Recommendations for effective collaboration and capacity building in epidemiological studies on the effect of alcohol and drug use on traffic safety in low- and middle-income countries.

OBJECTIVE: Alcohol or drug impairment is a major risk factor for road traffic crashes, and studies on this issue are essential to provide evidence-based data for policymakers. In low- and middle-income countries (LMICs), such studies are often conducted in partnership with one or more organizations in high-income countries (HICs). The aim of this article is to provide recommendations for improving project planning and decision-making processes in epidemiological studies on alcohol, drug and traffic safety in LMICs involving HICs. METHODS: We searched Pubmed, Google Scholar, and Google Search for articles and reports in English about lessons learned when conducting collaborative research in LMIC as well as papers presenting recommendations for effective research collaboration with partners in LMICs. RESULTS: Based on the search results, we selected 200 papers for full text examination. Few were related to studies on the effect of alcohol or drug use on road traffic safety. However, several conclusions and recommendations from other studies were found to be relevant. We combined the findings with our own experience in a narrative review. We also present a checklist for risk and quality assessment. CONCLUSIONS: Many papers presented similar recommendations, which included the importance of addressing local needs, ensuring adequate resources, local project ownership and leadership, establishing strong partnerships among all involved stakeholders, promoting shared decision-making and planning, and implementing strategies to translate research findings into policy, practice, and publications. It is also important to avoid HIC bias, which prioritizes the interests or perspectives of HICs over those of LMICs.

Poor oral health and the risk of esophageal squamous cell carcinoma in Malawi.

Esophageal squamous cell carcinoma (ESCC) is the second most common cancer in Malawi. Risk factors for this cancer in Malawi are poorly understood. Poor oral health has previously been linked to increased ESCC risk in other high-incidence regions, including parts of Eastern and Southern Africa. We assessed the relationship between oral health and ESCC risk in a sex, age and location frequency-matched case-control study based at two hospitals in Lilongwe, Malawi from 2017 to 2020. Trained interviewers used a structured questionnaire and direct observation to collect data on demographics; behaviors; oral hygiene habits; the sum of decayed, missing or filled teeth (DMFT score); oral mucosa status; lip depigmentation and dental fluorosis via a visual scale. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI), adjusted for known and suspected ESCC risk factors. During the study period, 300 cases and 300 controls were enrolled. Subjects in the highest tertile of DMFT score (≥7) had an increased risk of ESCC with an adjusted OR of 1.96 (95% CI: 1.16-3.36) compared to those with a DMFT score of 0. Severe dental fluorosis was associated with a statistically nonsignificant increased risk of ESCC (adjusted OR = 2.24, 95% CI: 0.97-5.49) compared to individuals with no fluorosis. Associations with oral mucosa status, lip depigmentation and toothbrushing method and frequency were mostly null or uncertain. Poor oral health, indicated by a higher DMFT score, was associated with increased ESCC risk in Malawi. Dental fluorosis is another possible risk factor in this population, but further evaluation is necessary to clarify any effects of fluorosis on ESCC risk.

Survival After Diagnosis of Esophageal Squamous Cell Carcinoma in Malawi.

PURPOSE: Esophageal cancer (EC) is the second most common cancer in Malawi, with esophageal squamous cell carcinoma (ESCC) representing >90% of all ECs. Despite significant morbidity and mortality, little is known about disease outcomes. In this study, we assess survival after ESCC diagnosis in Malawi. METHODS: We report on ESCC cases enrolled in a case-control study at Kamuzu Central Hospital in Lilongwe from August 2017 to April 2020. Suspected cases completed a questionnaire interview; provided blood, urine, and saliva specimens; and underwent a tumor biopsy for histologic confirmation. Cases were followed up by phone biweekly from enrollment to the study end date (December 31, 2020), date of death, or loss to follow-up. Survival was assessed using Kaplan-Meier analysis with the log-rank test. We also examined associations between treatment and ESCC mortality using Cox regression models. RESULTS: There were 300 patients with ESCC enrolled in this study, of whom 290 (97%) had known vital status at the end of follow-up and 10 (3%) were lost to follow-up. Among the 290 patients, 282 (97%) died during follow-up. The median age at enrollment was 55 years (IQR, 48-66), and the median time to death was 106 days (95% CI, 92 to 127). The 1-year, 2-year, and 3-year survival rates were 11% (95% CI, 8 to 15), 3% (95% CI, 1 to 6), and 0.9% (95% CI, 0.8 to 4), respectively. Palliative chemotherapy significantly improved the overall survival of patients with ESCC (Plog-rank = .038) and was significantly associated with reduced mortality (adjusted hazard ratio, 0.71 [95% CI, 0.51 to 0.99]). No significant association was observed between tobacco use, alcohol consumption, or HIV status and mortality. CONCLUSION: Survival after diagnosis of ESCC was poor in Malawi. Although palliative chemotherapy was associated with improved survival, prevention and earlier detection remain key priorities to improve ESCC mortality at a population level.

A Genomic Analysis of Esophageal Squamous Cell Carcinoma in Eastern Africa.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) comprises 90% of all esophageal cancer cases globally and is the most common histology in low-resource settings. Eastern Africa has a disproportionately high incidence of ESCC. METHODS: We describe the genomic profiles of 61 ESCC cases from Tanzania and compare them to profiles from an existing cohort of ESCC cases from Malawi. We also provide a comparison to ESCC tumors in The Cancer Genome Atlas (TCGA). RESULTS: We observed substantial transcriptional overlap with other squamous histologies via comparison with TCGA PanCan dataset. DNA analysis revealed known mutational patterns, both genome-wide as well as in genes known to be commonly mutated in ESCC. TP53 mutations were the most common somatic mutation in tumors from both Tanzania and Malawi but were detected at lower frequencies than previously reported in ESCC cases from other settings. In a combined analysis, two unique transcriptional clusters were identified: a proliferative/epithelial cluster and an invasive/migrative/mesenchymal cluster. Mutational signature analysis of the Tanzanian cohort revealed common signatures associated with aging and cytidine deaminase activity (APOBEC) and an absence of signature 29, which was previously reported in the Malawi cohort. CONCLUSIONS: This study defines the molecular characteristics of ESCC in Tanzania, and enriches the Eastern African dataset, with findings of overall similarities but also some heterogeneity across two unique sites. IMPACT: Despite a high burden of ESCC in Eastern Africa, investigations into the genomics in this region are nascent. This represents the largest comprehensive genomic analysis ESCC from sub-Saharan Africa to date.

Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis.

INTRODUCTION: Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery. METHODS: We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival. RESULTS: We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014). CONCLUSIONS: Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.

Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study.

Background: Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods: This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results: In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion: Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.

Chest Trauma Management in Low- and Middle-Income Countries.

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

An international report on bacterial communities in esophageal squamous cell carcinoma.

The incidence of esophageal squamous cell carcinoma (ESCC) is disproportionately high in the eastern corridor of Africa and parts of Asia. Emerging research has identified a potential association between poor oral health and ESCC. One possible link between poor oral health and ESCC involves the alteration of the microbiome. We performed an integrated analysis of four independent sequencing efforts of ESCC tumors from patients from high- and low-incidence regions of the world. Using whole genome sequencing (WGS) and RNA sequencing (RNAseq) of ESCC tumors from 61 patients in Tanzania, we identified a community of bacteria, including members of the genera Fusobacterium, Selenomonas, Prevotella, Streptococcus, Porphyromonas, Veillonella and Campylobacter, present at high abundance in ESCC tumors. We then characterized the microbiome of 238 ESCC tumor specimens collected in two additional independent sequencing efforts consisting of patients from other high-ESCC incidence regions (Tanzania, Malawi, Kenya, Iran, China). This analysis revealed similar ESCC-associated bacterial communities in these cancers. Because these genera are traditionally considered members of the oral microbiota, we next explored whether there was a relationship between the synchronous saliva and tumor microbiomes of ESCC patients in Tanzania. Comparative analyses revealed that paired saliva and tumor microbiomes were significantly similar with a specific enrichment of Fusobacterium and Prevotella in the tumor microbiome. Together, these data indicate that cancer-associated oral bacteria are associated with ESCC tumors at the time of diagnosis and support a model in which oral bacteria are present in high abundance in both saliva and tumors of some ESCC patients.

Inter-hospital Transfer Delays to a Tertiary Referral Center and Postoperative Outcomes in Patients with Abdominal Surgical Emergencies in Malawi.

BACKGROUND: In low-income countries (LICs), patients with abdominal surgical emergencies often initially present to primary or district hospitals and are transferred to referral hospitals for surgical management. The transfer process introduces a delay to care, but the relationship between transfer time and outcomes has not been studied in LICs. We sought to evaluate the effect of transfer delays on postoperative outcomes among patients undergoing emergency abdominal surgery in Malawi. METHODS: This is a retrospective analysis of the acute care surgery database at Kamuzu Central Hospital (KCH), a referral hospital in Malawi. Patients were eligible for inclusion if transferred from another facility to KCH for emergency abdominal surgery. We used logistic regression modeling to evaluate the relationship between transfer time and postoperative complications and mortality. RESULTS: The study included 2037 patients. Female patients, patients transferred from district hospitals, and patients with bowel obstructions were most likely to spend over three days at a referring facility before transfer. On regression modeling, each additional day until transfer was associated with an 18% increase in odds of developing a postoperative complication (OR 1.18, 95% CI 1.05-1.31, p = 0.005) and a 19% increase in odds of postoperative mortality (OR 1.19, 95% CI 1.08-1.31, p < 0.001). CONCLUSION: Among patients requiring emergency abdominal surgery in Malawi, transfer delays are associated with higher postoperative complications and mortality rates. Further research should focus on identifying the factors causing delays so that interventions aimed at improving the transfer process can be developed.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. METHODS: This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. DISCUSSION: This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. TRIAL REGISTRATION: This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393 .

Tobacco and other risk factors for esophageal squamous cell carcinoma in Lilongwe Malawi: Results from the Lilongwe esophageal cancer case: Control study.

OBJECTIVE: Esophageal cancer is the second commonest cancer in Malawi, and 95% of all cases are esophageal squamous cell carcinoma (ESCC). Very little is known about the epidemiology of ESCC in Malawi including risk factors. The main objective of the study was to evaluate and describe risk factors of ESCC in Malawi. METHODS: We conducted a case-control study from 2017 to 2020 at two hospitals in Lilongwe, Malawi and consenting adults were eligible for inclusion. Endoscopy was conducted on all cases and biopsies were obtained for histological confirmation. Controls were selected from patients or their guardians in orthopedic, dental and ophthalmology wards and they were frequency matched by sex, age, and region of origin to cases. An electronic structured questionnaire was delivered by a trained interviewer. Multivariate conditional logistic regression models were used to assess the associations between subject characteristics, habits, and medical history and risk of ESCC. RESULTS: During the study period, 300 cases and 300 controls were enrolled into the study. Median age of cases and controls was 56 years and 62% of the cases were male. Among cases, 30% were ever cigarette smokers as were 22% of controls. Smoking cigarettes had an adjusted odds ratio of 2.4 (95% CI 1.4-4.2 p = 0.003). HIV+ status was present in 11% of cases and 4% controls, which resulted in an adjusted odds ratio was 4.0 (95% CI 1.8-9.0 p = 0.001). Drinking hot tea was associated with an adjusted odd ratio of 2.9 (95% CI 1.3-6.3 p = 0.007). Mold on stored grain has an adjusted odd ratio of 1.6 (95% CI 1.1-2.5 p = 0.021). CONCLUSION: Reducing smoking cigarettes, consumption of scalding hot tea, and consumption of contaminated grain, could potentially help reduce the burden of ESCC in Malawi. Further investigation of the association between HIV status and ESCC are warranted.

Gastrointestinal endoscopy capacity in Eastern Africa.

Background and study aims Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity. Patients and methods In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020. Results Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services. Conclusions Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.

Epidemiology of prehospital trauma deaths in Malawi: A retrospective cohort study.

INTRODUCTION: Trauma is among the leading causes of death and disability in both adults and children worldwide. In Malawi, trauma patients are commonly brought in dead (BID). We aimed to describe the prevalence, sociodemographic, and injury-related characteristics of patients BID to Kamuzu Central Hospital (KCH), a referral hospital in Lilongwe, Malawi. METHODS: We retrospectively reviewed records of all patients BID in the trauma surveillance registry at KCH from February 2008 to September 2019. We excluded patients BID that did not present to the emergency centre, and were instead taken to the mortuary directly. We used descriptive statistics to evaluate the epidemiology of patients BID. RESULTS: We reviewed 106,198 trauma records and 1889 (1.8%) were BID patients. Most patients BID were male, in both adult (n = 1337/1528, 88.4%) and children (n = 231/360, 64.9%) cohorts. The mean age was 34.7 (SD 11.9) years in adults and 7.8 (SD 5.4) years in children. Among the adult BID patients, 33.2% were unemployed, 25.6% were construction workers, and 10.1% were small business owners or managers. The common injury mechanisms in adults were road traffic-related injuries (RTIs) (47.1%) and assaults (23.6%). In children, injuries resulted from RTIs (39.7%), with 74.4% of those were pedestrians hit by cars, drowning (22.9%), and burns (12.4%). In both groups, most injuries occurred on roads (60.2%) or at home (22.1%). Reported alcohol use at the time of trauma was present in 6.3%. The police (57.9%) and privately-owned vehicles (26.6%) transported most BID patients to KCH. CONCLUSION: Efforts to reduce prehospital trauma mortality must focus on improving prehospital care, including training the police and community in basic life support and improving resources towards prehospital trauma care. Further efforts to reduce prehospital mortality must aim to decrease injuries on the roads and at home.

Characteristics and outcomes following motorized and non-motorized vehicular trauma in a resource-limited setting.

INTRODUCTION: Despite the ubiquity of motorized vehicular transport, non-motorized transportation continues to be common in sub-Saharan Africa. METHODS: We performed a retrospective analysis of trauma patients presenting to Kamuzu Central Hospital in Malawi from February 2008 to May 2018. Demographic and clinical variables including injury characteristics and outcomes were collected. We performed bivariate and multivariate logistic regression to determine predictors of mortality following non-motorized vehicular trauma. RESULTS: This study included 36,412 patients involved in vehicular road injuries. Patients in the non-motorized group had a preponderance of men (84% versus 73%, p<0.01). The proportion of patients with Glasgow Coma Scale > 8 was slightly higher in the non-motorized group (99% versus 98%, p<0.01), though injury severity did not differ significantly between the two groups. A higher proportion in the motorized group had the most severe injury of contusions and abrasions (56% versus 50%, p<0.01). In contrast, the non-motorized group had a higher proportion of orthopedic injuries (24% versus 16%, p<0.01). The crude mortality rate was 4.51% and 2.15% in the motorized and non-motorized groups, respectively. After controlling for demographic factors and injury severity, the incidence rate ratio of mortality did not differ significantly between motorized and non-motorized trauma groups (IRR 0.91, p=0.35). CONCLUSIONS: Non-motorized vehicular trauma remains a significant proportion of morbidity and mortality resulting from road traffic injuries. The injury severity and incidence rate ratio of mortality did not differ between motorized and non-motorized trauma groups. Health care providers should not underestimate the severity of injuries from non-motorized trauma.

Geographical mapping of road traffic injuries in Lilongwe, Malawi.

BACKGROUND: Road traffic injuries are a leading cause of death and disability, especially in low- and middle-income countries. Identifying injury hotspots are valuable for introducing preventive measures. This is usually accomplished by using police data, but these are often unreliable in low-income countries. This study aimed to identify hotspots for injuries by collecting geographical data in the emergency room. METHODS: This was a cross-sectional study of adult road traffic injury patients presenting to the Casualty Department in the central hospital in Lilongwe, the capital of Malawi. An electronic tablet with downloaded maps and satellite photos was used to establish the exact location of the injuries. The geographical data were analyzed with geographic information software. RESULTS: We included 1244 road traffic injured patients, of which 23.9% were car passengers or drivers, 18.6% were motorcyclists, 17.8% were pedestrians and 18.0% were cyclists or bicycle passengers. Heatmaps of the injuries identified 5 locations where the incidence of injuries was especially high, and 148 patients were injured in these hotspots during the 90 days of inclusion. Four of these hotspots were along the main road through the capital. Age over 55, rural setting, alcohol use before the injury, high speed limit at the site of injury and being a pedestrian or motorcyclist were significantly associated with a higher degree of injury severity. Around half of the patients that were injured in a four-wheeled vehicle did not use a seat belt, and these patients had a much higher risk of getting a more severe injury. CONCLUSION: We have identified specific locations with a high incidence of road traffic injuries in Lilongwe, Malawi, with a simple methodology and within a short time frame. The study demonstrates the feasibility of collecting geographical data at admission to hospital.

Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy.

PURPOSE: The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. METHODS: In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. RESULTS: Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. CONCLUSION: The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.

Police Transportation Following Vehicular Trauma and Risk of Mortality in a Resource-Limited Setting.

BACKGROUND: In resource-limited settings, prehospital trauma care and transportation from the scene to a hospital is not well developed. Critically injured patients present to the hospital via privately owned vehicles (PV), public transportation, or the police. We aimed to determine the mortality following road traffic injury based on the mode of transportation to our trauma center. METHODS: We performed a retrospective analysis of the Kamuzu Central Hospital (KCH) Trauma Registry from January 2011 to May 2018. Patients with road traffic injuries, presenting from the scene, were included. Those brought in dead or discharged from casualty were excluded. Bivariate analysis was performed over mortality. A Poisson multivariate regression determined the relative risk of mortality by prehospital transportation. RESULTS: 2853 patients were included; 7.8% (n = 223) died. Patients were transported by PV (n = 1963, 68.8%), minibus (n = 497, 17.4%), and police (268, 9.4%). No patients were transported by ambulance. Patients transported by police (1 h, IQR 0-2) and PV (1 h, IQR 0-2), arrived earlier than those transported by minibus (2 h, IQR 0-27), p < 0.001. There was no difference in injury severity between the transportation cohorts. Compared to PV, patients transported by police (RR 1.56, 95% CI 1.13-2.17, p = 0.008) have an increased risk of mortality after controlling for injury severity. There was no difference in mortality in patients presenting by minibus (RR 0.83, 95% CI 0.55-1.24, p = 0.4). CONCLUSION: Patients transported to KCH via police have a higher risk of mortality than those transported via private vehicle after controlling for injury severity. Training police in basic life support may be an initial target of intervention in reducing trauma mortality. Overall, the creation of a functional prehospital ambulance system with a cadre of paramedics is necessary for both trauma and non-trauma patients alike. This can only be achieved by training all stakeholders, the police, public transport drivers, and the public at large.

Prevalence of alcohol use among road traffic crash victims presenting to a Malawian Central Hospital: A cross-sectional study.

BACKGROUND: Alcohol consumption is a well-known risk factor for sustaining road traffic injuries worldwide. Malawi is a low-income country with a large and increasing burden of road traffic injuries. It has generally been viewed as a country with relatively little alcohol consumption. This study investigates the role of alcohol in road traffic injuries in and around the capital Lilongwe. METHODS: All patients presenting to the emergency department of Kamuzu Central Hospital after being injured in road traffic crashes were asked to participate in the study. Alcohol testing was done with a breathalyzer or a saliva test. Participants were asked about alcohol use before the injury as well as hazardous drinking using the AUDIT-C questionnaire. RESULTS: Of 1347 patients age 18 years or older who were asked to participate, 1259 gave informed consent, and data on alcohol use (alcohol test results and/or self-reported intake) were available for 1251 participants. Of those, 251 (20.1%) tested positive for alcohol, whereas 221 (17.7%) reported alcohol use before the crash; in total 311 (24.9%, 95% CI 22.5-27.3) either tested positive, reported use, or both. Females had a low prevalence of alcohol use (2.5%), while 30.6% of males had consumed alcohol before the injuries. Pedestrians had the highest prevalence at 41.8% (95% CI 35.5-48.4), while car drivers had 23.8% (95% CI 18.2-30.5). Among male pedestrians, 49.5% had used alcohol before the injury. Alcohol-associated injuries had a peak in the evening and at night, especially in the weekends. Of the patients, 63.1% reported that they had not consumed alcohol during the last year, while 21.4% had an AUDIT-C score suggesting hazardous drinking, and 66.2% of those had used alcohol before the injury. CONCLUSIONS: A large percentage of road traffic injured patients had been drinking alcohol before their injury, especially male pedestrians. A large proportion of the patients were abstaining from alcohol, but those not abstaining had a high prevalence both of alcohol use when injured and hazardous drinking identified by AUDIT-C. This has important implications for prevention.

Epidemiological Comparisons and Risk Factors for Pre-hospital and In-Hospital Mortality Following Traumatic Injury in Malawi.

BACKGROUND: In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality. METHODS: A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD. RESULTS: Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52-2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34-1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11-1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14-1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD. CONCLUSIONS: Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi.

Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi.

INTRODUCTION: Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. METHODS: A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. RESULTS: Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6-31 versus median 26, IQR: 11-38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries. CONCLUSIONS: The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings.