Spatial and genomic data to characterize endemic typhoid transmission

Background Diverse environmental exposures and risk factors have been implicated in the transmission of Salmonella Typhi, however, the dominant transmission pathways through the environment to susceptible humans remain unknown. Here, we utilize spatial, bacterial genomic, and hydrological data to refine our view of Typhoid transmission in an endemic setting. Methods 546 patients presenting to Queen Elizabeth Central Hospital in Blantyre, Malawi with blood culture-confirmed typhoid fever between April 2015 and January 2017 were recruited to a cohort study. The households of a subset of these patients were geolocated, and 256 S. Typhi isolates were whole genome sequenced. Pairwise single nucleotide variant (SNV) distances were incorporated into a geostatistical modeling framework using multidimensional scaling. Results Typhoid fever was not evenly distributed across Blantyre, with estimated minimum incidence ranging across the city from less than 15 to over 100 cases/100,000/year. Pairwise SNV distance and physical household distances were significantly correlated (p=0.001). We evaluated the ability of river catchment to explain the spatial patterns of genomics observed, finding that it significantly improved the fit of the model (p=0.003). We also found spatial correlation at a smaller spatial scale, of households living <192 meters apart. Conclusions These findings reinforce the emerging view that hydrological systems play a key role in the transmission of typhoid fever. By combining genomic and spatial data, we show how multi-faceted data can be used to identify high incidence areas, understand the connections between them, and inform targeted environmental surveillance, all of which will be critical to shape local and regional typhoid control strategies.

#11: Post-malarial Hemolysis is Rare in Malawian Children with Cerebral Malaria

Background In severe malaria, artesunate decreases mortality compared to quinine. Artesunate’s introduction into clinical use in malaria-endemic areas revealed a unique adverse effect: severe hemolysis appearing several weeks after treatment completion. Though initial reports of post-artesunate hemolysis (PAH) were gathered from adult returning travelers, studies of African children revealed that PAH was less common in this semi-immune population. There are no published studies establishing the incidence and severity of PAH in several severe malarial syndromes in African children, including cerebral malaria (CM). We determined the incidence and severity of post-treatment hemolysis in Malawian children surviving CM by analyzing hospital and follow-up data from a long-standing study of CM pathogenesis. Methods Children aged 6 months to 14 years admitted to Queen Elizabeth Central Hospital (Blantyre, Malawi) with a clinical diagnosis of CM were enrolled in a retrospective cohort study. Children admitted before 2014 and treated with quinine (n=258) were compared to those admitted in 2014 and after and treated with artesunate (n=235). Hematocrit and parasite density were obtained at admission and every 6 hours until parasite clearance. The last hematocrit obtained during hospitalization was compared with the one-month post-hospitalization hematocrit value. Results The overall rate of a post-hospitalization decrease in hematocrit in children surviving CM was 5.3% (4.7% for quinine, 5.8% for artesunate, p value for difference= 0.582); no patients with a hematocrit decrease were symptomatic; none required transfusion. Of the 26 children with a decrease in hematocrit at one month after hospitalization, 23.1% had evidence of a new malaria infection. When children treated with quinine and artesunate were combined, a higher hematocrit on admission, lower quantitative histidine rich protein 2 level, and splenomegaly were independently associated with a post-treatment decrease in hematocrit. Conclusions In African survivors of CM, post-treatment hemolysis is rare, mild, and unassociated with the antimalarial treatment received.

Characteristics and visual outcome of ocular trauma patients at Queen Elizabeth Central Hospital in Malawi

Background To describe the epidemiology and visual outcome of patients with ocular trauma treated at Queen Elizabeth Central hospital in Malawi. Methods A prospective, observational study was undertaken from September 2017 to December 2017. Data on socio-demographic features, aetiology of trauma, type of ocular injury pre-referral pathway and treatment of ocular trauma was collected as the exposure variables. The main outcome variable was best corrected visual acuity at 8 weeks following initial visit. Results A total of 102 patients (103 eyes) with ocular trauma were recruited with loss of follow up of 11 participants at 8 weeks following recruitment. The most affected age group were children under 11 years old (35.3%), followed by young adults of age between 21–30 years (22.5%). The male-to-female ratio for ocular injury was 2.8:1. Most participants had closed globe injuries (n = 72, 70.6%), with over half the population injured by blunt objects (n = 62, 60.8%). Furthermore, among the adult population, majority (n = 19 38%) were injured on the road during assaults (n = 24, 48%), while most paediatric injuries (n = 32, 61.5%) occurred at home during play. The incidence of monocular blindness was 25.3% at eight weeks after the first presentation. Factors that were associated with monocular blindness on multivariate analysis were living in rural areas and open globe injuries. Conclusion Ocular trauma led to monocular blindness in a quarter of the study population. There is need for preventive education of ocular injuries at both family and community level.

A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi

Introduction Moderate to severe acute malnutrition (SAM/MAM) and severe anaemia are important and associated co-morbidities in children aged less than five years. Independently, these two morbidities are responsible for high risk of in-hospital and post-discharge deaths and hospital readmissions. The primary objective of this study is to investigate the risk of death among severely anaemic children with moderate to severe acute malnutrition compared to children with severe anaemia alone. Methods This was a retrospective analysis of data collected from a large prospective study that was investigating severe anaemia in children aged less than 5 years old. The study was conducted at Queen Elizabeth Central Hospital in Blantyre and Chikhwawa district hospital in southern Malawi. Children aged less than five years old; with severe anaemia were screened and enrolled. Each child was followed up for eighteen months at one, three, six, twelve and eighteen months after enrolment. Data were analysed using STATA 15. Results Between July 2002 and July 2004, 382 severely anaemic children were enrolled in the main study. A total of 52 children were excluded due to missing anthropometric data. Out of the 330 included, 53 children were moderately to severely malnourished and 277 were not. At the end of the 18-month follow period, 28.3% of children with MAM/SAM died compared to 13% of children without MAM/SAM (RR 2.1, CI 0.9–4.2, p = 0.03). Similarly, children with moderate to severe malnutrition reported a significantly higher number of malaria infection cases (33.9%) compared to children with severe anaemia alone (27.9%, p = 0.02). However, the number of hospitalizations and recurrence of severe anaemia was similar and not statistically significant between the two groups (RR 0.8 (0.4–1.4), p = 0.6 and RR 1.1 (0.3–2.8), p = 0.8). Conclusion Among children with severe anaemia, those who also had moderate to severe malnutrition had a twofold higher risk of dying compared to those who did not. It is therefore crucial to investigate acute malnutrition among severely anaemic children, as this might be treatable factor associated with high mortality.

Assessing Facilitators and Barriers to Referral of Children Under the Age of Five Years at Ndirande Health Centre in Blantyre, Malawi

Patient referrals among health facilities are initiated to maximize receipt of quality care at a proper level within the health system. This study explored the processes, factors that influence, and strategies for referral of children from Ndirande Health Centre to Queen Elizabeth Central Hospital in Blantyre, Malawi. We drew a purposive sample comprising health care workers, mothers, fathers, ambulance drivers, and Health Center Advisory Committee (HCAC) members and held 19 in-depth interviews and 1 focus group discussion in August 2020. The referral process is influenced by the availability of motor and bicycle ambulances that are well equipped with medical equipment, delay in seeking health services, uptake of referral, and community support. Education and communication with the community and parents respectively optimize the process of referral. There is a need to improve the referral system of under-five children by instituting a policy that is functional while addressing the main barriers.

Assessing knowledge and skills of laypersons bringing victims of road traffic collisions to Queen Elizabeth Central Hospital in Blantyre, Malawi

In Malawi, pre-hospital care assistance is mainly provided by laypersons who witnessed the event. The aim of our study was to determine the knowledge and skills of such persons who bring victims of road traffic crashes to hospital. The study was conducted at Adult Emergency and Trauma Centre at Queen Elizabeth Central Hospital in Blantyre, Malawi. A total of 392 participants were interviewed. Most were merchants (22%) and unskilled labourers (14.5%). Three quarters (75.8%) provided assistance on the scene. The most common assistance provided was transporting victim to the hospital (68.7%), assisting with safe lifting (57.9%) and calling for help (39.7%). Airway protection was provided by only 1% of participants. Therefore, it is recommended to establish some formal pre-hospital assistance to reduce morbidity and mortality from road traffic crashes. Laypersons, especially merchants, students and drivers are potential strong first responders, and training them may help improve pre-hospital care outcome.

Diagnostic point-of-care ultrasound in medical inpatients at Queen Elizabeth Central Hospital, Malawi: an observational study of practice and evaluation of implementation

Background In less well-resourced settings, where access to radiology services is limited, point-of-care ultrasound (POCUS) can be used to assess patients and guide clinical management. The aim of this study was to describe ultrasound practice in the assessment of medical inpatients at Queen Elizabeth Central Hospital, Blantyre, Malawi, and evaluate uptake and impact of POCUS following the introduction of a training programme at the college of Medicine, Blantyre, Malawi. Methods : A weekly prospective record review of sequential adult medical inpatients who had received an ultrasound examination was conducted. Results Of 835 patients screened, 250 patients were included; 267 ultrasound examinations were performed, of which 133 (50%) were POCUS (defined as performed by a clinician at the bedside). The time from request to performance of examination was shorter for POCUS examinations than radiology department ultrasound (RDUS) (median 0 [IQR 0–2, range 0–11] vs 2 [IQR 1–4, range 0–15] d, p=0.002); 104/133 (78.2%) POCUS and 90/133 (67.7%) RDUS examinations were deemed to have an impact on management. Conclusion Following the introduction of a training programme in POCUS, half of all ultrasound examinations were delivered as POCUS. POCUS was performed rapidly and impacted on patient management. POCUS may relieve the burden on radiology services in less well-resourced settings.

Availability, Accessibility and Proper Use of Personal Protective Equipment in Wards at Queen Elizabeth Central Hospital (QECH) Blantyre, Malawi: An Observational Study

BackgroundThe purpose of this study was to evaluate the availability, accessibility and proper use of personal protective equipment (PPE) in the wards at Queen Elizabeth Central Hospital (QECH).Methods: We conducted an observational study with a cross-section design. Convenience sampling method was used for selection of healthcare workers (HCWs) in wards. HCWs filled a checklist on accessibility of PPEs and they were observed on proper use of PPE while conducting clinical procedures. Nurse ward in-charge was asked to fill out a checklist on availability of PPE in their ward.Results PPE was available in 75.8% of wards, not available in 12.5%. Goggles were absent in 70.8% of wards. PPEs were 71.4% accessible and 28.6% inaccessible to healthcare workers in the wards. The most inaccessible PPEs were goggles (83.2%) and footwear (73.7%) while facemasks, sterile and non-sterile gloves and aprons were readily accessible. Non sterile gloves were 100% available and accessible. Only 13.5% of the HCWs had good compliance with PPE standard procedures. The average PPE compliance score of those who had been trained was 6 % greater than those who were not trained. ConclusionThis study identified areas of improvement in healthcare system delivery regarding standard precautions with emphasis on PPE. Improvements in training during professional college education and in-service refresher training could improve compliance with appropriate use of PPE for relatively low cost. Management support could improve availability and accessibility of PPE in the wards at QECH, with active supervision to improve adherence levels to personal protective equipment usage. The study can also help in the development of policies and guidelines regarding PPE usage by showing that most HCWs need to be trained in proper PPE usage.

The use of antibiotics in the intensive care unit of a tertiary hospital in Malawi

Background Antibiotic resistance is on the rise. A contributing factor to antibiotic resistance is the misuse of antibiotics in hospitals. The current use of antibiotics in ICUs in Malawi is not well documented and there are no national guidelines for the use of antibiotics in ICUs. The aim of the study was to describe the use of antibiotics in a Malawian ICU. Methods A retrospective review of medical records of all admissions to the main ICU in Queen Elizabeth Central Hospital in Blantyre, Malawi, between January 2017 and April 2019. Data were extracted from the ICU patient register on clinical parameters on admission, diagnoses, demographics and antibiotics both prescribed and given for all patients admitted to the ICU. Usage of antibiotics in the ICU and bacterial culture results from samples taken in the ICU and in the peri-ICU period, (from 5 days before ICU admission to 5 days after ICU discharge), were described. Results Six hundred-and-forty patients had data available on prescribed and received medications and were included in the analyses. Of these, 577 (90.2%) were prescribed, and 522 (81.6%) received an antibiotic in ICU. The most commonly used antibiotics were ceftriaxone, given to 470 (73.4%) of the patients and metronidazole to 354 (55.3%). Three-hundred-and-thirty-three (52.0%) of the patients received more than one type of antibiotic concurrently – ceftriaxone and metronidazole was the most common combination, given to 317 patients. Forty five patients (7.0%) were given different antibiotics sequentially. One-hundred-and-thirty-seven patients (21.4%) had a blood culture done in the peri-ICU period, of which 70 (11.0% of the patients) were done in the ICU. Twenty-five (18.3%) of the peri-ICU cultures were positive and eleven different types of bacteria were grown in the cultures, of which 17.2% were sensitive to ceftriaxone. Conclusion We have found a substantial usage of antibiotics in an ICU in Malawi. Ceftriaxone, the last-line antibiotic in the national treatment guidelines, is commonly used, and bacteria appear to show high levels of resistance to it, although blood culture testing is infrequently used. Structured antibiotic stewardship programs may be useful in all ICUs.