Improving the management of open tibia fractures, Malawi.

Objective: To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures. Methods: We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and-after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention. Findings: The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice. Conclusion: Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle.

Assessing the implementation fidelity, feasibility, and sustainability of community-based house improvement for malaria control in southern Malawi: a mixed-methods study.

BACKGROUND: Despite significant success in the fight against malaria over the past two decades, malaria control programmes rely on only two insecticidal methods: indoor residual spraying and insecticidal-treated nets. House improvement (HI) can complement these interventions by reducing human-mosquito contact, thereby reinforcing the gains in disease reduction. This study assessed the implementation fidelity, which is the assessment of how closely an intervention aligns with its intended design, feasibility, and sustainability of community-led HI in southern Malawi. METHODS: The study, conducted in 22 villages (2730 households), employed a mixed-methods approach. Implementation fidelity was assessed using a modified framework, with longitudinal surveys collecting data on HI coverage indicators. Quantitative analysis, employing descriptive statistics, evaluated the adherence to HI implementation. Qualitative data came from in-depth interviews, key informant interviews, and focus groups involving project beneficiaries and implementers. Qualitative data were analysed using content analysis guided by the implementation fidelity model to explore facilitators, challenges, and factors affecting intervention feasibility. RESULTS: The results show that HI was implemented as planned. There was good adherence to the intended community-led HI design; however, the adherence could have been higher but gradually declined over time. In terms of intervention implementation, 74% of houses had attempted to have eaves closed in 2016-17 and 2017-18, compared to 70% in 2018-19. In 2016-17, 42% of houses had all four sides of the eaves closed, compared to 33% in 2018-19. Approximately 72% of houses were screened with gauze wire in 2016-17, compared to 57% in 2018-19. High costs, supply shortages, labour demands, volunteers' poor living conditions and adverse weather were reported to hinder the ideal HI implementation. Overall, the community described community-led HI as feasible and could be sustained by addressing these socioeconomic and contextual challenges. CONCLUSION: Our study found that although HI was initially implemented as planned, its fidelity declined over time. Using trained volunteers facilitated the fidelity and feasibility of implementing the intervention. A combination of rigorous community education, consistent training, information, education and communication, and intervention modifications may be necessary to address the challenges and enhance the intervention's fidelity, feasibility, and sustainability.

Accuracy of and preferences for blood-based versus oral-fluid-based HIV self-testing in Malawi: a cross-sectional study.

BACKGROUND: HIV self-testing (HIVST) can use either oral-fluid or blood-based tests. Studies have shown strong preferences for self-testing compared to facility-based services. Despite availability of low-cost blood-based HIVST options, to date, HIVST implementation in sub-Saharan Africa has largely been oral-fluid-based. We investigated whether users preferred blood-based (i.e. using blood sample derived from a finger prick) or oral fluid-based HIVST in rural and urban Malawi. METHODS: At clinics providing HIV testing services (n = 2 urban; n = 2 rural), participants completed a semi-structured questionnaire capturing sociodemographic data before choosing to test using oral-fluid-based HVST, blood-based HIVST or provider-delivered testing. They also completed a self-administered questionnaire afterwards, followed by a confirmatory test using the national algorithm then appropriate referral. We used simple and multivariable logistic regression to identify factors associated with preference for oral-fluid or blood-based HIVST. RESULTS: July to October 2018, N = 691 participants enrolled in this study. Given the choice, 98.4% (680/691) selected HIVST over provider-delivered testing. Of 680 opting for HIVST, 416 (61.2%) chose oral-fluid-based HIVST, 264 (38.8%) chose blood-based HIVST and 99.1% (674/680) reported their results appropriately. Self-testers who opted for blood-based HIVST were more likely to be male (50.3% men vs. 29.6% women, p < 0.001), attending an urban facility (43% urban vs. 34.6% rural, p = 0.025) and regular salary-earners (49.5% regular vs. 36.8% non-regular, p = 0.012). After adjustment, only sex was found to be associated with choice of self-test (adjusted OR 0.43 (95%CI: 0.3-0.61); p-value < 0.001). Among 264 reporting blood-based HIVST results, 11 (4.2%) were HIV-positive. Blood-based HIVST had sensitivity of 100% (95% CI: 71.5-100%) and specificity of 99.6% (95% CI: 97.6-100%), with 20 (7.6%) invalid results. Among 416 reporting oral-fluid-based HIVST results 18 (4.3%) were HIV-positive. Oral-fluid-based HIVST had sensitivity of 88.9% (95% CI: 65.3-98.6%) and specificity of 98.7% (95% CI: 97.1-99.6%), with no invalid results. CONCLUSIONS: Offering both blood-based and oral-fluid-based HIVST resulted in high uptake when compared directly with provider-delivered testing. Both types of self-testing achieved high accuracy among users provided with a pre-test demonstration beforehand. Policymakers and donors need to adequately plan and budget for the sensitisation and support needed to optimise the introduction of new quality-assured blood-based HIVST products.

Modeling time to death for under-five children in Malawi using 2015/16 Demographic and Health Survey: a survival analysis.

BACKGROUND: Malawi has one of the highest under-five mortality rates in Sub Sahara Africa. Understanding the factors that contribute to child mortality in Malawi is crucial for the development and implementation of effective interventions to reduce child mortality. The aim of this study is to use survival analysis in modeling time to death for under-five children in Malawi. In turn, identify potential risk factors for child mortality and inform the development of interventions to reduce child mortality in the country. METHOD: This study used data from all births that occurred in the five years leading up to the 2015/16 Malawi Demographic and Health Survey. The Frailty hazard model was applied to predict infant survival in Malawi. In this analysis, the outcome of interest was death and it had two possible outcomes: "dead" or "alive". Age at death was regarded as the survival time variable. Infants who were still alive at the time of the study as of the day of the interview were considered as censored observations in the analysis. RESULTS: A total of 17,286 live births born during the 5 years preceding the survey were analysed. The study found that the risk of death was higher among children born to mothers aged 30-39 and 40 or older compared to teen mothers. Infants whose mothers attended fewer than four antenatal care visits were also found to be at a higher risk of death. On the other hand, the study found that using mosquito nets and early breastfeeding were associated with a lower risk of death, as were being male and coming from a wealthier household. CONCLUSION: The study reveals a notable decline in infant mortality rates as under-five children age, underscoring the challenge of ensuring newborn survival. Factors such as maternal age, birth order, socioeconomic status, mosquito net usage, early breastfeeding initiation, geographic location, and child's sex are key predictors of under-five mortality. To address this, public health strategies should prioritize interventions targeting these predictors to reduce under-five mortality rates.

A first report of Pseudosuccinea columella (Say, 1817), an alien intermediate host for liver fluke, in Malawi.

Starting in October 2021, quarterly malacological surveys have been undertaken in Malawi, with the sampling of 12 specified freshwater habitats throughout a calendar year. Each survey monitors the presence of aquatic intermediate snail hosts of medical and veterinary importance. In March 2023, the alien lymnaeid species Pseudosuccinea columella was encountered for the first time in the surveys, in Nsanje District. This species identity was later confirmed upon DNA analysis of mitochondrial ribosomal 16S sequences. In July 2023, P. columella was also noted at single sites within Mangochi and Chikwawa Districts, and again in Nsanje District, with an additional location observed. Of particular importance, our sampled location in Mangochi District was directly connected to Lake Malawi, which expands the species list of invasive molluscs in this lake. While P. columella is a well-known intermediate snail host for human and animal fascioliasis, screening collected snails for trematode cercariae, alongside molecular xenomonitoring, did not yield equivocal evidence of active fluke infection. However, the newly recognized presence of this alien intermediate snail host within Lake Malawi, and along the Shire River Valley, flags a new concern in altered local transmission potential for human and animal fascioliasis.

Factors associated with malaria vaccine uptake in Nsanje district, Malawi.

BACKGROUND: Malaria remains a significant global health burden affecting millions of people, children under 5 years and pregnant women being most vulnerable. In 2019, the World Health Organization (WHO) endorsed the introduction of RTS,S/AS01 malaria vaccine as Phase IV implementation evaluation in three countries: Malawi, Kenya and Ghana. Acceptability and factors influencing vaccination coverage in implementing areas is relatively unknown. In Malawi, only 60% of children were fully immunized with malaria vaccine in Nsanje district in 2021, which is below 80% WHO target. This study aimed at exploring factors influencing uptake of malaria vaccine and identify approaches to increase vaccination. METHODS: In a cross-sectional study conducted in April-May, 2023, 410 mothers/caregivers with children aged 24-36 months were selected by stratified random sampling and interviewed using a structured questionnaire. Vaccination data was collected from health passports, for those without health passports, data was collected using recall history. Regression analyses were used to test association between independent variables and full uptake of malaria vaccine. RESULTS: Uptake of malaria vaccine was 90.5% for dose 1, but reduced to 87.6%, 69.5% and 41.2% for dose 2, 3, and 4 respectively. Children of caregivers with secondary or upper education and those who attended antenatal clinic four times or more had increased odds of full uptake of malaria vaccine [OR: 2.43, 95%CI 1.08-6.51 and OR: 1.89, 95%CI 1.18-3.02], respectively. Children who ever suffered side-effects following immunization and those who travelled long distances to reach the vaccination centre had reduced odds of full uptake of malaria vaccine [OR: 0.35, 95%CI 0.06-0.25 and OR: 0.30, 95%CI 0.03-0.39] respectively. Only 17% (n = 65) of mothers/caregivers knew the correct schedule for vaccination and 38.5% (n = 158) knew the correct number of doses a child was to receive. CONCLUSION: Only RTS,S dose 1 and 2 uptake met WHO coverage targets. Mothers/caregivers had low level of information regarding malaria vaccine, especially on numbers of doses to be received and dosing schedule. The primary modifiable factor influencing vaccine uptake was mother/caregiver knowledge about the vaccine. Thus, to increase the uptake Nsanje District Health Directorate should strengthen communities' education about malaria vaccine. Programmes to strengthen mother/caregiver knowledge should be included in scale-up of the vaccine in Malawi and across sub-Saharan Africa.

Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria.

BACKGROUND: Sub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach. METHODS: We followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10-13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed. RESULTS: Based on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants. CONCLUSIONS: Through dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.

Analyses of drinking water quality during a protracted cholera epidemic in Malawi - a cross-sectional study of key physicochemical and microbiological parameters.

Anecdotal evidence and available literature indicated that contaminated water played a major role in spreading the prolonged cholera epidemic in Malawi from 2022 to 2023. This study assessed drinking water quality in 17 cholera-affected Malawi districts from February to April 2023. Six hundred and thirty-three records were analysed. The median counts/100 ml for thermotolerant coliform was 98 (interquartile range (IQR): 4-100) and that for Escherichia coli was 0 (IQR: 0-9). The drinking water in all (except one) districts was contaminated by thermotolerant coliform, while six districts had their drinking water sources contaminated by E. coli. The percentage of contaminated drinking water sources was significantly higher in shallow unprotected wells (80.0% for E. coli and 95.0% for thermotolerant coliform) and in households (55.8% for E. coli and 86.0% for thermotolerant coliform). Logistic regression showed that household water has three times more risk of being contaminated by E. coli and two and a half times more risk of being contaminated by thermotolerant coliform compared to other water sources. This study demonstrated widespread contamination of drinking water sources during a cholera epidemic in Malawi, which may be the plausible reason for the protracted nature of the epidemic.

Microbial keratitis in Southern Malawi: a microbiological pilot study.

OBJECTIVE: Microbial keratitis (MK) is a significant cause of blindness in sub-Saharan Africa. We investigated the feasibility of using a novel corneal impression membrane (CIM) for obtaining and processing samples by culture, PCR and whole-genome sequencing (WGS) in patients presenting with suspected MK in Malawi. METHODS AND ANALYSIS: Samples were collected from patients presenting with suspected MK using a 12 mm diameter polytetrafluoroethylene CIM disc. Samples were processed using culture and PCR for Acanthamoeba, herpes simplex virus type 1 (HSV-1) and the bacterial 16S rRNA gene. Minimum inhibitory concentrations of isolates to eight antimicrobials were measured using susceptibility strips. WGS was used to characterise Staphylococcus aureus isolates. RESULTS: 71 eyes of 71 patients were included. The overall CIM isolation rate was 81.7% (58 positive samples from 71 participants). 69 (81.2%) of isolates were Gram-positive cocci. Coagulase-negative Staphylococcus 31.8% and Streptococcus species 14.1% were the most isolated bacteria. Seven (9.9%) participants were positive for HSV-1. Fungi and Acanthamoeba were not detected. Moxifloxacin and chloramphenicol offered the best coverage for both Gram-positive and Gram-negative isolates when susceptibility was determined using known antimicrobial first quartile concentrations and European Committee on Antimicrobial Susceptibility Testing breakpoints, respectively. WGS identified known virulence genes associated with S. aureus keratitis. CONCLUSIONS: In a resource-poor setting, a CIM can be used to safely sample the cornea in patients presenting with suspected MK, enabling identification of causative microorganisms by culture and PCR. Although the microbiological spectrum found was limited to the dry season, these preliminary results could be used to guide empirical treatment.

Establishing the profile of eye diseases among elderly patients attending a tertiary hospital in Northern Malawi.

Globally, there has been a dramatic increase in the geriatric population. Sadly, this populace is highly prone to develop various ocular morbidities putting pressure on the strained eye care delivery system especially in low-income countries. Hence, the aim of this study was to determine the distribution of ocular morbidities among elderly. The study was a retrospective cross-sectional study conducted at Mzuzu Central Hospital in Malawi. We retrieved data from the hospital's Ophthalmology out-patient registry from January 2021 to December 2021. We recruited all 970 elderly patients who visited the clinic during the period of study. Data entry and analysis was done employing SPSS (v.26). More males than females had ocular morbidities. Cataract 400 (41.2%) was the most prevalent ocular morbidity followed by glaucoma 189 (19.5%), pinguecula 48 (4.9%) and allergic conjunctivitis 43 (4.4%). Anterior segment eye diseases were common 714 (73.6%). The prevalence of cataract, glaucoma, refractive error and allergic conjunctivitis was significantly associated with sex (p < 0.05). Age association was found with the prevalence of cataract, glaucoma, pinguecula, allergic conjunctivitis and corneal scar (p < 0.05). The pattern of eye diseases is endemic to the country. More resources should be targeting cataract and glaucoma among the age group.

Folate and vitamin B12 status and predicted neural tube defects risk among nonpregnant women of reproductive age from the Malawi National Micronutrient Survey, 2015-2016.

BACKGROUND: Maternal folate and vitamin B12 deficiency can lead to serious adverse pregnancy outcomes. There are no nationally representative estimates on folate and vitamin B12 status among women of reproductive age (WRA) in Malawi. OBJECTIVE: We assessed folate and vitamin B12 status among nonpregnant WRA in Malawi and predicted the risk of folate-sensitive neural tube defects (NTDs) were they to become pregnant. METHODS: Using data from the cross-sectional, nationally representative 2015-2016 Malawi Micronutrient Survey, we calculated the proportion of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 778 nonpregnant WRA (15-49 years). We predicted NTD prevalence using red blood cell (RBC) folate distributions and a published Bayesian model of the association between RBC folate and NTD risk. Analyses accounted for complex survey design. RESULTS: Among WRA, 8.5% (95% CI: 6.2, 11.6) and 13.3% (10.0, 17.4) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The proportion of vitamin B12 deficiency (<148 pmol/L) and insufficiency (≤221 pmol/L) was 11.8% (8.6, 16.0) and 40.6% (34.1, 47.4), respectively. RBC folate insufficiency (<748 nmol/L, defined as the concentration associated with the threshold for elevated NTD risk: >8 cases per 10,000 births) was widespread: 81.4% (75.0, 86.4). The predicted NTD risk nationally was 24.7 cases per 10,000 live births. RBC folate insufficiency and higher predicted NTD risk were more common among WRA living in urban areas or with higher education. CONCLUSIONS: These findings highlight the importance of nutritional and NTD surveillance in Malawi and the opportunity for improving folate and vitamin B12 nutrition among Malawian WRA.

Epidemiology and Treatment of Distal Radius Fractures at Four Public Hospitals in Malawi.

BACKGROUND: Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi. METHODS: We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi. RESULTS: Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery. CONCLUSION: The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols.

Implementation of post-discharge malaria chemoprevention (PDMC) in Benin, Kenya, Malawi, and Uganda: stakeholder engagement meeting report.

A Stakeholder engagement meeting on the implementation of post-discharge malaria chemoprevention (PDMC) in Benin, Kenya, Malawi, and Uganda was held in Nairobi, Kenya, on 27 September 2023. Representatives from the respective National Malaria Control Programmes, the World Health Organization (WHO) Geneva, Africa Regional and Kenya offices, research partners, non-governmental organizations, and the Medicines for Malaria Venture participated. PDMC was recommended by the WHO in June 2022 and involves provision of a full anti-malarial treatment course at regular intervals during the post-discharge period in children hospitalized with severe anaemia in areas of moderate-to-high malaria transmission. The WHO recommendation followed evidence from a meta-analysis of three clinical trials and from acceptability, delivery, cost-effectiveness, and modelling studies. The trials were conducted in The Gambia using monthly sulfadoxine-pyrimethamine during the transmission season, in Malawi using monthly artemether-lumefantrine, and in Kenya and Uganda using monthly dihydroartemisinin-piperaquine, showing a significant reduction in all-cause mortality by 77% (95% CI 30-98) and a 55% (95% CI 44-64) reduction in all-cause hospital readmissions 6 months post-discharge. The recommendation has not yet been implemented in sub-Saharan Africa. There is no established platform for PDMC delivery. The objectives of the meeting were for the participating countries to share country contexts, plans and experiences regarding the adoption and implementation of PDMC and to explore potential delivery platforms in each setting. The meeting served as the beginning of stakeholder engagement within the PDMC Saves Lives project and will be followed by formative and implementation research to evaluate alternative delivery strategies in selected countries. Meeting highlights included country consensus on use of dihydroartemisinin-piperaquine for PDMC and expansion of the target group to "severe anaemia or severe malaria", in addition to identifying country-specific options for PDMC delivery for evaluation in implementation research. Further exploration is needed on whether the age group should be extended to school-age children.

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi.

BACKGROUND: The increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts. METHODS: The FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS' latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS' convergent and divergent validity, as well as internal consistency, were also tested. RESULTS: Findings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled 'Supportive Management', 'Resource Management' and 'Time management'). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057-0.074]; SRMR = 0.047). CONCLUSION: The FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level.

Hospital admission and its common causes in children on antiretroviral therapy (ART) in Lilongwe Malawi between 2001 and 2016: a retrospective cross-sectional study.

BACKGROUND: Paediatric HIV data shows a variable and sometimes catastrophic response in the initial stage of ART regimen administration. The burden of disease that affects children in their first year of treatment is not comprehensively available. OBJECTIVE: Objective of our study was to describe patterns of admission in children; before ART initiation, within the first six months, and post-six months of ART between 2001 and 2016. METHODS: Principal caregivers of 260 children (45.7% females 54.2% males, all <15 years) on ART for at least six months were interviewed about admissions of their children. Diagnoses were verified from the health passport books. Data on age, sex, date of ART initiation was obtained from the database of Baylor College of Medicine in Lilongwe. Data were analysed using Excel for descriptive analysis. Chi Square Test was used to test for significance. RESULTS: There were more admissions before starting ART 74% (95%CI 68.67-79.33%) vs. 42% (95%CI 36.00-48.00%), after starting ART (p = <0.001 at 5% significance level); after six months of ART 34% (95%CI 28.24-39.76) vs. 20% (95% CI 15.51-24.86%) (p = <0.001 at 5% significance level). The commonest causes of admission were pneumonia, malaria, tuberculosis, anaemia; no difference in causes of admission within the first and after six months of ART initiation. CONCLUSION: ART significantly reduces admission in children living with HIV. The common causes of admission are HIV non-specific conditions. No difference between causes of admission within and after six months of ART.

Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi.

BACKGROUND: Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District. METHODS: We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model. RESULTS: In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed. CONCLUSIONS: Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.

The national distribution of lymphatic filariasis cases in Malawi using patient mapping and geostatistical modelling.

BACKGROUND: In 2020 the World Health Organization (WHO) declared that Malawi had successfully eliminated lymphatic filariasis (LF) as a public health problem. Understanding clinical case distributions at a national and sub-national level is important, so essential care packages can be provided to individuals living with LF symptoms. This study aimed to develop a national database and map of LF clinical cases across Malawi using geostatistical modelling approaches, programme-identified clinical cases, antigenaemia prevalence and climate information. METHODOLOGY: LF clinical cases identified through programme house-to-house surveys across 90 sub-district administrative boundaries (Traditional Authority (TA)) and antigenaemia prevalence from 57 sampled villages in Malawi were used in a two-step geostatistical modelling process to predict LF clinical cases across all TAs of the country. First, we modelled antigenaemia prevalence in relation to climate covariates to predict nationwide antigenaemia prevalence. Second, we modelled clinical cases for unmapped TAs based on our antigenaemia prevalence spatial estimates. PRINCIPLE FINDINGS: The models estimated 20,938 (95% CrI 18,091 to 24,071) clinical cases in unmapped TAs (70.3%) in addition to the 8,856 (29.7%), programme-identified cases in mapped TAs. In total, the overall national number of LF clinical cases was estimated to be 29,794 (95% CrI 26,957 to 32,927). The antigenaemia prevalence and clinical case mapping and modelling found the highest burden of disease in Chikwawa and Nsanje districts in the Southern Region and Karonga district in the Northern Region of the country. CONCLUSIONS: The models presented in this study have facilitated the development of the first national LF clinical case database and map in Malawi, the first endemic country in sub-Saharan Africa. It highlights the value of using existing LF antigenaemia prevalence and clinical case data together with modelling approaches to produce estimates that may be used for the WHO dossier requirements, to help target limited resources and implement long-term health strategies.

Transfusion and Mortality in Acute Care Surgical Patients in Malawi: A Propensity-Matched Analysis.

INTRODUCTION: Information on transfusion-associated outcomes is limited in sub-Saharan Africa. We sought to characterize predictors of mortality in transfused patients with acute care surgical conditions in Malawi. METHODS: We performed a retrospective propensity-matched analysis of patients with acute care surgical conditions at Kamuzu Central Hospital in Malawi from 2013 to 2021. We compared outcomes between patients who did and did not receive transfusions. RESULTS: A total of 7395 patients were included. Transfused patients (n = 1086) were older (median 43 y with interquartile range 30-59, versus 39 y [interquartile range 27-53] in the nontransfused group, P < 0.01), had a higher proportion of females (41% versus 27%, P < 0.01), presented earlier to the hospital (median 2.9 versus 3.7 d, P = 0.02), and with lower hemoglobin levels (27% versus 1% < 7 g/dL, P < 0.01). They had a lower rate of surgical intervention (48% versus 59%, P < 0.01) but a higher rate of complications (62% versus 33%, P < 0.01). Crude in-hospital mortality was 25.5% for the transfused group and 12.8% for the nontransfused group (P < 0.01). After propensity matching, transfused patients had three times the odds of mortality compared to nontransfused patients (odds ratio 3.3, 95% confidence interval 2.3, 4.8). CONCLUSIONS: In this propensity-matched study, transfused surgical patients were more likely to experience in-hospital mortality. These results suggest that the transfusion requirement reflects critical illness and warrants further investigation in this low-resource setting.