Factors influencing operationalization of Integrated Disease Surveillance in Malawi

OBJECTIVES

Malawi's disease surveillance system is built on several different data sources and systems and is informed by the Integrated Diseases Surveillance and Response (IDSR) strategy. This study was carried out as part of a larger multicountry study to identify context-specific factors, which influence the operationalization of integrated disease surveillance.

STUDY DESIGN AND METHODS

A total of six focus group discussions were conducted with 43 relevant personnel at the primary and secondary healthcare levels in two districts (Lilongwe and Dowa) and at the national level. The discussions were analyzed and sorted into predefined categories based on the domains of the International Association of Public Health conceptual framework.

RESULTS

We found ongoing efforts to enhance integrated disease surveillance operationalization, including the establishment of the Public Health Institute of Malawi for coordination, digitalizing the surveillance system through One Health Surveillance Platform, and improving communication among rapid response teams using WhatsApp. The adoption of World Health Organization's third edition IDSR technical guidelines was also underway. Nonetheless, there were major implementation barriers such as parallel and uncoordinated surveillance systems, priority conditions that cannot be diagnosed at the point of reporting, lack of case definitions and diagnostic codes for priority conditions, reporting forms with unexplained acronyms, illegible data sources, unstable electronic data transfers, inadequate supervision and training, poor enforcement of reporting from private health facilities, high reporting burden, and lack of and feedback to those reporting.

CONCLUSIONS

The results fit well into the predefined categories used. The study reveals basic problems with the operationalization, tools, and reporting forms used for IDSR. These findings may have implications for practice and policy in Malawi and other countries where IDSR is the national strategy for surveillance.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Reduced tuberculosis case notification associated with scaling up antiretroviral treatment in rural Malawi

OBJECTIVE

To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART).

METHODS

Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009.

RESULTS

There were a total of 10,070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002-2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100,000 population (χ(2) for trend 261, P < 0.001, cumulative reduction for 2005-2009 = 33%, 95%CI 27-39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100,000 (χ(2) for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9-49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847-1480) new TB cases and 78 (95%CI 23-151) recurrent TB cases.

CONCLUSIONS

High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.

High frequency of Tuberculosis in households of patients with Pulmonary Tuberculosis in Mzimba, Malawi

A case-control study was carried out in Mzimba district to determine whether household members of a patient with pulmonary tuberculosis (PTB) had an increased frequency of TB compared with households where no TB had been previously diagnosed. There were 79 patients with PTB (66 with smear-positive PTB and 13 with smear-negative PTB) and 79 controls, matched by age and sex. Household compositions were similar. During a mean period of observation of 35 months, 8 household members from PTB patient households developed TB compared with no household members from control households (RR 1.99, 95% CI 1.81 - 2.18). The case notification rate of TB in household members from patients with all types of PTB was calculated at 1221 / 100.000/ year: the rates were 1233 /100,000 / year for household members from patients with smear-positive PTB and 1127 for household members from patients with smear-negative PTB. The frequency of TB in households of TB patients is significantly higher than in households of control persons who have not suffered from TB.

Gender differences in relation to sputum submission and smear-positive pulmonary tuberculosis in Malawi

OBJECTIVE

To examine gender differences in sputum submission and sputum smear positivity.

METHODS

Laboratory registers in all diagnostic units in eight districts in Malawi were examined for the years 1995 and 1996.

RESULTS

During a 12-month period (averaged between 1995 and 1996), 26,624 new TB suspects submitted sputum samples, 3282 of which (12.3%) were smear-positive. Significantly more males submitted sputum (52%) compared with females (48%), and significantly more males (53%) were smear-positive compared with females (47%, P < 0.05). Rates of sputum submission per 100,000 adults were also significantly higher for males (1203) than females (1032).

CONCLUSION

In Malawi, fewer females are submitting sputum samples and are being diagnosed with smear-positive TB compared with males.

Care seeking behaviour and diagnostic processes in patients with smear-positive pulmonary tuberculosis in Malawi

SETTING

Government hospitals in five districts in Malawi.

OBJECTIVE

To determine care seeking behaviour and diagnostic processes in patients newly diagnosed with smear-positive pulmonary tuberculosis (PTB).

DESIGN

Structured questionnaires completed by interview between January to September 1998.

RESULTS

During the study period 1,518 patients were registered with PTB, of whom 1,099 (72%) were interviewed. The median delay between onset of cough and diagnosis was 8 weeks. There was a variable pattern of care seeking behaviour, with 70% of patients initially visiting a place of orthodox medical care and 30% visiting traditional healers, grocery shops, etc. Of these, 867 (79%) patients had one or more subsequent contacts for help, with these visits targeted more to orthodox medical care. At all stages, antibiotics resulted in symptomatic improvement in up to 40% of cases. There was a median time of 7 weeks between cough and first submission of sputum specimens. Almost all patients received sputum smear results after a median length of 4 days; 474 (43%) of patients were only aware of their diagnosis at the time of receiving smear results, this observation being significantly associated with lack of schooling and not knowing another person with TB.

CONCLUSION

More needs to be done to educate communities and non-orthodox care providers about the diagnosis and treatment of TB.