Musculoskeletal impairment and road traffic injuries in Malawi

Introduction: The global burden of musculoskeletal disease in low and middle-income countries is large, growing, and neglected. While there is considerable funding for the control of communicable disease, there has been little attention paid to either the prevention or the treatment of musculoskeletal impairment (MSI) in developing countries. Musculoskeletal disease is one of the major causes of physical disability globally, yet data regarding the magnitude of this burden in developing countries is scarce or lacking. Several studies have shown that the vast majority of those living with disability are children residing in Lower Middle-Income Countries (LMICs), but again, little research has been done in Malawi to establish the the actual burden of MSI in the population. Musculoskeletal disease encompasses a wide range of conditions that vary from traumatic injury to congenital malformations, disabling arthritis to chronic low back pain, many of which benefit from surgical intervention. They affect a large portion of the world’s population in one form or another, with non-traumatic musculoskeletal disease estimated to account for 6.8% of all disability adjusted life years lost according to the latest Global Burden of Disease studies. However, this 6.8% of disability adjusted life years does not include those lost owing to musculoskeletal trauma. Each year 5.1 million people worldwide die from injuries. 1.35 million of these deaths are due to road traffic accidents and ninety percent occur in developing countries. Africa has the highest rate of road traffic injuries (RTIs) in the world, despite being the least motorized of the world's 6 regions with only 2% of the world's registered vehicles. According to Global status Report on road safety 2018, there has been no reduction in number of road traffic deaths in any low-income country (LIC) since 2013. RTIs are the 8th leading cause of death for people of all age but are now the leading cause of death for children and young adults aged 5-29 years. For each person who dies from trauma, three to eight persons are permanently disabled and at least 20 persons survive with injuries that need treatment. WHO estimates suggest Malawi has one of the highest mortality rates due to road traffic injuries (RTIs) in the world, but very little research has been done to map the actual situation on the ground. Whereas WHO estimates of road traffic mortality in Malawi have remained relatively static over the last years, as clinicians we have had the impression that there is a rapidly increasing burden of RTIs in Malawi. The overall aim of this thesis was to assess the burden of MSI and to report the prevalence, causes, and treatment need among both adults and children, to evaluate the quality of life among people with MSI in Malawi and map the trend of RTIs in Lilongwe, Malawi. Methods: This thesis is based on 3 papers. Paper I assessed the trend over 7 years (from January 2009 to December 2015) of the burden of road traffic related trauma presented to Kamuzu Central Hospital (KCH) in Lilongwe, one of the main referral hospitals in Malawi. This was an analysis of prospectively collected data from the KCH Trauma Registry. Paper II assessed the prevalence, impact, causes, and service implications of MSIs in Malawi. To achieve this we used a validated survey tool to randomly select clusters across the whole country that matched the national distribution of the population. Then adult individuals were screened and examined for MSI by survey field teams. The questionnaire and Rapid Assessment of Musculoskeletal Impairment (RAM 1 & RAM 2) tools were installed on 17 tablet computers for data collection. Quality of life was measured using EQ-5D. Paper III critically analysed the same survey data to estimate the prevalence of MSI and the need for different treatment modalities among children aged 16 years or less in Malawi, and described the causes of MSI in Malawian children. Results: Paper I: The prospectively collected data from the KCH Trauma Registry showed that there was a 62.4% rise in the number of RTI victims treated at KCH from 2,447 in 2009 to 3,975 in 2015. If this trend continues, 7,997 patients will be expected to need treatment for RTIs at KCH in 2030, doubling the numbers seen in 2015 in just 15 years. The highest number of injuries occurred in pedestrians (32.3%) and cyclists (28.2%) and continually rose over the years studied. The length of hospital stay for RTIs increased from 6.4 (SD 9.1) days in 2009 to 15.0 (SD 19.4) days in 2015. Paper II: During our national survey of MSI in Malawi, we travelled the whole country for 2 months. We enumerated 8,548 people and found that 810 were living with MSI, representing 9.5% of the population. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic noninfective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the International Classification of Functioning (ICF) class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress, or unable to perform usual daily activities. Paper III: 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: Paper I: There was a rapidly growing burden of RTIs at KCH in Lilongwe, Malawi, between 2009 and 2015, and projections based on our data show that this burden is likely to continue to rise, and could double by 2030. The absence of a clear strategy to meet the growing epidemic of injuries in Malawi will come at a huge cost to an already strained economy, and the largest portion of the burden of injury will continue to be borne by the poorest segment of the population. However, 7 years down the line new data is urgently needed to assess the trend of RTIs. Observing the current situation on the ground, RTIs continue to rise and the hospital is struggling to cope up with the number of road traffic victims. Paper II: Our study showed that a huge burden of musculoskeletal impairment in Malawi is mostly unattended and has a profound impact on a large proportion of the population. The prevalence of MSI in the country was found to be high, revealing an urgent need to scale up surgical and rehabilitation services in the country. Increasing age was one of the factors that was associated with an increased risk of having MSI. The quality of life of a large proportion of patients with moderate and severe MSI was considerably affected. Paper III: This study also uncovered a large burden of MSI among children aged 16 and under in the country with an immense unmet need for treatment (P & O devices, physical & occupational therapy, and surgical services) of those affected children. A clear strategy should be made by policy makers to cope up with this burden of MSI in both adults and children and give the necessary support to those in need

The impact of long term institutional collaboration in surgical training on trauma care in Malawi

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Background Attempts to address the huge, and unmet, need for surgical services in Africa by training surgical specialists in well established training programmes in high-income countries have resulted in brain drain, as most trainees do not return home on completion of training for various reasons. Local postgraduate training is key to retaining specialists in their home countries. International institutional collaborations have enabled Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, to start training their own surgical specialists from 2009. Results and discussion The direct impact of this has been an increase in Malawian staff from none at all to 12 medical doctors in 2014 in addition to increased foreign faculty. We have also seen improved quality of care as illustrated by a clear reduction in the amputation rate after trauma at KCH, from nearly every fourth orthopaedic operation being an amputation in 2008 to only 4 % in 2014. Over the years the training program at KCH has, with the help from its international partners, merged with the College of Medicine in Blantyre, Malawi, into a national training programme for surgery. Conclusions Our experiences from this on-going international institutional collaboration to increase the capacity for training surgeons in Malawi show that long-term institutional collaboration in the training of surgeons in low-income countries can be done as a sustainable and up-scalable model with great potential to reduce mortality and prevent disability in young people. Despite the obvious and necessary focus on the rural poor in low-income countries, stakeholders must start to see the value of strengthening teaching hospitals to sustainably meet the growing burden of trauma and surgical disease. Methods Annual operating data from Kamuzu Central Hospital’s Main Operating Theatre log book for the years 2008–2014 was collected. Observed annual numbers were presented as graphs for easy visualization. Linear regression curve estimations were calculated and plotted as trend lines on the graphs

Untreated surgical conditions in Malawi: A randomised cross-sectional nationwide household survey

Background Noncommunicable diseases, such as surgical conditions have received little attention from public health planners in low income countries (LIC) like Malawi. Though increasingly recognised as a growing global health problem, the burden of surgical pathologies and access to surgical care has not been adequately identified in many LIC. Information on the spectrum and burden of surgical disease in Malawi is important to uncover the unmet need for surgery and for planning of the National Health Service.Methods This was a multistage random cluster sampling national survey. Households were selected from clusters using probability proportional to size method. 1448 households and 2909 interviewees were analysed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used to collect data. This electronic tablet based questionnaire tool included general information and a dual personalised head to toe inquiry on surgical conditions. The general information included number of household members, and inquired on any death within the past twelve months, and if any of the deaths in the family had a suspected surgical condition leading to that death. Data was collected by specially trained third year medical students.Results Out of 1480 selected households, 1448 (98%) agreed to participate, with 2909 interviewed individuals included in the study. The median household size was 6 individuals (range 1 – 47). Median age of interviewed persons was 35 years (range 0.25 – 104 years). 1027 out of 2909 (35%) of the interviewed people reported to be living with a condition requiring surgical consultation or intervention, whereas 146 of 616 (24%) of the total deaths reported to have occurred in the preceding 12 months were reported to have died from a surgically related condition. Most individuals did not seek health care due to lack of funds for transportation to the health facility. Only 3.1% of those that reported a surgical condition had surgical intervention.Conclusions There is a large unmet need for surgical care in Malawi. A third of the population is living with a condition needing surgical consultation or intervention, and a quarter of all deaths are potentially avoidable with surgery. Urgent scale up of surgical services and training are needed to reduce this huge gap in public health planning in the country

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. Previous studies in Malawi on childhood disability and the impact of musculoskeletal impairment (MSI) on the lives of children have been done but on a small scale and have not used disability measurement tools designed for children. Therefore in this study, we aimed to estimate the MSI prevalence, causes, and the treatment need among children aged 16 years or less in Malawi. Methods This study was carried out as a national cross sectional survey. 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 3792 children aged 16 or less who were enumerated, 3648 (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 (6000-33,000) 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.publishedVersio

Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey

Background Relatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility. Methods The study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey. Results The survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care. Conclusion In Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.publishedVersio

Paediatric surgical conditions in Malawi - A cross-sectional nationwide household survey

BackgroundUntreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce long-term effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need.AimTo estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries.MethodsA cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection. ResultsThere were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region. ConclusionAn extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care

Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey

Background There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF) Methods A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5–24% was mild, 25–49% was moderate and 50–90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education. Results A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9–10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8–14.8)] compared to those with formal education levels [8.9% (CI 8.1–9.7), p<0.001] for primary school and [5.9% (4.6–7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities. Conclusion This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.publishedVersio

Improving the management of open tibia fractures, Malawi.

To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures. We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and-after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention. The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice. Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle

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

Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study

Background: Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi. Methods: In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management. Findings: Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25–44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I–II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5–11·6; QALYs: 0·73, 95% HDI: 0·66–0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4–16·6; QALYs: 0·67, 95% HDI: 0·59–0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8–16·1; p=0·02). Interpretation: Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes. Funding: Wellcome Trust