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Immunisation is a proven cost effective strategy in promoting child health and one of the greatest medical achievements of our time. Along with advocacy, social mobilisation, and other important aspects of immunisation programmes, communication should be an inherent part of the programmes. Effective communication activities complement immunisation technical components. This paper provides an overview of the existing communication component in the Expanded Program on Immunisation (EPI) training in Zambia and critically analyses the need for a humane touch in the communication process so as to reach the target audience effectively. Interpersonal Communication (IPC) in Zambia has been shown to be effective. We recommend continuous multi modal communication with deliberate emphasis on IPC including attention to care givers or parental concerns. [ABSTRACT FROM AUTHOR]

Kenaf and sisal fibres were selected for the development of natural fibre-reinforced thermoplastic composites because they are in abundance in South Africa. These materials can be used in the building industry, where good mechanical and fire resistance properties are required for structural and non-structural applications. High load bearing, moisture and fire can negatively affect the properties of these composites and decrease their performance. The effect of water glass, maleic anhydride-grafted-polypropylene (MAPP) treatment and fibre loadings on mechanical and thermal properties as well as fire resistance of kenaf and sisal fibre-reinforced polypropylene composites were investigated. The fibre-reinforced polypropylene composites were produced by injection and compression moulding processes. A significant improvement of the tensile strength and modulus of kenaf fibre composites was more pronounced when compared to sisal fibre composites. However, the water glass has a slight negative influence on mechanical properties of fibre/polypropylene matrix composites but showed better fire resistance and thermal properties when compared to the untreated fibre/polypropylene composites. Generally, the impact strength of fibre/polypropylene composites decreased with the addition of MAPP. The low impact strength could be the results of weak interfacial bond strength between the fibre and the matrix. The total heat release was reduced by water glass treatment due to the non-flammable polysilicate coating, while the average mass loss rate was slightly reduced by MAPP. [ABSTRACT FROM AUTHOR]

Nitrogen is normally the nutrient most limiting production of maize (Zea mays) -- the main staple food crop -- in southern Africa. We conducted a field study to determine the effect of N sources on soil nitrate dynamics at three landscape positions in farmers' fields in southern Malawi. The landscape positions were dambo valley or bottomland,dambo margin, and steep slopes. The N sources were calcium ammonium nitrate fertilizer applied at 120 kg N ha-1, biomass from Sesbania sesban, and no added N. Sesbania biomass was produced in situ in the previous season from sesbania relay cropped with maize. Nitrate in the topsoil (0 to 15 cm depth) increased to 85 days after maize planting (mean = 48 kg N ha-1) and then decreased markedly. Application of N fertilizer and sesbania biomass increased soil nitrate, and nitrate-N in topsoil correlated positively with amount ofincorporated sesbania biomass. The strongest correlation between sesbania biomass added before maize planting and topsoil nitrate was observed at 85 days after maize planting. This suggests that the sesbania biomass (mean N content = 2.3%) mineralized slowly. Inorganic N accumulated in the subsoil at the end of the maize cropping season when N fertilizer and sesbania were applied. This study demonstrated the challenges associated with moderate quality organic N sources producedin smallholder farmer's fields. Soil nitrate levels indicated that Nwas released by sesbania residues in the first year of incorporation, but relay cropping of sesbania with maize may need to be supplemented with appropriately timed application of N fertilizer. [ABSTRACT FROM AUTHOR]

The relay cropping of sesbania (Sesbania sesban) -- a N2-fixing legume -- with maize (Zea mays) has been proposed as a strategy to increase soil fertility and food production in densely populatedareas in southern Africa. We determined the production of relay-cropped maize and sesbania at three landscape positions under researcher-designed and farmer-managed conditions in southern Malawi. Three landscape positions (dambo valley or bottomland, dambo margin with < 12% slope, and steep slopes with > 12% slope) were examined in factorial combination with N sources for maize (no added N, relay-cropped sesbania, and calcium ammonium nitrate fertilizer). Relay cropping of sesbania with maize increased maize grain yield, as compared to unfertilized sole maize in two of three years. Split application of 96 kg N ha-1 as N fertilizer, however, was more effective than sesbania in increasing maize yields. Survival of sesbania seedlings and biomass production of sesbania were greater in the dambo valley and dambo margin than on steep slopes. Maize yields tended to be lower on steep slopes than in the dambo valley and dambo margin areas. Biomass production of sesbania and hence the potential benefits of intercropping sesbania with maize appear greater in the dambo valleys and dambo margins than on steep slopes. [ABSTRACT FROM AUTHOR]

Anecdotal evidence and available literature indicated that contaminated water played a major role in spreading the prolonged cholera epidemic in Malawi from 2022 to 2023. This study assessed drinking water quality in 17 cholera-affected Malawi districts from February to April 2023. Six hundred and thirty-three records were analysed. The median counts/100 ml for thermotolerant coliform was 98 (interquartile range (IQR): 4-100) and that for Escherichia coli was 0 (IQR: 0-9). The drinking water in all (except one) districts was contaminated by thermotolerant coliform, while six districts had their drinking water sources contaminated by E. coli. The percentage of contaminated drinking water sources was significantly higher in shallow unprotected wells (80.0% for E. coli and 95.0% for thermotolerant coliform) and in households (55.8% for E. coli and 86.0% for thermotolerant coliform). Logistic regression showed that household water has three times more risk of being contaminated by E. coli and two and a half times more risk of being contaminated by thermotolerant coliform compared to other water sources. This study demonstrated widespread contamination of drinking water sources during a cholera epidemic in Malawi, which may be the plausible reason for the protracted nature of the epidemic., Competing Interests: The authors declare there is no conflict., (© 2024 The Authors This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).)

Aflatoxins B1 (AFB1) are fungi-produced toxins found in crops like peanuts, maize, and tree nuts. They constitute a public health concern due to their genotoxic and carcinogenic effects. A deterministic exposure risk assessment to AFB1 through the consumption of peanuts was conducted on children using the Margin of Exposure (MOE) and the liver cancer risk approaches. Data on AFB1 concentrations in peanuts, quantities of peanut consumption, and the weights of the children were obtained from the literature. Generally, MOE values were below the safe margin of 10,000, ranging between 3.68 and 0.14, 754.34 and 27.33, and 11,428.57 and 419.05 for the high (0.0466 ng/kg), median (0.00023 ng/kg), and low (0.000015 ng/kg) AFB1 concentration levels, respectively. The liver cancer risk upon lifetime exposure to highly AFB1-contaminated peanuts (0.0466 ng/kg) ranged between 1 and 23 (95% lower bound) and 2 and 50 (95% upper bound) cases in a million individuals: a public health concern. A low liver cancer risk (≤1 case in a billion individuals upon lifetime exposure) was shown at median and low AFB1 concentrations. However, the risk of AFB1 should be a priority for risk management since its harmful effects could be potentiated by poor diet, high malnutrition levels, and other disease burdens in Zambia's children.

There is an urgent need to alleviate protein deficiencies in low-income countries where cereal-based diets dominate. The objective of this study was to use the INFOGEST static digestion method and a recently established analytical workflow to determine the in vitro amino acid digestibility and protein quality of seven maize varieties grown in Malawi. Protein quality was measured using the in vitro digestible indispensable amino acid score (DIAAS). Amino acid digestibility was higher for the dehulled, low fibre, provitamin A maize flour (66%), compared to whole grain maize flours (51-61%), suggesting that the presence of fibre reduced digestibility (p < 0.05). Lysine was the limiting amino acid in all varieties, with the following DIAAS values for each variety; Provitamin A maize - 24, SC 719 - 32, Mtsikinya - 37, SC 167 - 39, Quality protein maize (QPM) - 40, Bantum - 40, SC 403 - 44. In addition to the variety of maize, protein quality was dependent on the level of processing and the agronomic practice applied with higher protein quality for the SC 403 variety in which zinc enriched fertilizer was applied. Comparing protein quality data with published in vivo data showed that DIAAS data were in closer agreement than amino acid digestibility data, which was slightly lower than published values, with mean in vitro amino acid digestibilities of 56-70% compared to a mean in vivo value of 77%. Overall, the in vitro method was able to correctly predict both the direction and magnitude of response. The INFOGEST digestion method coupled with the new analytical workflow will therefore be useful in the screening of high protein cereal crops and subsequent development of cereal-based foods with high protein quality., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Objective: This study explored the use of hydrothermally-treated soybean-fortified maize-based stiff porridge (nsima) in managing body weight losses among the farming family community in Malawi during the labour-intensive cropping (growing) season. We hypothesized that soybean-fortified maize-based nsima could prevent seasonal body weight losses in farming communities during labour-intensive seasons better than conventional 100% maize nsima., Research Methods & Procedures: A single-blind parallel dietary intervention 90-day study. During energy stress months, 42 farming households in Malawi were supplied with 15 kg of blind formulation of soybean-fortified maize flour (soybean: maize, 1:4, wt/wt) per person per month except for under-fives who were allotted half the quantity. Forty households were provided with equivalent quantities of 100% maize flour and served as control. Body weights of participants were taken at baseline and endpoint., Results: After 3 months, the experimental group registered 3.7, 4.2, 2.9, and 5.2% statistically higher body weight compared to the controls for the under-five, the 5-9-year-olds, the 10-19-year-olds, and the >20-year-olds, respectively., Conclusion: Soybean-fortified stiff porridge could feasibly be used to alleviate wasting among the resource-constraint populace in Malawi and many other parts of sub-Saharan Africa that rely on maize as a major staple., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors. Published by Elsevier Ltd.)

This study reports onthe effect of various production steps on levels of aflatoxins during preparation of thobwa , a traditional maize-based fermented non-alcoholic beverage, brewed across Malawi. The effect of boiling, fermentation and their interaction on the level of aflatoxins, the trends of aflatoxin reduction during brewing, and the distribution of aflatoxins between the solid and liquid phases of the beverage were studied using VICAM AflaTest immunoaffinity fluorometric assay. Fermenting and boiling thobwa pre-mix- , with initial aflatoxin content of 45-183 μg/kg, resulted in aflatoxin reduction of 47% (13-61 μg/kg) on average. Fermentation and boiling contributed about 20 and 33% aflatoxin reduction, respectively, but without interactive effect between the two factors. Fermenting the thobwa  for 24 h led to further reduction of aflatoxins to about 37% of the initial content, and remainedconstant for up to 8 days. Thobwa is a popular beverage in Malawi which is consumed in large quantities by all gender categories including infants, therefore the presence of aflatoxins may constitute a significant health risk factor. This study highlights the need to use raw materials with low levels of aflatoxins for production of maize-based non-alcoholic beverages to ensure consumer safety., Competing Interests: We declare that we have no conflict of interest., (© 2023 The Authors. Food Science & Nutrition published by Wiley Periodicals LLC.)

Background: Selenium deficiency is widespread in the Malawi population. The selenium concentration in maize, the staple food crop of Malawi, can be increased by applying selenium-enriched fertilizers. It is unknown whether this strategy, called agronomic biofortification, is effective at alleviating selenium deficiency. Objectives: The aim of the Addressing Hidden Hunger with Agronomy (AHHA) trial was to determine whether consumption of maize flour, agronomically-biofortified with selenium, affected the serum selenium concentrations of women, and children in a rural community setting. Design: An individually-randomized, double-blind placebo-controlled trial was conducted in rural Malawi. Participants were randomly allocated in a 1:1 ratio to receive either intervention maize flour biofortified with selenium through application of selenium fertilizer, or control maize flour not biofortified with selenium. Participant households received enough flour to meet the typical consumption of all household members (330 g capita -1 day -1 ) for a period of 8 weeks. Baseline and endline serum selenium concentration (the primary outcome) was measured by inductively coupled plasma mass spectrometry (ICP-MS). Results: One woman of reproductive age (WRA) and one school-aged child (SAC) from each of 180 households were recruited and households were randomized to each group. The baseline demographic and socioeconomic status of participants were well-balanced between arms. No serious adverse events were reported. In the intervention arm, mean (standard deviation) serum selenium concentration increased over the intervention period from 57.6 (17.0) μg L -1 ( n = 88) to 107.9 (16.4) μg L -1 ( n = 88) among WRA and from 46.4 (14.8) μg L -1 ( n = 86) to 97.1 (16.0) μg L -1 ( n = 88) among SAC. There was no evidence of change in serum selenium concentration in the control groups. Conclusion: Consumption of maize flour biofortified through application of selenium-enriched fertilizer increased selenium status in this community providing strong proof of principle that agronomic biofortification could be an effective approach to address selenium deficiency in Malawi and similar settings. Clinical Trial Registration: http://www.isrctn.com/ISRCTN85899451, identifier: ISRCTN85899451., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Joy, Kalimbira, Sturgess, Banda, Chiutsi-Phiri, Manase, Gondwe, Ferguson, Kalumikiza, Bailey, Young, Matandika, Mfutso-Bengo, Millar, Niksic, Segovia de la Revilla, Likoswe, Phuka, Phiri, Lark, Gashu, Langley-Evans, Ander, Lowe, Dangour, Nalivata, Broadley and Allen.)

Background: The participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants' motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi., Methods: We conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group discussions with trial participants and their partners. Interviews were audio-recorded and transcribed verbatim. We used a grounded theory methodology to analyse data that included coding, detailed memo writing, and data interpretation., Findings: The findings reveal that many participants had concerns during the trial. Thematically, experiences included anxieties, mistrust of researchers, rumours, fears of exploitation, and misconceptions. Anonymous concerns collected from the participants were reported to the trial team which enabled the researchers to appropriately support participants. Despite initial concerns, participants described being supported and expressed motivation to take up their role., Conclusion: These findings highlight a diverse map of multiple notions of what is ethically relevant and what can impact participation and retention within a study. The study has revealed how embedding a responsive approach to address participants' concerns and ethical issues can support trust relationships. We argue for the need to employ embedded ethics strategies that enhance informed consent, focus on participants' needs and positive experiences, and support researchers to fulfill their roles. This work highlights the need for research ethics committees to focus on the risks of undue influence and prevent exploitation especially in settings with a high asymmetry in resources and power between researcher and participant groups., Trial Registration: The Addressing Hidden Hunger with Agronomy (Malawi) trial was registered on 5th March 2019 (ISCRTN85899451)., (© 2021. The Author(s).)

Background: This study reports findings from formative research conducted to assess the feasibility and inform the design and implementation of the Addressing Hidden Hunger with Agronomy (AHHA) trial. The AHHA trial was a randomised, controlled trial conducted in rural Malawi, in which participants were given maize flour biofortified with selenium or control flour not biofortified with selenium for a period of 10 weeks, after which blood samples were taken to measure selenium status., Methods: Formative research was conducted in villages near to the AHHA trial study site 1 year before the planned intervention. A short questionnaire with adult women (n = 50), focus group discussions with male (n groups = 3) and female (n groups = 3) community members, and in-depth key informant interviews (n = 7) were conducted to understand community practices and perceptions., Findings: Meals were typically cooked and eaten at home in this community, while participants reported that maize flour would be less readily sold than maize grain - important considerations for the design of the trial. Regarding intervention delivery, we identified potential concerns around effects on fertility, links between blood sampling and witchcraft, and the potential for social stigma if community members considered participants lazy for receiving free flour. Participants reported that involvement of the Malawi government partners including health extension workers would increase trust., Interpretation: Following the formative research, the AHHA trial appeared feasible. However, community sensitisation would be essential to address potential fears and concerns; effective sensitisation would support recruitment and treatment adherence, and would protect the safety and wellbeing of participants and researchers. People in positions of authority and trust including village headmen, religious leaders, health and agriculture extension workers, and community care groups should be involved in community sensitisation.

Background: In 2013, the Zambian Ministry of Health identified action priorities for strengthening their emergency care system; one of these priorities was emergency care training for healthcare providers. To rapidly train the existing cadre of frontline providers, trainings were implemented in multiple provinces using the World Health Organization's Basic Emergency Care (BEC) course. The BEC course is open-access and emphasizes a practical syndrome-based approach to critical emergency conditions. This paper describes the first reported larger scale educational intervention of the BEC course in 7 provinces of Zambia., Methods: Course delivery occurred at seven Zambian hospitals selected by the Ministry of Health over a 1 year period. Participant emergency care knowledge was assessed pre- and post-course with a 25-question multiple choice exam. Participant confidence levels related to emergency care provision and emergency care skills were assessed pre- and post-course using a Likert scale survey., Results: Overall, 210 participants were trained at 7 sites. Participants demonstrated significant improvements in their multiple-choice exam scores; the overall pre-course mean was 61.47, and the post-course mean was 79.87 (p < 0.0001). Self-reported confidence in the care of ill and injured adults and children increased after taking the course, and participants generally agreed that the BEC course was highly valuable and applicable to local needs., Conclusion: Implementation of the WHO's BEC course at seven hospitals throughout Zambia led to improvement in the participants' emergency care knowledge and confidence levels at all sites. The BEC course has the potential to be implemented in a nationwide initiative but would require allocation of significant human and physical resources. Additional work evaluating patient outcomes and long-term participant educational outcomes is needed., Competing Interests: The authors have no conflicts of interest to report., (© 2020 African Federation for Emergency Medicine. Publishing services provided by Elsevier.)

Introduction: Limited information exists on health care workers' (HCWs) perceptions about use of multidose vaccine vials and their preferences about doses per container (DPC). We present findings from qualitative studies conducted in Senegal, Vietnam, and Zambia to explore HCWs' behavior regarding opening vials and their perceptions and preferences for the number of doses in vials of BCG and measles-containing vaccine (MCV). Zambia and Senegal currently offer MCV in 10-dose vials and BCG in 20-dose vials; 10-dose vials are used for both vaccines in Vietnam. Unused doses in vials of these reconstituted vaccines must be discarded within 6 hours., Methods: Key informant interviews (KIIs) were conducted with frontline HCWs in Senegal, Vietnam, and Zambia. In Senegal and Vietnam, the KIIs were conducted as part of broader formative research; in Zambia, KIIs were conducted in control districts using 10-dose MCV vials only and in intervention districts that switched from 10- to 5-dose vials during the study. During analysis, themes common to all 3 countries were synthesized. Critical themes relevant to country contexts were also examined., Results: HCWs in all 3 countries preferred containers with fewer doses for BCG and MCV to reduce wastage and increase the likelihood of vaccinating every eligible child. HCWs in Senegal and HCWs using 10-dose vials in Zambia reported sending unvaccinated children away because not enough children were present to warrant opening a new vial. In Vietnam, where sessions are typically held monthly, and in Zambia when the 5-dose vials were used, almost all HCWs reported opening a vial of MCV for even 1 child., Discussion: HCWs prefer vials with fewer DPC. Their concerns about balancing coverage and wastage influence their decisions to vaccinate every eligible child; and their perspectives are crucial to ensuring that all target populations are reached with vaccines in a timely manner., (© Kanagat et al.)

Introduction: Vaccines procured for low-income countries are often packaged in multi-dose vials to reduce program costs. To avoid wastage, health workers may refrain from opening a vial if few children attend an immunization session, possibly leading to lower coverage. Lowering the number of doses in a vial may increase coverage and reduce wastage., Methods: We used a mixed methods approach to measure the effects of switching from conventional 10-dose measles containing vaccine (MCV) vials to 5-dose MCV vials on coverage and open vial wastage in 14 districts purposely selected from two provinces in Zambia. The districts were paired based on the number of health facilities and the average size of the health facility catchment population. One district from each pair was randomly allocated to receive 5-dose vials while the other continued with the conventional vials. We applied propensity score matched difference-in-difference analysis to estimate intervention effects on coverage using pre-intervention household survey and post-intervention household survey after 11 months of the intervention. The intervention effects on wastage rates were estimated from multivariate analysis of the administrative data. Key informant interviews were conducted to better understand health workers' behavior and preferences at baseline, midline and endline, and analyzed using thematic analysis techniques., Results: MCV coverage rates increased across both arms for both doses. A five percentage-point intervention effect was detected for MCV1 and 3.5 percentage-point effect for MCV2. The MCV wastage rate was 47% lower in facilities using 5-dose vials (16.2%) versus 10-dose vials (30.5%). Healthcare workers reported being more willing to open a 5-dose vial than a 10-dose vial for one child, as they were less concerned about wastage., Discussion: Switching 10-dose MCV vials to 5-dose vials improved coverage, decreased wastage, and improved willingness to open a vial. These findings can contribute to strategies for reducing missed opportunities for vaccination., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Micronutrient deficiencies including selenium (Se) are widespread in Malawi and potentially underlie a substantial disease burden, particularly among poorer and marginalised populations. Concentrations of Se in staple cereal crops can be increased through application of Se fertilisers - a process known as agronomic biofortification (agro-biofortification) - and this may contribute to alleviating deficiencies. The Addressing Hidden Hunger with Agronomy (AHHA) trial aims to establish the efficacy of this approach for improving Se status in rural Malawi., Methods: A double-blind, randomised, controlled trial will be conducted in a rural community in Kasungu District, Central Region, Malawi. The hypothesis is that consumption of maize flour agro-biofortified with Se will increase serum Se concentration. We will recruit 180 women of reproductive age (WRA) (20-45 years) and 180 school-age children (SAC) (5-10 years) randomly assigned in a 1:1 ratio to receive either maize flour enriched through agro-biofortification with Se or a control flour not enriched with Se. Households will receive flour (330 g per capita per day) for 12 weeks. The primary outcome is Se concentration in serum (μg/L). Serum will be extracted from venous blood samples drawn at baseline (prior to flour distribution) and end-line. Selenium concentration will be measured by using inductively coupled plasma mass spectrometry., Discussion: Findings will be communicated to policy stakeholders and participating communities and reported in peer-reviewed journals., Trial Registration: The Addressing Hidden Hunger with Agronomy (Malawi) trial is registered (5 th  March 2019; ISCRTN85899451).

Background: National guidelines for sexually transmitted infections (STIs) in primary care exists but their management is uncertain., Aim: To assess the management of STIs against national standards in primary care., Design & Setting: A questionnaire based study in London and Brighton. The survey was conducted in 2015 following reorganisation of sexual health services in England., Method: Questionnaires were sent to GPs in London and Brighton about testing for STIs, treatment for gonorrhoea, specialist advice, and referral services., Results: Of 119 GPs who responded, most expressed confidence in treating chlamydia ( n = 105/119, 88%), trichomonas ( n = 81/119, 68%), and herpes ( n = 82/119, 69%) but not gonorrhoea ( n = 32/119, 27%). Most referred cases of syphilis ( n = 92/119, 77%) and genital warts (83/119, 70%) to genito-urinary medicine (GUM) as per guidance. Most GPs tested for gonorrhoea on patient request ( n = 95/119, 80%), in tandem with chlamydia screening ( n = 89/119, 75%), because of high risk status ( n = 85/119, 71%) and genital symptoms ( n = 108/119, 91%). Some GPs ( n = 22/119, 18%) sampled urine for culture, 53/119 (45%) provided high vaginal swabs (HVS), and 28/119 (24%) provided self-taken vulvovaginal swabs (STVVS) for culture. These samples are not appropriate for gonococcal culture and not processed in the laboratory. Urethral swabs for men and endocervical swabs (ECS) are recommended for gonococcus culture. Over half ( n = 60/102, 59%) of GPs did not treat gonorrhoea but some prescribed cefixime, ciprofloxacin, or azithromycin. Eighty-seven per cent ( n = 104/119) sought advice from GUM, and 83/103 (81%) referred gonorrhoea nucleic acid amplification test (NAAT)-positive patients., Conclusion: There is scope for improvement of STIs management in primary care to ensure that patients are optimally investigated, treated, and referred., (Copyright © 2019, The Authors.)

Background: Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality., Methods: This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality., Results: There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001)., Conclusions: Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.

Background: Frequently, a country will procure a single vaccine vial size, but the question remains whether tailoring the use of different size vaccine vial presentations based on populations or location characteristics within a single country could provide additional benefits, such as reducing open vial wastage (OVW) or reducing missed vaccination opportunities., Methods: Using the Highly Extensible Resource for Modeling Supply Chains (HERMES) software, we built a simulation model of the Zambia routine vaccine supply chain. At baseline, we distributed 10-dose Measles-Rubella (MR) vials to all locations, and then distributed 5-dose and 1-dose MR vials to (1) all locations, (2) rural districts, (3) rural health facilities, (4) outreach sites, and (5) locations with average MR session sizes <5 and <10 children. We ran sensitivity on each scenario using MR vial opening thresholds of 0% and 50%, i.e. a healthcare worker opens an MR vaccine for any number of children (0%) or if at least half will be used (50%)., Results: Replacing 10-dose MR with 5-dose MR vials everywhere led to the largest reduction in MR OVW, saving 573,892 doses (103,161 doses with the 50% vial opening threshold) and improving MR availability by 1% (9%). This scenario, however, increased cold chain utilization and led to a 1% decrease in availability of other vaccines. Tailoring 5-dose MR vials to rural health facilities or based on average session size reduced cold transport constraints, increased total vaccine availability (+1%) and reduced total cost per dose administered (-$0.01) compared to baseline., Conclusions: In Zambia, tailoring 5-dose MR vials to rural health facilities or by average session size results in the highest total vaccine availability compared to all other scenarios (regardless of OVT policy) by reducing open vial wastage without increasing cold chain utilization., (Copyright © 2018. Published by Elsevier Ltd.)

Introduction: Colon cancer is preventable. There is a plethora of data regarding epidemiology and screening guidelines, however this data is sparse from the African continent. Objective: we aim to evaluate the trends of colorectal cancer (CRC) in a native African population based on age at diagnosis, gender and stage at diagnosis., Methods: We conducted a retrospective analysis of the Cancer Disease Hospital (CDH) registry in Zambia, Southern Africa., Results: 377 charts were identified in the CDH registry between 2007 and 2015, of which 234 were included in the final analysis. The mean age at diagnosis was 48.6 years and 62% are males. Using descriptive analysis for patterns: mode of diagnosis was surgical in 195 subjects (84%), histology adenocarcinoma in 225 (96.5%), most common location is rectum 124 (53%) followed by sigmoid 31 (13.4%), and cecum 26 (11%). 122 subjects (54%) were stage 4 at diagnosis. Using the Spearman rank correlation, we see no association between year and stage at diagnosis (p = 0.30) or year and age at diagnosis (p = 0.92)., Conclusion: Colorectal cancer was diagnosed at a young age and late stage in the Zambian patients.

This study assessed caregivers' knowledge and practices and factors that influence the adoption of improved infant and young child feeding (IYCF) practices after nutrition education in Kasungu and Mzimba districts among 198 caregivers. Mixed-methods convergent-parallel design, including knowledge tests, focus group discussions, and in-depth interviews in the intervention areas, was used to collect quantitative and qualitative data. Data were analyzed using count regression and content analysis, which showed that knowledge increased among caregivers after nutrition education. The knowledge about diet diversification for young children as well as about hygienic practices when preparing food and during feeding improved in addition. Enhanced health among children motivated caregivers to apply improved IYCF practices. The study was based on the caregivers' reports. Long-term effects of exposure to nutrition education are unknown. However, the nutrition education that focused on the child's health benefits motivated mothers to adopt improved IYCF practices.

Background: Medical male circumcision is a promising HIV prevention tool in countries with generalized HIV epidemics, but demand creation interventions are needed to support scale-up. We piloted a peer referral intervention in which circumcision clients were offered incentives for referring their peers for circumcision., Methods: The intervention was implemented between June 2014 and February 2015 in 6 randomly selected health facilities in Southern Province, Zambia. For the first 5 months, circumcision clients ≥18 years of age were given referral vouchers that allowed them to refer up to 5 peers for circumcision within a 3-month period. An incentive of US$2 was offered for each referral. The primary outcome was the number of circumcisions performed per month in each facility. To assess the effect of the intervention, a difference-in-difference analysis was performed using longitudinal data from the intervention facilities and 22 nonintervention facilities. A questionnaire was also implemented to understand men's perceptions of the intervention., Results: During the 8-month intervention period, 1222 men over 18 years of age were circumcised in intervention facilities. In the first 5 months, 699 circumcision clients were enrolled and 385 clients brought a referral voucher given to them by an enrolled client. Difference-in-difference analyses did not show a significant increase in circumcisions performed in intervention facilities. However, circumcision clients reported that the referral incentive motivated them to encourage their friends to seek male circumcision. Peer referrals were also reported to be an important factor in men's decisions because 78% of clients who were referred reported that talking with a circumcised friend was important for their decision to get circumcised., Conclusions: The peer referral incentive intervention for male circumcision was feasible and acceptable. However, the intervention did not have a significant effect on demand for male circumcision. Barriers to circumcision and features of the intervention may have limited the effect of the intervention. Further efforts regarding encouraging male-to-male communication and evaluations with larger sample sizes are needed., Competing Interests: The authors have no conflicts of interest to disclose.

Background: An intensive, prospective, open-label pharmacokinetic (PK) study in a subset of HIV-infected mothers and their uninfected infants enrolled in the Breastfeeding, Antiretroviral and Nutrition (BAN) Study was performed to describe drug exposure and antiviral response., Methods: Women using Combivir(®) (zidovudine [ZDV] + lamivudine [3TC]) +Aluvia(®) (lopinavir/ritonavir [LPV/RTV]) were enrolled. Breast milk (BM), mother plasma (MP) and infant plasma (IP) samples were obtained over 6 h after observed dosing at 6, 12 or 24 weeks post-partum for drug concentrations and HIV RNA., Results: A total of 30 mother/infant pairs (10 each at 6, 12 and 24 weeks post-partum) were enrolled. Relative to MP, BM concentrations of ZDV and 3TC were 35% and 21% higher, respectively, whereas LPV and RTV were 80% lower. Only 3TC was detected in IP with concentrations 96% and 98% lower than MP and BM, respectively. Concentrations in all matrices were similar at 6-24 weeks. The majority (98.3%) of BM concentrations were >HIV(wt) IC50, with one having detectable virus. There was no association between PK parameters and MP or BM HIV RNA., Conclusions: ZDV and 3TC concentrated in BM whereas LPV and RTV did not, possibly due to protein binding and drug transporter affinity. Undetectable to low antiretroviral concentrations in IP suggest prevention of transmission while breastfeeding may be due to antiretroviral effects on systemic or BM HIV RNA in the mother. Low IP 3TC exposure may predispose an infected infant to HIV resistance, necessitating testing and treating infants early.