming and outgoing patient referrals at the facility and make sure patients are at the right place at the right time.

Patients in Sierra Leone face a myriad of obstacles when they get sick, from knowing who to visit for a diagnosis or navigating where they need to get to receive treatment, to the availability of health care workers who are trained and able to provide the specific care a patient may need. In Sierra Leone, this is complicated by significant resource constraints – on both individuals and the health system. For the hospitals, doctors, nurses, midwives and laboratory staff that work in the government hospitals across Sierra Leone, getting each patient the care they need is often accomplished through a clever mix of compassion, teamwork and communication. As the Hospital Performance Monitor Volunteer, I lead the referral coordination team in training and supporting our Referral Coordinators (RCs) and working with the Ministry of Health.

Lucy and the KSLP Referral Coordinator mentors, Sorie Samura and Hassan Shaw, recently supported district level leadership meetings in Makeni.

It is exciting, if not initially intimidating, to be able to work with King’s Sierra Leone Partnership! I am not clinical and instead have a background in ‘global health’, spanning biomedical sciences, public health and health partnerships. While much of KSLP focuses on overcoming challenges in clinical care, which you can read more about here, the referral coordination work is pioneering a new model of enhanced hospital coordination to overcome wider Sierra Leone health system challenges. The two KSLP RC Mentors, Sorie Samura and Hassan Shaw, and myself make up the Referral Coordination support team. They both bring clinical experience and a near-unlimited understanding of the Sierra Leone health system to our project, while I bring the baked goods (sometimes) and Americanisms. Together, we support the RCs spread across the country – mainly from the KSLP ‘Clinical Office’ tucked the end of the hall after Ward 10 in Connaught Hospital.

By referral coordination, we mean the networks, information and communication that helps clinicians direct patients to the right places, where they can get the right services, at the right time. This is different than the ambulance networks patients use, although the RCs link closely with emergency alert systems in each district to help notify hospitals of patient details prior to arrival, helping them prepare. For incoming referrals, this means receiving calls from Peripheral Health Units (PHUs), District Emergency Alert Systems or NGO and private facilities wanting to send patients to the government hospital; notifying clinical and laboratory staff of incoming patient diagnosis, needs and estimated time of arrival; and advocating for access to facility services for Free Health Care Initiative (FHCI) patients. For outgoing referrals, the RCs play a critical role in helping patients navigate the complex landscape of service delivery in Sierra Leone – a patchwork of government, private and NGO offerings. The RCs work with clinicians, patients and patient caretakers to determine which other facilities have the services the patient needs and their availability, and then contacts the next facility’s referral coordinator, who supports patients from the receiving end.

RCs are also hugely beneficial to the facilities that they work within, supporting hospital preparedness and improving patient flow. What is innovative about the RC-based referral coordination system is it’s ability to make huge impact and improvement within the space and resources available. Success has so far been build on small-small changes- the use of standardized referral forms, a designated hospital employee to take over a role often ad-hoc filled by clinicians, sharing of phone numbers with information on different hospital service offerings, a system of reporting these referrals on a weekly basis – to name a few. The referral system has given the MoH its most comprehensive understanding of patient referral numbers, needs and flow – fed back in KSLP-produced weekly and monthly reports. This is used by the Referral Coordinator’s hospitals, District Health Management Teams and the Ministry of Health and Sanitation for prioritising resources, visualizing system gaps and demand and advocacy for more accessible, high-quality health service provision across the country.

The referral coordination team is made up of 17 KSLP-supported referral coordinators, working at facilities across the country.

It is exciting to impact on this innovative creation – a national network providing individual patient, facility and system benefits. My role focuses on studying the referral system in real-time. I use the information produced by our RCs and RC Mentors for not only improved referral project implementation, but also through newly created feedback loops to help hospitals and the Ministry of Health plan, to advocate for services and resources for patients and facilities, and to enhance the global health sector’s understanding of patient access to care. It’s a process of constantly learning. New and updated patient referral information is compiled every week – a truly incredible feat and something which exists in few countries! From this, I get to think about interesting questions like: what challenges hospitals are facing, how to share the information to best visualizes these challenges, how the referral coordinators are impacting patient outcomes, and what the different benefits of referral coordinators in each unique facility and district are. What I think makes KSLP different from many other organisations is that we focus beyond just enhancing the understanding of the patients, hospitals and health system. For me, it’s about turning that knowledge of patient referrals and system access into action – informing policy, projects and research for better patient care.

Just as patients in Sierra Leone benefit from the teamwork and compassion of their health workers, I depend on the skill, expertise, collegiality and unrelenting commitment of the two KSLP RC Mentors, seventeen referral coordinators and the team at the MoH program implementation unit. They are responsible for the success of the referral system so far. As we approach the end of February, they can boast of having trained almost twenty specialist referral coordinators, supported over 4,200 referrals and helped patients navigate over 500 facilities!

New Nursing Curriculum – Update

Before she heads back to the UK at the end of her 15 month placement, our Nurse Educator Linda provides an overview of the curriculum implementation planning.

 

Nursing education leads at COMAHS are making good progress with designing their new curriculum for registered nurses. They have been working with me for the last year and the journey has been long and winding but is really taking shape now.

On Friday 20th November, I assisted the Faculty of Nursing team to work on an implementation plan for the new programmes which will start in 2018. It is quite a challenge to develop the detail of a plan such as this. The faculty staff welcomed the opportunity to get started, building on their expertise in delivering the current nurse education programmes. One example of a change in the new curriculum plans came from the feeling that degree students had plenty of theory base but less clinical experience. The new curriculum is focused on introducing clinical practice for degree nurse students earlier in their training. For Diploma students they will experience a good balance between sufficient theory to match the clinical experience that forms a core part of their programme.

Each lecturer has a responsibility for a subject area depending on their clinical background. Here they are hard at work devising lesson plans for units in their subject (below). This work is the start of building a bank of accessible documents for use by all lecturing staff both full and part time. I wish them well in their endeavours as I head back to the UK this week. KSLP will continue to support the role of nurse educator at COMAHS so watch this space for updates!

Happy World AIDS Day!

Our infectious diseases volunteer Hannah unravels the complex picture of HIV in Sierra Leone and explains how KSLP are supporting the National HIV/AIDS Control Programme to improve diagnostics and testing.

 

Happy World AIDS Day. Maybe an odd thing to say on a day that commemorates a disease which has killed 70 million people worldwide. But despite the ongoing tragedy of the HIV pandemic, in 2017 there is lots to celebrate.

While a vaccine or a cure remain distant prospects, we now have incredibly effective treatment for HIV. Antiretroviral therapy (ART) can suppress the activity of the virus in the body to the point that it is undetectable and people show absolutely no symptoms or signs of the disease. Many people living with HIV can now take a single, well-tolerated pill each day, and live a normal healthy life. Perhaps even more impressively, we now understand that people with HIV who are taking effective treatment with a suppressed viral load cannot transmit the virus to other people.

With such powerful weapons to fight this disease, reversing the growth of the pandemic now seems possible. UNAIDS has adopted the ambitious 90-90-90 targets – that by 2020, 90% of people living with HIV should know their status, 90% of those should be on treatment, and 90% of those on treatment should have a suppressed viral load. This has driven a huge global scale-up of ART provision, and data from severely-affected countries such as Swaziland is beginning to show the benefits.

So what about Sierra Leone? In Western Africa the picture is complex. On the one hand, fortunately, levels of infection have not reached the levels seen in Southern and Eastern Africa. Sierra Leone’s 2013 Demographic Health Survey found a prevalence of 1.5%, with up-to-date results due in 2018. However, the lower burden of infection means that HIV has previously been afforded a lower priority and less international donor support than in other countries. There is an increasing recognition that Western and Central Africa are being “left out” of the HIV progress seen elsewhere in the continent.

The problem is multifactorial. In the highest-burden countries, almost everyone will know a friend or neighbour who is affected by HIV, which has some effect on normalising the disease. In Sierra Leone, despite the support of counsellors and peer networks, the majority of people living with HIV have not disclosed their status to anyone, for fear of discrimination or even abandonment. As a result, many people believe HIV to be a rare problem, or one that is confined to certain marginalised groups such as men who have sex with men or commercial sex workers. Most sexually-active young adults do not perceive themselves as being at risk of infection, and condom use is low. Fear of HIV affects testing rates, while infected people who are hiding their HIV status from their families find it very difficult to access care and take treatment regularly.

While ART medications are provided free to patients through the Global Fund, people living with HIV face multiple other barriers to care. Limited human and physical resources mean that patients may have to travel some distance to an ART site, and the cost in time and money may be prohibitive. In the rainy season, it can be difficult for supplies to reach remote clinics and stock-outs may occur. This is particularly problematic because excellent adherence is required for ART to successfully suppress the virus. Missed doses because of stock-outs or financial problems, or interruption of care during the Ebola outbreak, can lead to irreversible drug resistance developing.

This formidable challenge means that many people living with HIV in Sierra Leone are not benefiting from prompt diagnosis and effective suppressive ART, and instead develop weakened immune systems and infections such as tuberculosis and cryptococcal meningitis. People living with HIV therefore make up a very high proportion of medical inpatients in Connaught Hospital, with associated high mortality.

Recognising the scale of the challenge facing Sierra Leone, in 2017 the National HIV/AIDS Secretariat launched the ambitious “Catch Up Plan”, which aims to rapidly scale-up HIV testing and treatment across the country. Along with other NGOs, KSLP has been working with the National HIV/AIDS Control Programme to support implementation of the plan.

As part of the national HIV Technical Working Group, KSLP members have been centrally involved in updating the 2017 ART Guidelines to reflec,t the WHO’s 2015 “Test and Treat” recommendation – that all people living with HIV should initiate ART, rather than just those who have evidence of a weakened immune system. We have also been supporting national training sessions on these new guidelines for HIV workers across Sierra Leone, mentoring and supervising staff in Connaught to ensure their implementation, and working on translating these guidelines into a more accessible format which can be disseminated by smartphone app.

In Connaught we have been working with the hospital management and HIV counsellors to increase testing through provider-initiated testing and counselling for patients attending the hospital. This strategy, which is recommended by the WHO, takes advantage of a person’s contact with health services to offer them HIV testing, regardless of the reason for presentation. This has led to a dramatic increase in the rates of HIV testing, particularly amongst medical inpatients. We support care for these inpatients through clinical work with the junior doctors and regular HIV ward rounds with Connaught’s clinicians, and by improving systems to promote access to important tests such as CD4 and TB screening. We are collaborating with a local infectious disease specialist to pilot screening for cryptococcal disease in HIV patients with advanced immunosuppression , and to learn more about the prevalence of cryptococcosis in Sierra Leone.

Treating HIV in Sierra Leone can involve witnessing a tragic loss of young lives when people present with very advanced disease. However, the amazing effects of the treatment mean that it can also be extremely rewarding. A few months ago, I reviewed a lady in her twenties who presented with speech difficulty and complete paralysis of the right side of her body. She had initially been diagnosed with a stroke, but when her admission HIV test was positive we decided to treat her empirically for cerebral toxoplasmosis, a parasitic brain infection seen in people with advanced HIV. The improvement was remarkable. She regained her ability to walk and talk, started ART, and now just has some mild hand weakness. I regularly bump into her and her mother waiting outside the physiotherapy department for her appointment, gaining weight and looking healthy.

In addition to individual success stories there is definite progress following the Catch Up Plan, on both concrete targets and more subtle indicators. When I first arrived in Sierra Leone in January I found many people reluctant to talk about HIV. Healthcare workers adopt euphemistic acronyms – RVS (retroviral syndrome) or ISD (immunosuppressive disease) rather than utter those other three letters. One of the aims of provider-initiated HIV testing was to normalise HIV as “just another disease”, like hypertension or diabetes. Now it feels like the dialogue is changing, with a noticeable increase in awareness and willingness to discuss the problem. Connaught’s young doctors are passionate advocates for their HIV patients, and gain a lot of knowledge and experience about HIV management. While there is still a long way to go in tackling stigma, it feels like people are talking more openly about it.

HIV progress starts with openness and advocacy. So, Happy World AIDS Day! Celebrate by telling one other person the news that people who are on treatment with a suppressed viral load live a normal healthy life and are unable to transmit the virus. We’re looking forward to continuing to work with Connaught and the National HIV/AIDS Secretariat to make that a reality for more people living with HIV in Sierra Leone.

Hannah and Dr Lakoh teaching a session on scaling up HIV services across Sierra Leone last week.

Antibiotic Awareness Week: Guideline Launch!


In this post, our infectious diseases volunteer Imogen offers some insight into the issue of antimicrobial resistance in Sierra Leone and describes the antimicrobial guidelines project which was launched during World Antibiotic Awareness Week.

 

 

This week is World Antibiotic Awareness Week and around the world there has been a focus on promoting both awareness of antimicrobial resistance and the need for antimicrobial stewardship, i.e. responsible usage by clinicians and patients alike. During this time, the KSLP infectious diseases team oversaw the launch of the University of Sierra Leone Teaching Hospitals Complex (USLTHC) Connaught Hospital Anti Microbial Guideline. This is the fruit of over a year’s work, drawing on expertise from a variety of local and international partners. We hope this will be a useful reference for junior doctors at Connaught Hospital, who requested guidelines like these to improve their ability in prescribing as they report not much formal teaching about prescribing in their undergraduate training. Following graduation, they bear huge levels of responsibility, especially as due to well documented human resource constraints, they can find themselves operating fairly independently very early in their careers.

Audit data from Connaught Hospital from March 2016 showed that 76% of medical admissions through the emergency department were prescribed antibiotics, and of those prescribed, 88% had an inappropriate dose, route or frequency. It is evident there was a clear need for simple guidance to help those who provide frontline medical services here with prescribing decisions around this crucial area, especially when it is known that the use of broad spectrum antibiotics (those that target a number of different types of bacteria) drives resistance.  This guideline serves as the first formal promotion of antimicrobial stewardship in Sierra Leone but there is much more work to be done – firstly, in improving surveillance data. Without a robust laboratory service in the country, anti-microbial resistance goes largely unrecognised with an ‘out of sight, out of mind’ attitude. However, we know there is widespread, indiscriminate use of broad spectrum antibiotics (e.g ciprofloxacin and ceftriaxone) in the community, so it is unsurprising that worrying levels of resistance are starting to be seen with improved surveillance.

The guidelines were drafted by a committee of clinical and pharmacists from Connaught Hospital and KSLP, drawing on national and international guidelines, and local resistance data (where available). The draft was reviewed by stakeholders in Sierra Leone as well as KSLP technical advisors based in the UK, before being presented to the Drugs and Therapeutics Committee at Connaught Hospital. We know the guideline is not perfect, but we hope the recommendations are an improvement on the current practice. One major constraint is the lack of reliable local sensitivity data, and also data about what are the prevalent pathogens. Consideration was given not only to likely pathogens and resistance mechanisms, but also the affordability of drugs to patients – in the interests of best antimicrobial stewardship principles, we would like to always recommend the most narrow spectrum option available for any given condition, but from our experience in clinical practice, we know if this means going from a once daily administered drug to a four times a day administered drug, the price may quadruple, and become unaffordable.

Tests to confirm diagnosis, either pathological or radiological, are also expensive, and therefore a luxury the junior doctors often have to do without. For this reason, we have not emphasised the antibiotic review in this first edition of the guideline as this principle relies so much on good diagnostic support. This principle states that the antibiotics should be reviewed ideally at 48 hours to see if they can be stopped, changed or stepped down from IV to oral.  We have encouraged oral step down, but if there is no additional information to confirm or refute an assumed diagnosis, it is difficult to advocate strongly the other courses of action. In addition, there is the recognition that counterfeit drugs are common in this part of the world, so it is easy to blame the drugs rather than the bugs if the patient is not improving. As a doctor, it is a disheartening environment in which to practice medicine, as you rarely get feedback on whether the right course of action was taken, making it difficult to learn and improve in the crucial early postgraduate stages of training.

It was decided to make use of the smartphone app format, making the resource easily accessible to junior doctors (who all have a smartphone, or perhaps even more than one) and reducing the risk of the documents deteriorating in quality over the years or indeed going missing altogether as we often see in the UK too! To achieve this, we worked with Essential Medical Guidance, based in South Africa, who agreed to host the content on their platform. We hope that using this format will allow changes to be made to content as surveillance data and knowledge evolves in Sierra Leone. We’re very grateful for their support in hosting the guidelines and adapting into the app format and are very proud of the outcome. If the implementation and dissemination is successful then we hope to develop similar guidelines for internal medicine and opportunistic infections which can also be hosted through the Essential Medicine Guidance platform.

So after many months of work, this week we finally launched the app, accompanied by a training session for junior doctors at Connaught Hospital to provide an introduction to antimicrobial resistance and stewardship as well as the functionality of the app. The initial feedback from Junior Doctors was very positive. This launch event also facilitated dialogue between senior clinicians and members of the Pharmacy Board of Sierra Leone, who are leading the delivery of the National Strategic Plan for Combating Antimicrobial Resistance.

Looking to the future, the next steps will be to promote use of the app during mentoring sessions with the junior doctors, complete another audit after implementation, and ultimately continue to develop the ongoing research capacity building projects which are essential to generate local resistance data and inform the next iteration of the guideline. It is also essential to recognise the importance of infection prevention and control (IPC)  – with a reduced level of infections there will be less need for antibiotic use. During the launch of the guidelines, we took the opportunity to strengthen messages around IPC best practices, reminding doctors that IPC exists not only to protect the workforce from the patients, but vice versa as well. Ultimately, we hope that by developing a culture of antimicrobial stewardship in Connaught Hospital, it will be possible to reduce the emergence of antimicrobial resistant infections and consequently reduce avoidable deaths from hospital and community acquired infections.

You can read more about antimicrobial resistance on the WHO website – http://www.who.int/antimicrobial-resistance/en/

And you can also make your stewardship pledge and become an Antibiotic Guardian here – http://antibioticguardian.com

World Mental Health Day 2017

By Dawn Harris, Mental Health Coordinator

 

 

On November 10th, we will be celebrating World Mental Health Day with the theme of ‘Mental Health in the Workplace’. The concept of mental health in Sierra Leone is poorly understood by many and often highly stigmatised. Discrimination against mental illness is common and I imagine that conversations about mental health at work are almost non-existent. Any opportunities to raise awareness need to be embraced.

A large amount of my time in Sierra Leone is spent working with the national team of twenty Mental Health Nurses. These nurses run mental health clinics throughout the country, often working in isolation in their respective units but together they form a vital work force.

On the 14th August 2017 Sierra Leone experienced a deadly mudslide and widespread flooding. Over 500 people lost their lives and an estimated 8000 people were displaced. On the morning of the disaster the mental health nurses had all travelled to Freetown for a training week. Anticipating that the mental health needs of the affected population could rise, the Ministry of Health and Sanitation called upon these nurses to work directly at the worst affected sites as part of the disaster response efforts. My work at KSLP suddenly altered from delivering a teaching week to assisting with the coordination of this response.

Over the following weeks the team worked tirelessly to provide psychological support to thousands of individuals. The environment on the ground was initially very chaotic, with many distressed individuals still searching for loved ones. I heard tragic stories of individuals losing their entire families as they had left the house early to go to work while the rest of the family slept. I witnessed many people sheltering in half-built houses that were not fit for human habitation, with people sleeping directly on dirty floors and with poor sanitation. It was so overwhelming I found it hard to emotionally comprehend the enormity of it all. The burden of carrying out this work on the mental health nurses was vast. They spoke directly with many affected individuals each day, showing continued compassion and empathy. It was almost impossible not to become emotionally invested.

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In the wake of this tragedy I must remind myself to focus on the positives so that we can move forwards in a meaningful way. Despite the devastating circumstances there have been moments of relief; children laughing and playing together in the half-built houses, people singing and dancing while sheltering in a church, a young female smiling after receiving potentially lifesaving epilepsy treatment when she had been left untreated for over ten years, and a lone child reunited with family members who they thought had been lost. This, in no way makes up for the enormous losses but has given me a new sense of hope and recovery for these affected individuals.

It has been a privilege working closely with the mental health nurses over this time. There seems to be a renewed enthusiasm within the team for the delivery of mental health support in spite of the daily challenges they face. The nurses have been able to spend more time together, strengthening their bond as a team and building their confidence. It has been inspiring to watch the team grow over this time, despite being stretched to their absolute maximum.

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I have been inspired by one health worker in particular who often talks of her passion for mental health and wanting to raise awareness. She lost family members in the mudslide but worked together with the nurses to deliver psychosocial support. Her input on the ground with knowledge of the area was crucial for the success of the intervention, particularly while the environment was so chaotic. I hope that this passion continues and we can harness it to drive forward this outreach service that will now be vital so for this devastated community.

For me personally, this experience has also been a reminder that any of us can be affected by mental health issues at any time. Life can suddenly be altered in ways we cannot predict and potentially trigger mental illness. Even as a mental health worker I am not immune and will acknowledge that this has been a stressful time for everyone involved. Some of the group work carried out in the response has involved talking with the nurses, psychosocial support workers and domestic staff at the camps to raise awareness of stress and its management. The sense of team work, with a sharing of experience and burden has been vital to maintaining each other’s mental health. This can be said of almost any circumstance.

Unfortunately, as a result of the disaster and prioritisation of the response, events to commemorate World Mental Health Day in Sierra Leone may not be as large as previously hoped. At Connaught Hospital the team of Mental Health Link Nurses will visit each ward to raise awareness. At the Ministry level and nationally we are seeing greater recognition of mental health issues. This progress has been achieved as the result of many years of advocacy work by multiple organisations, plus a willingness within the government to improve mental health services. It will take time for this progress to filter outwards to the wider population, when mental illness may be openly talked about in the work place but I believe this is something that will happen. It is exciting to be in Sierra Leone at a time when we have a real opportunity to continue this momentum and build on what has already been achieved.