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Background: Bioelectrical impedance analysis (BIA) is a simple tool to assess total body water (TBW), from which body composition can be estimated using statistical equations. However, standard BIA equations have not been sufficiently validated during pregnancy, in HIV infection, or in sub-Saharan Africa. We therefore compared TBW estimates from multifrequency BIA with those from the reference method deuterium isotope dilution (Deut) in a cohort of 30 HIV-uninfected and 30 HIV-infected pregnant women from Tanzania. Methods: We enrolled pregnant women presenting for routine antenatal care and collected data on pregnancy outcomes. At each trimester of gestation and once at 10-wk post-partum, we measured maternal anthropometry, TBWBIA, and TBWDeut. Results: TBWBIA was highly correlated at each time point with TBWDeut among HIV-infected (all P ⩽0.001) and HIV-uninfected women (all P <0.0001). During pregnancy, mean TBWBIA progressively underestimated TBWDeut in the overall cohort; trimester-specific differences (mean ±SD) were -1.02 ±2.36 kg, -1.47 ±2.43 kg, and -2.42 ±2.63 kg, respectively. The difference at 10-wk postpartum was small (-0.24 ±2.07 kg). In Bland-Altman and regression models, TBWBIA was subject to a systematic predictive bias at each antenatal and postnatal time point (all P ⩽0.038). Among HIV-positive women, TBWDeut measured during the first (P =0.02) and second trimester (P =0.03) was positively related to birthweight. Conclusions: The validity of current BIA equations to assess TBW during pregnancy and in the postpartum period among women from sub-Saharan Africa remains uncertain. Deuterium dilution may assess aspects of maternal body composition relevant for pregnancy outcomes among HIV-infected women. [ABSTRACT FROM AUTHOR]

Introduction: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania., Methods and Analysis: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel., Ethics and Dissemination: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Non-communicable diseases (NCDs) are rising in low-income and middle-income countries, including Malawi. To inform policy-makers and planners on the preparedness of the Malawian healthcare system to respond to NCDs, we estimated NCD service readiness in publicly financed healthcare facilities in Malawi., Methods: We analysed data from 564 facilities surveyed in the 2019 Harmonised Health Facility Assessment, including 512 primary healthcare (PHC) and 52 secondary and tertiary care (STC) facilities. To characterise service readiness, applying the law of minimum, we estimated the percentage of facilities with functional equipment and unexpired medicines required to provide NCD services. Further, we estimated permanently unavailable items to identify service readiness bottlenecks., Results: Fewer than 40% of PHC facilities were ready to deliver services for each of the 14 NCDs analysed. Insulin and beclomethasone inhalers had the lowest stock levels at PHC facilities (6% and 8%, respectively). Only 17% of rural and community hospitals (RCHs) have liver and kidney diagnostics. STC facilities had varying service readiness, ranging from 27% for managing acute diabetes complications to 94% for chronic type 2 diabetes management. Only 38% of STC facilities were ready to manage chronic heart failure. Oral pain medicines were widely available at all levels of health facilities; however, only 22% of RCHs and 29% of STCs had injectable morphine or pethidine. Beclomethasone was never available at 74% of PHC and 29% of STC facilities., Conclusion: Publicly financed facilities in Malawi are generally unprepared to provide NCD services, especially at the PHC level. Targeted investments in PHC can substantially improve service readiness for chronic NCD conditions in local communities and enable STC to respond to acute NCD complications and more complex NCD cases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: We declare no competing interests. The PEN-Plus Partnership is supported by grants from the Leona M and Harry B Helmsley Charitable Trust and the JDRF. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

HLA-DRB1*15:184 differs from HLA-DRB1*15:01:01 by a single base substitution in exon 3 at codon 134., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

HLA-B*42:28 differs from HLA-B*42:01:01 by a single base substitution in exon 4 at codon 267.2., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background and Objectives: Isoantibodies to human neutrophil antigen 2 (CD177) have been associated with several clinical conditions but to date the molecular basis for altered or non-expression has not been determined. Reliance on phenotyping and crossmatch to investigate these neutropenic clinical cases are inconvenient for the patients and demanding of resources within the laboratory. Therefore, a molecular approach has been introduced to address both issues., Materials and Methods: A DNA panel of 100 randomly selected blood donors were collected and supplemented with 18 DNA samples from blood donors previously shown to be CD177 null. All DNA samples were sequence-based typed for all exons and observed polymorphisms recorded. The DNA from two families previously investigated for neonatal alloimmune neutropenia due to CD177 isoantibodies were also analysed., Results: The incidence of CD177 null could be associated with a known exon 7 single-nucleotide polymorphism in 16/21 known CD177 null samples, which is consistent with previously published findings. Two additional mutations that may lead to null expression were also identified, of which one may be novel. In both family investigations, this same mutation could also be observed in the maternal DNA sample., Conclusion: Based on these observations, introduction of CD177 genotyping into routine use would identify null expression in over 75% (16/21) of associated cases. In turn, this could significantly reduce the need for supplementary testing and associated inconvenience to patients while permitting increased efficiency of laboratory testing. An added benefit would potentially elucidate other clinically relevant mutations and associated antigenic targets., (© 2022 International Society of Blood Transfusion.)

Introduction: The majority of people living with type 1 diabetes (PLWT1D) struggle to access high-quality care in low-income countries (LICs), and lack access to technologies, including continuous glucose monitoring (CGM), that are considered standard of care in high resource settings. To our knowledge, there are no studies in the literature describing the feasibility or effectiveness of CGM at rural first-level hospitals in LICs., Methods and Analysis: This is a 3-month, 2:1 open-randomised trial to assess the feasibility and clinical outcomes of introducing CGM to the entire population of 50 PLWT1D in two hospitals in rural Neno, Malawi. Participants in both arms will receive 2 days of training on diabetes management. One day of training will be the same for both arms, and one will be specific to the diabetes technology. Participants in the intervention arm will receive Dexcom G6 CGM devices with sensors and solar chargers, and patients in the control arm will receive Safe-Accu home glucose metres and logbooks. All patients will have their haemoglobin A1c (HbA1c) measured and take WHO Quality of Life assessments at study baseline and endline. We will conduct qualitative interviews with a selection of participants from both arms at the beginning and end of study and will interview providers at the end of the study. Our primary outcomes of interest are fidelity to protocols, appropriateness of technology, HbA1c and severe adverse events., Ethics and Dissemination: This study is approved by National Health Sciences Research Committee of Malawi (IRB Number IR800003905) and the Mass General Brigham (IRB number 2019P003554). Findings will be disseminated to PLWT1D through health education sessions. We will disseminate any relevant findings to clinicians and leadership within our study catchment area and networks. We will publish our findings in an open-access peer-reviewed journal., Trial Registration Number: PACTR202102832069874., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Health sector priorities and interventions to prevent and manage noncommunicable diseases and injuries (NCDIs) in low- and lower-middle-income countries (LLMICs) have primarily adopted elements of the World Health Organization Global Action Plan for NCDs 2013-2020. However, there have been limited efforts in LLMICs to prioritize among conditions and health-sector interventions for NCDIs based on local epidemiology and contextually relevant risk factors or that incorporate the equitable distribution of health outcomes. The Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion supported national NCDI Poverty Commissions to define local NCDI epidemiology, determine an expanded set of priority NCDI conditions, and recommend cost-effective, equitable health-sector interventions. Fifteen national commissions and 1 state-level commission were established from 2016-2019. Six commissions completed the prioritization exercise and selected an average of 25 NCDI conditions; 15 conditions were selected by all commissions, including asthma, breast cancer, cervical cancer, diabetes mellitus type 1 and 2, epilepsy, hypertensive heart disease, intracerebral hemorrhage, ischemic heart disease, ischemic stroke, major depressive disorder, motor vehicle road injuries, rheumatic heart disease, sickle cell disorders, and subarachnoid hemorrhage. The commissions prioritized an average of 35 health-sector interventions based on cost-effectiveness, financial risk protection, and equity-enhancing rankings. The prioritized interventions were estimated to cost an additional US$4.70-US$13.70 per capita or approximately 9.7%-35.6% of current total health expenditure (0.6%-4.0% of current gross domestic product). Semistructured surveys and qualitative interviews of commission representatives demonstrated positive outcomes in several thematic areas, including understanding NCDIs of poverty, informing national planning and implementation of NCDI health-sector interventions, and improving governance and coordination for NCDIs. Overall, national NCDI Poverty Commissions provided a platform for evidence-based, locally driven determination of priorities within NCDIs., (© Gupta et al.)

Background: Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes., Methods: We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model., Discussion: This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence., Trial Registration: ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021., (© 2021. The Author(s).)

Background: Neonatal alloimmune thrombocytopenia (NAIT) is a potentially serious clinical condition caused by maternal alloantibodies directed to human platelet antigens (HPA), inherited from the father and expressed on fetal/neonatal platelets. We report a case of an otherwise well, full term child, with a profound thrombocytopenia (33 x 109/L). There was no bleeding or obvious explanation for the low platelet count. Samples were sent for the investigation of NAIT., Method: Serological investigations were performed on maternal serum taken at day (D)+4 and D+78. The platelet immunofluorescence test (PIFT) and monoclonal antibody immobilization of platelet antigens (MAIPA) assays were performed with a panel of HPA typed donor platelets and against paternal platelets in a crossmatch. HPA 1-6, -9 and -15 and HLA genotyping was performed by in-house PCR-sequence based typing (SBT) and next generation sequencing (NGS)., Results: HPA antibody screening of D+4 maternal serum indicated that platelet-specific antibodies were absent. HPA genotyping of the father and child revealed the presence of the low frequency HPA antigen (LFHPA), HPA-6b, which was absent in the mother. Maternal samples were crossmatched against paternal platelets and were positive by PIFT and glycoprotein (GP) IIb/IIIa and HLA class I in the MAIPA assay. The infant required no platelet transfusion support as the thrombocytopenia resolved spontaneously., Discussion: We conclude that the positive crossmatch reaction was due to anti-HPA-6b alloantibodies. This case further emphasizes the importance of platelet crossmatching and HPA genotyping of LFHPA in cases where there is a high clinical suspicion of NAIT but initial screening is negative., (© 2021 AABB.)

Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this "household model," how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no "one-size-fits-all" approach. Other countries planning on adopting this model should plan to analyze and adapt as needed., (© Palazuelos et al.)

Objective: The aim of our study was to ascertain relationships between DaTSCAN, olfactory loss, behavioural and subjective measurements of impulsivity and emotional responsiveness in patients with clinically suspected Parkinsonian syndrome (PS)., Methods: A prospective study of 20 drug-naive patients with parkinsonism, underwent the University of Pennsylvania Smell Identification Test, impulsivity measurements and mood-state-questionnaires before visual and semi-quantitative DaTQUANT analyses. There were two subgroups: nine patients with scans without evidence of dopaminergic deficit (SWEDD - controls) and 11 patients with PS., Results: The PS group reported lower non-planning impulsivity than the SWEDD group (P = 0.039). A positive correlation was found between the non-planning impulsivity ratings and right anterior putamen/background (bck) ratio in PS group (r = 0.598, P = 0.068). Higher ratings of anger (r = 0.575, P = 0.016), fatigue (r = 0.746, P = 0.001), confusion (r = 0.561, P = 0.019) and depression were positively correlated with putamen/caudate ratios (R > L) on DaTSCAN. Higher self-reported arousal was associated with lower right putamen/caudate ratio (P = -0.581, P = 0.014). Only fatigue was positively correlated with putamen/bck (r = 0.564, P = 0.018). The degree of smell deficit correlated negatively with performance on reflection impulsivity tasks (r = -0.470, P = 0.049)., Conclusion: DaTSCAN appearances correlated with emotional dysfunction and self-reported impulsivity in patients with PS. Olfactory impairment was associated with increased reflection impulsivity and the age of patients. Higher DaTSCAN putamen/caudate ratios were associated with higher emotional responsiveness and higher non-planning impulsivity in PS patients. These preliminary findings may be relevant in clinical practice in differentiating PS from SWEDD and identifying susceptibility to impulse control disorder although larger studies are warranted.

Accurate rapid genotyping of the genes within the HLA region presents many difficulties because of the complexity of this region. Here we present the results of our proof of concept nanopore-based long read polymerase chain reaction (PCR) solution for HLA genotyping. For 15 HLA anthropology-based samples and 13 NHS Blood and Transplant derived samples 40 ng of genomic DNA underwent long-range PCR for class I and II HLA alleles. Pooled PCR products were sequenced on the Oxford Nanopore MinIoON R9.4.1 flow cell. Sequenced reads had HLA genotype assigned with HLA-LA. Called genotypes were compared with reference derived from a combination of short-read next-generation sequencing, Sanger sequence and/or single-site polymorphism (SSP) typing. For concordance, accuracy was 100%, 98.4%, 97.5% and 95.1% for the first, second, third and fourth fields, respectively, to four field accuracy where it was available, otherwise three field in 28 samples for class I calls and 17 samples for class II calls. Phasing of maternal and paternal alleles, as well as phasing based identification of runs of homozygosity, was shown successfully. Time for assay run was 8 hours and the reconstruction of HLA typing data was 15 minutes. Assay cost was £55 ($80USD)/sample. We have developed a rapid and cost-effective long-range PCR and nanopore sequencing-based assay that can genotype the genes within HLA region to up to four field accuracy, identify runs of homozygosity in HLA, reconstruct maternal and paternal haplotypes and can be scaled from multi-sample runs to a single sample., (© 2020 The Authors. HLA published by John Wiley & Sons Ltd.)

Background: Choosing who should be recruited as a community health worker (CHW) is an important task, for their future performance partly depends on their ability to learn the required knowledge and skills, and their personal attributes. Developing a fair and effective selection process for CHWs is a challenging task, and reports of attempts to do so are rare. This paper describes a five-stage process of development and initial testing of a CHW selection process in two CHW programmes, one in Malawi and one in Ghana, highlighting the lessons learned at each stage and offering recommendations to other CHW programme providers seeking to develop their own selection processes., Case Presentation: The five stages of selection process development were as follows: (1) review an existing selection process, (2) conduct a job analysis, (3) elicit stakeholder opinions, (4) co-design the selection process and (5) test the selection process. Good practice in selection process development from the human resource literature and the principles of co-design were considered throughout. Validity, reliability, fairness, acceptability and feasibility-the determinants of selection process utility-were considered as appropriate during stages 1 to 4 and used to guide the testing in stage 5. The selection methods used by each local team were a written test and a short interview., Conclusions: Working with stakeholders, including CHWs, helped to ensure the acceptability of the selection processes developed. Expectations of intensiveness-in particular the number of interviewers-needed to be managed as resources for selection are limited, and CHWs reported that any form of interview may be stressful. Testing highlighted the importance of piloting with CHWs to ensure clarity of wording of questions, interviewer training to maximise inter-rater reliability and the provision of guidance to applicants in advance of any selection events. Trade-offs between the different components of selection process utility are also likely to be required. Further refinements and evaluation of predictive validity (i.e. a sixth stage of development) would be recommended before roll-out.

Africa is experiencing an increasing prevalence of noncommunicable diseases (NCD). However, few reliable data are available on their true burden, main risk factors, and economic impact that are needed to inform implementation of evidence-based interventions in the local context. In Malawi, a number of initiatives have begun addressing the NCD challenge, which have often utilized existing infectious disease infrastructure. It will be crucial to carefully leverage these synergies to maximize their impact. NCD-BRITE (Building Research Capacity, Implementation, and Translation Expertise) is a transdisciplinary consortium that brings together key research institutions, the Ministry of Health, and other stakeholders to build long-term, sustainable, NCD-focused implementation research capacity. Led by University of Malawi-College of Medicine, University of North Carolina, and Dignitas International, NCD-BRITE's specific aims are to conduct detailed assessments of the burden and risk factors of common NCD; assess the research infrastructure needed to inform, implement, and evaluate NCD interventions; create a national implementation research agenda for priority NCD; and develop NCD-focused implementation research capacity through short courses, mentored research awards, and an internship placement program. The capacity-building activities are purposely designed around the University of Malawi-College of Medicine and Ministry of Health to ensure sustainability. The NCD BRITE Consortium was launched in February 2018. In year 1, we have developed NCD-focused implementation research capacity. Needs assessments will follow in years 2 and 3. Finally, in year 4, the generated research capacity, together with findings from the needs assessments, will be used to create a national, actionable, implementation research agenda for NCD prioritized in this consortium, namely cardiovascular disease, diabetes mellitus, and asthma and chronic obstructive pulmonary disease., (Copyright © 2019. Published by Elsevier B.V.)

Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi., (Copyright © 2019 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background: Community Health Workers (CHWs) provide basic health screening and advice to members of their own communities. Although CHWs are trained, no CHW programmes have used a formal method to identify the level of achievement on post-training assessments that distinguishes "safe" from "unsafe". Objectives: The aim of this study was to use Ebel method of standard setting for a post-training written knowledge assessment for CHWs in Neno, Malawi., Methods: 12 participants agreed the definitions of a "just-deployment ready" and an "ideal" CHW. Participants rated the importance and difficulty of each question on a three-point scale and also indicated the proportion of "just-deployment ready" CHWs expected to answer each of the nine question types correctly. Mean scores were used to determine the passing standard, which was reduced by one standard error of measurement (SEM) as this was the first time any passing standard had been employed.The level of agreement across participants' ratings of importance and difficulty was calculated using Krippendorf's alpha. The assessment results from the first cohort of CHW trainees were analysed using classical test theory., Findings: There was poor agreement between participants on item ratings of both importance and difficulty (Krippendorf's alphas of 0.064 and 0.074 respectively). The pass mark applied to the assessment, following adjustment using the SEM, was 53.3%. Based on this pass mark, 68% of 129 CHW trainees were 'clear passes', 11% 'borderline passes', 9% 'borderline fails' and 12% 'clear fails'., Conclusions: Determining whether a CHW is deployment-ready is an important, but difficult exercise, as evidenced by a lack of agreement regarding question importance and difficulty. Future exercises should allow more time for training, discussion and modification of ratings. Based on the assessment, most CHWs trained could be considered deployment-ready, but following-up their performance in the field will be vital to validate the pass mark set., Competing Interests: The authors have no competing interests to declare., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Background: Ensuring that selection processes for Community Health Workers (CHWs) are effective is important due to the scale and scope of modern CHW programmes. However they are relatively understudied. While community involvement in selection should never be eliminated entirely, there are other complementary methods that could be used to help identify those most likely to be high-performing CHWs. This study evaluated the predictive validity of three written tests and two individual sections of a one-to-one interview used for selection into CHW posts in eight areas of Kenya., Methods: A cohort study of CHWs working for Living Goods in eight local areas of Kenya was undertaken. Data on the selection scores, post-training assessment scores and subsequent on-the-job performance (number of household and pregnancy registrations, number of child assessments, proportion of on-time follow-ups and value of goods sold) were obtained for 547 CHWs. Kendall's tau-b correlations between each selection score and performance outcome were calculated., Results: None of the correlations between selection scores and outcomes reached the 0.3 threshold of an "adequate" predictor of performance. Correlations were higher for the written components of the selection process compared to the interview components, with some small negative correlations found for the latter., Conclusions: If the measures of performance included in this study are considered critical, then further work to develop the CHW selection tools is required. This could include modifying the content of both tools or increasing the length of the written tests to make them more reliable, for if a test is not reliable then it cannot be valid. Other important outcomes not included in this study are retention in post and quality of care. Other CHW programme providers should consider evaluating their own selection tools in partnership with research teams.

Background Following convection from blood capillaries, plasma proteins are transported to loco-regional lymph nodes in two stages: first, uptake into peripheral lymphatics, and second, transport to nodes. Purpose To introduce a new parameter of lymphatic function that quantifies stage 2 - lymphatic drainage efficiency (LDE). Material and Methods Percentage injected activity (IIQ) in ilio-inguinal nodes 150 min following subcutaneous foot web-space injection of Tc-99 m-nanocolloid was measured in 102 patients undergoing lymphoscintigraphy using a method in which a standard is placed by image guidance over the nodes. Percentage activity leaving the injection depot by 150 min ( k) was measured in 60/102 patients. LDE (%) = 100 × (IIQ/ k). Abnormal lymphoscintigraphy was defined qualitatively as: (i) no activity in ilio-inguinal nodes at 45 min or negligible activity at 150 min (delay); (ii) lymph diversion through skin and/or deep system; and (iii) focal tracer accumulation suggesting cellulitis. Results Scintigraphy was bilaterally normal in 82 limbs, unilaterally normal in 40 limbs and abnormal in 82 limbs. IIQ correlated with k in bilaterally normal (r = 0.86; n = 52), unilaterally normal (r = 0.67; n = 27), and abnormal (r = 0.82; n = 41) limbs. IIQ, k, and LDE were significantly lower in unilaterally normal (9.3 ± 5.4%, 13.8 ± 7.1%, and 65 ± 30%) compared with bilaterally normal limbs (15.4 ± 8.4% [ P > 0.0001], 18.3 ± 8.9% [ P = 0.025], and 84 ± 30% [ P = 0.01]). LDE was lower in limbs displaying skin diversion and/or delay. Conclusion LDE is a new quantitative index that has potential value in clinical research but requires further clinical evaluation. Abnormal quantitative indices indicate that limbs unilaterally normal on lymphoscintigraphy are not functionally normal.

Background: As Malawi continues to suffer from a large burden of noncommunicable diseases (NCDs), models for NCD screening need to be developed that do not overload a health system that is already heavily burdened by communicable diseases., Methods: This descriptive study examined 3 screening programmes for NCDs in Neno, Malawi, that were implemented from June 2015 to December 2016. The NCD screening models were integrated into existing platforms, utilising regular mass screening events in the community, patients awaiting to be seen in a combined NCD and HIV clinic, and patients awaiting treatment at outpatient departments (OPDs). Focusing on hypertension and diabetes, we screened all adults 30 years and above for hypertension using a single blood pressure cut-off of 160/110 mmHg, as well as adults 40 years and above for diabetes, measuring either random blood sugar (RBS) or fasting blood sugar (FBS), with referral criteria of FBS > 126 mg/dL and RBS > 200 mg/dL. Data were collected on specifically designed screening registers, then entered and analysed in Excel., Results: Over 14,000 adults (≥ 12 years old) were screened for an array of common conditions at community screening events. Of these adults, 58% (n = 8133) and 29% (n = 4016) were screened for hypertension and diabetes, respectively. Nine percent (n = 716) and 3% ( n = 113) were referred for further hypertension and diabetes assessment respectively. At one OPD, 5818 patients (60%) had their blood pressures measured, and among adults 30 years and above, 168 eligible adults were referred for further hypertension assessment. Since the initiation of the screening programmes, the number of patients ever enrolled for NCD care every 3 months has nearly tripled, from 40 to 114., Conclusions: The screening models have shown that it is not only feasible to introduce NCD screening into a public system, but screening may have also contributed to increased enrolment in NCD care in Neno, Malawi.

Noncommunicable diseases and injuries (NCDIs) account for nearly 70% of deaths worldwide, with an estimated 75% of these deaths occurring in low- and middle-income countries. Globally, the burden of disease from noncommunicable diseases (NCDs) is most often caused by the "big 4," namely: diabetes, cardiovascular diseases, cancer, and chronic lung diseases. However, in Malawi, these 4 conditions account for only 29% of the NCDI disease burden. The Malawi National NCDI Poverty Commission was launched in November 2016 and will describe and evaluate the current NCDI situation in Malawi, with a focus on the poorest populations. The National Commission will investigate which NCDIs cause the biggest burden, which are more present in the young, and which interventions are available to avert death and disability from NCDIs in Malawi, particularly among the poorest segments of the population. The evidence gained through the work of this Commission will help inform research, policy, and programme interventions, all through an advocacy lens, as we strive to address the impact of NCDIs among all populations in Malawi.

The Rohingya people of Myanmar (known as Burma before 1989) were stripped of citizenship in 1982, because they could not meet the requirement of proving their forefathers settled in Burma before 1823, and now account for one in seven of the global population of stateless people. Of the total 1·5 million Rohingya people living in Myanmar and across southeast Asia, only 82 000 have any legal protection obtained through UN-designated refugee status. Since 2012, more than 159 000 people, most of whom are Rohingya, have fled Myanmar in poorly constructed boats for journeys lasting several weeks to neighbouring nations, causing hundreds of deaths. We outline historical events preceding this complex emergency in health and human rights. The Rohingya people face a cycle of poor infant and child health, malnutrition, waterborne illness, and lack of obstetric care. In December, 2014, a UN resolution called for an end to the crisis. We discuss the Myanmar Government's ongoing treatment of Rohingya through the lens of international law, and the steps that the newly elected parliament must pursue for a durable solution., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Aims: The aims of this study were to improve the quantification of lower extremity lymphoscintigraphy, determine its value and lower limit of normal, and determine whether intermediate postinjection time imaging is necessary., Patients and Methods: This was a study of 102 consecutive patients undergoing routine lower extremity lymphoscintigraphy using subcutaneous Tc-99m-nanocolloid with imaging at 5, 45 and 150 min after injection. Abnormal imaging criteria were delay (no activity in ilio-inguinal nodes at 45 min or negligible activity at 150 min), lymph diversion (through skin or deep system) and focal accumulation suggesting cellulitis. Lymphatic function was quantified as % injected activity in ilio-inguinal nodes at 150 min (IIQ) using a standard placed, by image guidance, exactly over the nodes., Results: Forty-one patients had bilateral normal scintigraphy. IIQ was normally distributed in 15 limbs, with IIQ of 1-7.5%. In contrast, it was log-normally distributed in 68 limbs, with IIQ of at least 7.5%, suggesting 8% as the lower limit of normal. In 57 limbs, delay was the only scintigraphic abnormality at 45 min. Of these, 33 were abnormal at 150 min. Of the remaining 24 limbs, 17 had reduced IIQ; thus, 50 of these 57 (88%) limbs had lymphatic dysfunction. The seven limbs that remained normal at 150 min were in six patients. The contralateral limb was abnormal in five of these six patients; hence, lymphatic dysfunction would have been missed in only one patient without 45 min imaging., Conclusion: IIQ is strongly recommended. Isolated delay at 45 min is abnormal. However, 45 min imaging is not necessary if IIQ is performed.

With the support of the World Health Organization's Evidence-Informed Policy Network, knowledge translation platforms have been developed throughout Africa, the Americas, Eastern Europe, and Asia to further evidence-informed national health policy. In this commentary, we discuss the approaches, activities and early lessons learned from the development of a Knowledge Translation Platform in Malawi (KTPMalawi). Through ongoing leadership, as well as financial and administrative support, the Malawi Ministry of Health has strongly signalled its intention to utilize a knowledge translation platform methodology to support evidence-informed national health policy. A unique partnership between Dignitas International, a medical and research non-governmental organization, and the Malawi Ministry of Health, has established KTPMalawi to engage national-level policymakers, researchers and implementers in a coordinated approach to the generation and utilization of health-sector research. Utilizing a methodology developed and tested by knowledge translation platforms across Africa, a stakeholder mapping exercise and initial capacity building workshops were undertaken and a multidisciplinary Steering Committee was formed. This Steering Committee prioritized the development of two initial Communities of Practice to (1) improve data utilization in the pharmaceutical supply chain and (2) improve the screening and treatment of hypertension within HIV-infected populations. Each Community of Practice's mandate is to gather and synthesize the best available global and local evidence and produce evidence briefs for policy that have been used as the primary input into structured deliberative dialogues. While a lack of sustained initial funding slowed its early development, KTPMalawi has greatly benefited from extensive technical support and mentorship by an existing network of global knowledge translation platforms. With the continued support of the Malawi Ministry of Health and the Evidence-Informed Policy Network, KTPMalawi can continue to build on its role in facilitating the use of evidence in the development and refinement of health policy in Malawi.