ProblemReported levels of mental health and psychosocial problems rose during the 2014–2015 Ebola virus disease outbreak in Sierra Leone.ApproachAs part of the emergency response, existing plans to create mental health units within the existing hospital framework were brought forward. A nurse-led mental health and psychosocial support service, with an inpatient liaison service and an outpatient clinic, was set up at the largest government hospital in the country. One mental health nurse trained general nurses in psychological first aid, case identification and referral pathways. Health-care staff attended mental well-being workshops on coping with stigma and stress.Local settingMental health service provision in Sierra Leone is poor, with one specialist psychiatric hospital to serve the population of 7 million.Relevant changesFrom March 2015 to February 2016, 143 patients were seen at the clinic; 20 had survived or had relatives affected by Ebola virus disease. Half the patients (71) had mild distress or depression, anxiety disorders and grief or social problems, while 30 patients presented with psychosis requiring medication. Fourteen non-specialist nurses received mental health awareness training. Over 100 physicians, nurses and auxiliary staff participated in well-being workshops. Lessons learntA nurse-led approach within a non-specialist setting was a successful model for delivering mental health and psychosocial support services during the Ebola outbreak in Sierra Leone. Strong leadership and partnerships were essential for establishing a successful service. Lack of affordable psychotropic medications, limited human resources and weak social welfare structures remain challenges.

It has been shown by references to the writings of other workers, and some personal observations in the early part of this paper, that destruction of certain species of bacteria takes place in the alimentary canal of flies—especially in the early developmental stages of the insect—and ticks. In addition, emphasis has been laid on the remarkable sterility of the gut-contents and faeces of some parasitic and semi-parasitic blood-feeders.That these conditions result from the operation of several factors is possible, and the bactericidal principle described in this paper may reasonably be accepted as one of these factors.The investigation has been limited to the adult stage of the insects Stomoxys calcitrans, Musca domestica, Anopheles bifurcatus, Aëdes cinereus, Cimex lectularius and Rhodnius prolixus, and the arachnids Argas persicus and Ornithodorus moubata. In all of these a bactericidal principle has been demonstrated in the gut-contents, and, in the case of the insects, also in the faeces.The bacteria most affected were the common sporing aerobes and the staphylococci, but B. anthracis was destroyed by gut-contents of Stomoxys, and M. catarrhalis and S. haemolyticus by those of Argas.It may be inferred, from the results of the bactericidal and absorption tests, that the active principle in any one species of arthropod is single, but that different groups of bacteria exhibit differences in susceptibility to its action; some, such as the subtilis group, being very susceptible, are destroyed by concentrations too weak to affect other species, while others, as the staphylococci, require relatively high concentrations for their destruction, and many bacteria appear to be wholly resistant.The bactericidal principle occurring in different arthropod species showed some differences in the groups of bacteria susceptible to its action, and in the degree of susceptibility of particular groups. Thus, the widest range of action was shown by gut-contents of Argas and Stomoxys, and the least by those of the bugs. The sporing bacilli seemed to be affected more by material from Stomoxys than by that from Argas, but, on the other hand, the staphylococci were apparently more susceptible to the action of Argas material than to that of Stomoxys. The gut-contents of the ticks had a feebly destructive action on B. pestis, while those of some insects actually enhanced its growth. This last observation is of some interest in connection with the case of the plague flea.With regard to the properties of the active principle, bactericidal action is greater and more rapid at 37° C. than at room temperature. This action is not accompanied by any visible bacteriolysis. The bactericidal principle retains its activity unimpaired for at least six months when kept in the dry state. It is very thermostable, resisting temperatures as high as 120° C. It is not destroyed by tryptic digestion. It is precipitated from solution with proteins by alcohol or acetone, but is not itself affected by these reagents. It is not soluble in the common fat-solvents, ether, chloroform, alcohol or acetone. By allowing it to act upon repeated small doses of bacteria, it rapidly becomes exhausted, and it can be inactivated, possibly through adsorption, by large doses of killed bacteria; even those species which are not destroyed by it. It may also be adsorbed in small amount by bibulous paper.It exhibits none of the properties of the bacteriophage, and it differs from lysozyme.In the bactericidal action it is clear that no vital process is involved, in fact it very closely resembles the action of an antiseptic.Regarding the source of the active principle, there is no doubt that it is formed in the stomach, but whether as a secretion of the gastric cells or as a result of the processes of digestion is not clear. (Nuttall (1908) showed that the destruction of Spirochaeta duttoni in the gut of the bed bug was definitely related to digestion.) An examination of material collected from ticks, kept at 25° C. at various stages of digestion seemed to point to an increase in bactericidal activity during the first two weeks after feeding, and a decline after the sixth or eighth week, but the activity of material from individual ticks, taken at similar intervals after feeding, often varied greatly. Control tests with the blood of the hosts, on which the arthropods were fed, showed that this was not the source of the active principle.

(1) Reaction changes and production of gas in organic salt media are not sufficiently constant to form a reliable diagnostic criterion for the differentiation of bacterial types.(2) The enhancement or inhibition of bacterial growth in such media in the majority of cases bears a direct relationship to the utilisation of the salt by the organism. This furnishes a useful differential test for certain organisms when citrates are used, but cannot be applied in the cases of all salts.(3) The bacterial decomposition of the salts of those organic acids which form insoluble lead salts can be clearly demonstrated by the addition of suitable quantities of a solution of lead acetate to the culture.(4) By the use of six organic salts, seven different groupings of the common Salmonella types can be obtained, whereas the sugar reactions have, up to the present, yielded only four different groupings.(5) Regarding other groups of bacteria, the organic salts form an easy means of distinguishing between pathogenic and certain non-pathogenic vibrios, and between certain of the members of thecoli-aërogenesgroup, and also betweenB. diphtheriaeand Hofmann's bacillus, as well as betweenB. malleiandB. whitmori.(6) The six organic salts employed in this test are relatively inexpensive, will stand sterilising by autoclave, and can be obtained with certainty in a state of purity much more readily than the rarer “sugars.”(7) The nature of the decomposition products of citric acid has been fully examined in the case ofBacillus suipestifer; it has been shown that the products are acetic acid, carbon dioxide and succinic acid, and a simple explanation of the mechanism of this reaction is put forward. In the case of fumaric acid a preliminary examination shows that the acid is converted into succinic acid probably by direct reduction. Maleic acid appears to behave in an analogous manner to fumaric acid. Further work on these acids is in progress.(8) A large number of organic acid salts have been tried, but only the six suggested have given useful results. It appears that simple aliphatic monobasic and dibasic acids, with the exception of formic acid, are not decomposed readily by the bacteria investigated, and this is also true of monohydroxycarboxylic acids. Readiness of decomposition is first shown by the dihydroxydicarboxylic acids (tartaric acids), and appears to be at its best in the hydroxytricarboxylic acid (citric acid).(9) While organic salt fermentation tests have been found particularly useful in the cases of the bacterial groups dealt with in this paper, they cannot be substituted for the “sugar reactions” in general use.

Investigations at two hospitals, P and S, showedStaphylococcus aureusto be commonly present in the milk of healthy nursing mothers and the throat and intestine of their babies. In hospital P, the proportion affected in a group of eighty-two mothers and their babies was over 90%. The condition may not be uncommon in maternity hospitals, but no information of its occurrence is available from private obstetrical practice. The cocci concerned seemed to be of low virulence, for babies swallowing relatively massive doses in their mothers' milk suffered no perceptible ill effect. On the other hand, the coccus was found in the pus of the only case of breast abscess encountered, and in some minor external pustular lesions. It was present in the milk of all the cases of flushed breast examined, but its causal connexion with this condition awaits proof.The staphylococci, in the majority of cases, seemed to occur first in the baby's throat, possibly from a focus of infection in the babies' ward, and to be transmitted from baby to baby and from baby to mother, with a return infection, in larger amount, through the mother's milk. The mother's nose and throat must be included amongst other, but less frequent, sources of the infection.The predominating type ofStaph. aureusgave a relatively strong coagulase reaction which was caused only by actively growing cocci, but it would seem that the reaction caused by this agency is less trustworthy as an index of virulence of the coccus than one in which free coagulase also operates.