Validating a verbal autopsy tool to assess pre-hospital trauma mortality burden in a resource-poor setting.

OBJECTIVES: To present the validation of a verbal autopsy (VA) tool using inpatient deaths in order to ultimately assess the burden of adult pre-hospital trauma mortality in Lilongwe, Malawi. METHODS: A WHO VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe to family members of inpatient deceased. Two physicians assigned cause of death as 'trauma' or 'non-trauma' as well as a standard VA cause of death based on the VA tool. These assignments were compared to the 'gold standard' of physician review of hospital records using a kappa statistic. RESULTS: The VA method had near-perfect agreement with the hospital record in determining 'trauma' vs. 'non-trauma'. There was moderate agreement when comparing types of death, for example cardiovascular vs. infectious disease, and limited agreement when comparing specific causes of death. CONCLUSION: This VA tool can accurately ascertain trauma-related mortality with almost perfect agreement. The next step is to assess pre-hospital trauma mortality burden using the VA tool to determine whether hospital records underestimate the burden of trauma in the community.

Surgery and global public health: the UNC-Malawi surgical initiative as a model for sustainable collaboration.

Addressing global health disparities in the developing world gained prominence during the first decade of the twenty-first century. The HIV/AIDS epidemic triggered much interest in and funding for health improvement and mortality reduction in low- and middle-income nations, particularly in sub-Saharan Africa. Alliances between U.S. academic medical centers and African nations were created through the departments of internal medicine and infectious disease. However, the importance of addressing surgical disease as part of global public health is becoming recognized as part of international health development efforts. We propose a novel model to reduce the global burden of surgical diseases in resource poor settings by incorporating a sustained institutional surgical presence with our residency training experience by placing a senior surgical resident to provide continuity of care and facilitate training of local personnel. We present the experiences of the University of North Carolina (UNC) Department of Surgery as part of the UNC Project in Malawi as an example of this innovative approach.

Short- and long-term results of low cost trauma training in a low-income resource-poor country.

This article was migrated. The article was marked as recommended. Introduction: Malawi is among the world's least developed countries. There are 2.1 physicians per 100 000 people and a high trauma-related mortality and morbidity. The lack of healthcare resources requires essential high capacity trauma training at a low cost. Methods: A one-week trauma course was conducted at the Kamuzu Central Hospital in Lilongwe, Malawi. 15 students (13 interns and 2 chief nurses) attended the course. They were trained in initial trauma care, triage and basic practical procedures. Thereafter, evaluated through an identical multiple-choice exam, pre- (PRE) and post-course (POE), following a similar exam 6 months post-course (6MPOE). Prior to, and after the course a confidence-based questionnaire was completed. Results: The participants presented significantly higher test-scores after the course in both POE (26.2±3.2 vs. 21.8±3.1; p>0.001) and 6MPOE (25.7±2.4 vs. 21.8±3.1; p 0.003). We also identified the nurses to improve significantly after the course. The highest score of improvement was 27.3%. Higher confidence scores were noticed after the course. Conclusion: This study shows that any healthcare personnel in a low-income setting could benefit from a designed course in trauma management. Thus, we emphasize that healthcare staff undertake similar course to orient towards correct management and assessment of initial trauma patients.

Head injury triage in a sub Saharan African urban population.

BACKGROUND: Injuries are the ninth leading cause of death in the world and disproportionately affect low- and middle-income countries. Head injury is the leading cause of trauma death. This study examines the epidemiology and outcomes of traumatic head injury presenting to a tertiary hospital in Malawi, in order to determine effective triage in a resource limited setting. METHODS: The study was conducted at Kamuzu Central Hospital (KCH) in Lilongwe Malawi during a three-month period. Vital signs and Glasgow Coma Score (GCS) were prospectively collected for all patients that presented to the casualty department secondary to head injury. All head injury admissions were followed until death or discharge. RESULTS: During the three-month study period, 4411 patients presented to KCH secondary to trauma and 841 (19%) had a head injury. A multivariate logistic regression model revealed that GCS and heart rate changes correlated strongly with mortality. There is a four-fold increase in the odds of mortality in moderate versus mild head injury based on GCS. CONCLUSION: In a resource limited setting, basic trauma tools such as GCS and heart rate can effectively triage head injury patients, who comprise the most critically ill trauma patients. Improvements in head injury outcome require multifaceted efforts including the development of a trauma system to improve pre-hospital care.

Addressing Malawi's surgical workforce crisis: a sustainable paradigm for training and collaboration in Africa.

BACKGROUND: The exodus of health professionals including surgeons from sub-Saharan Africa has been well documented, but few effective, long-term solutions have been described. There is an increasing burden of surgical diseases in Africa attributable to trauma (road traffic injuries), burns, and other noncommunicable diseases such as cancer, increasing the need for surgeons. METHODS: We conducted a Descriptive analysis of surgical academic partnership between Kamuzu Central Hospital (KCH) Malawi, the University of Malawi-College of Medicine, the University of North Carolina in the United States, and Haukeland University Hospital, Norway, to locally train Malawian surgical residents in a College of Surgeons of East, Central and Southern Africa (COSECSA) approved program. RESULTS: The KCH Surgery Residency program began in 2009 with 3 residents, adding 3 general surgery and 2 orthopedic residents in 2010. The intention is to enroll ≥ 3 residents per year to fill the 5-year program and the training has been fully accredited by COSECSA. International partners have provided near-continuous presence of attending surgeons for direct training and support of the local staff surgeons, while providing monetary support in addition to the Malawi Ministry of Health salary. CONCLUSION: This collaborative, academic model of local surgery training is designed to limit brain drain by keeping future surgeons in their country of origin as they establish themselves professionally and personally, with ongoing collaboration with international colleagues.

Under-reporting of road traffic mortality in developing countries: application of a capture-recapture statistical model to refine mortality estimates.

Road traffic injuries are a major cause of preventable death in sub-Saharan Africa. Accurate epidemiologic data are scarce and under-reporting from primary data sources is common. Our objectives were to estimate the incidence of road traffic deaths in Malawi using capture-recapture statistical analysis and determine what future efforts will best improve upon this estimate. Our capture-recapture model combined primary data from both police and hospital-based registries over a one year period (July 2008 to June 2009). The mortality incidences from the primary data sources were 0.075 and 0.051 deaths/1000 person-years, respectively. Using capture-recapture analysis, the combined incidence of road traffic deaths ranged 0.192-0.209 deaths/1000 person-years. Additionally, police data were more likely to include victims who were male, drivers or pedestrians, and victims from incidents with greater than one vehicle involved. We concluded that capture-recapture analysis is a good tool to estimate the incidence of road traffic deaths, and that capture-recapture analysis overcomes limitations of incomplete data sources. The World Health Organization estimated incidence of road traffic deaths for Malawi utilizing a binomial regression model and survey data and found a similar estimate despite strikingly different methods, suggesting both approaches are valid. Further research should seek to improve capture-recapture data through utilization of more than two data sources and improving accuracy of matches by minimizing missing data, application of geographic information systems, and use of names and civil registration numbers if available.

An Observational Study of the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi.

INTRODUCTION: Peritonitis is a life-threatening condition with a multitude of etiologies that can vary with geographic location. The aims of this study were to elucidate the etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi. METHODS: All patients admitted to Kamuzu Central Hospital (KCH) who underwent an operation for treatment of peritonitis during the calendar year 2008 were eligible. Peritonitis was defined as abdominal rigidity, rebound tenderness, and/or guarding in one or more abdominal quadrants. Subjects were identified from a review of the medical records for all patients admitted to the adult general surgical ward and the operative log book. Those who met the definition of peritonitis and underwent celiotomy were included. RESULTS: 190 subjects were identified. The most common etiologies were appendicitis (22%), intestinal volvulus (17%), perforated peptic ulcer (11%) and small bowel perforation (11%). The overall mortality rate associated with peritonitis was 15%, with the highest mortality rates observed in solid organ rupture (35%), perforated peptic ulcer (33%), primary/idiopathic peritonitis (27%), tubo-ovarian abscess (20%) and small bowel perforation (15%). Factors associated with death included abdominal rigidity, generalized (versus localized) peritonitis, hypotension, tachycardia and anemia (p < 0.05). Age, gender, symptoms (obstipation, vomiting) and symptom duration, tachypnea, abnormal temperature, leukocytosis, hemoconcentration, thrombocytopenia and thrombocytosis were not associated with mortality (p = NS). CONCLUSIONS: There are several signs and laboratory findings predictive of poor outcome in Malawian patients with peritonitis. Tachycardia, hypotension, anemia, abdominal rigidity and generalized peritonitis are the most predictive of death (P < 0.05 for each). Similar to studies from other African countries, in our population the most common cause of peritonitis was appendicitis, and the overall mortality rate among all patients with peritonitis was 15%. Identified geographical differences included intestinal volvulus, rare in the US but the 2nd most common cause of peritonitis in Malawi and gallbladder disease, common in Ethiopia but not observed in Malawi. Future research should investigate whether correction of factors associated with mortality might improve outcomes.