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IntroductionCryptococcal meningitis (CM) is the most common systemic fungal infection in patients with HIV infection. Rapid diagnosis and timely initiation of antifungal therapy are key to reducing mortality rate associated with CM. This study aims to evaluate the ability of four different diagnostic tests (Gram stain, India ink, and two types of commercial lateral flow assay [LFA]) to identify CM-positive patients and to compare the sensitivity and specificity of these tests.MethodsThis was a prospective cross-sectional study on diagnostic tests accuracy conducted in Northern Malawi. The target population was HIV-infected adult patients presenting with features of meningitis. Four types of diagnostic tests were conducted: India ink, Gram stain, and two types of commercial lateral flow assay (LFA) (Immy, Inc., OK, USA and Dynamiker Biotechnology (Tianjin) Co., Ltd), Singapore). Culture was conducted as the reference standard.ResultsA total of 265 samples were collected. The rate of positive CM detection ranged from 6.4% (using India ink) to 14.3% (using LFA). India ink exhibited the lowest sensitivity of 54.8% (95% confidence interval [CI]: 36.0%–72.7%), followed by Gram stain (61.3%; 95% CI: 42.2%–78.2%). The Dynamiker LFA exhibited the highest sensitivity of 100.0% (95% CI: 90.0%–100.0%) but a lower specificity (97.0%; 93.9%–98.8%) compared to the Immy LFA (98.3%; 95% CI: 95.7%–99.5%). ConclusionLFA diagnostic methods have the potential to double the detection rate of CM-positive patients in resource-limited countries such as Malawi. As such, LFAs should be considered to become the main diagnostic tests used for CM diagnostics in these countries. Our data indicate that LFAs may be the best method for diagnosing CM and exhibits the highest diagnostic accuracy as it has shown that it outperforms cell culture, the current gold standard.

ObjectiveOrbito-ocular cancers are a common cause of morbidity and mortality in our population, yet these cancers have not been adequately described in Malawi. This study sought to describe the burden and histopathological profile of orbito-ocular cancers in Northern Malawi.Methods and AnalysisA retrospective review of pathology reports was done. Descriptive analyses were performed to summarise patients’ demographic and clinical characteristics, and histopathological results. A binary logistic regression was used to explore the association between demographic variables, site of lesion and cancer.Results210 pathology reports of orbito-ocular biopsies were reviewed. 60.0% of patients were female. The majority (39.5%) of patients were in the 31 to 40 age group but overall mean age (±SD) was 34.81±15.9 years. Cancer was diagnosed in 84 (40.0%) patients. Squamous cell carcinoma constituted the majority (82.1%) of cancers followed by retinoblastoma at 7.1%. Orbito-ocular cancers were associated with HIV infection (OR5.9, 95% CI 2.0 to 17.2) and intraocular tumours were 8.3 times (OR 8.3, 95% CI 2.0 to 33.8) more likely to be malignant. However, squamous cell carcinoma was the only type of cancer found in patients with HIV infection and mostly affected the conjunctiva, constituting 94.4% of cancers affecting this site. Retinoblastoma on the other hand only affected children less than 10 years of age.ConclusionCancer constituted a substantial proportion of orbito-ocular lesions in our study population, with conjunctiva being the common site. This calls for improved capacity to prevent, diagnose and manage orbito-oracular cancers in Northern Malawi and similar settings.

BackgroundIn 2016 the Malawi government embarked on several interrelated health sector reforms aimed at improving the quality of health services at all levels of care and attain Universal Health Coverage by 2030. Patient satisfaction with services is an important proxy measure of quality. We assessed patient satisfaction at a tertiary hospital in Northern Malawi to understand the current state in the country. MethodsWe conducted exit interviews with patients aged18 years and above using a 28 statement interviewer administered questionnaire. Patients were asked to express their level of agreement to the statements on a five-point Likert scale – strongly disagree to strongly agree, corresponding to scores of 1 to 5. Overall patient satisfaction was calculated by summing up the scores and diving the sum by the number of statements. Scores >3 constituted satisfaction while scores ≤3 constituted dissatisfaction. Patient self-rated satisfaction was determined from a single statement that asked patients to rate their satisfaction with services on a five-point Likert scale. We also solicited inputs from patients on aspects of hospital care that needed improvement. Responses were reviewed and grouped into themes. Recurring themes are presented according to frequencies.ResultsOverall patient satisfaction was 8.4% (95% CI: 5.2% - 12.9%). Patient self-rated satisfaction was 8.9% (95% CI: 5.5% - 13.4%). Patients raised six major issues that dampened their healthcare seeking experience including health workers reporting late to work, doctors not listening to patients concerns and neither examining them properly nor explaining the diagnosis, shortage of medicines, diagnostics and medical equipment, unprofessional conduct of health workers, poor sanitation and cleanliness, and health workers behaviour of favouring or priotising their relatives and friends over other patients.ConclusionWe found very low levels of patient satisfaction, suggesting that quality of services in the public health sector is still low. It is therefore critical to accelerate and innovate the Ministry of Health’s quality improvement initiatives to attain Malawi’s health goals.

ObjectivesThis study was carried out to determine the histopathological profile of cervical biopsies in a public tertiary hospital in Mzuzu, northern region of Malawi.SettingA public tertiary hospital in Mzuzu, northern region of MalawiParticipantsThis was a retrospective study of all cervical biopsy specimen reports received in a public tertiary hospital in northern Malawi over a period of 5 years from July 2013-June 2018. Eleven reports which had missing demographic and clinical data or had inconclusive results were excluded. Demographic, clinical and histopathological data was obtained from original histology reports.ResultsA total of 500 cervical biopsy reports were reviewed during the study period. The mean age of the patients was 41.99±12.5. Age ranged from 15 to 80 years. Cervicitis accounted for 46.0% (n=162) of the total nonmalignant lesions seen, followed by cervical intraepithelial neoplasm (CIN), at 24.4% (n=86) and endocervical polyp, at 20.5% (n=72). Squamous cell carcinoma (SCC) accounted for 15.6% (n=78) of the total cervical biopsies studied and 85.7% of all total malignant lesions. All malignant tumours had HIV.ConclusionOur study shows that cervicitis and squamous cell carcinoma were most common among nonmalignant and malignant cervical biopsies respectively. Since the frequency of cervical cancer is high, there is need to have well detailed national policies to be put in place to increase detection of pre-invasive lesions in order to reduce the prevalence of cervical cancer.Strengths and limitation of this study StrengthsThis paper has shownThe need for well detailed national policies to be put in place to increase detection of pre-invasive lesions, which in turn will decrease the frequency of cervical cancer in the country.The importance of intensifying cervical cancer screening programmes among women and provision of long term ART to the HIV infected which may offer an opportunity for appropriate interventions to reduce morbidity, mortality and reduce complications among these women.LimitationsThis study used available programme health facility data and histopathological reports on cervical cancer which has its own limitations, such as incompleteness and bias in the sense that information is obtained only from people who came to the facility and underwent biopsy, leaving out those that did not seek medical care and or were not biopsied and therefore cannot be generalized to the general population.The study is a single-hospital-based review and as such inadequate to draw conclusions, but it does shed some light on pathological pattern of cervical cancer in Malawi.

Background World Health Organisation (WHO) has approved and recommended several public health measures to halt the Coronavirus Disease 2019 (COVID-19) pandemic. The implementation of recommended interventions vary between higher income and Low and Middle-Income Countries (LMICs). The economical constraints within LMICs posed challenges in accessing resources for COVID-19 prevention. The study aimed to identify the workable community-based interventions being utilised in LMICs.Main body We applied systematic review approach for this study. Included articles were searched in eight online databases. The analysis was guided by the acceptable of best practice developed by the PROSPERO and COCHRANE for systematic search and selection of articles using pre-defined search terms. Furthermore, a PRISMA flow diagram was used to show the number of articles retrieved, retained, excluded with rationales given for every action. Studies conducted on community-based intervention for preventing COVID-19 and levels of knowledge, attitudes and practice (KAP) on community-based intervention for preventing COVID-19 regardless of the design were included. A mixed method appraisal tool (MMAT) was used to appraise studies.Six studies from LMICs were included for detail analysis after the systematic review screening process from 10,100 articles. The quality assessment using MMAT tool appraised these articles were all in highest quality. Among the six articles, 10 community-based interventions were implemented in LMICs. The three key workable and implemented interventions are: use of masks, social distance and hand wash. The review identified varying levels of KAP between LMICs and social-demographical factors affecting KAP in these settings.Conclusion This systematic review has identified the community-based interventions implemented in LMICs to prevent COVID-19 during the pandemic and key factors affecting the level of KAP among the population. This study re-affirms the importance of effective and suitable implementation of the identified interventions. More studies need to be conducted in LMICs to establish the effectiveness and adoption of the implemented and recommended interventions.

Data on the prevalence of extrapulmonary tuberculosis (EPTB) patients are limited in many African countries including Malawi. We conducted a retrospective review of all histology reports for cancer suspected patients at Mzuzu Central Hospital (MZCH) between 2013 and 2018 to determine the proportion of EPTB cases among cancer suspected patients and characterised them epidemiologically. All reports with inconclusive findings were excluded. In total, 2214 reports were included in the review, 47 of which reported EPTB, representing 2.1% (95% CI 1.6−2.8). The incidence of EPTB was significantly associated with sex, age and HIV status. Men were more than twice (OR 2.1; 95% CI 1.2–3.9) as likely to have EPTB as women while those with HIV were more than six times (OR 6.4; 95% CI 1.7–24.8) as likely to have EPTB compared to those who were HIV-negative. EPTB demonstrated an inverse relationship with age. The highest proportion of EPTB was found from neck lymph nodes (10.3% (5.4–17.2)). A reasonable number of EPTB cases are diagnosed late or missed in Malawi's hospitals. There is a need for concerted efforts to increase EPTB awareness and likely come up with a policy to consider EPTB as a differential diagnosis in cancer suspected patients.

Objective: Schistosomiasis cause significant morbidity and mortality worldwide. This is a retrospective cross-sectional study conducted at Mzuzu Central Hospital (MCH) from northern Malawi aiming at determining prevalence of schistosomiasis infection in cancer suspected patients. The data was collected from hospital files and the duration under review was from July 2013 to June 2018. A total of 790 Histopathological samples were analysed at University of North Carolina (UNC) Histopathology lab. Results were made available to the facility – Mzuzu Central Hospital.Results: The overall prevalence of schistosoma (S. mansoni & haematobium) infection was 1.7% (14/790). About 93% (13/14) of schistosomiasis cases were observed in female patients while 7% (1/14) from male patients. Of the 14 cases from different histopathological pattern (Cervix, Ureter, Liver, Ovary, GIT and Urinary bladder), 43% (6/14) of cases were diagnosed from cervical tissues. Correlation between HIV infection and schistosomiasis infection was not reached as Serostatus for reasonable number of patients was unknown. Schistosomiasis chronic infection is highly prevalent in Malawi. This disease is neglected and underestimated due to lack of clinical skills and capacity in most of the public laboratories to accurately diagnose it as such, most cases are misdiagnosed as cancer.

BackgroundOrbito-ocular lesions are common cause of morbidity and mortality in our population yet, there is paucity of data on their pattern which is crucial for developing an effective strategy for prevention, timely detection and management. This study sought to describe the burden and histopathological pattern of orbito-ocular lesions at Mzuzu Central Hospital (MCH) over a period of five years (July 2013 to June 2018). MethodsA retrospective review of the clinicopathological profile of orbito-ocular lesions diagnosed at MCH was done. Demographic, clinical and histopathological data was obtained from original histology reports. Data analysis was conducted using Stata, version 13.0 (Stata Corp. LP, College Station, TX, United States of America). Descriptive analyses were performed to summarize patients’ sociodemographic and clinical characteristics, and histopathological analysis results.ResultsTwo hundred and fourteen (214) patients’ records of orbito-ocular lesions were reviewed. Patients were predominantly females 60.3%. The overall mean age was 34.81± 15.93 years. Conjunctiva was the most common site of orbito-ocular lesion accounting for 65.0% of the cases. This was followed by lid and adnexa (16.4 %) and intraocular lesions (9.3 %). Malignant lesions were the most prevalent (39.3%), followed by degenerative conditions (25.2%), other benign lesions (15.0%), Conjunctival Intraepithelial Neoplasia (CIN) (8.4%), pyogenic and inflammatory conditions (8.4 %). The burden of cancer among males was 45.9% while in female was 34.9%. Malignant lesions were common in HIV infected patients 64.1%. There was bimodal distribution of orbito-ocular malignancies, one in the first decade of life and the other in third and fourth decade of life. Among cancers cases (84), squamous cell carcinoma, retinoblastoma, Kaposi Sarcoma and lymphoma contributed to 82.1%, 8.3%, 2.4% and 1.2% respectively. Kaposi sarcoma was found only in patient with HIV infection.ConclusionCancer constituted a substantial proportion of orbito-ocular lesions in our study population with squamous cell carcinoma being the most common malignancy in adults and retinoblastoma in children. Degenerative disease contributed a high proportion of non-malignant lesions. Therefore, there is need for appropriate strategies to improve preventive, diagnostic and management capacity for orbito-ocular lesions at MCH.

Background Most of the information on modifiable risk factors linked to cardiac dysfunction comes from high income countries and/or hospitalized patients. We sought to evaluate the challenge of non-communicable diseases (NCDs) in the community setting in Malawi, and to compare the cardiometabolic profile of these patients with age, sex and diabetes matched European participants. Methods MTIMA I is a prospective, observational, cohort study of community dwelling patients attending a NCD clinic in Malawi together with age, sex and diabetes matched European participants. All consenting patients were evaluated for clinical history, blood pressure, heart rate, body mass index (BMI), fasting glucose, left ventricular ejection fraction and medications. Results Amongst 251 sub-Saharan African patients and 502 age, sex and diabetes matched European patients, the average age was 61.8±10.6 years, 31% were male and 53% had diabetes and the majority had hypertension (80.0% and 70.7% in the African and European cohorts respectively, p=NS). The African population had poorer pressure control (147/90±21/13 mmHg vs 137/82±19/11 mmHg, p Conclusions The profile of cardiovascular risk factors, medications and cardiac dysfunction is different in community dwelling African and European patients with chronic cardiovascular disease. One in 5 African patients in our study has undiagnosed left ventricular systolic dysfunction reflecting the need for increased focus on non-communicable diseases and cardiovascular prevention. Further work on the pathophysiology of the high rate of LVSD noted and prevention strategies are required