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Continuity of Essential Health Services (CES) study - Exploring effect of COVID-19 on demand for maternal, newborn and child health services in selected districts in Malawi by William Stones
(Kamuzu University of Health Sciences, 4-06-21) Stones, William
Type of Study This is a Qualitative study in selected geographical areas including key informant interviews (KIIs), focus group discussions (FDGs) and in-depth interviews with specific target groups (e.g. women living with HIV/AIDS). The scope will include data collection, data quality monitoring, transcription/translation, data analysis and reports on study results. BACKGROUND RATIONALE Malawi registered its first Covid-19 cases in March 2020. A Presidential Taskforce on Covid -19 was immediately set up and Covid-19 prevention measures were put in place and these included: Closing down of schools, social distancing, wearing of masks, self- quarantine for all who tested COVID positive and all in-coming travelers, public gatherings were initially limited to 100 people and this was suspended due to injunctions. While government public health and social measures have likely forestalled some COVID-19 spread, they also have deleterious indirect social, economic and health impacts. While attention is understandably focused on the direct impact of the COVID-19 pandemic, it is essential to see the health crisis from a broader perspective. In Malawi, health systems are already fragile and people often live in extremely precarious conditions. The coronavirus pandemic risks further reducing vulnerable people’s already limited access to healthcare, as resources – both human and financial – get diverted from regular healthcare to the COVID-19 response. OBJECTIVES The overall study objective is: • To investigate the effect of COVID-19 pandemic on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. Specific study objectives are to: 1. Comprehend how COVID-19 has affected pregnant and breastfeeding women’s access to maternal and newborn health services. 2. Comprehend how COVID-19 has affected access to child health services for the under-fives. 3. Comprehend any specific challenges faced by vulnerable groups during COVID-19 with regard to access to MNCH services. METHODS The methodology will include focus group discussions (FGDs) and key informant interviews (KIIs), followed by in-depth interviews (IDIs) to capture respondents of vulnerable groups. The data will be collected from Mchinji and Blantyre Districts (indicative locations to be confirmed following consultation) and the study population will include adult pregnant/breastfeeding women, parents/caretakers of children under five years of age, adolescents (15 to 19 years of age, 7 companions/partners of pregnant/breastfeeding women and pregnant/breastfeeding adolescents, community-based health workers, health workers and facility based managers. DATA MANAGEMENT AND ANALYSIS All audio and handwritten data collected from the FGDs and interviews will be stored securely. Electronic notes, transcripts and translations will be stored electronically and protected by a password. Only members of the research team will have access to these documents. As soon as the audio-recordings have been transcribed and verified, they will be destroyed by erasing the voice recordings. Framework analysis will be used for cross-sectional analysis of data from FGDs, IDIs and KIIs. The focus will be on understanding the demand and supply-side barriers to seeking routine and emergency health care services, the extent to which the pandemic has impacted people’s willingness and ability to access MNCH services and how service readiness and provision has changed as a result of COVID- 19 and its effects. A combination of deductive and inductive themes will be included. POSSIBLE CONSTRAINTS COVID-19 situation might require adaptation of study methods using more or only virtual methods for interviews and FDGs; virtual FDGs might be not ideal given that moderators should be physically present to be able to catch the dynamics in the groups and to be able to guide and facilitate appropriately. However, the research teams will only do virtual FDGs in case there is no alternative. RESULTS PRESENTATION Key findings will be presented during a webinar with a UN, participating districts and MoH audience. All data collected, analytical memos and framework analysis files will be de-identified and shared with UNICEF alongside draft reports. The report will also be shared with COMREC. IMPLICATIONS OF THIS STUDY We anticipate that findings from this study will highlight the impact of Covid-19 on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. 1. Background In Malawi, since March 2020 when the first COVID-19 cases were reported, a Presidential Taskforce on Covid -19 was set up with a mixed membership of Public Health Experts, technocrats and members of the Cabinet. Covid-19 prevention measures were put in place and these included: Closing down of schools, social distancing, wearing of masks, self- quarantine for all who tested COVID positive and all in-coming travelers, public gatherings were initially limited to 100 people and this was suspended due to injunctions. In addition, number of passengers in public vehicles were also limited to 2 people per seat only. Between September and December, 2020, the number of COVID-19 cases reduced which may have fuelled non-adherence to COVID prevention measures. Since January, 2021, Malawi has been hit hard by the second wave of COVID-19 which has caused a sharp rise in the numbers of cases and increase in COVID-19 related deaths. The country has been declared a State of Disaster. The Vice President of Malawi has since led the team to develop new guidelines on COVID response and management. Further restrictions have been made to public gatherings now at 50 people only, the wearing of masks has become mandatory in all public places including markets, shops etc. Restrictions have also been made to trading hours in bars and markets. Since the second wave of COVID-19, more people have tested and hospitalized leading to an overburdened health care system. Government has embarked on efforts to increase the number of health care staff, increase treatment centres and lobby for resources (equipment and supplies) especially oxygen cylinders and accessories and COVID-19 testing kits which are in limited supply. While government public health and social measures have likely forestalled some COVID-19 spread, they also have deleterious indirect social, economic and health impacts. Given relatively limited health care capacity, particularly for critical care, a “bend the curve” paradigm may be less salient in the region and governments need to balance the threat of COVID-19-specific mortality with the potential secondary impacts of mitigation measures, which may also result in excess mortality. The West Africa Ebola epidemic (2014-16) is instructive as it demonstrated that indirect mortality can exceed the direct mortality of the health emergency. Scenario-based modelling of excess maternal and child mortality due to reduced coverage of essential health and nutrition services suggests that the indirect impact of COVID-19 mitigation measures could result in an increase of 9·8% to 44·7% in under-5 child deaths per month, and an 8·3% to 38·6% increase in maternal deaths per month, across 118 countries1. COVID-19 projections estimate that 15 million additional unintended pregnancies could occur over one year if COVID-related service disruptions affected 10% of women in need of sexual and reproductive health (SRH) services in low- and middle-income countries2. Anecdotal evidence from Kenya, Malawi and Mozambique indicates an increase in adolescent pregnancies since the closure of schools due to COVID-19. Within schools, Malawian adolescents have some access to reproductive health information and counselling, presence of mother-groups to support girls in need of services, peer to peer support. The impact of COVID-19 on the availability and quality of MNCH services and social-economic disruption on access to these services requires investigation. The Pulse survey by WHO in 105 responding countries on continuity of essential health services during the COVID-19 pandemic showed disruptions of essential health services reported by nearly all countries, and more so in lower- 1 Timothy Roberton, DrPH. Emily D Carter, PhD. Victoria B Chou, PhD. Angela R Stegmuller, BS. Bianca D Jackson, MSPH. Yvonne Tam, MHS. et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Articles; Volume 8, ISSUE 7, E901-E908, July 01, 2020 2 Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low- and Middle-Income Countries. Int Perspect Sex Reprod Health. 2020;46:73–6 income than higher-income countries. The majority of service disruptions were partial defined as a change of 5–50% in service provision or use. All services were affected, including essential services for communicable diseases, non-communicable diseases, mental health, reproductive, maternal, newborn, child and adolescent health, and nutrition services. Emergency services were the least disrupted, although 16 countries reported disruptions across all emergency services. The most severely affected service delivery platforms were mobile services, often suspended by government, and campaigns, for example as used for malaria prevention or immunization. The causes of the disruptions were a mix of demand and supply factors. On the demand side, 76% of countries reported reductions in outpatient care attendance. Other factors, such as lockdowns hindering access and financial difficulties during lockdown were also mentioned. On the supply side, the most commonly reported factor was cancellation of elective services (66%). Other factors mentioned included staff redeployment to provide COVID-19 relief, unavailability of services owing to closures of health facilities or health services, and supply-chain difficulties. 2. RATIONALE While attention is understandably focused on the direct impact of the COVID-19 pandemic, it is essential to see the health crisis from a broader perspective. In Malawi, health systems are already fragile and people often live in extremely precarious conditions. The coronavirus pandemic risks further reducing vulnerable people’s already limited access to healthcare, as resources – both human and financial – get diverted from regular healthcare to the COVID-19 response. During 2020, Malawi experienced that health services were downsized or closed to limit the risk of transmission. Shortage of staff was accelerated as frontline healthcare workers fell sick or died in places where there were already too few to provide essential services. Keeping essential health services available and accessible is vital to prevent losing even more lives, whether from malaria, measles, malnutrition or complicated pregnancies. This study study on Continuity of Essential Health Services (CES) aims at contributing to fill the knowledge gap on the demand and supply-side factors exploring barriers to seeking routine and emergency MNCH services. The immediate target groups include pregnant women, women of reproductive age with newborns and children under five years of age including breast-feeding women and adolescent women. In addition, health personnel, both clinical and management, as well as relevant community members will be included in the study. There is a need to understand the extent to which the pandemic has impacted people’s willingness and ability to access (i.e. availability, accessibility, affordability and acceptability) essential MNCH services and experiences of care during the pandemic. Furthermore, this study will also explore the supply side of health service delivery including the perception of health programme managers and health staff on resiliency of the health system and their view on why people are or are not coming in for care and the impact that the pandemic has on quality and the continuation of routine services delivery. The study will have a specific focus on vulnerable populations groups of women of reproductive age, including those living with HIV/AIDS and adolescents, as well as children under five. 3. Objectives of the study The overall study objective is:  To investigate the effect of COVID-19 pandemic on people’s willingness and ability to access essential MNCH services, their experiences of care and the perspectives of staff on MNCH services’ readiness to provide essential care during the pandemic. Specific study objectives are to: 1. Comprehend how COVID-19 has affected pregnant and breastfeeding women’s access to maternal and newborn health services.2. Comprehend how COVID-19 has affected access to child health services for the under-fives. 3. Comprehend any specific challenges faced by vulnerable groups during COVID-19 with regard to access to MNCH services. Specific research questions: The two main research questions are: (A) What is the influence of demand side factors (intention action/gap drivers, reaching care, and receiving care); (B) what is the influence of supply side factors (providing care). These are further elaborated as below. A. Maternal, newborn and child health: Demand side factors Intention action/gap drivers a. Did the target groups of primary interest (as defined above) during COVID-19 pandemic use essential MNCH services (essential as defined in the national packages of care and provided by skilled personnel) to the same extent (frequency, based on needs/demands) as during non-COVID times? b. What were the main factors / reasons that affected the use of essential MNCH services by the primary target groups during COVID-19 pandemic? What was different to non-COVID times in regard to the topics below? Reaching essential MNCH services a. To what extent and how were the primary target groups able to reach to a health facility / seek essential MNCH services during COVID-19 pandemic compared to non-COVID times? b. What were the main factors/reasons that stopped or made it difficult for the primary target groups to reach essential MNCH care during COVID-19 pandemic compared to non-COVID times? Receiving essential MNCH services when the health facility is reached c. To what extent and why were essential MNCH services not available to the primary target groups when reached? d. What kind of changes were observed or experienced by the primary target groups with regard to the quality of MNCH services provided during COVID-19 pandemic compared to non-COVID times? B. Maternal, newborn and child health: Supply side factors Providing adequate care to the primary target groups according to demand and needs a. To what extent did essential MNCH services become disrupted and/or unavailable during COVD-19? How was the readiness of essential MNCH - to serve the primary target population as needed - affected? b. Which MNCH services were most affected and why? Lessons learned- demand and supply-side The study teams will elaborate based on above raised questions on what were the main lessons learned from the COVID-19 pandemic in regard to demand for, access to and readiness of MNCH services. In addition, the interviews will include a question on what the lessons learned were 11  Health services  Health care providers  Health care users  Community-based health service delivery  Referral pathways/linkages between community systems and health systems, and other. 4.3 Target groups of the study The target groups will include specifically: (1) Adult pregnant/breastfeeding women (20 to 49 years) (2) Adolescent pregnant/breastfeeding women (15-19 years) (3) Pregnant/breastfeeding women (15 – 49 years) living with HIV/AIDS (4) Parents/caretakers of children under five years of age including adolescent mothers and fathers (5) Facility based health care workers and health facility managers (6) Community health workers/volunteers and other community-based health agents such as peer mother supporters etc. (7) Sub-national health care managers (district/subcounty, region/county/province) 4. STUDY DESIGN This is a Qualitative study in selected geographical areas including key informant interviews (KIIs), focus group discussions (FDGs) and in-depth interviews with specific target groups (e.g. women living with HIV/AIDS). The scope will include data collection, data quality monitoring, transcription/translation, data analysis and reports on study results. Conceptual Framework The “Governance and Capacity to Manage Resilience of Health Systems” conceptual framework postulates that health systems have three levels of resilience: absorptive capacity, adaptivecapacity and transformative capacity3. This framework is considered relevant as it arose from African experience of the Ebola outbreaks, that presented certain similar challenges to health systems. The absorptive capacity relates to the capacity of a health system to continue to deliver the same level (quantity, quality and equity) of basic healthcare services and protection to populations despite the shock (in this instance the Covid-19 pandemic) using the same level of resources and capacities. Adaptive capacity is the capacity of the health system actors (such as health workers) to deliver the same level of healthcare services with fewer and/ or different resources, which requires making organisational adaptations. Finally, the transformative capacity describes the ability of health system actors to transform the functions and structure of the health system to respond to a changing environment such as adaptations to Covid-19 guidelines and provision of Covid-19 care without compromising other services.
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Prevalence of asymptomatic SARS-CoV-2 infection among returnees from South Africa at Mwanza Border
(Kamuzu University of Health Sciences, 10-03-22) Kenneth, Owen Ajassie Zacchaeus
SARS-CoV-2 which has spread rapidly throughout the world can present as symptomatic or asymptomatic infection. Literature shows that asymptomatic individuals play a significant role in the ongoing pandemic, but their relative number and effect have been uncertain. In Malawi, there are no reliable estimates of the true burden of imported asymptomatic SARS-CoV-2 cases published. Malawi’s mainland testing algorithm for MoH priotises those with symptoms, thereby maximizing the risk for silent spread by asymptomatic persons. It is thus imperative that testing programs include those without symptoms. Under travel restrictions, Mwanza border, the main border for most returnees from SA (a high risk nation), remained the only border which was open during the partial border lockdown and SARS-CoV-2 testing was conducted in all the returnees irrespective of symptoms. With the information above, a retrospective study will be conducted to estimate the burden of asymptomatic SARS-CoV-2 infection where 350 cases will be employed as participants. Stratified sampling will be used to recruit the participants. The design has both quantitative and qualitative aspects The quantitative aspect will involve reviewing existing case-based records of returnees who presented at Mwanza border The qualitative aspect will involve administering of questionnaires to health-care workers at the border to find out how they managed the cases. No patient names will be mentioned in any of our data collection tools for complete privacy. Data analysis will be done both manually and electronically using SPSS. The aim of the study is to review and provide the available evidence on asymptomatic SARS-CoV-2 infection among returnees from SA at Mwanza Border. In this study we are going assess the prevalence of SARS-CoV-2 infection among the returnees at Mwanza border as our main objective and specific objectives as follows: to assess clinical and demographic characteristics of the returnees with asymptomatic SARS-CoV-2 infection, to develop an understanding on how returnees with SARS-CoV-2 were managed according to the standard management protocol, to compare the proportion of asymptomatic cases to symptomatic cases and to assess the association between demographic characteristics and SARS-CoV-2 status stratified by symptom status. We expect to find a high prevalence of asymptomatic SARS-CoV-2 infection among the returnees as testing was carried out on the returnees regardless of symptom presentation and the returnees were coming from a high risk nation. A report of the findings will be handed in to COMREC, Kuhes library and other relevant institutions. Findings from this study will have potential role to inform policy-makers and stake holders to devise, review and enforce measures and policies to effectively combat the pandemic, will help in laying a foundation for future studies, and the data collected will help us estimate the magnitude of the problem at Mwanza Border so that with our recommendations together, we can somehow help improve the quality of health-care services.
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Assessing the association of COVI-19 with under-five children malnutrition in Namphungo and Chambe rural Health Centers of Mulanje District by Carolyn Kang’ombe
(Kamuzu University of Health Sciencies, 13-07-21) Kang'ombe, Carolyn
XECUTIVE SUMMARY Background: Malnutrition contributes significantly to child morbidity and mortality. While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. The economic, food, and health systems disruptions resulting from the COVID-19 pandemic are expected to continue to exacerbate all forms of malnutrition. In this study, we generate information about the burden of Covid-19 towards under-5 child nutrition resulting from the potential disruption of health systems, economic system and decreased access to food. Objectives: The broad objective of the study is to assess the association of covid-19 with underfive child malnutrition in rural health centers of Mulanje District.. To achieve the broad objective, the study will achieve the three specific objectives outlined; 1. To conduct a comparative description of accumulated cases of malnutrition in under-five children cases admitted on Outpatient Therapeutic Program and Supplementary Feeding Program during and before onset on COVID-19 pandemic. 2 To assess the food situation and income security in households of malnourished under five children during and before onset of COVID-19 pandemic. 3 To compare the health services delivery in under five clinics before and during the COVID-19 pandemic in the rural areas of Mulanje. Methods: The study will be conducted at Namphungo and Chambe Health centers. A mixed method design will be used where cross-sectional qualitative and quantitative study design will be employed. For quantitative data, secondary data will be used to address the first objective. Health center under-five clinic registration will be used to extract data. Participants will be care givers to the admitted under five children under Out-patient Therapeutic Program and Supplementary Feeding Program (n=71) that will be randomly sampled from the secondary data in the respective health centers registry. Qualitative data will be collected through in-depth interview with care takers (n=10) that have under-five children on out-patient therapeutic program and supplementary feeding program on food situation analysis. Key informants (n=4) at the respective health centers will be interviewed to understand the working modalities that were applied as COVID-19 response measure. Expected results and dissemination: This study expects to enlighten any association and impact on food production and access, provision of health services and changes in practices and behavior due to the COVID-19 and its contribution towards exacerbation of malnutrition among under five children in the communities. The results will assist in informing policy and advocacy which may 13-Jul-2021 Version 3, revised 22nd June,2021 2 | P a g e lead to the refinement and improvement of maternal and child nutrition preparedness in emergencies. The findings will be disseminated to COMREC, college of medicine school of public health and family medicine, Department of Nutrition, HIV and AIDS (DNHA), Mulanje District Health Office, Mulanje Agriculture Office as well as research dissemination conferences. Results will help to advocate for under-five nutrition measures that will assist in coping with the COVID- 19 pandemic and hence reducing under-five malnutrition.
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Factors affecting retention in care of patients initiated on antiretroviral treatment at Umodzi Art Clinic, Blantyre
(Kamuzu University of Health Sciences, 16-03-22) Kaunda, Esther Shalom
Type of research study: The study is a cross-sectional analytical that will use mixed methods. Problem to be studied: The United Nations Programme on HIV/AIDS (UNAIDS) 95–95-95 target states that 95% of people living with HIV should know their status, 95% of people living with HIV who know their status should be on treatment, and 95% of people on treatment should be virally suppressed by 2025. Malawi strives to ensure that by the year 2030, she achieves this 95-95-95 target. However, only 69% of all people living with HIV were virally suppressed in Malawi in the year 2018, plus, available data at Umodzi clinic indicate that not all people that are initiated on ART are retained in care after 12 months which puts the 3rd 95 at a far to reach place. Broad Objective The study will investigate factors affecting retention in care of clients initiated on antiretroviral treatment at Umodzi ART clinic, Blantyre. Specifically, the study will: 1. Describe the social, economic and demographic profiles of both retainers and nonretainers, 2. Describe the factors affecting retention in care of patients on antiretroviral treatment, 3. Determine ways through which clients can be retained in care from their own perspective. Methodology: Study population will include all clients that were initiated on ART from January, 2017 to December, 2021 but did not retain in care. The sample size will be 172 and we will systematically enrol participants into the study. A checklist will be used to collect data from the files and an interviewer administered questionnaire will be used to have a deeper insight on the reasons for non-retention and ways that could help in improving retention of clients into care from their perspective. Collected data will be stored securely in computer data base that have a pass word and only limited access to key study team will be provided. Data analysis will be done using Stata software for quantitative data, and deductive analysis for the qualitative part. Informed consent will be obtained from each and every study participant before enrolment in the study and confidentiality will be ensured throughout the study period. Permission to undertake the study will be sought from QECH and ethical approval will be sought from the College of Medicine Research and Ethics Committee (COMREC). Expected findings and their dissemination: We expect to describe the profile of those that retain and that do not retain in care, find factors that lead to no-retention and find ways that will improve retention among those initiated on ART. These expected results will be disseminated in writing and presentations as feedback made to Umodzi clinic, QECH and the District Health Management Team (DHMT) for Blantyre. Recommendations will be made to various levels of decision making including, Umodzi clinic, QECH, BDHO, MOH and other key implementing partners on improvements that need to be made to ensure that clients are retained in care in ART clinics.
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Impact of the coronavirus disease (COVID-19) pandemic on routine childhood immunization in Mwanza-Malawi, version 1.0
(Kamuzu University of Health Sciences, 16-03-22) Kuchanje, Tamandani R. Reuben
The type of research study: Before and after study design using routine immunization data collected in all Mwanza health facilities. - The problem COVID-19 pandemic has created a number of global challenges which includes access to the general health care. Routine child immunization maybe part of the components affected by the COVID-19 pandemic as several studies done in different countries have shown reduction in vaccine coverage before and after or during COVID-19. The impact of COVID-19 in low income settings may be far more than what has been shown in studies conducted in other settings. Immunization has played a major role in reducing child mortality world-wide. Reduction in coverage may thus affect the fight in reducing global child mortality. Understanding the impact of COVID-19 on immunization may therefore help in putting up targeted intervention to improve immunization amidst the COVID-19 pandemic. - The broad objective To compare the vaccine coverage before and during (COVID-19) pandemic on routine childhood immunization among under-five children in Mwanza district - Specific objective 1. To equate coverage of three specific vaccines (DPT, PCV and Measles vaccine) received by under-five children between pre and post Covid-19 at Mwanza health facility 2. To balance vaccine coverage between male and female under-five children who got their immunization services from Mwanza health facilities between pre-pandemic period (January to December 2019) and during pandemic period (January to December 2021) 3. To assimilate vaccine coverage among under-five children who got their vaccines timely according to vaccine schedule based on age between pre-pandemic period (January to December 2019) and during pandemic period (January to December 2021) - Methodology A before and after study design will be used for this study. All the children who received vaccine before covid-19 and those who received vaccine during covid-19 will be included into the study until the sample size is reached, using routinely collected medical data dated 1st April to 31st July, 2019 and 1st April to 31st July, 2020.. This study will collect demographic data of children, Children vaccination data before Covid-19, and Children vaccination data during Covid-19 pandemic. Our Primary outcomes will be the percentage difference in the proportion of vaccinated and the secondary outcome is Vaccine preventable outbreak. Distributions of age, and sex will be compared between the 2019 pre-COVID-19 period and 2020 COVID-19 period. Trend analysis will be done to see the progress of vaccination. The percentage differences of routine vaccine doses administered during the pre-pandemic period (April to July 2019) and during the period of COVID-19 (April to July 2020) will be calculated and compared. The percentage difference of routine vaccine doses administered at each health facility before and during COVID-19 will be calculated and compared. The percentage difference of routine vaccine doses administered based on age eligibility will be calculated and compared. The difference-indifference (DID) analyses will be done to take care of any normal trends due to changes in the size of the population and vaccine acceptance. And Pearson Chi-square test will be used for statistical significance test. Complete vaccination coverage for all mentioned routinely-recommended vaccines at each milestone age (6, 10, 14, weeks, 9 months and 12-15 months) in a period will be calculated by dividing the number of children who received all routine vaccine doses before a milestone age by the number of eligible children who reached that milestone age during the period. Complete vaccination coverage by month from April to July 2019 and April to July 2020 will be estimated. - Expected findings and their dissemination. The study anticipates finding reduced vaccine coverage. Findings will prompt the Government of Malawi and stakeholders to introduce or roll out adequate communication strategies in order to reduce concerns about vaccinations and to redress the decline in vaccination coverage that will occur during the covid-19 pandemic period. At the same time, it will inform ministry for the need for immunization catch up campaign.
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Reproductive health practices among women with heart disease at Queen Elizabeth Central Hospital, version 3.0
(Kamuzu University of Health Sciences, 16-03-22) Kumwenda, Wanangwa
Type of Study This is a qualitative study that is going to be conducted at an outpatient clinic at Queen Elizabeth Central Hospital. Problem Heart disease is one of the leading causes of Indirect Maternal deaths in developed countries (1). The obstetric transition concept suggests that as a country’s maternal mortality ratio decreases, as has been the case for Malawi, the burden of maternal mortality switches from direct to indirect causes, such as heart disease (2–5). In Malawi, data for heart disease in pregnancy is meagre but likely to be underestimated. However, studies in LMICs have demonstrated heart disease in pregnancy to be associated with increased mortality and morbidity, as the provision of optimal care is challenging in most circumstances (6). The recommended strategies for reducing the burden of heart disease on maternal health include counselling on the possible complications that can arise if they get pregnant, avoiding unintended pregnancies by offering appropriate contraception, optimising health before pregnancy and good antenatal care with a multidisciplinary approach (7,8). These strategies are recommended to be started at the time of diagnosis or as early as menarche for those with congenital heart disease (9). There is need to understand the local reproductive health practices among women with heart disease as the obstetric transition happens. This understanding will help identify the factors to address when promoting the reproductive health of women with heart disease. Objectives The main objective is to understand the factors affecting the reproductive health practices among women with heart disease who attend the Chest Clinic at QECH. Specific Objectives • To identify the factors that influence the desired fertility of women with heart disease • To assess perceptions of effects of heart disease on reproductive health among women with heart disease • To explore perceptions about the effects of pregnancy on heart disease among women with heart disease To compare provisions contained in the international, national, and local normative guidance on the care of pregnant women with heart disease with the actual practice of providing care to this group at QECH Methodology This study will use qualitative methods. It will be done at Queen Elizabeth Central Hospital and will recruit 25 women with heart diseases and 3 medical key informants. In-depth interviews will be used to collect the data, and thematic analysis will be done. Expected Findings This study will provide an understanding of the reproductive health practices among women with heart disease and the factors affecting them. This knowledge will help with areas of focus when planning ways of promoting the reproductive health of women with heart disease
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Serum levels of vitamin C and D in adult individuals with diabetes and hypertension compared to healthy controls, and the supplementation tendencies of the vitamins among non-severe COVID-19 patients in Blantyre, Malawi by Dr Kondwani Katundu
(Kamuzu University of Health Sciencies, 18-10-21) Katundu, Kondwani
Executive Summary Study Title: Serum levels of vitamin C and D in adult individuals with diabetes and hypertension compared to healthy controls in Blantyre, Malawi. Study Type: Cross-sectional Background: Vitamin C and D mitigate the progression of atherosclerosis in individuals with Diabetes mellitus (DM) and hypertension. DM and hypertension are risks for worse outcome in COVID-19, and low blood Vitamin C and D associate with the severity of COVID-19 disease. Vitamin C and D status in healthy controls compared with DM and hypertension has not been well described in Malawi. Study Objectives: This study aims to determine the prevalence of serum vitamin C and D deficiency in adult individuals with diabetes and hypertension in Blantyre, Malawi. Methods: This will be a cross-sectional where we will analyse serum samples for vitamin C and D from a cross-sectional study in adult individuals with DM (n=75) and hypertension (n=75) at QECH and age-matched healthy controls (n=75). Sample-size: The sample size for the determination of serum vitamin C and D study of 75 participants in each of the three groups (total 225) was calculated to detect at least 15% prevalence of hypovitaminosis in the healthy individuals compared to the individuals with DM and hypertension, respectively, at a power of 80% and 95% confidence interval. Outcomes and definitions: The primary outcomes of the study will be the prevalence of vitamin C and D deficiency and insufficiency in the study population groups. Vitamin C deficiency and insufficiency will be defined as serum vitamin C concentration of ≤11.4 μmol/L and ≤23.0 - 28 μmol/L respectively. Vitamin D deficiency and insufficiency will be defined as 25(OH)D of ≤20 ng/ml (50 nmol/L) and ≤21–29 ng/ml respectively. Expected findings and dissemination: Vitamin C deficiency and insufficiency is prevalent (up 56%) in low-income countries, and the low fruit intake in most Malawian households likely predispose individuals to low vitamin C status. We expect low vitamin C status of at least 20% in the study populations. Low vitamin D status of up to 60% has also been reported in a recent African review, which did not include data from Malawian adults. We also expect a positive association between the low vitamin C status with HBA1C, dyslipidaemia and poorly controlled hypertension. The results once analysed will be published in an international scientific journal and will be presented both at local and regional or international conferences. Published results will also be submitted to the Malawi Liverpool Welcome Trust Clinical Research Programme, College of Medicine Research and Ethics Committee (COMREC), Kamuzu University of Health Sciences Library, Blantyre District Health and Social Services Office and Queen Elizabeth Central Hospital.
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The effect of Covid-19 on uptake of HIV and AIDS health services at St Martin’s Community Hospital
(Kamuzu University of Health Sciences, 19-01-22) Lusinje, Alinafe
A cross-sectional study design and will employ both qualitative and quantitative methods. Data will be collected using questionnaires (refer appendix 12.3), review of registers, key informant interviews (refer appendix 12.5) and focus group discussions (refer appendix 12.7) Quantitative sample size will be 123 among HIV and AIDS clients and qualitative sample simple size will be 32 Malawi is one of the most affected countries with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) epidemic in the sub-Saharan Africa. The emergency of Corona Virus Disease 2019 (COVID-19) pandemic has disrupted provision of health services globally as well as nationally, and has led to low uptake of health services. This study seeks to assess the effect of COVID-19 pandemic on uptake of HIV and AIDS health services at St Martin’s Community Hospital in Mangochi. Results for this study may help to inform decision and policy makers on how to make HIV and AIDS programs resilient to emerging health issues. Methods This will be a cross-sectional study and will employ both qualitative and quantitative methods. Data will be collected using questionnaires (refer appendix 12.3), review of registers, key informant interviews (refer appendix 12.5) and focus group discussions (refer to appendix 12.7). Quantitative sample size will be 123 among HIV and AIDS clients and qualitative sample simple size will be 32; four key informant interviews with a priest, group village head, a nurse or clinician working at HIV service point of delivery and head of clinical department. Four sessions of focus group discussions comprising seven members who are HIV and AIDS clients will be conducted. Data will be analysed using STATA and thematic content analysis. Ethical approval will be sought from Kamuzu University of Health Sciences’ College of Medicine Research and Ethics Committee (COMREC).
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Determinants of postpartum disorders following early hospital discharge in Blantyre, Malawi
(Kamuzu University of Health Sciences, 2020-03-21) Thindwa, Deus
Introduction: Social mixing patterns shape the transmission of respiratory infections such as pneumococcus. Understanding social contact structures may help inform precise prediction of pneumococcal transmission dynamics, and optimise control strategies such as vaccination. Type of research study: A quantitative cross-sectional epidemiological study The problem: What determines social mixing patterns that are relevant for pneumococcal transmission in populations with high HIV prevalence? The objectives were: 1. To determine factors that are associated with Social contact types; Social contact frequency 2. To estimate age-specific rates of social contacts, relevant for pneumococcal transmission in age groups: <1 years (infants), 1-5 (preschool), 6-15 (primary school), 16-19 (secondary school), 20-49 (adults), and 50+ (elderly). 3. To determine the role in social contact rates of social contact place, adult HIV-infection status, spatial distance between place of contact and participant’s household. Data analysis methodology: 1. Multivariate regression analysis for factors associated with contact types and frequency. 2. Computed ratio of measured probability of a contact between individual age-groups to a null model of the probability of that contact under an assumption of random mixing, resulting in social contact matrices representing intensity of contacts between different age groups. 1.3. Stratification of social contact matrices by place of contact and HIV-infection status. Inverse cumulative distribution for spatial distance and the number of contacts. Expected findings: 1. Ratio of the mean number of contacts in each category of the factor (covariate) relative to the reference category for each contact type and frequency. The mean number of daily contacts in age groups: <1 years (infants), 1-5 (preschool), 6-15 (primary school), 16-19 (secondary school), 20-49 (adults), and 50+ (elderly) presented as social contact matrices. 3. Age-specific mean number of daily contacts stratified by place of contact and adult HIV infection status presented as social contact matrices. 4. A cumulation distribution plot of spatial distance between contact place and participant’s household and the mean number of contacts. Dissemination of findings The results of SOMIPA study will be shared with the College of Medicine Research Ethics Committee, LSHTM Research Ethics Committee, Blantyre District Health Office (DHO), host organisation, sponsor, the Malawi Ministry of Health, College of Medicine Library, the University Research and Publication Committee and the Health Sciences Research Committee. The results will also be shared to other researchers through peer-reviewed publication, scientific conferences, dissemination seminar as well as written as a PhD chapter for my PhD thesis.
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Characterising COVID-19 occupational exposure among healthcare workers through the validation of point-of-care diagnostics
(Kamuzu University of Health Sciences, 2020-06-02) Tonney, Nyirenda
Study type Prospective cohort study Problem A substantial number of COVID-19 infections have been reported in health care workers (HCWs) in over 50 countries. In Malawi, HCWs are particularly vulnerable, owing to the lack of personal protective equipment and infection prevention and control measures in healthcare facilities, fragile healthcare infrastructure and the lowest number of physicians per population. In Malawi, COVID-19 infection amongst HCWs can have devastating effects on an already fragile healthcare system. A key challenge facing Malawi is the lack of access to specialist laboratory infrastructure. If the pandemic takes off in Malawi, these diagnostic facilities will be rapidly overwhelmed. Validation of low-cost rapid diagnostic tests will allow the accurately diagnosis of COVID- 19 infection.Validation of low-cost rapid diagnostic tests that can accurately diagnose current COVID-19 infection. Timely diagnosis of current COVID-19 infection will enable timely health facilities to make investigations and implement institution of containment measures, such as quarantine and contract tracing. Objectives  Characterise COVID-19 occupational exposure among healthcare workers in Blantyre district  Evaluate existing point-of-care (POC) antibody tests, an in-house enzyme-linked immunosorbent assay (ELISA) and a novel POC loop-mediated isothermal amplification (LAMP) assay. The study will recruit 150 HCWs and 150 matching community controls at the following healthy facilities in Blantyre district: Queen Elizabeth Central Hospital (QECH), Kameza Isolation Centre and health centres in Blantyre urban To determine current infection and exposure, nasopharyngeal and serum samples will be screened for SARS-CoV-2 by RT-PCR and immune response (IgM/IgG) evaluated respectively using in-house and commercial SARS-CoV-2 enzyme-linked immunosorbent assays (ELISA). We will also carry out a double-blind investigation to validate a novel RTLAMP assay using RT-PCR as gold standard. Additionally, we will evaluate the performance of other commercially available point-of-care (POC) rapid diagnostic tests (RDTs). We will then use bulk and single cell transcriptomic approaches to try and understand why immunological response varies. Laboratory analyses will be performed at College of Medicine, University of Malawi. Expected findings The risk of HCW to COVID-19 will be established; this will inform guidelines on occupational safety. POC assays will be validated, which will establish the best diagnostics for use in district hospitals and health centres, where there are no RT-PCR facilities. Furthermore, the study will provide guidance on diagnostics for COVID-19. Finally, we will evaluate the immunological response to SARS-CoV-2 and why this varied between individuals and attempt to determine why some individuals exhibit symptoms.
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Characterising COVID-19 occupational exposure among healthcare workers through the validation of point-of-care diagnostics
(Kamuzu University of Health Sciences, 2020-06-02) Nyirenda, Tonney
Study type Prospective cohort study Problem A substantial number of COVID-19 infections have been reported in health care workers (HCWs) in over 50 countries. In Malawi, HCWs are particularly vulnerable, owing to the lack of personal protective equipment and infection prevention and control measures in healthcare facilities, fragile healthcare infrastructure and the lowest number of physicians per population. In Malawi, COVID-19 infection amongst HCWs can have devastating effects on an already fragile healthcare system. A key challenge facing Malawi is the lack of access to specialist laboratory infrastructure. If the pandemic takes off in Malawi, these diagnostic facilities will be rapidly overwhelmed. Validation of low-cost rapid diagnostic tests will allow the accurate diagnosis of COVID- 19 infection.. Timely diagnosis of current COVID-19 infection will enable health facilities to make investigations and implement containment measures, such as quarantine and contact tracing. Objectives • Characterise COVID-19 occupational exposure among healthcare workers in Blantyre district • Evaluate existing point-of-care (POC) antibody tests, an in-house enzyme-linked immunosorbent assay (ELISA) and a novel POC loop-mediated isothermal amplification (LAMP) assay Methodology. The study will recruit 150 HCWs and 150 matching community controls at the following healthy facilities in Blantyre district: Queen Elizabeth Central Hospital (QECH), Kameza Isolation Centre and health centres in Blantyre urban To determine current infection and exposure, nasopharyngeal and serum samples will be screened for SARS-CoV-2 by RT-PCR and immune response (IgM/IgG) evaluated respectively using in-house and commercial SARS-CoV-2 enzyme-linked immunosorbent assays (ELISA). We will also carry out a double-blind investigation to validate a novel RTLAMP assay using RT-PCR as gold standard. Additionally, we will evaluate the performance of other commercially available point-of-care (POC) rapid diagnostic tests (RDTs). We will then use bulk and single cell transcriptomic approaches to try and understand why immunological response varies. Laboratory analyses will be performed at College of Medicine, University of Malawi. Expected findings The risk of HCW to COVID-19 will be established; this will inform guidelines on occupational safety. POC assays will be validated, which will establish the best diagnostics for use in district hospitals and health centres, where there are no RT-PCR facilities. Furthermore, the study will provide guidance on diagnostics for COVID-19. Finally, we will evaluate the immunological response to SARS-CoV-2 and why this varied between individuals and attempt to determine why some individuals do not exhibit symptoms. Dissemination of results Findings of this study will be presented to COMREC and during CoM research in progress meetings at Blantyre DHO, QECH, Public Health Institute of Malawi (PHIM) and the national COVID-19 taskforce. Further findings will be published in peer reviewed journals
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Characterising health care workers’ risk of exposure to SARS-COV-2 compared to non-health care workers in Blantyre, Malawi.
(Kamuzu University of Health Sciences, 2020-06-05) Kateta, Steve Robert
Background: Cases of COVID-19 continue to rise exponentially globally and also in Malawi. Frontline health care workers (HCWs) remain at increased risk of contracting SARS-CoV-2, a virus that causes COVID-19. Sickness and death of HCWs to COVID- 19 will have devastating effects on Malawi’s already fragile health system. This study aims at characterising risk of exposure to SARS-CoV-2 among HCWs compared to non-HCWs. Main Objective To characterize the exposure and risk of HCWs to COVID-19 in Blantyre compared to non-HCWs Specific objectives i) To describe the demographic characteristics of HCW in the frontline of COVID-19 response ii) To establish the incidence (proportion of HCWs with) of COVID-19 among HCW compared to the non-HCWs iii) To ascertain the workplace/ occupational factors associated with/or contributing to health care workers contracting SARS-CoV-2 Study design: Prospective descriptive cohort study Study place: Blantyre District, Malawi Study population: Frontline HCWs and matched non-HCWs in Blantyre Study duration: May to August 2020 Data management and analysis: An electronic, predesigned questionnaire will be used to collect data. Data curation and storage will be GCP compliant. STATA software will be used to analyse the results. Proportions of HCWs and non-HCWs infected with SARS-CoV-2 will be calculated and Chi-square test used to test the difference. Multivariable logistic regression will be performed to explore occupational factors that increase the risk of being infected. Expected results: We expect to understand the risk health care workers have of contracting SARS-CoV-2 and ascertain the workplace factors that increase this risk. This information will assist policy makers in optimising infection prevention control measures in workplaces, contributing to protecting HCWs in Malawi. Dissemination of results: Results of this study will be presented to Blantyre DHO, QECH, College of Medicine and Ministry of Health. Furthermore, results will be disseminated through local, regional and international scientific meetings/conferences/seminars/workshops and by publications in peer-reviewed journals. In addition to a thesis being submitted in fulfilment of a Master of Medicine degree, a copy of the final report and any enduing publications will be submitted to COMREC and the College of Medicine Library.
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Perspectives of health care workers towards COVID-19 epidemic response measures at Queen Elizabeth Central Hospital, Malawi
(Wellcome Trust, 2020-08-31) Limbani, Felix
This is a hospital-based qualitative descriptive study to investigate health care workers’ perspectives and experience towards potential epidemic response measures at Queen Elizabeth Central Hospital (QECH). We propose to conduct in-depth interviews with a purposively selected sample of Health Care Workers (HCWs). The Problem Cases of COVID-19 continue to rise in Malawi through cross-border and community infections,and the country is at high risk of the spread of COVID-19 epidemic. The healthcare system is fragile, and the population vulnerable to severe disease. Malawi’s national COVID-19 preparedness and response plan has prioritized; prevention, rapid detection, and effective response to any COVID-19 outbreak. The World Health Organization (WHO) has recognized health care workers’ vulnerability of exposure to hazards that put them at risk of infection as a result of being at the frontline of the COVID-19 outbreak response. Hospitals in Malawi have developed and adopted strategies for responding to COVID-19 epidemic including protection of HCWs. We want to know health care workers’ experience and thoughts of the hospital’s COVID- 19 response strategies, response approaches that are feasible to their hospital setting and ideas about what is important when adopting international guidelines. We want to know this so as to ascertain how confident HCWs are in the environment they are working in, and their confidence to provide services in demanding COVID-19 epidemic environment The objectives Broad objective To understand the implementation of COVID-19 response strategies at QECH from perspectives of health care workers in order to inform interventions and standards of appropriate epidemic response strategies and pragmatic adaptation of recommended treatment protocols Specific Objectives 1. To explore barriers and facilitators affecting the implementation of appropriate epidemic response strategies at QECH; 2. To describe how the hospital context, its general functioning, and the broader health system factors including national guidelines affect epidemic response strategies and processes, including measures of surge capacity and reverse triage; 3. To explore how the wider and local context impact on health care workers attitudes and perceptions towards their role in management of COVID-19; 4. To determine the feasibility of WHO recommended clinical management guidelines (diagnostic sampling, use of personal protective equipment and care delivery) and acceptability of pragmatic adaptation to the local resource-limited context. Methodology We will conduct in-depth interviews with a purposively selected sample of HCWs. We will explore their experiences and preferences of the hospital’s epidemic response strategies to determine priorities of HCWs in implementing appropriate epidemic response strategies and factors that affect the successful adoption of internationally recommended treatment and care protocols in a low-income and severely resource-constrained health system. Expected findings and their dissemination Findings from this study will contribute toinclude: (1) understanding factors that would facilitate the adaptation of recommended clinical management guidelines in resource-limited setting; (2)describing the state and availability of resources in the hospital including the infrastructure and the pathway of patients with COVID-19, and their effect on epidemic response measures; (3)recommending priorities of HCWs in implementing appropriate epidemic response strategies. We will disseminate these findings to MoH, national COVID-19 preparedness and response committee, staff and management of QECH, COMREC, College of Medicine, and other partners.
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Seroprevalence of SARS-CoV-2 antibodies in Malawi blood donors
(Kamuzu University of Health Sciences & Malawi-Liverpool-Wellcome Trust, 2020-09-07) Jambo, Kondwani; Swarthout, Todd; M'baya, Bridon; Heyderman, Robert; Jere, Khuzwayo; French, Neil; Gordon, Stephen; Muula, Adamson; Chibwana, Marah; Kalata, Newton; Hosseinipour, Mina
Type of study: Cross-sectional observation study. Problem: In low-income countries, such as Malawi, important public health measures including universal face mask use, social distancing or a lockdown, have been challenging to implement owing to socioeconomic constraints, leading to predictions that the COVID-19 pandemic would progress rapidly. However, due to limited capacity to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, there are no reliable estimates of the true burden of infection and death. SARS-CoV-2 serosurveys of blood donor samples in blood banks are supported by WHO as a potential useful tool for tracking the emergence and progression of the COVID-19 pandemic. Broad and Specific Objectives: Broad objective: to identify for SARS-CoV-2 antibodies in blood donors in Malawi, as a marker of past infection and an estimate of population exposure. Specific objectives: Primary objective: to estimate the seroprevalence of SARS CoV-2-specific antibodies in blood donor sera of different age-strata across the entire country. Secondary objectives a) to establish when COVID-19 started circulating in Malawi, and b) to determine the COVID-19 epidemic trajectory over time in Malawi Methodology: Repeated cross-sectional investigation of blood donors from across the country. Using the MBTS sample archive database, we will identify sera collected from multiple age groups, including 15-19, 20-29, 30-39, 40-49, 50-59 and 60+. We will conduct two serosurveys using sera collected between December 2019 to May 2020 (Serosurvey 1), and also those to be collected between June 2020 to December 2020 (Serosurvey 2). SARSCoV-2 antibodies will be measured from the sera using ELISA and Luminex-based IgG/IgM multiplex assay targeting Spike (S) and Nucleoprotein (N). We will also measure neutralisation potency of the detected SARS-CoV-2 antibodies. Study setting and period: The laboratory experiments will be conducted at the MLW laboratories. The study will be conducted between October 2020 to July 2021. Ethical considerations: At time of donation, blood donors provide consent to participate in studies of public health importance or those aimed at improving availability of supplies of safe blood. COVID-19 research qualifies for an activity of emergency Public Health importance. We will generate unique sample identifiers and will not have access to the donor details with identifiable names. Data Management and analysis: All data will be stored in secure password protected computers at the MLW. Only study investigators will have access to the data, unless prior collaborative agreements are in place or data has been released as part of open access. We will calculate population and age-specific seroprevalence of SARS CoV-2. These will be reported as proportions of SARS CoV-2 antibody positive individual in the total population or per age strata. We will also estimate the potential period of SARS-CoV-2 entry into Malawi, by using the latest known validated SARS-CoV-2 antibody positive sample. Expected findings: a) Prevalence of SARS CoV-2 exposure amongst blood donors, as a surrogate of population exposure, b) An estimate of potential time of SARS CoV-2 entry into Malawi. Dissemination: The results will be disseminated at local and international conference and manuscripts will be published in an international peer-reviewed journal, and policy-related findings will be shared via the MLW Policy unit. The results will also be shared with COMREC.
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Pilot Implementation of a multi-faceted COVID-19 response at the department of paediatrics, QECH
(Kamuzu University of Health Sciences, 2020-09-16) Freyner, Bridget
Type of Study This is a mixed-methods pilot implementation study Problem COVID-19 is the current major disease of concern globally. The guidance developed by the World Health Organisation (WHO) to help in the implementation of infection prevention and case management of COVID-19 must be locally relevant for it to be effective in Malawi. This study will apply the RE-AIM framework to assess key process and implementation outcomes of the QECH Paediatric COVID-19 response. The QECH Paediatric departmental response to COVID-19 has three elements (i) the implementation of WHO guidance on infection prevention, rationale use of PPE and case management of children with suspected COVID-19 disease (ii) ongoing monitoring and evaluation of in-patient case load, case fatality rate and quality of care and (iii) the development of strategies to minimise in-patient length of stay. Underpinning these three elements are ongoing communication strategies, logistics support and real-time data utilisation through audit-feedback. The aim of this study is to describe the implementation of this response and to pilot strategies for (i) real time data utilisation and (ii) reduction of in-patient length of stay to mitigate against both the direct and indirect effects of COVID-19. Specific Objectives I. To evaluate the implementation of COVID-19 specific guidance (infection prevention, environmental cleaning and the rationale use of PPE) and how it changes over the course of the epidemic. II. To evaluate the pilot implementation of a data dashboard and associated learning system on (i) compliance with COVID-19 guidance and (ii) in-patient quality of care. III. To describe the effect of the COVID-19 epidemic on the in-patient caseload, case fatality rate and in-patient quality of care compared to baseline. IV. To determine the optimal strategies for minimising in-patient length of stay in our department with the aim of reducing unnecessary patient exposure to COVID-19. IV.V. To generate pilot effectiveness data on the utility of a “learning system” to support the COVID- 19 response at the QECH paediatric department. Methods: All elements of the COVID-19 response (the intervention) will be described at baseline using the TiDieR checklist. The implementation of this response will be assessed using a modified RE-AIM framework, supplemented with qualitative enquiry based on the Consolidated Framework for Implementation Research. A key element of the intervention is real time data utilisation via implementation of a data dashboard. The dashboard will be updated weekly. The aim of the dashboard is to provide a “learning” system to inform ongoing COVID-19 specific activities and maintain in-patient quality of care through identification of key indicators requiring improvement on a weekly basis which will be entered into a PDSA cycle. The efficacy of the dashboard will be defined as a 20% improvement in the chosen indicator over the following month. A key safety element in the COVID response is minimising unnecessary length of stay (LOS) for in-patients. We will pilot two strategies to reduce inpatient LOS; (i) IV-PO switch antibiotic ward rounds and a (ii) care pathway for complex patients. These interventions will be developed through (i) audit of existing practices including 6 months of retrospective data review and (ii) participatory work-shops with clinicians and nurses in the department. Pilot efficacy of these interventions will be assessed by comparing length of stay and changes in antibiotic prescribing days in the department. The interventions will be refined through feedback from key users and developed for future formal process evaluation.
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The African Covid-19 critical care outcomes study (ACCCOS)
(Kamuzu University of Health Sciences, 2020-10-08) Kachitsa, Clement Precious
TYPE OF STUDY Multi-centre prospective observational cohort study. PROBLEM The infectious disease COVID-19, caused by coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), has been declared a pandemic and an international healthcare emergency by the World Health Organization (WHO). It has spread across the globe, overwhelming healthcare systems by causing high rates of critical illness. Mortality from COVID-19 exceeds 4%, with older people with comorbidities being extremely vulnerable. It is expected that between 50-80% of the world’s population may contract SARS-CoV-2 over the next two years. In Africa there is a limited workforce and there are limited intensive care facilities and critical care resources across to provide sufficient care. It is important therefore to establish what resources, comorbidities and interventions are potentially associated with either mortality or survival in patients with COVID-19 who are referred for critical care in Africa. Rapid dissemination of these findings may help mitigate mortality from COVID-19 in critical care patients in Africa. These points provide the rationale for the African COVID-19 Critical Care Outcomes Study (ACCCOS). STUDY OBJECTIVES The main objectives of this study are to identify critical care resources associated with survival, identify patient comorbidities and other risk factors associated with in-hospital mortality and to identify in hospital interventions associated with in-hospital survival in patients with suspected or known COVID-19 in Africa. METHODS An African multi-centre retrospective and prospective observational cohort study of adult (≥18 years) patients referred to critical care or high-care units with suspected or known COVID-19 infection. Patient follow up will be for a maximum of 30 days in-hospital. The intention is to provide a representative sample of the mortality and the risk factors associated with mortality in adult patients with suspected or known COVID-19 referred for critical care in Africa. This study will run between Aprils to December 2020. EXPECTED FINDINGS AND DISSEMINATION We expect the outcomes to be potentially worse in Africa, because firstly, there is a limited workforce, and secondly there are limited intensive care facilities and critical care resources across Africa to provide sufficient care. A report of the research findings will be submitted to the College of Medicine Research and Ethics Committee, the College of Medicine Library, the Health Sciences research committee, the University research and publication committee, the Lancet Commission and the Ministry of Health.
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Impact of COVID-19 pandemic on patient retention and resource capacity in HIV care clinics in Blantyre urban
(Kamuzu University of Health Sciences, 2021-02-16) Moyo, Reuben
Type of study: This is an interrupted time series retrospective study involving the same population of adults patronizing HIV services in four urban health facilities in Blantyre whose outcomes would be measured before and after the declaration of COVID-19 as a state of disaster in Malawi. Problem COVID-19 pandemic has led to many socioeconomic challenges in addition to the lives lost and disability caused by the illness itself. Measures such as lockdowns and quarantines have led to decreased access to health services due to restricted movements and interruptions in supply chain. Objectives: The broad aim of this study is to determine the impact of COVID-19 pandemic on patient retention and resource capacity in HIV care clinics in Blantyre urban before and during COVID-19 pandemic. This will consider the numbers of patients attending or failing to attend their ART clinic visits in these two periods. It will also assess the clinics capacity to offer uninterrupted HIV services during the pandemic with possible explanations of the observations. Methodology: This study compares HIV treatment service utilization during similar months before and after declaration of state of disaster in Malawi which is the exposure. The outcomes are observed over a period of six months from April to September, 2020, and are compared to a similar period in 2019 to determine the differences. The data will be obtained from patient records at the participating health facilities as well as input from the clinic staff through questionnaire interviews. Expected findings: The findings from this study will help to understand the short-term impacts of COVID- 19 pandemic on the HIV service delivery and may provide insights for larger studies to be conducted based on the findings. Dissemination: Results from this study will be disseminated to various stake holders such as COMREC, participating health facilities, Blantyre District Health Office, M-HIRST, research conferences and various peer reviewed journals.
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A situation assessment of multi-stakeholder experiences, prison system preparedness and health, penal and judicial measures taken to mitigate COVID-19 in Malawian and Zimbabwean prisons
(Kamuzu University of Health Sciences, 2021-05-12) Muula, Adamson
Study type: This is a qualitative study using Empirical Phenomenological Psychological (EPP) five-step quality framework. Problem being studied: Prisons in the sub-Saharan region have been neglected in State COVID-19 responses and state budgeting, with efforts by government limited to prison lockdowns, and early release schemes, presidential pardoning and amnesties in an effort to reduce congestion. There are reports of insufficient disease mitigation measures for both staff (testing capacity, personal protective equipment, sanitation, disinfection) and prisoners alike, leading to prison riots and staff strike actions demanding hazard pay. Tackling disease in prisons is a human rights and public health imperative, given the bridge of transmission between prison and community via visitors, legal representatives, staff and prisoners. Broad objective The broad objective of the study is to assess the COVID-19 response and level of human rights assurance of prisoners and staff. Research Objectives: Specific objectives The specific objectives of the study are to: 1. Map and describe international human, health, occupational and gender rights standards applicable to those living and working in prisons, and WHO/UNODC/UNAIDS/OHCHR technical guidance on minimum standards of care and working conditions. 2. Conduct a legal realist analysis of domestic prison policies relating to disease response preparedness, and health, penal and judicial measures taken by the government to mitigate contagion, especially COVID-19; and the extent to which rights of prisoners and staff are upheld. 3. Explore multi-stakeholder perspectives of the COVID-19 response Methodogy: The EPP approach to collecting and analysing data focus on the subjective experience, in this sense the lived experience of COVID-19 in the prison, and adheres to Husserl’s principle of active efforts to ‘bracket out’ the researchers’ theoretical preunderstanding in the first steps of a text analysis. Data will be collected from Chichiri central prison in Blantyre, Malawi. Focus group discussions will be conducted with consenting male and female prisoners and prison warders. Key informant Interviews will be conducted with prison officers, prison medical officer, legal personnel and other key stakeholders who work closely with prisons. All interviews will be recorded, transcribed verbatim and translated into English where required for analysis. In order to ensure scientific rigour, the EPP five-step quality framework will be used to analyse qualitative and observational data. Expected results and benefits: We expect to find gaps in adherence to COVID-19 preventive measures and adherence to standard human rights protocols within the prison setting.These results will help advocate for adherence to health and human rights standards to prevent populations in these settings from getting infected with COVID-19. Dissemination of findings: The findings will be disseminated to study respondents and key stakeholders through meetings/workshop. Again we intend to share the study findings with COMREC and participants at scientific conferences either in Malawi or internationally. The results will also be published in a peer reviewed journal.
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Understanding choice, control and risk in community responses to the Covid-19 epidemic across the health divide to inform public health strategies in Malawi
(Kamuzu University of Health Sciences, 2021-05-21) Desmond, Nicola
The type of research study: This study will employ a mixed method, cross-sectional study design to explore the capacity of vulnerable groups in urban and peri-urban areas to respond to the risk of COVID-19. We propose to conduct a household survey, key informant interviews and photo voice. The problem: Despite WHO guidance to prevent spread of COVID-19, the extent to which governments have accorded populations freedom to choose how to respond to the risk of infection on one hand or enforced stringent control measures on the other has varied dramatically. In an international pandemic, the decisions and actions of individuals, the capacity of populations to protect their health and adhere to social distancing, hygiene and self-isolation measures will have a bearing on the speed and spread of infection globally. This mixed methods study seeks to explore the capacity of the most vulnerable population groups in Malawi to respond to the risk of Covid-19, to inform national policy responses to protect the health of those most at risk and to mitigate the adverse socioeconomic consequences of containment measures on population health and wellbeing. The objectives: 1. Explore with community groups the measures they are able to take to protect the health of community members and those they support. 2. Explore with community groups their assessment of the government’s response to COVID-19 and its impact on community health and wellbeing. 3. Explore what additional measures community groups believe are necessary and feasible in tackling COVID-19. 4. Understand how vulnerable populations in lower socioeconomic groups resident in high density urban and peri-urban settlements with little possibility of social distancing or self-isolation prioritize risk within precarious settings. 5. Understand how vulnerable populations in lower socioeconomic groups protect their own health and that of their household’s from covid-19. Methodology: We plan to conduct a household survey, photo voice and key informant interviews in order to respond to the specific objectives above. We plan to build on the community of practice identified as local governing structures to identify and interview potential community support groups. We also plan to conduct a householdtelephone survey as well as a digital photovoice study with follow-up telephone narrative interviews. Expected findings and their dissemination. The findings will contribute to 1) understanding the health and social impacts of COVID-19 in urban and peri-urban settings and amongst different vulnerable groups in Southern Malawi, 2) developing community-driven strategies to mitigate the social, economic and health impacts of COVID-19 and 3) inform the MoH and COVID-19 planning committee of community perspectives and responses to COVID- 19 (through the Department of Risk Communication and Community Engagement) to target future communication messages. A copy of the report will also be shared with COMREC, College of Medicine and other local institutions who may be interested with the findings.
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Impact of COVID-19 on optimal infant and young child feeding (IYCF) practices in Mzimba North District
(Kamuzu University of Health Sciences, 2021-05-21) Msadala, Sonintcho Chisomo
Type of research study: Mixed methods study using cross sectional survey and qualitative data collection The problem: COVID-19 response has resulted in health systems shifting focus and resources away from traditional services and this has disrupted provision of such essential services as nutrition education in Mzimba district. This has arisen from task shifting of health care personnel away from nutrition services to COVID-19, disruption to programming from COVID-19 service, gathering and movement restrictions thereby affecting child clinics and community nutrition services, worsening of household incomes and livelihoods and rising case of food insecurity. Optimal Infant and Young Child Feeding (IYCF) which enhances child nutrition has been affected greatly as interventions geared towards achieving such cannot be achieved due to the aforementioned distortions hence escalating child malnutrition. Objectives: The main objective of the study is to explore implications of COVID 19 on optimal infant and young child feeding practices. Specifically, the study aims at describing the effect of COVID-19 on Optimal Infant and Young Child Feeding (IYCF) practices (timely introduction of complementary food, dietary diversity, meal frequency); describing impact of COVID-19 on proportions of children meeting Minimum Acceptable Diets (MAD) which is a composite indicator for the proportion of children meeting both the minimum dietary diversity and minimum meal frequency; describing patterns of consumption of iron rich foods uptake amongst 6-23 month old infants and children in Mzimba district and describing the effect of COVID-19 on nutrition education service provision in Mzimba district.