On prioritising global health’s triple crisis of sepsis, COVID-19 and antimicrobial resistance: a mixed-methods study from Malawi

Sepsis causes 20% of global deaths, particularly among children and vulnerable populations living in developing countries. This study investigated how sepsis is prioritised in Malawi’s health system to inform health policy. In this mixed-methods study, twenty multisectoral stakeholders were qualitatively interviewed and asked to quantitatively rate the likelihood of sepsis-related medium-term policy outcomes being realised. Respondents indicated that sepsis is not prioritised in Malawi due to a lack of local sepsis-related evidence and policies. However, they highlighted strong linkages between sepsis and maternal health, antimicrobial resistance and COVID-19, which are already existing national priorities, and offers opportunities for sepsis researchers as policy entrepreneurs. To address the burden of sepsis, we recommend that funding should be channelled to the generation of local evidence, evidence uptake, procurement of resources and treatment of sepsis cases, development of appropriate indicators for sepsis, adherence to infection prevention and control measures, and antimicrobial stewardship.

Epidemiology of adult trauma injuries in Malawi: results from a multisite trauma registry

Background
Large-scale multisite trauma registries with broad geographic coverage in low-income countries are rare. This lack of systematic trauma data impedes effective policy responses.

Methods
All patients presenting with trauma at 10 hospitals in Malawi from September 2018 to March 2020 were enrolled in a prospective registry. Using data from 49,241 cases, we analyze prevalence, causes, and distribution of trauma in adult patients, and timeliness of transport to health facilities and treatment.

Results
Falls were the most common mechanism of injury overall, but road traffic crashes (RTCs) were the most common mechanism of serious injury, accounting for (48%) of trauma admissions. This pattern was consistent across all central and district hospitals, with only one hospital recording  55, Glasgow Coma Score < 12, and presentation at hospital on a weekend.

Conclusions
RTCs make up almost half of hospitalized trauma cases in this setting, are equally common in referral and district hospitals, and are an important predictor of injury severity. Pedestrians and cyclists are just as affected as those in vehicles. Many of those injured in vehicles do not take adequate safety precautions. Most trauma patients, including those with serious injuries, do not receive prompt medical attention. Greater attention to safety for both motorized and especially non-motorized road users, and more timely, higher quality emergency medical services, are important policy priorities for Malawi and other developing countries with high burdens of RTC trauma.

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.

A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi

The burden of healthcare-associated infections (HAIs) is greater in low- and middle-income countries than in high-income countries. Inadequate environmental health (EH) conditions and work systems contribute to HAIs in countries like Malawi. We collected qualitative data from 48 semi-structured interviews with healthcare workers (HCWs) from 45 healthcare facilities (HCFs) across Malawi and conducted a thematic analysis. The facilitators of infection prevention and control (IPC) practices in HCFs included disinfection practices, patient education, and waste management procedures. HCWs reported barriers such as lack of IPC training, bottlenecks in maintenance and repair, hand hygiene infrastructure, water provision, and personal protective equipment. This is one of the most comprehensive assessments to date of IPC practices and environmental conditions in Malawian HCFs in relation to HCWs. A comprehensive understanding of barriers and facilitators to IPC practices will help decision-makers craft better interventions and policies to support HCWs to protect themselves and their patients.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

Objective
Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

Methods
Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women’s experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

Results
There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

Conclusion
There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

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.

Unmet Surgical Need in Malawi

Introduction
Globally, and especially in sub-Saharan Africa, including Malawi, surgical conditions receive a low level of priority in national health systems. The burden of surgical diseases is not well documented and the reasons for which people still live with treatable conditions and disabilities or sometimes present late for care have also not been studied. There is also little information on surgical deaths from untreated conditions in both adults and children, including trauma, as well as potential barriers to obtaining surgical care.
Objectives
The aim of this thesis was therefore to describe the untreated surgical conditions, in both adults and children, the barriers to surgical health care, as well as to document information about deaths from surgical conditions in Malawi.
Methods
This thesis is based on four papers. All four involved data collected using the SOSAS tool, which is a questionnaire-based data collection tool for documenting household information in the communities. The tool had three sections, the first section capturing demographic data for the households; including number of occupants, ages, gender, location and type of household, and tribe. The next two sections were similar but involved interviewing two different people and asking about information relating to surgical conditions present for both adults and paediatric age groups, including injuries, associated disability from acquired or congenital disorders, transportation to health facility and location of death from different surgical conditions. The two household members interviewed, included the head of household and another random member within the household. Data collection was centrally organized by a project group, and performed by third year medical students from the University of Malawi, College of Medicine.
Data was collected as a national survey from the 28 districts in Malawi. The National Statistics Board helped us to identify the villages used in the study.
Results
We found that a third of the Malawian population were living with a surgical condition and were in need of a surgical consultation or treatment. These conditions were either congenital or the result of a traumatic or other non-traumatic condition. We also found that almost one fifth of the children with a surgical condition that could have been treated by surgery, instead remained with a disability that affected their daily lives.
In addition, we found that transportation poses a barrier to timely access to surgical health care. Transportation barriers included the lack of efficient public transportation, cost implications, and long travel distances to get to a health facility capable of offering care by either consultation or surgical procedures.
Other findings were that acute abdominal distention, body masses and trauma, contribute to surgical conditions that are highly associated with mortality in Malawian communities. We also noted that there are various reasons that lead to delays in obtaining formal health care, including initial consultations with traditional herbalists before going to the hospital.
Conclusion
Almost 6 million Malawian people, including an estimated 2 million children, are living with a condition that could be treated by either a surgical procedure or consultation. There are an estimated 1 million disabled children currently living with such surgically treatable conditions. The treatment of these conditions is hampered by transportation barriers. The transportation barriers have led to delays in obtaining timely surgical health care service, something that often leads to mortality. The common causes of these deaths are from injuries, but also other surgical emergencies. Most of these deaths occur outside a health facility environment.

Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines

Background: Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines.
Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period.
Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines.
Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.

Road Traffic Injuries in Malawi with special focus on the role of alcohol

Driving under the influence of alcohol is one of the principal causes of road traffic crashes (RTCs) [1]. The use of alcohol is also a risk factor for other road users, such as pedestrians and bicyclists. The association of alcohol in injurious and fatal RTCs has been well documented in most high-income countries, but data for low- and middle-income countries is scarce, particularly for African countries [2]. The study was a collaborative effort between Kamuzu Central Hospital (KCH), the Norwegian Institute of Public Health (NIPH) and Oslo University Hospital (OUH), with the financial support of UK Aid through the Global Road Safety Facility (GRSF) hosted by the World Bank, the International Council on Alcohol Drugs and Traffic Safety (ICADTS) and the Norwegian Council for Road Safety (Trygg Trafikk). The objective of the study was to generate new knowledge about road traffic injuries in Malawi and the extent of traffic accidents related to alcohol use, to increase capacity to conduct alcohol testing, and develop a database for the findings, which in turn will form the basis for future policymaking to reduce traffic accidents.
The objectives were achieved through collecting data on patients who sought treatment after road traffic crashes and admitted to the Emergency Department at KCH in Lilongwe, Malawi. A questionnaire was developed for data collection in cooperation between the project groups in Norway and Malawi. The data included basic information about the patients, alcohol use before the injury, and information about accident circumstances, including types of road users and vehicles involved. Participation was voluntary and anonymous. All weekdays, weekends and nights were covered. Alcohol was measured using a breathalyzer or saliva test for those who were not able to blow. Knowledge and training of local KCH employees to perform alcohol testing and record data were an important aspect of this study.
The project was approved by the National Health Science Research Committee (NHSRC) in Malawi. The Regional Committee for Medical and Health Research Ethics in Norway was consulted, and their conclusion was that no formal application was needed, with reference to the Norwegian Health Research Act Section, §2 and 4a. A Data Protection Impact Assessment was performed as required by NIPH. There were 1251 patients in the study, representing nearly 95 per cent of those who were asked to participate. The results show a rather high prevalence of alcohol use among several injured road user groups (totally about 25 percent), particularly among those injured during weekend nights and evenings, but also during weekday evenings and nights. It was estimated that about 15 per cent of injured motor vehicle drivers and riders had BACs above the legal limit of 0.8 grams/L at the time of the crash. The findings also show that it is important to focus on bus/minibus/lorry drivers who often carry passengers, where about one out of five tested positive for alcohol. It is worth noting that pedestrians had the highest prevalence of alcohol use before being injured. They constitute a vulnerable group; they often walk in the dark with no road lighting, no pavements, walkways or safe places to cross
the road. Combined with alcohol use their injury risk is even higher. The collected data can contribute to future road traffic safety procedures and measures. The long-term goal is to contribute to sustainable development goal 3, target 3.6, to reduce by half the number of global RTC deaths and injuries. Road Traffic Inuries in Malawi • Norwegian Institute of Public Health This study shows the importance of collecting adequate and relevant data for health authorities particularly in low- and middle-income countries in battling the challenge of alcohol-related road traffic crashes, deaths and injuries. Due to the COVID-19 pandemic, a
number of recommendations were presented to Malawian authorities at a virtual seminar held in autumn 2020.

Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning

Importance
Injuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements.

Objective
To use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings.

Design
Multicentre prospective registry study.

Setting
Two large referral centres and two district hospitals in Malawi.

Participants
All patients with a fracture (confirmed by radiographs)—including patients with multiple fractures—were eligible to be included in the registry.

Exposure
All fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020).

Main outcome(s) and measure(s)
Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants.

Results
Between September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10–35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68–72.09), distal femoral fractures (OR:2.59, CI:1.78–3.78), patella (OR:10.31, CI:7.04–15.07), supracondylar humeral fractures (OR:3.10, CI:2.38–4.05), ankle fractures (OR:2.97, CI:2.26–3.92) and tibial plateau fractures (OR:2.08, CI:1.47–2.95) were more likely to be treated operatively compared to distal radius fractures.

Conclusions and relevance
The current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.