Program Planning to Develop Infrastructure for Cancer Care in Liberia

Liberia’s health infrastructure was completely devastated after 14 years of back-to-back civil war. Postconflict rebuilding of the country’s health workforce and infrastructure has become a priority. Initially, the focus was on the diagnosis and treatment of communicable diseases that caused multigenerational family losses. With the increasing burden of noncommunicable diseases, however, the country has turned its attention to addressing diabetes, cancer, and cardiovascular and respiratory diseases, with the development of the noncommunicable disease unit under the Ministry of Health. Recovering from another setback caused by the Ebola virus outbreak in 2014, the country assembled a diverse group of stakeholders to form Liberia’s first National Cancer Committee. To structure a program that would address the increasing burden of cervical and breast cancers, the major cause of mortality among reproductive-aged women in Liberia, input from the International Atomic Energy Agency was critical. This article describes the preplanning activities for developing infrastructure to support cancer care in Liberia that occurred between 2013 and 2020 and is still ongoing. This case study is intended to serve as a planning guide for countries with limited resources as they work toward the goal of eliminating cervical cancer and developing infrastructure to address their country’s burden of all cancers.

Assessing the prevalence of refractive errors and accuracy of vision screening by schoolteachers in Liberia

Background
Evidence indicates that school-based vision screening by trained teachers is an effective way of identifying and addressing potential vision problems in schoolchildren. However, inconsistencies have been reported in both the testing methods and accuracy of the screeners. This study assessed the prevalence of refractive errors and accuracy of screening by teachers in Grand Kru County, Liberia.

Methods
We conducted a retrospective analysis of data from four schools where, in February 2019, children were screened for refractive errors by trained teachers and then re-examined by ophthalmic technicians. One row of five optotypes of the Snellen 6/9 (0.2 logMar) scale (tumbling E chart) was used at a distance of 3 m. The prevalence of visual impairment and associations with sex, age and school were explored. Sensitivity, specificity and predictive values were calculated.

Results
Data were available for 823 of 1095 eligible children with a mean age of 13.7 y (range 5–18) and male:female ratio of 1:0.8. Poor vision was identified in 24 (2.9%) children with no differences by either sex or age but small differences by school. Screening by teachers had a sensitivity of 0.25 (95% confidence interval [CI] 0.077 to 0.423) and a specificity of 0.996 (95% CI 0.992 to 1.000). Positive and negative predictive values were 0.667 (95% CI 0.359 to 0.975) and 0.978 (95% CI 0.968 to 0.988), respectively. The results were influenced by a high number of misclassifications in one of the four schools.

Conclusions
Teachers can be trained to conduct vision screening tests on schoolchildren to an acceptable level of accuracy, but strong monitoring and quality assurance systems should be built into screening programmes from the onset. In settings like Liberia, where many children do not attend school regularly, screening programmes should extend to community platforms to reach children out of school.

High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities

Background: HIV/AIDS remains one of the world’s most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic.

Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions.

Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed.

Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2–3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018.

Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND:
The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014–2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country’s maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS:
Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS:
Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1–3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS:
Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.