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.

Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

Background
There are limited data on healthcare-associated infections (HAI) from African countries like Malawi.

Aim
We undertook a point prevalence survey of HAI and antimicrobial use in the surgery department of Queen Elizabeth Central Hospital (QECH) in Malawi and ascertained the associated risk factors for HAI.

Methods
A cross-sectional point prevalence survey (PPS) was carried out in the surgery department of QECH. The European Centre for Disease Prevention and Control PPS protocol version 5.3 was adapted to our setting and used as a data collection tool.

Findings
105 patients were included in the analysis; median age was 34 (IQR: 24–47) years and 55.2% patients were male. Point prevalence of HAI was 11.4% (n=12/105) (95% CI: 6.0%–19.1%), including four surgical site infections, four urinary tract infections, three bloodstream infections and one bone/joint infection. We identified the following risk factors for HAI; length-of-stay between 8 and 14 days (OR=14.4, 95% CI: 1.65–124.7, p=0.0143), presence of indwelling urinary catheter (OR=8.3, 95% CI: 2.24–30.70, p=0.003) and history of surgery in the past 30 days (OR=5.11, 95% CI: 1.46–17.83, p=0.011). 29/105 patients (27.6%) were prescribed antimicrobials, most commonly the 3rd-generation cephalosporin, ceftriaxone (n=15).

Conclusion
The prevalence rates of HAI and antimicrobial use in surgery wards at QECH are relatively high. Hospital infection prevention and control measures need to be strengthened to reduce the burden of HAI at QECH.

The unmet need for treatment of children with musculoskeletal impairment in Malawi

Background More than a billion people globally are living with disability and the prevalence is likely to increase rapidly in the coming years in low- and middle-income countries (LMICs). The vast majority of those living with disability are children residing in LMICs. There is very little reliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and even less is available for Malawi

Methods Clusters were selected across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the national distribution of the population. Clusters were distributed around all 27-mainland districts of Malawi. Population of Malawi was 18.3 million from 2018 estimates, based on age categories we estimated that about 8.9 million were 16 years and younger. MSI diagnosis from our randomized sample was extrapolated to the population of Malawi, confidence limits was calculated using normal approximation.

Results Of 3,792 children aged 16 or less who were enumerated, 3,648 (96.2%) were examined and 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7-7.3). Extrapolated to the Malawian population this means as many as 576,000 (95% CI 505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were due to congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% were acquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6,000-33,000) children in need of orthopaedic surgery. Low parents’ educational level was one factor associated with an increased risk of MSI

Conclusion This survey has uncovered a large burden of MSI among children aged 16 and under in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended, revealing a need to scale up both P&O services, physical & occupational therapy, and surgical services in the country

Quality improvement training for burn care in low-and middle-income countries: A pilot course for nurses

Background
There is an urgent need to empower practitioners to undertake quality improvement (QI) projects in burn services in low-middle income countries (LMICs). We piloted a course aimed to equip nurses working in these environments with the knowledge and skills to undertake such projects.

Methods
Eight nurses from five burns services across Malawi and Ethiopia took part in this pilot course, which was evaluated using a range of methods, including interviews and focus group discussions.

Results
Course evaluations reported that interactive activities were successful in supporting participants to devise QI projects. Appropriate online platforms were integral to creating a community of practice and maintaining engagement. Facilitators to a successful QI project were active individuals, supportive leadership, collaboration, effective knowledge sharing and demonstrable advantages of any proposed change. Barriers included: staff attitudes, poor leadership, negative culture towards training, resource limitations, staff rotation and poor access to information to guide practice.

Conclusions
The course demonstrated that by bringing nurses together, through interactive teaching and online forums, a supportive community of practice can be created. Future work will include investigating ways to scale up access to the course so staff can be supported to initiate and lead quality improvement in LMIC burn services.

Supply the demand: Assessment of the feasibility of local non-urologists in relieving the burden of chronic indwelling catheters in a low-income country

Introduction: Despite the high prevalence rates of urinary retention in sub-Saharan Africa, regional deficiencies in urological care have culminated in inadequate medical management, and a backlog of urology cases. Our study examined the efficacy and safety of a surgical camp enlisting local non-urologists performing simple open prostatectomy on the rate of chronic catheter usage secondary to urinary retention.

Methods: We reported on a prospective case series of patients with chronic indwelling catheters who underwent open simple prostatectomy during a one-week urology camp in the Machinga District of Malawi. All operations were performed by a locally trained general surgeon and a clinical officer.

Results: Twenty-three (47.9%) of 48 male patients with urinary retention assessed for eligibility for open simple prostatectomy were deemed eligible and underwent the procedure. Of the patients who underwent an open simple prostatectomy, histopathological findings demonstrated benign prostatic hyperplasia in 19 patients (82.6%), while six patients (26.1%) had coincidental malignancy. At postoperative followup, the entire cohort was catheter-free and reported regular sexual activity and the ability to return to work, while 87.0% noted improvements in social integration and 34.8% cited higher self-esteem. Two patients required treatment for infection and one patient experienced fascial dehiscence. Two months following prostatectomy, all patients were catheter-free and able to void independently.

Conclusions: Local surgical practitioners without formal urology training can successfully perform open simple prostatectomy to relieve patients of chronic indwelling catheters and assist in addressing the disease burden in a low-resource setting.

Why Do They Leave? Challenges to Retention of Surgical Clinical Officers in District Hospitals in Malawi

Background
Low- and middle-income countries (LMICs) are the worst affected by a lack of safe and affordable access to safe surgery. The significant unmet surgical need can be in part attributed to surgical workforce shortages that disproportionately affect rural areas of these countries. To combat this, Malawi has introduced a cadre of non-physician clinicians (NPCs) called clinical officers (COs), trained to the level of a Bachelor of Science (BSc) in Surgery. This study explored the barriers and enablers to their retention in rural district hospitals (DHs), as perceived by the first cohort of COs trained to BSc in Surgery level in Malawi.

Methods
A longitudinal qualitative research approach was used based on interviews with 16 COs, practicing at DHs, during their BSc training (2015); and again with 15 of them after their graduation (2019). Data from both time points were analysed and compared using a top-down thematic analysis approach.

Results
Of the 16 COs interviewed in 2015, 11 intended to take up a post at a DH following graduation; however, only 6 subsequently did so. The major barriers to remaining in a DH post as perceived by these COs were lack of promotion, a more attractive salary elsewhere; and unclear, stagnant career progression within surgery. For those who remained working in DH posts, the main enablers are a willingness to accept a low salary, to generate greater opportunities to engage in additional earning opportunities; the hope of promotional opportunities within the government system; and greater responsibility and recognition of their surgical knowledge and skills as a BSc-holder at the district level.

Conclusion
The sustainability of surgically trained NPCs in Malawi is not assured and further work is required to develop and implement successful retention strategies, which will require a multi-sector approach. This paper provides insights into barriers and enablers to retention of this newly-introduced cadre and has important lessons for policy-makers in Malawi and other countries employing NPCs to deliver essential surgery.

Economic benefits and costs of surgery for filarial hydrocele in Malawi

Background
Lymphatic filariasis (LF) is endemic in 72 countries of Africa, Asia, Oceania, and the Americas. An estimated 25 million men live with the disabling effects of filarial hydrocele. Hydrocele can be corrected with surgery with few complications. For most men, hydrocelectomy reduces or corrects filarial hydrocele and permits them to resume regular activities of daily living and gainful employment.

Methodology and principal findings
This study measures the economic loss due to filarial hydrocele and the benefits of hydrocelectomy and is based on pre- and post-operative surveys of patients in southern Malawi. We find the average number of days of work lost due to filarial hydrocele and daily earnings for men in rural Malawi. We calculate average annual lost earnings and find the present discounted value for all years from the time of surgery to the end of working life. We estimate the total costs of surgery. We compare the benefit of the work capacity restored to the costs of surgery to determine the benefit-cost ratio. For men younger than 65 years old, the average annual earnings loss attributed to hydrocele is US$126. The average discounted present value of lifetime earnings loss for those men is US$1684. The average budgetary cost of the hydrocelectomy is US$68. The ratio of the benefit of surgery to its costs is US$1684/US$68 or 24.8. Sensitivity analysis demonstrates that the results are robust to variations in cost of surgery and length of working life.

Conclusion
The lifetime benefits of hydrocelectomy–to the man, his family, and his community–far exceed the costs of repairing the hydrocele. Scaling up subsidies to hydrocelectomy campaigns should be a priority for governments and international aid organizations to prevent and alleviate disability and lost earnings that aggravate poverty among the many millions of men with filarial hydrocele.

The Burden of Urological Disease in Zomba, Malawi: A Needs Assessment in a sub-Saharan Tertiary Care Center

Introduction: A large part of the developing world continues to lack access to surgical care. Urology remains one of the least represented surgical subspecialties in global health. To begin understanding the burden of urological illness in sub-Saharan Africa, we sought to characterize all patients presenting to a tertiary care hospital in Malawi with a urological diagnosis or related complaint in the past year.

Methods: Retrospective review of the surgical clinic and surgical theater record books at Zomba Central Hospital (ZCH) was performed over a one-year time span. Patients presenting with urological diagnoses or undergoing a urological procedure under local or general anesthetic in the operating theater were identified and entered into a database.

Results: We reviewed 440 clinical patients. The most common clinical presentations were for urinary retention (34.7%) and lower urinary tract symptoms (15.5%). A total of 182 surgical cases were reviewed. The most common diagnoses for surgical patients were urethral stricture disease (22%), bladder masses (17%), and benign prostatic hyperplasia (BPH) symptoms (14.8%). Urethral stricture-related procedures, including direct visual internal urethrotomy and urethral dilatation, were the most common (14.2% and 7.7%, respectively). BPH-related procedures, including simple prostatectomy and transurethral resection of the prostate were the second most common (6.7% and 8.2%, respectively).

Conclusions: Urethral stricture disease, BPH, and urinary retention represent the clinical diagnoses with the highest burden of visits. Despite these numbers, few definitive procedures are performed annually. Further focus on urological training in sub-Saharan Africa should focus on these conditions and their surgical management.