Fight against cholera outbreak, efforts and challenges in Malawi.

Cholera is endemic in many African countries with recurrent seasonal outbreaks in parts of the region. Malawi has been experiencing seasonal outbreaks of Cholera since 1998, and it is one of the major public health problems. The current cholera outbreak is one of Malawi's worst cholera outbreaks in the past 10 years. Since the beginning of the outbreak about 56,090 cumulative cases of cholera have been reported with 1712 deaths representing a case fatality rate of 3.1%. This is happening when the country is recovering from the COVID-19 epidemic, the devastating effects of tropical storms, and is also tackling the polio outbreak. Clearly, the Malawian health system is overstretched. Nevertheless, the country has taken a positive step in responding to the current cholera outbreak. Setting up treatment facilities, stepping up Water, Sanitation, and Hygiene (WASH) initiatives in impacted areas, and improving the surveillance system for early case detection and treatment are some of the actions taken. As the fight against cholera continues there is a need to significantly increase monitoring in all districts, particularly at the community level for early detection and control of the cholera. Considering there are some cross-border cases from neighboring countries such as Mozambique, good collaboration between the two countries in strengthening surveillance and hygiene practices in the borders will help in controlling the spread of the disease. While it is commendable that dozens of oral cholera vaccines have been given, it should be noted that this provides short-term prevention. In addressing the nation's ongoing and recurrent cholera outbreaks, we advise prioritizing WASH efforts in addition to oral cholera vaccine administration.

The health policy response to COVID-19 in Malawi.

Malawi declared a state of national disaster due to the COVID-19 pandemic on 20th March 2020 and registered its first confirmed coronavirus case on the 2 April 2020. The aim of this paper was to document policy decisions made in response to the COVID-19 pandemic from January to August 2020. We reviewed policy documents from the Public Health Institute of Malawi, the Malawi Gazette, the Malawi Ministry of Health and Population and the University of Oxford Coronavirus Government Response Tracker. We found that the Malawi response to the COVID-19 pandemic was multisectoral and implemented through 15 focused working groups termed clusters. Each cluster was charged with providing policy direction in their own area of focus. All clusters then fed into one central committee for major decisions and reporting to head of state. Key policies identified during the review include international travel ban, school closures at all levels, cancellation of public events, decongesting workplaces and public transport, and mandatory face coverings and a testing policy covering symptomatic people. Supportive interventions included risk communication and community engagement in multiple languages and over a variety of mediums, efforts to improve access to water, sanitation, nutrition and unconditional social-cash transfers for poor urban and rural households.

Tailoring HIV testing in a setting of late HIV diagnosis: is the tide turning?

INTRODUCTION: Routine HIV testing in areas of high HIV prevalence has been shown to be both cost effective and to avert downstream morbidity and mortality from 'late' HIV diagnosis (defined as CD4 cell count<350 cells/ml). In the London borough of Waltham Forest in 2010, late HIV diagnoses were resulting in high morbidity with associated lengthy and costly hospital admissions. METHODS: A retrospective analysis of all new HIV diagnoses was undertaken within a two-phased quality improvement project 2010-13. Newly diagnosed patients in 2010 were characterized, including immunological state, presence of HIV-related illness and department where they presented. After an intervention to set up an opt-out, walk-in rapid HIV testing service in outpatients, an analysis was conducted of numbers of tests, prevalence and immunological state of newly diagnosed patients in 2013. RESULTS: A total of 91 patients were diagnosed with HIV, January-December 2010, 70% of which were a late diagnosis, including 48% defined as 'very immunosuppressed' (CD4 count<100 cells/ml). Of these, 51 out of 91 patients (56%) had attended hospital services in the 5 years before diagnosis, including 204 outpatient department attendances. After the intervention, rates of late diagnosis in 2013 had reduced to 46%, and rates of those diagnosed 'very immunosuppressed' had reduced from 48% to 8%. CONCLUSIONS: HIV testing in outpatients is feasible and acceptable to patients and can be offered alongside routine outpatient care. The rate of positive HIV tests in this group of patients in the authors' setting has been much higher than the HIV positivity rate of larger scale HIV testing interventions in other hospital settings. This approach also provides a model for more integrated care of HIV-positive patients.