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Fungal infections are common causes of death and morbidity in those with advanced HIV infection. Data on access to diagnostic tests in Africa are scarce. We aimed to evaluate the diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa.We did a continent-wide survey by collecting data from 48 of 49 target countries across Africa with a population of more than 1 million; for Lesotho, only information on the provision of cryptococcal antigen testing was obtained. This survey covered 99·65% of the African population. We did the survey in six stages: first, questionnaire development, adaptation, and improvement; second, questionnaire completion by in-country respondents; third, questionnaire review and data analysis followed by video conference calls with respondents; fourth, external validation from public or private sources; fifth, country validation by video conference with senior figures in the Ministry of Health; and sixth, through five regional webinars led by the Africa Centres for Disease Control and Prevention with individual country profiles exchanged by email. Data was compiled and visualised using the Quantum Geographic Information System software and Natural Earth vectors to design maps showing access.Data were collected between Oct 1, 2020, and Oct 31, 2022 in the 48 target countries. We found that cryptococcal antigen testing is frequently accessible to 358·39 million (25·5%) people in 14 African countries. Over 1031·49 million (73·3%) of 1·4 billion African people have access to a lumbar puncture. India ink microscopy is frequently accessible to 471·03 million (33·5%) people in 23 African countries. About 1041·62 million (74·0%) and 1105·11 million (78·5%) people in Africa do not have access to histoplasmosis and Pneumocystis pneumonia diagnostics in either private or public facilities, respectively. Fungal culture is available in 41 countries covering a population of 1·289 billion (94%) people in Africa. MRI is routinely accessible to 453·59 million (32·2%) people in Africa and occasionally to 390·58 million (27·8%) people. There was a moderate correlation between antiretroviral therapy usage and external expenditure on HIV care (RThis survey highlights the enormous challenges in the diagnosis of HIV-associated Pneumocystis pneumonia, cryptococcal disease, histoplasmosis, and other fungal infections in Africa. Urgent political and global health leadership could improve the diagnosis of fungal infections in Africa, reducing avoidable deaths.Global Action For Fungal Infections.

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.

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.

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.

BackgroundNon-tuberculosis Mycobacteria (NTM) are increasingly being recognized as human pathogens, causing substantial morbidity and mortality in progressive lung disease, immunosuppressed, the elderly and the youth. Similarity of clinical symptoms with MTB, coupled with limited diagnostic capacities in tuberculosis (TB) endemic developing countries has led to misdiagnosis of NTM pulmonary disease. The study aimed at establishing the prevalence and distribution of NTM among Multi-Drug Resistance Tuberculosis (MDR-TB) suspected patients in Northern Region of Malawi based on laboratory culture records from 2015 to 2018 conducted at Mzuzu Central Hospital.MethodsThe study used a retrospective cross-sectional design. All culture positive underwent MTB confirmatory test using the SD-Bio line TB Ag MPT64 Kit to confirm MTB or to suspect for NTM. Data was analysed for descriptive statistics in SPSS version 20 and presented using frequency tables, charts and graphs.Results Out of 170 culture positive reports reviewed, 30 (18%) were NTM. Much as there were generally more males (69.4%) who were MDR-TB suspected patients, the proportion of NTM patients was female predominant 13/52 (25%) as compared to 17/118 (14%) for males while the age range of 30-49 was the most (22%) affected. Twenty-nine (97%) of the NTM cases were previously treated for MTB.ConclusionsThe high prevalence of NTM among MDR-TB suspected patients shows that the disease is a serious public health problem. This therefore calls for urgent attention from Ministry of Health and partners, health workers and all stakeholders involved in policy making so that NTM diagnosis should have a clear algorithm to avoid wastage a of resources as well as for good patient care.

Background Bacterial infections are a significant cause of sickness and death in sub-Saharan Africa. This study aimed at establishing the prevalence, distribution and antimicrobial susceptibility pattern of major bacterial isolates from patients accessing medical care at a tertiary hospital in Malawi. Methods We retrospectively reviewed bacteria culture and antimicrobial susceptibility records for 4617 patients from 2002 to 2014 at Mzuzu Central Hospital (MCH). No inclusion and exclusion criteria were followed. Data was analysed using excel (Microsoft office, USA) and GraphPad prism 7 software programs. Results The most prevalent isolates were S. aureus (34.7%, n = 783), Klebsiella species (17.4%, n = 393) and Proteus species (11.4%, n = 256). Most microorganisms were isolated from adults (88.3%, n = 3889) and pus was the main source (69.3%, n = 1224). S. pneumoniae was predominantly isolated from cerebrospinal fluid (60.3%, n = 44) largely collected from children (88.2%, n = 64). Overall, most bacteria exhibited high resistance to all regularly used antimicrobials excluding ciprofloxacin. Conclusions Our report demonstrates an increase in bacterial infection burden in sites other than blood stream and subsequent increase in prevalence of antimicrobial resistance for all major isolates. Creating an epidemiological survey unit at MCH will be essential to help inform better treatment and management options for patients with bacterial infections.

IntroductionSickle cell disease (SCD) remains a major cause of childhood mortality and morbidity in Malawi. However, literature to comprehensively describe the disease in the paediatric population is lacking.MethodsA retrospective review of clinical files of children with SCD was conducted. Descriptive statistics were performed to summarise the data. χ2 or Fisher’s exact test was used to look for significant associations between predictor variables and outcome variables (case fatality and length of hospital stay). Predictor variables that were significantly associated with outcome variables (p≤0.05) in a χ2 or Fisher’s exact test were carried forward for analysis in a binary logistic regression. A multivariable binary logistic regression was used to identify covariates that independently predicted length of hospital stay.ResultsThere were 16 333 paediatric hospitalisations during the study period. Of these, 512 were patients with SCD representing 3.1% (95% CI: 2.9%- 3.4%). Sixty-eight of the 512 children (13.3%; 95% CI: 10.5% - 16.5%) were newly diagnosed cases. Of these, only 13.2% (95% CI: 6.2% - 23.6%) were diagnosed in infancy. Anaemia (94.1%), sepsis (79.5%) and painful crisis (54.3%) were the most recorded clinical features. The mean values of haematological parameters were as follows: haemoglobin (g/dL) 6.4 (SD=1.9), platelets (×109/L) 358.8 (SD=200.9) while median value for white cell count (×109/L) was 23.5 (IQR: 18.0–31.2). Case fatality was 1.4% (95% CI: 0.6% - 2.8%)and 15.2% (95% CI: 12.2% -18.6%) of the children had a prolonged hospital stay (>5 days). Patients with painful crisis were 1.7 (95% CI: 1.02 - 2.86) times more likely to have prolonged hospital stay than those without the complication.ConclusionAnaemia, sepsis and painful crisis were the most common clinical features paediatric patients with SCD presented with. Patients with painful crisis were more likely to have prolonged hospital stay. Delayed diagnosis of SCD is a problem that needs immediate attention in this setting. Although somewhat encouraging, the relatively low in-hospital mortality among SCD children may under-report the true mortality from the disease considering community deaths and deaths occurring before SCD diagnosis is made.

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.

Our data show low accuracy of a single CD4 count for individuals with observed CD4 counts of 350-650 cells/mm3. We hope our data will be interesting to programs making decisions around continued use of CD4 thresholds versus adopting WHO universal eligibility for ART., Background. Given the uncertainty about the ability of a single CD4 count to accurately classify a patient as antiretroviral therapy (ART) eligible, we sought to understand the extent to which CD4 variability results in misclassification at a CD4 threshold of 500 cells/mm3. Methods. We performed a prospective study of CD4 variability in Malawian human immunodeficiency virus-infected, ART-naive, World Health Organization (WHO) stage 1 or 2, nonpregnant adults. CD4 counts were performed daily for 8 days. We fit a Bayesian linear mixed-effects model of log-transformed CD4 cell counts to the data. We used Monte Carlo approximations to estimate misclassification rates for different observed values of CD4. The misclassification rate was calculated based on the conditional probability of true CD4 given the geometric mean of observed CD4 measurements. Results. Fifty patients were enrolled from 2 sites. The median age was 33.5 years (interquartile range, 27.5–40.0) and 34 (68%) were female. Misclassification rates were