Point-of-care lactate and creatinine analysis for sick obstetric patients at Queen Elizabeth Central Hospital in Blantyre, Malawi : a feasibility study

Background To achieve good outcomes in critically ill obstetric patients it is necessary to identify organ dysfunction rapidly so that life saving interventions can be appropriately commenced. However, timely access to clinical chemistry results is problematic even in referral institutions in the sub Saharan African region. Reliable point of care tests licensed for clinical use are now available for lactate and creatinine. Aim We aimed to assess whether implementation of point of care testing for lactate and creatinine is feasible in the obstetric unit at the Queen Elizabeth Central Hospital (QECH), Malawi, by obtaining the opinions of clinical staff on the use of these tests in practice. Methods During a two month evaluation period nurse-midwives, medical interns, clinical officers, registrars and consultants were given the opportunity to use StatStrip® and StatSensor® (Nova Biomedical) devices for lactate and creatinine estimation as part of their routine clinical practice in the obstetric unit. They were subsequently asked to complete a short questionnaire. Results 37 questionnaire responses were received, 22 from nurse-midwives and the remainder from clinicians. The mean satisfaction score for the devices was 7.6/10 amongst clinicians and 8.0/10 amongst nurse-midwives. The majority of participants stated that the obstetric high dependency unit (HDU) was the most suitable location for the devices. For lactate, 31 participants strongly agreed that testing should be continued and 24 strongly agreed that it would influence patient management. For creatinine, 29 strongly agreed that testing should be continued and 28 strongly agreed that it would influence their patient management. 20 participants strongly agreed that they trust point of care devices. Conclusion Point of care clinical chemistry testing is feasible, practical, well received by staff and was considered by staff to have a useful role to play in the clinical care of very sick obstetric patients at this referral centre.PostprintPeer reviewe

Sexually transmitted diseases at Queen Elizabeth Central Hospital, Blantyre, Malawi

Objectives: To re-assess attendance at the sexually transmitted diseases (STDs) clinic in relation to age, sex and seasonal variation over a three-year period, and to determine the pattern of STD syndromes presenting at the STDs clinic, Queen Elizabeth Central Hospital, Blantyre, Malawi.Design: A retrospective study.Setting: STDs clinic, Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi.Results: The study findings indicate that of the 50,524 attendees, 52.72% and 47.28% were males and females respectively. Over the period there was a significant (30.7%) increase in the number of attendees from 14,622 (28.94%) in 1996 and 16,794 (33.24%) in 1997 to 19,008 (37.82%) in 1998, a trend that was also observed among the sexes. The age range was between 11 and 72 years. More than half(53.55%) of the patients were within 21 to 30 years age rangewhile a total of 48,054 (95.11%) were below 50 years. The most frequently presented STDs syndromes among the 21- 30 year age group were genital ulcer disease (GUD) (40.86%), genitourinary symptoms high risk (GUS - HR) (20.46%), urethral discharge (UD) (15.65%) and pelvic inflammatory diseases (PID) (13.37%). The four constituted 90.34% of all case presentations. Balanitis (BA) was the least common at 0.32% or 86 cases in three years. Whilethe incidence of genitourinary symptoms low risk (GUS - LR) decreased over the years and no clear pattern could be established with (GUS - HR), acute scrotal swelling/pain (SS), and BA, numerical increase in the presentation of UD, PID and enlarged inguinal lymph nodes(BU) was observed. However, the phenomenal increase in the prevalence of STDs particularly GUD rising from 2,988 (37.70%) in 1996 and 3,674 (40.27%) in 1997 to 4,392 (43.88%) in 1998 respectively was noted with concern. There seemed to be a link between seasonal variation and attendance at the STD clinic as more cases presented between March and May peaking in April of each year while December period recorded the least attendance.Conclusion: Attendance rate at the STDs clinic, Queen Elizabeth Central Hospital, Blantyre, is still on the increase in spite of the various STDs/HIV/AIDS awareness campaign programmes

Delays in seeking treatment for sick children in rural Malawi: A study of the utilisation of village clinics

The world’s highest mortality figures are found in developing countries among under-five children (Black et al., 2003:2227). Efforts in reducing childhood mortality are stifled if treatment is delayed (sought after 24 hours). The aim of this study was to find out the factors that contribute to delays in seeking treatment for sick children in a community where health services are free and accessible. From data collected using a questionnaire through face-to-face interviews and focus group discussions (FGDs), the study found out the factors that contribute to delayed care. It collected data from 150 mothers who sought treatment at village clinics within 14 days prior to the survey date. Qualitative data were collected in five FGDs with old women, young women, men, youth and community leaders. The study found that out of 150 mothers, 54 percent delayed seeking treatment for sick children. Mothers who had given sick children home treatment and those who sought treatment from other providers for the same illness brought to the village clinic were more likely to delay care. FGDs revealed that most factors contributing to delayed care were to do with the health system, although beliefs and perceptions played a part. In summary, delays in seeking treatment for sick children are a product of an interplay of many factors. Overall, it was found that caregivers’ interpretation of the child’s illness influenced timeliness of care and the choice of health care provider.Thesis (MA) -- Faculty of Social Sciences and Humanities, 201

Delays in seeking treatment for sick children in rural Malawi: A study of the utilisation of village clinics

The world’s highest mortality figures are found in developing countries among under-five children (Black et al., 2003:2227). Efforts in reducing childhood mortality are stifled if treatment is delayed (sought after 24 hours). The aim of this study was to find out the factors that contribute to delays in seeking treatment for sick children in a community where health services are free and accessible. From data collected using a questionnaire through face-to-face interviews and focus group discussions (FGDs), the study found out the factors that contribute to delayed care. It collected data from 150 mothers who sought treatment at village clinics within 14 days prior to the survey date. Qualitative data were collected in five FGDs with old women, young women, men, youth and community leaders. The study found that out of 150 mothers, 54 percent delayed seeking treatment for sick children. Mothers who had given sick children home treatment and those who sought treatment from other providers for the same illness brought to the village clinic were more likely to delay care. FGDs revealed that most factors contributing to delayed care were to do with the health system, although beliefs and perceptions played a part. In summary, delays in seeking treatment for sick children are a product of an interplay of many factors. Overall, it was found that caregivers’ interpretation of the child’s illness influenced timeliness of care and the choice of health care provider.Thesis (MA) -- Faculty of Social Sciences and Humanities, 201

Recruiting the social contacts of patients with STI for HIV screening in Lilongwe, Malawi: process evaluation and assessment of acceptability

To explore acceptability of recruiting social contacts for HIV and STI screening in Lilongwe, Malawi

STI Patients Are Effective Recruiters of Undiagnosed Cases of HIV: Results of a Social Contact Recruitment Study in Malawi

Patients with newly diagnosed HIV may be part of social networks with elevated prevalence of undiagnosed HIV infection. Social network recruitment by persons with newly diagnosed HIV may efficiently identify undiagnosed cases of HIV infection. We assessed social network recruitment as a strategy for identifying undiagnosed cases of HIV infection

Association between contraceptive implant knowledge and intent with implant uptake among postpartum Malawian women: a prospective cohort study

Abstract Background Long-acting reversible contraception (LARC) can assist women with birth spacing and reduce unintended pregnancies. Sub-Saharan Africa has low uptake of the two available methods of LARC, the subdermal implant and intrauterine contraception (IUC). Our primary objectives were to: 1) calculate the incidence of LARC use among postpartum Malawian women, and 2) assess if LARC knowledge and intent to use LARC were associated with LARC uptake. Methods This study was a prospective cohort study of 634 postpartum women who were recruited from the postpartum ward of Bwaila Hospital in Lilongwe, Malawi. Study participants completed a baseline survey in the postpartum ward. Follow-up telephone surveys about contraceptive use were conducted at 3, 6, and 12 months postpartum. Cox proportional hazards regression analysis was performed to evaluate if implant knowledge and intent to use implant were associated with implant uptake. Results One hundred thirty-seven implant and 10 IUC placements were reported over 12 months of follow-up; given the low rate of IUC uptake, further analysis was only done for implant uptake. The incidence rate for implant uptake was 35.6 per 100 person-years (95 % CI 30.0, 42.2). Correct implant knowledge (adjusted HR = 1.69; 95 % CI 1.06, 2.68) and intent to use implant (adjusted HR 1.95; 95 % CI 1.28, 2.98) were both associated with implant uptake. Conclusions More women reported implant use than IUC use in our study. Correct implant knowledge and intent to use implant were both associated with implant uptake, with a stronger association for intent. Interventions to increase LARC uptake should focus on improving LARC knowledge and removing barriers to LARC. Trial registration Clinical Trial Registration #: NCT0189302

Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women

The objectives of this study were to describe the most recent pregnancy intentions and family planning preferences of HIV-infected and HIV-uninfected postpartum Malawian women, and to assess whether HIV status is associated with fertility desire and knowledge of intrauterine contraception (IUC) and the subdermal contraceptive implant. We conducted a cross-sectional analysis of the baseline characteristics of Malawian women enrolled in a prospective cohort study assessing postpartum contraceptive uptake and continuation. Women at a government hospital completed a baseline survey assessing reproductive history, family planning preferences, and knowledge of IUC and the implant. We used Pearson's chi-square tests to compare these parameters between HIV-infected and HIV-uninfected women. Modified Poisson regression was performed to assess the association between HIV status and fertility desire and knowledge about IUC and the implant. Of 634 postpartum women surveyed, HIV-infected women were more likely to report their most recent pregnancy was unintended (49% versus 37%, p=0.004). Nearly all women (97%) did not want a child in the next two years but HIV-infected women were more likely to desire no more children (adjusted PR: 1.59; 95% CI: 1.33, 1.89). HIV-infected women were also less likely to know that IUC (adjusted PR 0.72; 95% CI: 0.61, 0.84) and the implant (adjusted PR 0.83; 95% CI: 0.75, 0.92) are safe during breastfeeding. Postpartum women strongly desire family spacing and many HIV-infected postpartum women desire no more children, suggesting an important role for these long-acting methods. Education about the efficacy and safety of IUC and the implant particularly during breastfeeding may facilitate postpartum use

Effects of Urethritis on Human Immunodeficiency Virus (HIV) in Semen: Implications for HIV Prevention and Cure

Background: Prior to the widespread availability of antiretroviral therapy (ART), men living with human immunodeficiency virus (HIV) with urethritis had increased concentrations of HIV in semen. This study aims to better evaluate HIV shedding in men with urethritis receiving ART, and its implications for the cure of HIV. Methods: Men living with HIV with urethritis taking ART ≥12 weeks were enrolled at a sexually transmitted infections clinic in Lilongwe, Malawi. Study follow-up included visits at 1, 2, 4, 8, 12, 24, 36, and 48 weeks after urethritis diagnosis and treatment. Matched blood and semen samples were collected at all visits, and all additional episodes of urethritis were followed with extra visits 1, 2, and 4 weeks after treatment. Results: There were 111 men enrolled in the study between January 2017-March 2019, and 77 (69%) were suppressed in the blood (<400 copies/mL). Among the 77 men, 87 episodes of urethritis were evaluated during follow-up. Of the 87 episodes, 15 episodes (17%) had instances of seminal viral shedding ≥400 copies/mL despite viral suppression in the blood. During nonurethritis follow-up, ≤6% of men at each visit had a viral load ≥400 copies/mL in the semen while maintaining viral suppression in the blood. Conclusions: An HIV cure requires the elimination of HIV from every body compartment, but available ART does not currently accomplish this. Our study highlights the male genital tract as a local source of HIV that can be reversibly activated. A better understanding of this phenomenon is important to advance the HIV cure field

Gentamicin Susceptibility in Neisseria gonorrhoeae and Treatment Outcomes for Urogenital Gonorrhea After 25 Years of Sustained Gentamicin Use in Malawi

Background Gentamicin has been used for the treatment of gonorrhea in Malawi since 1993. However, declining clinical cure rates have been suspected. We evaluated current Neisseria gonorrhoeae susceptibility to gentamicin in vitro and clinically. Methods Men with acute urethritis were recruited at the Bwaila District Hospital STI Clinic in Lilongwe, Malawi, between January 2017 and August 2019. All men provided urethral swabs for etiological testing at enrollment and test of cure (TOC), 1 week later, using Gram-stained microscopy and culture. We used Etest to determine minimum inhibitory concentrations (MICs) of gentamicin, azithromycin, cefixime, ceftriaxone, ciprofloxacin, and spectinomycin; disc diffusion for tetracycline susceptibility; and whole-genome sequencing (WGS) to verify/refute treatment failure. Results Among 183 N. gonorrhoeae culture-positive men enrolled, 151 (82.5%) had a swab taken for TOC. Of these 151 men, 16 (10.6%) had a positive culture at TOC. One hundred forty-one baseline isolates were tested for gentamicin susceptibility using Etest: 2 (1.4%), MIC = 2 μg/mL; 111 (78.7%), MIC = 4 μg/mL; and 28 (19.9%), MIC = 8 μg/mL. All isolates were susceptible to azithromycin, cefixime, ceftriaxone, and spectinomycin, whereas 63.1% had intermediate susceptibility or resistance to ciprofloxacin. Almost all (96.1%) isolates were resistant to tetracycline. All examined isolates cultured at TOC (n = 13) had gentamicin MICs ≤8 μg/mL. Ten men had pretreatment and posttreatment isolates examined by whole-genome sequencing; 2 (20%) were verified new infections (4119 and 1272 single-nucleotide polymorphisms), whereas 8 (80%) were confirmed treatment failures (0-1 single-nucleotide polymorphism). Conclusions Gentamicin MICs poorly predict gonorrhea treatment outcome with gentamicin, and treatment failures are verified with gonococcal strains with in vitro susceptibility to gentamicin. The first-line treatment of gonorrhea in Malawi should be reassessed