Starting a spine surgery service in a low-resource setting: a look back over twenty five years of spine surgery in Malawi

Purpose This is a short historical narrative of the development of spine surgery in Malawi. Methods The authors communicated and both drew on memories and anecdotes over the last 25 years. Results This is not a scientific paper, so there are no results. Conclusion The short paper outlines the development of spine surgery in Malawi over the last 25 years. This develops in association with the overall increase in the number of surgeons in the country

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

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

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

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

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

Total Joint Arthroplasty in HIV-Positive Patients in Malawi: Outcomes from the National Arthroplasty Registry of the Malawi Orthopaedic Association.

In this observational study, we describe the medium-term outcomes of total joint arthroplasty (TJA) in human immunodeficiency virus (HIV)-positive patients in Malawi, a low-income country. With a high prevalence of HIV and increasing arthroplasty rates in low and middle-income countries, understanding the outcomes of TJA in this unique cohort of patients is essential to ensure that surgical practice is evidence-based. Data for all HIV-positive patients who had TJA from January 2005 to March 2020 were extracted from the National Arthroplasty Registry of the Malawi Orthopaedic Association (NARMOA). From January 2005 to March 2020, a total of 102 total hip arthroplasties (THAs) and 20 total knee arthroplasties (TKAs) were performed in 97 patients who were HIV-positive and without hemophilia or a history of intravenous drug use. The mean length of follow-up was 4 years and 3 months (range, 6 weeks to 15 years) in the THA group and 4 years and 9 months (range, 6 weeks to 12 years) in the TKA group. The mean patient age was 50 years (range, 21 to 76 years) and 64 years (range, 48 to 76 years) at the time of THA and TKA, respectively. The primary indication for THA was osteonecrosis (66 hips). In the THA group, the mean preoperative Oxford Hip Score and Harris hip score were 14.0 (range, 2 to 33) and 29.4 (range, 1 to 64), respectively, and improved to 46.6 (range, 23 to 48) and 85.0 (range, 28 to 91) postoperatively. The primary indication for TKA was osteoarthritis (19 knees). The mean preoperative Oxford Knee Score was 14.9 (range, 6 to 31) and increased to 46.8 (range, 40 to 48) postoperatively. In patients who underwent THA, there was 1 deep infection (1 of 102 procedures), and 6 patients developed aseptic loosening (6 of 102). There was 1 postoperative superficial infection following TKA (1 of 20 procedures), and 1 patient developed aseptic loosening (1 of 20). Postoperative 6-week mortality among all patients was zero. To our knowledge this is the largest medium-term follow-up of HIV-positive patients, without hemophilia or a history of intravenous drug use, who have had TJA in a low-income country. This study demonstrated good medium-term results among HIV-positive patients undergoing TJA, low complication rates, and improvements in patient-reported outcome measures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi

Background and purpose — In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST. Patients and methods — This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty. Results — Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66–0.76) and 0.77 (CI 0.71–0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer’s perspective, or$1,035 from the societal perspective. Interpretation — IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.publishedVersio