%PDF-1.3 1 0 obj << /Type /Catalog /Outlines 2 0 R /Pages 3 0 R >> endobj 2 0 obj << /Type /Outlines /Count 0 >> endobj 3 0 obj << /Type /Pages /Kids [6 0 R 104 0 R 131 0 R 133 0 R ] /Count 4 /Resources << /ProcSet 4 0 R /Font << /F1 8 0 R /F2 9 0 R /F3 10 0 R /F4 11 0 R >> /XObject << /I1 12 0 R /I2 13 0 R /I3 114 0 R >> >> /MediaBox [0.000 0.000 612.000 792.000] >> endobj 4 0 obj [/PDF /Text /ImageC ] endobj 5 0 obj << /Creator (DOMPDF) /CreationDate (D:20170830090631+00'00') /ModDate (D:20170830090631+00'00') /Title (Ebola and Indirect Effects on Health Service Function in Sierra Leone PLOS Currents Outbreaks) >> endobj 6 0 obj << /Type /Page /Parent 3 0 R /Annots [ 14 0 R 16 0 R 18 0 R 20 0 R 22 0 R 24 0 R 26 0 R 28 0 R 30 0 R 32 0 R 34 0 R 36 0 R 38 0 R 40 0 R 42 0 R 44 0 R 46 0 R 48 0 R 50 0 R 52 0 R 54 0 R 56 0 R 58 0 R 60 0 R 62 0 R 64 0 R 66 0 R 68 0 R 70 0 R 72 0 R 74 0 R 76 0 R 78 0 R 80 0 R 82 0 R 84 0 R 86 0 R 88 0 R 90 0 R 92 0 R 94 0 R 96 0 R 98 0 R 100 0 R 102 0 R ] /Contents 7 0 R >> endobj 7 0 obj << /Length 22655 >> stream q 375.000 0 0 39.000 222.000 738.000 cm /I2 Do Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Leone)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(December 19, 2014)] TJ ET BT 96.500 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 101.375 675.088 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Hkon Angell Bolkan)] TJ ET 0.271 0.267 0.267 rg BT 116.749 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 122.171 663.247 Td /F1 9.8 Tf [(Donald Alpha Bash-Taqi)] TJ ET 0.271 0.267 0.267 rg BT 227.841 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 233.262 663.247 Td /F1 9.8 Tf [(Mohammed Samai)] TJ ET 0.271 0.267 0.267 rg BT 315.074 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 320.495 663.247 Td /F1 9.8 Tf [(Martin Gerdin)] TJ ET 0.271 0.267 0.267 rg BT 379.551 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 384.972 663.247 Td /F1 9.8 Tf [(Johan von Schreeb)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Bolkan HA, Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Leone. PLOS Currents Outbreaks. 2014 Dec 19 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.0307d588df619f9c9447f8ead5b72b2d.)] TJ ET q 15.000 31.187 577.500 593.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Background: The indirect effects of the Ebola epidemic on health service function may be significant but is not known. The aim )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(of this study was to quantify to what extent admission rates and surgery has changed at health facilities providing such care in )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(Sierra Leone during the time of the Ebola epidemic.)] TJ ET BT 26.250 535.262 Td /F1 9.8 Tf [(Methods: Weekly data on facility inpatient admissions and surgery from admission and surgical theatre register books were )] TJ ET BT 26.250 523.357 Td /F1 9.8 Tf [(retrospectively retrieved during September and October. 21 Community Health Officers enrolled in a surgical task-shifting )] TJ ET BT 26.250 511.452 Td /F1 9.8 Tf [(program personally visited the facilities. The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014.)] TJ ET BT 26.250 492.048 Td /F1 9.8 Tf [(Results: Data was retrieved from 40 out of 55 facilities. A total of 62,257 admissions and 12,124 major surgeries were registered )] TJ ET BT 26.250 480.143 Td /F1 9.8 Tf [(for the study period.)] TJ ET BT 26.250 468.238 Td /F1 9.8 Tf [(Total admissions in the week of the first Ebola case were 2,006, median 40 \(IQR 20-76\) compared to 883, median 12 \(IQR 4-)] TJ ET BT 26.250 456.333 Td /F1 9.8 Tf [(30\) on the last week of the study. This equals a 70% drop in median number of admissions \(p=0.005\) between May and )] TJ ET BT 26.250 444.429 Td /F1 9.8 Tf [(October. Total number of major surgeries fell from 342, median 6 \(IQR 2-14\) to 231, median 3 \(IQR 0-6\) in the same period, )] TJ ET BT 26.250 432.524 Td /F1 9.8 Tf [(equal 50% reduction in median number of major surgeries \(p=0.014\).)] TJ ET BT 26.250 413.119 Td /F1 9.8 Tf [(Conclusions: Inpatient health services have been severely affected by the Ebola outbreak. The dramatic documented decline in )] TJ ET BT 26.250 401.214 Td /F1 9.8 Tf [(facility inpatient admissions and major surgery is likely to be an underestimation. Reestablishing such care is urgent and must )] TJ ET BT 26.250 389.310 Td /F1 9.8 Tf [(be a priority.)] TJ ET BT 26.250 352.707 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 332.753 Td /F1 9.8 Tf [(The Non Governmental Organization, CapaCare and Norwegian University of Science and Technology are paying the data )] TJ ET BT 26.250 320.848 Td /F1 9.8 Tf [(collectors. A grant from the national board of health and welfare in Sweden covered JvS and MG contribution. The funders had )] TJ ET BT 26.250 308.943 Td /F1 9.8 Tf [(no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.)] TJ ET BT 26.250 279.841 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 259.887 Td /F1 9.8 Tf [(Ebola Viral Disease \(EVD\) continues to ravage Sierra Leone. Experts have expressed concerns of complete breakdown in civic )] TJ ET BT 26.250 247.982 Td /F1 9.8 Tf [(society.)] TJ ET 0.267 0.267 0.267 rg BT 59.303 249.489 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 64.121 247.982 Td /F1 9.8 Tf [( To date the direct effects of EVD in Sierra Leone includes over 8,000 infected and 1,820 deaths among them 106 )] TJ ET BT 26.250 236.077 Td /F1 9.8 Tf [(health care workers.)] TJ ET 0.267 0.267 0.267 rg BT 114.029 237.584 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 118.848 236.077 Td /F1 9.8 Tf [( Of the 124 medical doctors in the country, 10 have died due to Ebola, corresponding to a risk ratio of 280 )] TJ ET BT 26.250 224.172 Td /F1 9.8 Tf [(compared to the general population.)] TJ ET 0.267 0.267 0.267 rg BT 182.338 225.680 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 187.156 228.061 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 189.566 225.680 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 204.768 Td /F1 9.8 Tf [(In addition to the direct health effects of the viral disease, indirect EVD effects on health service may lead to increased morbidity )] TJ ET BT 26.250 192.863 Td /F1 9.8 Tf [(and mortality. Factors such as patients fear of Ebola and death of health care staff has reportedly affected health-seeking )] TJ ET BT 26.250 180.958 Td /F1 9.8 Tf [(behavior and reduced the function of health service.)] TJ ET 0.267 0.267 0.267 rg BT 250.081 182.465 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 254.899 180.958 Td /F1 9.8 Tf [( Patients suffering from complicated deliveries, injuries, incarcerated )] TJ ET BT 26.250 169.053 Td /F1 9.8 Tf [(hernias and malaria may today not find the care they acutely need.)] TJ ET 0.267 0.267 0.267 rg BT 314.021 170.561 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 318.840 172.942 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 321.249 170.561 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 26.250 149.649 Td /F1 9.8 Tf [(The scale of such indirect effects on health facility function is unknown. Such data remain essential for any health agencies )] TJ ET BT 26.250 137.744 Td /F1 9.8 Tf [(aiming at providing care in the EVD affected country. The aim of this study was to, in the midst of the EVD epidemic, assess to )] TJ ET BT 26.250 125.839 Td /F1 9.8 Tf [(what extent admission rates and surgery has changed in Sierra Leone since the onset of the EVD epidemic.)] TJ ET BT 26.250 89.237 Td /F4 12.0 Tf [(Material and Methods)] TJ ET BT 26.250 69.282 Td /F1 9.8 Tf [(This study was carried out to provide data and guidance for agencies providing health care in Sierra Leone. The study was done )] TJ ET BT 26.250 57.378 Td /F1 9.8 Tf [(in collaboration between the Ministry of Health and Sanitation in Sierra Leone, Karolinska Institutet in Sweden, Norwegian )] TJ ET BT 26.250 45.473 Td /F1 9.8 Tf [(University of Science and Technology and the Non Governmental Organization CapaCare, as part of a new surveillance )] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Leone)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(December 19, 2014)] TJ ET BT 96.500 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 101.375 675.088 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Hkon Angell Bolkan)] TJ ET 0.271 0.267 0.267 rg BT 116.749 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 122.171 663.247 Td /F1 9.8 Tf [(Donald Alpha Bash-Taqi)] TJ ET 0.271 0.267 0.267 rg BT 227.841 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 233.262 663.247 Td /F1 9.8 Tf [(Mohammed Samai)] TJ ET 0.271 0.267 0.267 rg BT 315.074 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 320.495 663.247 Td /F1 9.8 Tf [(Martin Gerdin)] TJ ET 0.271 0.267 0.267 rg BT 379.551 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 384.972 663.247 Td /F1 9.8 Tf [(Johan von Schreeb)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Bolkan HA, Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Leone. PLOS Currents Outbreaks. 2014 Dec 19 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.0307d588df619f9c9447f8ead5b72b2d.)] TJ ET q 15.000 31.187 577.500 593.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Background: The indirect effects of the Ebola epidemic on health service function may be significant but is not known. The aim )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(of this study was to quantify to what extent admission rates and surgery has changed at health facilities providing such care in )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(Sierra Leone during the time of the Ebola epidemic.)] TJ ET BT 26.250 535.262 Td /F1 9.8 Tf [(Methods: Weekly data on facility inpatient admissions and surgery from admission and surgical theatre register books were )] TJ ET BT 26.250 523.357 Td /F1 9.8 Tf [(retrospectively retrieved during September and October. 21 Community Health Officers enrolled in a surgical task-shifting )] TJ ET BT 26.250 511.452 Td /F1 9.8 Tf [(program personally visited the facilities. The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014.)] TJ ET BT 26.250 492.048 Td /F1 9.8 Tf [(Results: Data was retrieved from 40 out of 55 facilities. A total of 62,257 admissions and 12,124 major surgeries were registered )] TJ ET BT 26.250 480.143 Td /F1 9.8 Tf [(for the study period.)] TJ ET BT 26.250 468.238 Td /F1 9.8 Tf [(Total admissions in the week of the first Ebola case were 2,006, median 40 \(IQR 20-76\) compared to 883, median 12 \(IQR 4-)] TJ ET BT 26.250 456.333 Td /F1 9.8 Tf [(30\) on the last week of the study. This equals a 70% drop in median number of admissions \(p=0.005\) between May and )] TJ ET BT 26.250 444.429 Td /F1 9.8 Tf [(October. Total number of major surgeries fell from 342, median 6 \(IQR 2-14\) to 231, median 3 \(IQR 0-6\) in the same period, )] TJ ET BT 26.250 432.524 Td /F1 9.8 Tf [(equal 50% reduction in median number of major surgeries \(p=0.014\).)] TJ ET BT 26.250 413.119 Td /F1 9.8 Tf [(Conclusions: Inpatient health services have been severely affected by the Ebola outbreak. The dramatic documented decline in )] TJ ET BT 26.250 401.214 Td /F1 9.8 Tf [(facility inpatient admissions and major surgery is likely to be an underestimation. Reestablishing such care is urgent and must )] TJ ET BT 26.250 389.310 Td /F1 9.8 Tf [(be a priority.)] TJ ET BT 26.250 352.707 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 332.753 Td /F1 9.8 Tf [(The Non Governmental Organization, CapaCare and Norwegian University of Science and Technology are paying the data )] TJ ET BT 26.250 320.848 Td /F1 9.8 Tf [(collectors. A grant from the national board of health and welfare in Sweden covered JvS and MG contribution. The funders had )] TJ ET BT 26.250 308.943 Td /F1 9.8 Tf [(no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.)] TJ ET BT 26.250 279.841 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 259.887 Td /F1 9.8 Tf [(Ebola Viral Disease \(EVD\) continues to ravage Sierra Leone. Experts have expressed concerns of complete breakdown in civic )] TJ ET BT 26.250 247.982 Td /F1 9.8 Tf [(society.)] TJ ET 0.267 0.267 0.267 rg BT 59.303 249.489 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 64.121 247.982 Td /F1 9.8 Tf [( To date the direct effects of EVD in Sierra Leone includes over 8,000 infected and 1,820 deaths among them 106 )] TJ ET BT 26.250 236.077 Td /F1 9.8 Tf [(health care workers.)] TJ ET 0.267 0.267 0.267 rg BT 114.029 237.584 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 118.848 236.077 Td /F1 9.8 Tf [( Of the 124 medical doctors in the country, 10 have died due to Ebola, corresponding to a risk ratio of 280 )] TJ ET BT 26.250 224.172 Td /F1 9.8 Tf [(compared to the general population.)] TJ ET 0.267 0.267 0.267 rg BT 182.338 225.680 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 187.156 228.061 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 189.566 225.680 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 204.768 Td /F1 9.8 Tf [(In addition to the direct health effects of the viral disease, indirect EVD effects on health service may lead to increased morbidity )] TJ ET BT 26.250 192.863 Td /F1 9.8 Tf [(and mortality. Factors such as patients fear of Ebola and death of health care staff has reportedly affected health-seeking )] TJ ET BT 26.250 180.958 Td /F1 9.8 Tf [(behavior and reduced the function of health service.)] TJ ET 0.267 0.267 0.267 rg BT 250.081 182.465 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 254.899 180.958 Td /F1 9.8 Tf [( Patients suffering from complicated deliveries, injuries, incarcerated )] TJ ET BT 26.250 169.053 Td /F1 9.8 Tf [(hernias and malaria may today not find the care they acutely need.)] TJ ET 0.267 0.267 0.267 rg BT 314.021 170.561 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 318.840 172.942 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 321.249 170.561 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 26.250 149.649 Td /F1 9.8 Tf [(The scale of such indirect effects on health facility function is unknown. Such data remain essential for any health agencies )] TJ ET BT 26.250 137.744 Td /F1 9.8 Tf [(aiming at providing care in the EVD affected country. The aim of this study was to, in the midst of the EVD epidemic, assess to )] TJ ET BT 26.250 125.839 Td /F1 9.8 Tf [(what extent admission rates and surgery has changed in Sierra Leone since the onset of the EVD epidemic.)] TJ ET BT 26.250 89.237 Td /F4 12.0 Tf [(Material and Methods)] TJ ET BT 26.250 69.282 Td /F1 9.8 Tf [(This study was carried out to provide data and guidance for agencies providing health care in Sierra Leone. The study was done )] TJ ET BT 26.250 57.378 Td /F1 9.8 Tf [(in collaboration between the Ministry of Health and Sanitation in Sierra Leone, Karolinska Institutet in Sweden, Norwegian )] TJ ET BT 26.250 45.473 Td /F1 9.8 Tf [(University of Science and Technology and the Non Governmental Organization CapaCare, as part of a new surveillance )] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Leone)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(December 19, 2014)] TJ ET BT 96.500 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 101.375 675.088 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Hkon Angell Bolkan)] TJ ET 0.271 0.267 0.267 rg BT 116.749 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 122.171 663.247 Td /F1 9.8 Tf [(Donald Alpha Bash-Taqi)] TJ ET 0.271 0.267 0.267 rg BT 227.841 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 233.262 663.247 Td /F1 9.8 Tf [(Mohammed Samai)] TJ ET 0.271 0.267 0.267 rg BT 315.074 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 320.495 663.247 Td /F1 9.8 Tf [(Martin Gerdin)] TJ ET 0.271 0.267 0.267 rg BT 379.551 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 384.972 663.247 Td /F1 9.8 Tf [(Johan von Schreeb)] TJ ET 0.271 0.267 0.267 rg BT 26.250 651.342 Td /F1 9.8 Tf [(Bolkan HA, Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and Indirect Effects on Health Service Function in Sierra )] TJ ET BT 26.250 639.438 Td /F1 9.8 Tf [(Leone. PLOS Currents Outbreaks. 2014 Dec 19 . Edition 1. doi: )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(10.1371/currents.outbreaks.0307d588df619f9c9447f8ead5b72b2d.)] TJ ET q 15.000 31.187 577.500 593.965 re W n 0.271 0.267 0.267 rg BT 26.250 598.430 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 578.476 Td /F1 9.8 Tf [(Background: The indirect effects of the Ebola epidemic on health service function may be significant but is not known. The aim )] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(of this study was to quantify to what extent admission rates and surgery has changed at health facilities providing such care in )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(Sierra Leone during the time of the Ebola epidemic.)] TJ ET BT 26.250 535.262 Td /F1 9.8 Tf [(Methods: Weekly data on facility inpatient admissions and surgery from admission and surgical theatre register books were )] TJ ET BT 26.250 523.357 Td /F1 9.8 Tf [(retrospectively retrieved during September and October. 21 Community Health Officers enrolled in a surgical task-shifting )] TJ ET BT 26.250 511.452 Td /F1 9.8 Tf [(program personally visited the facilities. The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014.)] TJ ET BT 26.250 492.048 Td /F1 9.8 Tf [(Results: Data was retrieved from 40 out of 55 facilities. A total of 62,257 admissions and 12,124 major surgeries were registered )] TJ ET BT 26.250 480.143 Td /F1 9.8 Tf [(for the study period.)] TJ ET BT 26.250 468.238 Td /F1 9.8 Tf [(Total admissions in the week of the first Ebola case were 2,006, median 40 \(IQR 20-76\) compared to 883, median 12 \(IQR 4-)] TJ ET BT 26.250 456.333 Td /F1 9.8 Tf [(30\) on the last week of the study. This equals a 70% drop in median number of admissions \(p=0.005\) between May and )] TJ ET BT 26.250 444.429 Td /F1 9.8 Tf [(October. Total number of major surgeries fell from 342, median 6 \(IQR 2-14\) to 231, median 3 \(IQR 0-6\) in the same period, )] TJ ET BT 26.250 432.524 Td /F1 9.8 Tf [(equal 50% reduction in median number of major surgeries \(p=0.014\).)] TJ ET BT 26.250 413.119 Td /F1 9.8 Tf [(Conclusions: Inpatient health services have been severely affected by the Ebola outbreak. The dramatic documented decline in )] TJ ET BT 26.250 401.214 Td /F1 9.8 Tf [(facility inpatient admissions and major surgery is likely to be an underestimation. Reestablishing such care is urgent and must )] TJ ET BT 26.250 389.310 Td /F1 9.8 Tf [(be a priority.)] TJ ET BT 26.250 352.707 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 332.753 Td /F1 9.8 Tf [(The Non Governmental Organization, CapaCare and Norwegian University of Science and Technology are paying the data )] TJ ET BT 26.250 320.848 Td /F1 9.8 Tf [(collectors. A grant from the national board of health and welfare in Sweden covered JvS and MG contribution. The funders had )] TJ ET BT 26.250 308.943 Td /F1 9.8 Tf [(no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.)] TJ ET BT 26.250 279.841 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 259.887 Td /F1 9.8 Tf [(Ebola Viral Disease \(EVD\) continues to ravage Sierra Leone. Experts have expressed concerns of complete breakdown in civic )] TJ ET BT 26.250 247.982 Td /F1 9.8 Tf [(society.)] TJ ET 0.267 0.267 0.267 rg BT 59.303 249.489 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 64.121 247.982 Td /F1 9.8 Tf [( To date the direct effects of EVD in Sierra Leone includes over 8,000 infected and 1,820 deaths among them 106 )] TJ ET BT 26.250 236.077 Td /F1 9.8 Tf [(health care workers.)] TJ ET 0.267 0.267 0.267 rg BT 114.029 237.584 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 118.848 236.077 Td /F1 9.8 Tf [( Of the 124 medical doctors in the country, 10 have died due to Ebola, corresponding to a risk ratio of 280 )] TJ ET BT 26.250 224.172 Td /F1 9.8 Tf [(compared to the general population.)] TJ ET 0.267 0.267 0.267 rg BT 182.338 225.680 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 187.156 228.061 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 189.566 225.680 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 204.768 Td /F1 9.8 Tf [(In addition to the direct health effects of the viral disease, indirect EVD effects on health service may lead to increased morbidity )] TJ ET BT 26.250 192.863 Td /F1 9.8 Tf [(and mortality. Factors such as patients fear of Ebola and death of health care staff has reportedly affected health-seeking )] TJ ET BT 26.250 180.958 Td /F1 9.8 Tf [(behavior and reduced the function of health service.)] TJ ET 0.267 0.267 0.267 rg BT 250.081 182.465 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 254.899 180.958 Td /F1 9.8 Tf [( Patients suffering from complicated deliveries, injuries, incarcerated )] TJ ET BT 26.250 169.053 Td /F1 9.8 Tf [(hernias and malaria may today not find the care they acutely need.)] TJ ET 0.267 0.267 0.267 rg BT 314.021 170.561 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 318.840 172.942 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 321.249 170.561 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 26.250 149.649 Td /F1 9.8 Tf [(The scale of such indirect effects on health facility function is unknown. Such data remain essential for any health agencies )] TJ ET BT 26.250 137.744 Td /F1 9.8 Tf [(aiming at providing care in the EVD affected country. The aim of this study was to, in the midst of the EVD epidemic, assess to )] TJ ET BT 26.250 125.839 Td /F1 9.8 Tf [(what extent admission rates and surgery has changed in Sierra Leone since the onset of the EVD epidemic.)] TJ ET BT 26.250 89.237 Td /F4 12.0 Tf [(Material and Methods)] TJ ET BT 26.250 69.282 Td /F1 9.8 Tf [(This study was carried out to provide data and guidance for agencies providing health care in Sierra Leone. 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916.949 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(initiative to monitor effects of the Ebola epidemic on health services. The director of research and Non-Communicable diseases )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(\(MS\) and the Director of Laboratory and Hospitals \(DB-T\) of the Ministry of Health and Sanitation both approved the study. )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(Since September 2014 we survey 61 governmental, private non- and for-profit healthcare facilities that offer in-patient care and )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(major surgery. This represents all facilities that offer such care in Sierra Leone identified in a 2013 countrywide study that )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(systematically mapped such facilities.)] TJ ET 0.267 0.267 0.267 rg BT 188.256 721.364 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 193.075 719.857 Td /F1 9.8 Tf [( The study did not include facilities providing inpatient tuberculosis or psychiatric care. )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(For this study six facilities were excluded. Three because they only performed cataract surgery and three were closed in the )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(whole of 2014. Hence 55 facilities were included. A pre-condition for the study was that data collection had to be simple, quick )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(and not expose data collectors to EVD during data collection. We therefore decided to base the study on readily available facility )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(data. We assumed that the number of general inpatient admissions and number of surgeries could serve as proxy indicators on )] TJ ET BT 26.250 660.333 Td /F1 9.8 Tf [(the function of the health facility providing such service.)] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(This study was done with the help of 21 courageous data collectors, Community Health Officers enrolled in a surgical task-)] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(shifting program. They were trained in data collection during two days and received a tablet with SIM card to allow direct data )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(entering. They personally visited the facilities.)] TJ ET 0.267 0.267 0.267 rg BT 222.410 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 227.229 617.119 Td /F1 9.8 Tf [( Weekly data on facility inpatient admissions and surgery from 2014 from )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(admission and surgical theatre register books were retrospectively retrieved during September and October. The Ministry of )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(Health and Sanitation wrote a letter encouraging all healthcare facilities share the required data, which enabled data collectors )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(to access the facility registry books. Data was entered into excel, compiled and analyzed with Stata. We used a 5% )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(significance level. Averages are reported as medians with interquartile ranges. Tests were parametric or non-parametric. We )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(used segmented linear regression to detect significant temporal trends.)] TJ ET 0.267 0.267 0.267 rg BT 332.429 559.103 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014. As the first case of Ebola in Sierra Leone were )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(reported on May 23, we defined the pre-outbreak period as the time between week 2 and week 21 and post-outbreak as week )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(22-41.)] TJ ET BT 26.250 477.779 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(Out of the 55 facilities included, data was not available for 15; three were not accessible while 12 were closed during our visits, )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(reportedly due to the EVD outbreak. However, it was not possible to get exact information regarding the reasons for their )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(closure. From the remaining 40 facilities, a total of 62,257 admissions and 12,124 major surgeries were registered for the study )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(period.)] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(Out of these, 35,609 admissions were in the period before the outbreak and 26,648 admissions were after the outbreak. )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(Furthermore, 12,124 major surgeries were registered for the study period, out of which 7,078 surgeries were in the period )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(before the outbreak and 5,096 surgeries were after the outbreak.)] TJ ET BT 26.250 359.491 Td /F1 9.8 Tf [(Total number of admissions in the 40 facilities in week 21, the week of the first Ebola case was 2,006, median per facility was 40 )] TJ ET BT 26.250 347.586 Td /F1 9.8 Tf [(\(IQR 20-76\). Total number of admissions in week 41, the last week of this study, was 883, median 12 \(IQR 4-30\) \(figure 1\). This )] TJ ET BT 26.250 335.682 Td /F1 9.8 Tf [(equals a 70% drop in median number of admissions \(p-value=0.005\))] TJ ET 0.965 0.965 0.965 rg 26.250 -139.949 555.000 465.750 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 325.801 m 581.250 325.801 l 581.250 325.051 l 26.250 325.051 l f q 450.000 0 0 450.000 35.250 -133.949 cm /I3 Do Q q 35.250 -139.949 537.000 0.000 re W n Q Q q 15.000 -139.949 577.500 916.949 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(initiative to monitor effects of the Ebola epidemic on health services. The director of research and Non-Communicable diseases )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(\(MS\) and the Director of Laboratory and Hospitals \(DB-T\) of the Ministry of Health and Sanitation both approved the study. )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(Since September 2014 we survey 61 governmental, private non- and for-profit healthcare facilities that offer in-patient care and )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(major surgery. This represents all facilities that offer such care in Sierra Leone identified in a 2013 countrywide study that )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(systematically mapped such facilities.)] TJ ET 0.267 0.267 0.267 rg BT 188.256 721.364 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 193.075 719.857 Td /F1 9.8 Tf [( The study did not include facilities providing inpatient tuberculosis or psychiatric care. )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(For this study six facilities were excluded. Three because they only performed cataract surgery and three were closed in the )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(whole of 2014. Hence 55 facilities were included. A pre-condition for the study was that data collection had to be simple, quick )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(and not expose data collectors to EVD during data collection. We therefore decided to base the study on readily available facility )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(data. We assumed that the number of general inpatient admissions and number of surgeries could serve as proxy indicators on )] TJ ET BT 26.250 660.333 Td /F1 9.8 Tf [(the function of the health facility providing such service.)] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(This study was done with the help of 21 courageous data collectors, Community Health Officers enrolled in a surgical task-)] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(shifting program. They were trained in data collection during two days and received a tablet with SIM card to allow direct data )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(entering. They personally visited the facilities.)] TJ ET 0.267 0.267 0.267 rg BT 222.410 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 227.229 617.119 Td /F1 9.8 Tf [( Weekly data on facility inpatient admissions and surgery from 2014 from )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(admission and surgical theatre register books were retrospectively retrieved during September and October. The Ministry of )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(Health and Sanitation wrote a letter encouraging all healthcare facilities share the required data, which enabled data collectors )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(to access the facility registry books. Data was entered into excel, compiled and analyzed with Stata. We used a 5% )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(significance level. Averages are reported as medians with interquartile ranges. Tests were parametric or non-parametric. We )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(used segmented linear regression to detect significant temporal trends.)] TJ ET 0.267 0.267 0.267 rg BT 332.429 559.103 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014. As the first case of Ebola in Sierra Leone were )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(reported on May 23, we defined the pre-outbreak period as the time between week 2 and week 21 and post-outbreak as week )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(22-41.)] TJ ET BT 26.250 477.779 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(Out of the 55 facilities included, data was not available for 15; three were not accessible while 12 were closed during our visits, )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(reportedly due to the EVD outbreak. However, it was not possible to get exact information regarding the reasons for their )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(closure. From the remaining 40 facilities, a total of 62,257 admissions and 12,124 major surgeries were registered for the study )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(period.)] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(Out of these, 35,609 admissions were in the period before the outbreak and 26,648 admissions were after the outbreak. )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(Furthermore, 12,124 major surgeries were registered for the study period, out of which 7,078 surgeries were in the period )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(before the outbreak and 5,096 surgeries were after the outbreak.)] TJ ET BT 26.250 359.491 Td /F1 9.8 Tf [(Total number of admissions in the 40 facilities in week 21, the week of the first Ebola case was 2,006, median per facility was 40 )] TJ ET BT 26.250 347.586 Td /F1 9.8 Tf [(\(IQR 20-76\). Total number of admissions in week 41, the last week of this study, was 883, median 12 \(IQR 4-30\) \(figure 1\). This )] TJ ET BT 26.250 335.682 Td /F1 9.8 Tf [(equals a 70% drop in median number of admissions \(p-value=0.005\))] TJ ET 0.965 0.965 0.965 rg 26.250 -139.949 555.000 465.750 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 325.801 m 581.250 325.801 l 581.250 325.051 l 26.250 325.051 l f q 450.000 0 0 450.000 35.250 -133.949 cm /I3 Do Q q 35.250 -139.949 537.000 0.000 re W n Q Q q 15.000 -139.949 577.500 916.949 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(initiative to monitor effects of the Ebola epidemic on health services. The director of research and Non-Communicable diseases )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(\(MS\) and the Director of Laboratory and Hospitals \(DB-T\) of the Ministry of Health and Sanitation both approved the study. )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(Since September 2014 we survey 61 governmental, private non- and for-profit healthcare facilities that offer in-patient care and )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(major surgery. This represents all facilities that offer such care in Sierra Leone identified in a 2013 countrywide study that )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(systematically mapped such facilities.)] TJ ET 0.267 0.267 0.267 rg BT 188.256 721.364 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 193.075 719.857 Td /F1 9.8 Tf [( The study did not include facilities providing inpatient tuberculosis or psychiatric care. )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(For this study six facilities were excluded. Three because they only performed cataract surgery and three were closed in the )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(whole of 2014. Hence 55 facilities were included. A pre-condition for the study was that data collection had to be simple, quick )] TJ ET BT 26.250 684.143 Td /F1 9.8 Tf [(and not expose data collectors to EVD during data collection. We therefore decided to base the study on readily available facility )] TJ ET BT 26.250 672.238 Td /F1 9.8 Tf [(data. We assumed that the number of general inpatient admissions and number of surgeries could serve as proxy indicators on )] TJ ET BT 26.250 660.333 Td /F1 9.8 Tf [(the function of the health facility providing such service.)] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(This study was done with the help of 21 courageous data collectors, Community Health Officers enrolled in a surgical task-)] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(shifting program. They were trained in data collection during two days and received a tablet with SIM card to allow direct data )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(entering. They personally visited the facilities.)] TJ ET 0.267 0.267 0.267 rg BT 222.410 618.626 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 227.229 617.119 Td /F1 9.8 Tf [( Weekly data on facility inpatient admissions and surgery from 2014 from )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(admission and surgical theatre register books were retrospectively retrieved during September and October. The Ministry of )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(Health and Sanitation wrote a letter encouraging all healthcare facilities share the required data, which enabled data collectors )] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(to access the facility registry books. Data was entered into excel, compiled and analyzed with Stata. We used a 5% )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(significance level. Averages are reported as medians with interquartile ranges. Tests were parametric or non-parametric. We )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(used segmented linear regression to detect significant temporal trends.)] TJ ET 0.267 0.267 0.267 rg BT 332.429 559.103 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(The study period was January 6 \(week 2\) to October 12, \(week 41\) 2014. As the first case of Ebola in Sierra Leone were )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(reported on May 23, we defined the pre-outbreak period as the time between week 2 and week 21 and post-outbreak as week )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(22-41.)] TJ ET BT 26.250 477.779 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(Out of the 55 facilities included, data was not available for 15; three were not accessible while 12 were closed during our visits, )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(reportedly due to the EVD outbreak. However, it was not possible to get exact information regarding the reasons for their )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(closure. From the remaining 40 facilities, a total of 62,257 admissions and 12,124 major surgeries were registered for the study )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(period.)] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(Out of these, 35,609 admissions were in the period before the outbreak and 26,648 admissions were after the outbreak. )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(Furthermore, 12,124 major surgeries were registered for the study period, out of which 7,078 surgeries were in the period )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(before the outbreak and 5,096 surgeries were after the outbreak.)] TJ ET BT 26.250 359.491 Td /F1 9.8 Tf [(Total number of admissions in the 40 facilities in week 21, the week of the first Ebola case was 2,006, median per facility was 40 )] TJ ET BT 26.250 347.586 Td /F1 9.8 Tf [(\(IQR 20-76\). Total number of admissions in week 41, the last week of this study, was 883, median 12 \(IQR 4-30\) \(figure 1\). 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Total number of major surgeries in week 41 was )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(231, median 3 \(IQR 0-6\). This equals a 50% drop in median number of major surgeries \(p-value=0.014\).)] TJ ET BT 26.250 687.607 Td /F1 9.8 Tf [(Using segmented linear regression, we estimate that each facility admitted 335 \(95% CI 174-536\) less patients post-outbreak )] TJ ET BT 26.250 675.702 Td /F1 9.8 Tf [(compared to pre-outbreak \(p-value for trend <0.001\). Each facility performed 48 \(95% CI 16-86\) less major surgeries in the post-)] TJ ET BT 26.250 663.798 Td /F1 9.8 Tf [(outbreak period \(p-value for trend <0.001\).)] TJ ET BT 26.250 627.195 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 607.241 Td /F1 9.8 Tf [(This is the first study to document the indirect effects of the Ebola epidemic on health facility functioning in Sierra Leone, one of )] TJ ET BT 26.250 595.336 Td /F1 9.8 Tf [(the countries most severely affected by the epidemic. The dramatic documented decline in facility inpatient admissions and )] TJ ET BT 26.250 583.431 Td /F1 9.8 Tf [(major surgery is likely to be an underestimation for several reasons.)] TJ ET BT 26.250 564.027 Td /F1 9.8 Tf [(First, admissions normally increase due to more malaria during the rainy season, which starts in May. Second, by comparing )] TJ ET BT 26.250 552.122 Td /F1 9.8 Tf [(medians of only facilities with complete data before and after the outbreak, the significance of the post- outbreak-closed health )] TJ ET BT 26.250 540.217 Td /F1 9.8 Tf [(facilities remain unaccounted for. Third, it is likely that patients who normally seek care at the now closed facilitates went to )] TJ ET BT 26.250 528.312 Td /F1 9.8 Tf [(those open, limiting the observed decline.)] TJ ET BT 26.250 508.908 Td /F1 9.8 Tf [(This study has several limitations. Data is retrospective and based on routine data collected at the facility. We could not )] TJ ET BT 26.250 497.003 Td /F1 9.8 Tf [(document the reasons for why facilities were closed, other than it was because of the Ebola epidemic. Nevertheless we are )] TJ ET BT 26.250 485.098 Td /F1 9.8 Tf [(convinced that the trends identified represent a real decline in facility function. We will continue to monitor the trend over time )] TJ ET BT 26.250 473.193 Td /F1 9.8 Tf [(even when the last case of Ebola has been reported.)] TJ ET BT 26.250 453.789 Td /F1 9.8 Tf [(The study was conducted in the midst of the epidemic in an extremely challenging context. We were shocked as one of the data )] TJ ET BT 26.250 441.884 Td /F1 9.8 Tf [(collectors fell ill and died of Ebola during the study period. He did however not contract EVD during data collection, but was )] TJ ET BT 26.250 429.979 Td /F1 9.8 Tf [(exposed to EVD as frontline healthcare worker at a governmental hospital.)] TJ ET BT 26.250 410.574 Td /F1 9.8 Tf [(To put a number on Ebolas indirect health service effects, our results indicate that an estimated 35,000 sick in Sierra Leone will )] TJ ET BT 26.250 398.670 Td /F1 9.8 Tf [(be excluded from inpatient care from the onset of the epidemic in mid-May and until the end of the year if current low level of )] TJ ET BT 26.250 386.765 Td /F1 9.8 Tf [(admissions remains. Significant international efforts are needed, not only to stop and contain the Ebola epidemic, but also to )] TJ ET BT 26.250 374.860 Td /F1 9.8 Tf [(limit its indirect effects on health service functioning.)] TJ ET BT 26.250 338.258 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 318.303 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 281.701 Td /F4 12.0 Tf [(Correspondence)] TJ ET BT 26.250 261.747 Td /F1 9.8 Tf [(Hkon Angell Bolkan, MD)] TJ ET BT 26.250 242.342 Td /F1 9.8 Tf [(Norwegian University of Science and Technology)] TJ ET BT 26.250 222.937 Td /F1 9.8 Tf [(Department of Cancer Research and Molecular Medicine ?)] TJ ET BT 26.250 203.532 Td /F1 9.8 Tf [(Post box 8905?)] TJ ET BT 26.250 184.128 Td /F1 9.8 Tf [(N-7491 Trondheim, ?Norway)] TJ ET BT 26.250 164.723 Td /F1 9.8 Tf [(Phone: +47 99150768)] TJ ET BT 26.250 145.318 Td /F1 9.8 Tf [(E-mail: hakon.bolkan@capacare.org)] TJ ET Q q 15.000 26.857 577.500 750.143 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Median \(A\) and total number \(B\) of admissions and median \(C\) and total number \(D\) of surgeries by week in )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(Sierra Leone until October 12 \(week 41\), 2014 compared to Ebola cases \(WHO data\).)] TJ ET Q BT 26.250 718.917 Td /F1 9.8 Tf [(Total number of major surgeries in week 21 was 342, median 6 \(IQR 2-14\). Total number of major surgeries in week 41 was )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(231, median 3 \(IQR 0-6\). This equals a 50% drop in median number of major surgeries \(p-value=0.014\).)] TJ ET BT 26.250 687.607 Td /F1 9.8 Tf [(Using segmented linear regression, we estimate that each facility admitted 335 \(95% CI 174-536\) less patients post-outbreak )] TJ ET BT 26.250 675.702 Td /F1 9.8 Tf [(compared to pre-outbreak \(p-value for trend <0.001\). Each facility performed 48 \(95% CI 16-86\) less major surgeries in the post-)] TJ ET BT 26.250 663.798 Td /F1 9.8 Tf [(outbreak period \(p-value for trend <0.001\).)] TJ ET BT 26.250 627.195 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 607.241 Td /F1 9.8 Tf [(This is the first study to document the indirect effects of the Ebola epidemic on health facility functioning in Sierra Leone, one of )] TJ ET BT 26.250 595.336 Td /F1 9.8 Tf [(the countries most severely affected by the epidemic. The dramatic documented decline in facility inpatient admissions and )] TJ ET BT 26.250 583.431 Td /F1 9.8 Tf [(major surgery is likely to be an underestimation for several reasons.)] TJ ET BT 26.250 564.027 Td /F1 9.8 Tf [(First, admissions normally increase due to more malaria during the rainy season, which starts in May. Second, by comparing )] TJ ET BT 26.250 552.122 Td /F1 9.8 Tf [(medians of only facilities with complete data before and after the outbreak, the significance of the post- outbreak-closed health )] TJ ET BT 26.250 540.217 Td /F1 9.8 Tf [(facilities remain unaccounted for. Third, it is likely that patients who normally seek care at the now closed facilitates went to )] TJ ET BT 26.250 528.312 Td /F1 9.8 Tf [(those open, limiting the observed decline.)] TJ ET BT 26.250 508.908 Td /F1 9.8 Tf [(This study has several limitations. Data is retrospective and based on routine data collected at the facility. We could not )] TJ ET BT 26.250 497.003 Td /F1 9.8 Tf [(document the reasons for why facilities were closed, other than it was because of the Ebola epidemic. Nevertheless we are )] TJ ET BT 26.250 485.098 Td /F1 9.8 Tf [(convinced that the trends identified represent a real decline in facility function. We will continue to monitor the trend over time )] TJ ET BT 26.250 473.193 Td /F1 9.8 Tf [(even when the last case of Ebola has been reported.)] TJ ET BT 26.250 453.789 Td /F1 9.8 Tf [(The study was conducted in the midst of the epidemic in an extremely challenging context. We were shocked as one of the data )] TJ ET BT 26.250 441.884 Td /F1 9.8 Tf [(collectors fell ill and died of Ebola during the study period. He did however not contract EVD during data collection, but was )] TJ ET BT 26.250 429.979 Td /F1 9.8 Tf [(exposed to EVD as frontline healthcare worker at a governmental hospital.)] TJ ET BT 26.250 410.574 Td /F1 9.8 Tf [(To put a number on Ebolas indirect health service effects, our results indicate that an estimated 35,000 sick in Sierra Leone will )] TJ ET BT 26.250 398.670 Td /F1 9.8 Tf [(be excluded from inpatient care from the onset of the epidemic in mid-May and until the end of the year if current low level of )] TJ ET BT 26.250 386.765 Td /F1 9.8 Tf [(admissions remains. Significant international efforts are needed, not only to stop and contain the Ebola epidemic, but also to )] TJ ET BT 26.250 374.860 Td /F1 9.8 Tf [(limit its indirect effects on health service functioning.)] TJ ET BT 26.250 338.258 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 318.303 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 281.701 Td /F4 12.0 Tf [(Correspondence)] TJ ET BT 26.250 261.747 Td /F1 9.8 Tf [(Hkon Angell Bolkan, MD)] TJ ET BT 26.250 242.342 Td /F1 9.8 Tf [(Norwegian University of Science and Technology)] TJ ET BT 26.250 222.937 Td /F1 9.8 Tf [(Department of Cancer Research and Molecular Medicine ?)] TJ ET BT 26.250 203.532 Td /F1 9.8 Tf [(Post box 8905?)] TJ ET BT 26.250 184.128 Td /F1 9.8 Tf [(N-7491 Trondheim, ?Norway)] TJ ET BT 26.250 164.723 Td /F1 9.8 Tf [(Phone: +47 99150768)] TJ ET BT 26.250 145.318 Td /F1 9.8 Tf [(E-mail: hakon.bolkan@capacare.org)] TJ ET Q q 15.000 26.857 577.500 750.143 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Median \(A\) and total number \(B\) of admissions and median \(C\) and total number \(D\) of surgeries by week in )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(Sierra Leone until October 12 \(week 41\), 2014 compared to Ebola cases \(WHO data\).)] TJ ET Q BT 26.250 718.917 Td /F1 9.8 Tf [(Total number of major surgeries in week 21 was 342, median 6 \(IQR 2-14\). Total number of major surgeries in week 41 was )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(231, median 3 \(IQR 0-6\). This equals a 50% drop in median number of major surgeries \(p-value=0.014\).)] TJ ET BT 26.250 687.607 Td /F1 9.8 Tf [(Using segmented linear regression, we estimate that each facility admitted 335 \(95% CI 174-536\) less patients post-outbreak )] TJ ET BT 26.250 675.702 Td /F1 9.8 Tf [(compared to pre-outbreak \(p-value for trend <0.001\). Each facility performed 48 \(95% CI 16-86\) less major surgeries in the post-)] TJ ET BT 26.250 663.798 Td /F1 9.8 Tf [(outbreak period \(p-value for trend <0.001\).)] TJ ET BT 26.250 627.195 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 607.241 Td /F1 9.8 Tf [(This is the first study to document the indirect effects of the Ebola epidemic on health facility functioning in Sierra Leone, one of )] TJ ET BT 26.250 595.336 Td /F1 9.8 Tf [(the countries most severely affected by the epidemic. The dramatic documented decline in facility inpatient admissions and )] TJ ET BT 26.250 583.431 Td /F1 9.8 Tf [(major surgery is likely to be an underestimation for several reasons.)] TJ ET BT 26.250 564.027 Td /F1 9.8 Tf [(First, admissions normally increase due to more malaria during the rainy season, which starts in May. Second, by comparing )] TJ ET BT 26.250 552.122 Td /F1 9.8 Tf [(medians of only facilities with complete data before and after the outbreak, the significance of the post- outbreak-closed health )] TJ ET BT 26.250 540.217 Td /F1 9.8 Tf [(facilities remain unaccounted for. Third, it is likely that patients who normally seek care at the now closed facilitates went to )] TJ ET BT 26.250 528.312 Td /F1 9.8 Tf [(those open, limiting the observed decline.)] TJ ET BT 26.250 508.908 Td /F1 9.8 Tf [(This study has several limitations. Data is retrospective and based on routine data collected at the facility. We could not )] TJ ET BT 26.250 497.003 Td /F1 9.8 Tf [(document the reasons for why facilities were closed, other than it was because of the Ebola epidemic. Nevertheless we are )] TJ ET BT 26.250 485.098 Td /F1 9.8 Tf [(convinced that the trends identified represent a real decline in facility function. We will continue to monitor the trend over time )] TJ ET BT 26.250 473.193 Td /F1 9.8 Tf [(even when the last case of Ebola has been reported.)] TJ ET BT 26.250 453.789 Td /F1 9.8 Tf [(The study was conducted in the midst of the epidemic in an extremely challenging context. We were shocked as one of the data )] TJ ET BT 26.250 441.884 Td /F1 9.8 Tf [(collectors fell ill and died of Ebola during the study period. He did however not contract EVD during data collection, but was )] TJ ET BT 26.250 429.979 Td /F1 9.8 Tf [(exposed to EVD as frontline healthcare worker at a governmental hospital.)] TJ ET BT 26.250 410.574 Td /F1 9.8 Tf [(To put a number on Ebolas indirect health service effects, our results indicate that an estimated 35,000 sick in Sierra Leone will )] TJ ET BT 26.250 398.670 Td /F1 9.8 Tf [(be excluded from inpatient care from the onset of the epidemic in mid-May and until the end of the year if current low level of )] TJ ET BT 26.250 386.765 Td /F1 9.8 Tf [(admissions remains. Significant international efforts are needed, not only to stop and contain the Ebola epidemic, but also to )] TJ ET BT 26.250 374.860 Td /F1 9.8 Tf [(limit its indirect effects on health service functioning.)] TJ ET BT 26.250 338.258 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 318.303 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 281.701 Td /F4 12.0 Tf [(Correspondence)] TJ ET BT 26.250 261.747 Td /F1 9.8 Tf [(Hkon Angell Bolkan, MD)] TJ ET BT 26.250 242.342 Td /F1 9.8 Tf [(Norwegian University of Science and Technology)] TJ ET BT 26.250 222.937 Td /F1 9.8 Tf [(Department of Cancer Research and Molecular Medicine ?)] TJ ET BT 26.250 203.532 Td /F1 9.8 Tf [(Post box 8905?)] TJ ET BT 26.250 184.128 Td /F1 9.8 Tf [(N-7491 Trondheim, ?Norway)] TJ ET BT 26.250 164.723 Td /F1 9.8 Tf [(Phone: +47 99150768)] TJ ET BT 26.250 145.318 Td /F1 9.8 Tf [(E-mail: hakon.bolkan@capacare.org)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(3)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Outbreaks)] TJ ET Q endstream endobj 133 0 obj << /Type /Page /Parent 3 0 R /Annots [ 135 0 R 137 0 R 139 0 R 141 0 R 143 0 R 145 0 R 147 0 R 149 0 R 151 0 R 153 0 R 155 0 R 157 0 R 159 0 R 161 0 R 163 0 R 165 0 R 167 0 R 169 0 R 171 0 R 173 0 R 175 0 R ] /Contents 134 0 R >> endobj 134 0 obj << /Length 11146 >> stream 0.271 0.267 0.267 rg q 15.000 371.896 577.500 405.104 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [( Hkon A. Bolkan: Contributed to literature search, figures, study design, data collection, data analysis, data interpretation and )] TJ ET BT 26.250 718.419 Td /F1 9.8 Tf [(writing and review of the final manuscript. Donald A Bash-Taqi: Contributed to study design, data collection, data interpretation )] TJ ET BT 26.250 706.515 Td /F1 9.8 Tf [(and review of the final manuscript. Mohammed Samai: Contributed to study design, data collection, data interpretation and )] TJ ET BT 26.250 694.610 Td /F1 9.8 Tf [(review of the final manuscript. Martin Gerdin: Contributed to study design, data collection, data interpretation and review of the )] TJ ET BT 26.250 682.705 Td /F1 9.8 Tf [(final manuscript. Johan von Schreeb: Contributed to literature search, figures, study design, data collection, data collection )] TJ ET BT 26.250 670.800 Td /F1 9.8 Tf [(training, data analysis, data interpretation and writing and review of the final manuscript.)] TJ ET BT 26.250 641.698 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 614.244 Td /F1 9.8 Tf [(Farrar, J. J. and P. Piot \(2014\). The Ebola emergency immediate action, ongoing strategy. New England Journal of Medicine )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(371\(16\): 1545-1546.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 593.853 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 575.303 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 575.303 Td /F1 9.8 Tf [(World Health Organization: Ebola Response Roadmap, December 10, 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 566.817 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 548.267 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 548.267 Td /F1 9.8 Tf [(World Health Organisation: Sierra Leone Workforce Statistics. 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 539.781 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 521.231 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 521.231 Td /F1 9.8 Tf [(Check Hayden, E. \(2014\). Ebola obstructs malaria control. Nature 514\(7520\): 15-16.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 512.745 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 494.195 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 494.195 Td /F1 9.8 Tf [(Delamou, A., et al. Ebola in Africa: beyond epidemics, reproductive health in crisis. The Lancet 384\(9960\): 2105.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 485.709 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 467.159 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 467.159 Td /F1 9.8 Tf [(Bolkan, H. A., et al. \(2014\). Met and unmet need for surgery in Sierra Leone: a comprehensive retrospective countrywide )] TJ ET BT 26.250 455.254 Td /F1 9.8 Tf [(survey from all healthcare facilities performing surgery in 2012. Surgery Submitted November 2014.)] TJ ET BT 26.250 435.849 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 435.849 Td /F1 9.8 Tf [(CapaCare \(2014\). CapaCare. Retrieved 13. December, 2014.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 427.363 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 408.813 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 408.813 Td /F1 9.8 Tf [(Wagner, A. K., et al. \(2002\). Segmented regression analysis of interrupted time series studies in medication use research. )] TJ ET BT 26.250 396.909 Td /F1 9.8 Tf [(Journal of Clinical Pharmacy and Therapeutics 27\(4\): 299-309.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 388.423 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET Q q 15.000 371.896 577.500 405.104 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [( Hkon A. Bolkan: Contributed to literature search, figures, study design, data collection, data analysis, data interpretation and )] TJ ET BT 26.250 718.419 Td /F1 9.8 Tf [(writing and review of the final manuscript. Donald A Bash-Taqi: Contributed to study design, data collection, data interpretation )] TJ ET BT 26.250 706.515 Td /F1 9.8 Tf [(and review of the final manuscript. Mohammed Samai: Contributed to study design, data collection, data interpretation and )] TJ ET BT 26.250 694.610 Td /F1 9.8 Tf [(review of the final manuscript. Martin Gerdin: Contributed to study design, data collection, data interpretation and review of the )] TJ ET BT 26.250 682.705 Td /F1 9.8 Tf [(final manuscript. Johan von Schreeb: Contributed to literature search, figures, study design, data collection, data collection )] TJ ET BT 26.250 670.800 Td /F1 9.8 Tf [(training, data analysis, data interpretation and writing and review of the final manuscript.)] TJ ET BT 26.250 641.698 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 614.244 Td /F1 9.8 Tf [(Farrar, J. J. and P. Piot \(2014\). The Ebola emergency immediate action, ongoing strategy. New England Journal of Medicine )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(371\(16\): 1545-1546.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 593.853 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 575.303 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 575.303 Td /F1 9.8 Tf [(World Health Organization: Ebola Response Roadmap, December 10, 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 566.817 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 548.267 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 548.267 Td /F1 9.8 Tf [(World Health Organisation: Sierra Leone Workforce Statistics. 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 539.781 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 521.231 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 521.231 Td /F1 9.8 Tf [(Check Hayden, E. \(2014\). Ebola obstructs malaria control. Nature 514\(7520\): 15-16.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 512.745 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 494.195 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 494.195 Td /F1 9.8 Tf [(Delamou, A., et al. Ebola in Africa: beyond epidemics, reproductive health in crisis. The Lancet 384\(9960\): 2105.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 485.709 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 467.159 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 467.159 Td /F1 9.8 Tf [(Bolkan, H. A., et al. \(2014\). Met and unmet need for surgery in Sierra Leone: a comprehensive retrospective countrywide )] TJ ET BT 26.250 455.254 Td /F1 9.8 Tf [(survey from all healthcare facilities performing surgery in 2012. Surgery Submitted November 2014.)] TJ ET BT 26.250 435.849 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 435.849 Td /F1 9.8 Tf [(CapaCare \(2014\). CapaCare. Retrieved 13. December, 2014.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 427.363 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 408.813 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 408.813 Td /F1 9.8 Tf [(Wagner, A. K., et al. \(2002\). Segmented regression analysis of interrupted time series studies in medication use research. )] TJ ET BT 26.250 396.909 Td /F1 9.8 Tf [(Journal of Clinical Pharmacy and Therapeutics 27\(4\): 299-309.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 388.423 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET Q q 15.000 371.896 577.500 405.104 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [( Hkon A. Bolkan: Contributed to literature search, figures, study design, data collection, data analysis, data interpretation and )] TJ ET BT 26.250 718.419 Td /F1 9.8 Tf [(writing and review of the final manuscript. Donald A Bash-Taqi: Contributed to study design, data collection, data interpretation )] TJ ET BT 26.250 706.515 Td /F1 9.8 Tf [(and review of the final manuscript. Mohammed Samai: Contributed to study design, data collection, data interpretation and )] TJ ET BT 26.250 694.610 Td /F1 9.8 Tf [(review of the final manuscript. Martin Gerdin: Contributed to study design, data collection, data interpretation and review of the )] TJ ET BT 26.250 682.705 Td /F1 9.8 Tf [(final manuscript. Johan von Schreeb: Contributed to literature search, figures, study design, data collection, data collection )] TJ ET BT 26.250 670.800 Td /F1 9.8 Tf [(training, data analysis, data interpretation and writing and review of the final manuscript.)] TJ ET BT 26.250 641.698 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 614.244 Td /F1 9.8 Tf [(Farrar, J. J. and P. Piot \(2014\). The Ebola emergency immediate action, ongoing strategy. New England Journal of Medicine )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(371\(16\): 1545-1546.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 593.853 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 575.303 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 575.303 Td /F1 9.8 Tf [(World Health Organization: Ebola Response Roadmap, December 10, 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 566.817 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 548.267 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 548.267 Td /F1 9.8 Tf [(World Health Organisation: Sierra Leone Workforce Statistics. 2014)] TJ ET 0.267 0.267 0.267 rg BT 26.250 539.781 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 521.231 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 521.231 Td /F1 9.8 Tf [(Check Hayden, E. \(2014\). Ebola obstructs malaria control. Nature 514\(7520\): 15-16.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 512.745 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 494.195 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 494.195 Td /F1 9.8 Tf [(Delamou, A., et al. Ebola in Africa: beyond epidemics, reproductive health in crisis. The Lancet 384\(9960\): 2105.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 485.709 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 467.159 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 467.159 Td /F1 9.8 Tf [(Bolkan, H. A., et al. \(2014\). Met and unmet need for surgery in Sierra Leone: a comprehensive retrospective countrywide )] TJ ET BT 26.250 455.254 Td /F1 9.8 Tf [(survey from all healthcare facilities performing surgery in 2012. Surgery Submitted November 2014.)] TJ ET BT 26.250 435.849 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 435.849 Td /F1 9.8 Tf [(CapaCare \(2014\). CapaCare. Retrieved 13. December, 2014.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 427.363 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 408.813 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 408.813 Td /F1 9.8 Tf [(Wagner, A. K., et al. \(2002\). 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