Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi.

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

A clinical and molecular epidemiological survey of hepatitis C in Blantyre, Malawi, suggests a historic mechanism of transmission.

Hepatitis C virus (HCV) is a leading cause of liver disease worldwide. There are no previous representative community HCV prevalence studies from Southern Africa, and limited genotypic data. Epidemiological data are required to inform an effective public health response. We conducted a household census-based random sampling serological survey, and a prospective hospital-based study of patients with cirrhosis and hepatocellular carcinoma (HCC) in Blantyre, Malawi. We tested participants with an HCV antigen/antibody ELISA (Monolisa, Bio-Rad), confirmed with PCR (GeneXpert, Cepheid) and used line immunoassay (Inno-LIA, Fujiribio) for RNA-negative participants. We did target-enrichment whole-genome HCV sequencing (NextSeq, Illumina). Among 96,386 censused individuals, we randomly selected 1661 people aged ≥16 years. Population-standardized HCV RNA prevalence was 0.2% (95% CI 0.1-0.5). Among 236 patients with cirrhosis and HCC, HCV RNA prevalence was 1.9% and 5.0%, respectively. Mapping showed that HCV RNA+ patients were from peri-urban areas surrounding Blantyre. Community and hospital HCV RNA+ participants were older than comparator HCV RNA-negative populations (median 53 vs 30 years for community, p = 0.01 and 68 vs 40 years for cirrhosis/HCC, p < 0.001). Endemic HCV genotypes (n = 10) were 4v (50%), 4r (30%) and 4w (10%). In this first census-based community serological study in Southern Africa, HCV was uncommon in the general population, was centred on peri-urban regions and was attributable for <5% of liver disease. HCV infection was observed only among older people, suggesting a historic mechanism of transmission. Genotype 4r, which has been associated with treatment failure with ledipasvir and daclatasvir, is endemic.

Hepatitis B Vaccination Impact and the Unmet Need for Antiviral Treatment in Blantyre, Malawi.

BACKGROUND: Hepatitis B is the leading cause of cirrhosis and liver cancer in sub-Saharan Africa. To reduce mortality, antiviral treatment programs are needed. We estimated prevalence, vaccine impact, and need for antiviral treatment in Blantyre, Malawi. METHODS: We conducted a household study in 2016-2018. We selected individuals from a census using random sampling and estimated age-sex-standardized hepatitis B surface antigen (HBsAg) seroprevalence. Impact of infant hepatitis B vaccination was estimated by binomial log-linear regression comparing individuals born before and after vaccine implementation. In HBsAg-positive adults, eligibility for antiviral therapy was assessed. RESULTS: Of 97386 censused individuals, 6073 (median age 18 years; 56.7% female) were sampled. HBsAg seroprevalence was 5.1% (95% confidence interval [CI], 4.3%-6.1%) among adults and 0.3% (95% CI, .1%-.6%) among children born after vaccine introduction. Estimated vaccine impact was 95.8% (95% CI, 70.3%-99.4%). Of HBsAg-positive adults, 26% were HIV-positive. Among HIV-negative individuals, 3%, 6%, and 9% were eligible for hepatitis B treatment by WHO, European, and American hepatology association criteria, respectively. CONCLUSIONS: Infant HBV vaccination has been highly effective in reducing HBsAg prevalence in urban Malawi. Up to 9% of HBsAg-positive HIV-negative adults are eligible, but have an unmet need, for antiviral therapy.

Comparative Analysis of Rural Health Demographics in 2 East African Communities During Medical Camps: Volunteers' Perspectives'.

AIMS AND OBJECTIVES: To compare of basic health and social demographics observed during 4-day medical camps in 2 rural communities in Zambia and Malawi to determine any significant differences or similarities. METHOD: About 12 and 10 local and international volunteers at medical camps (at a temporary rural health post or community hall) in rural Zambia and Malawi respectively treated 488 patients in total, with basic health and social demographic data collected and results analyzed. RESULTS: The mean age of patients seen in Malawi and Zambia were 34.5 and 38.9 years respectively, with 39% and 40% of patients in Malawi and Zambia respectively being within the 18 to 44 years age group, and mostly females (59.7% in Malawi and 65.7% in Zambia). Most were non-infectious diseases (97.3% in Zambia, 95% in Malawi), mostly musculoskeletal (17.0% in Malawi and 30.5% in Zambia), while medications prescribed were mostly analgesics (35.7% in Malawi and 29.9% in Zambia). Only a small proportion of patients were referred to local secondary facilities or district hospitals, 51 (28.7%) in Malawi and 59 (19.9%) in Zambia respectively. Chi square test shows a significant difference (P < .001) in diseases in both countries, but there was no statistically significant difference between the mean age of patients seen in both countries, using the independent t-test (P = .365). CONCLUSION: This study highlights statistically significant demographic differences between the 2 communities and possible reasons for these, and how volunteers' roles in rural healthcare in the East African communities could be further evaluated.

Systematic review: epidemiology of oesophageal cancer in Sub-Saharan Africa.

BACKGROUND: Currently, oesophageal cancer is not a public health priority disease in Sub-Saharan Africa. AIM: Analysis of published scientific studies regarding oesophageal cancer in Sub-Saharan Africa was done to ascertain the incidence, prevalence and geographical distribution of the disease in the region. METHODS: A pub med literature search was conducted for articles ranging from 1950 to 2009 database involving the following key words: oesophageal carcinoma, incidence, prevalence and sub-Saharan Africa. RESULTS: 54 articles were retrieved, of which 16 were analyzed. Differences in the study methodologies used made the comparison amongst studies difficult. Overall, however, studies show that oesophageal cancer is on the increase in the region with its epicenter in the eastern and southern Africa. Incidence of the disease is higher in males than females and is prominent among 45-64 years age group in both sexes. Squamous cell carcinoma is a cell type more common than adenocarcinoma. CONCLUSION: Oesophageal cancer is on the increase in the Sub-Saharan African Region with uneven geographical distribution. Therefore, countries in the region are encouraged together with global health organizations to include oesophageal cancer amongst diseases of public health importance for effective prevention, early diagnosis and effective treatment.