Childhood disability in Malawi: a population based assessment using the key informant method

Background

Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services.

Methods

Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy.

Results

Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9–17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%).

Conclusion

Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

Testing Pediatric Acuity With an iPad: Validation of "Peekaboo Vision" in Malawi and the UK

Purpose

To evaluate two builds of the digital grating acuity test, “Peekaboo Vision” (PV), in young (6–60 months) populations in two hospital settings (Malawi and United Kingdom).

Methods

Study 1 evaluated PV in Blantyre, Malawi (N = 58, mean age 33 months); study 2 evaluated an updated build in Glasgow, United Kingdom (N = 60, mean age 44 months). Acuities were tested-retested with PV and Keeler Acuity Cards for Infants (KACI). Bland-Altman techniques were used to compare results and repeatability. Child engagement was compared between groups. Study 2 included test-time comparison.

Results

Study 1 (Malawi): The mean difference between PV and KACI was 0.02 logMAR with 95% limits of agreement (LoA) of 0.33 to 0.37 LogMAR. On test-retest, PV demonstrated 95% LoA of −0.283 to 0.198 logMAR with coefficient of repeatability (CR) 0.27. KACI demonstrated 95% LoA of −0.427 to 0.323 logMAR, and larger CR was 0.37. PV evidenced higher engagement scores than KACI (P = 0.0005). Study 2 (UK): The mean difference between PV and KACI was 0.01 logMAR; 95% LoA was −0.413 to 0.437 logMAR. Again, on test-retest, PV had narrower LoA (−0.344 to 0.320 logMAR) and lower CR (0.32) versus KACI, with LoA −0.432 to 0.407 logMAR, CR 0.42. The two tests did not differ in engagement score (P = 0.5). Test time was ∼1 minute shorter for PV (185 vs. 251 s, P = 0.0021).

Conclusions

PV gives comparable results to KACI in two pediatric populations in two settings, with benefits in repeatability indices and test duration.

Translational Relevance

Leveraging tablet technology extends reliable infant acuity testing to bedside, home, and rural settings, including areas where traditional equipment cannot be financed.

Severe eye complications from Stevens-Johnson syndrome in a human immunodeficiency virus-infected patient in Malawi

Stevens-Johnson syndrome (SJS) is a severe form of erythema multiforme that primarily affects skin and mucous membranes. In Malawi, manifestations of SJS may become more common in human immunodeficiency virus-infected patients receiving nevirapine-based antiretroviral therapy (ART) because the CD4 cell threshold for starting ART has increased from 250 to 350 cells/μL. We describe a patient with severe ocular complications from SJS that developed soon after initiation of nevirapine-based ART and cotrimoxazole preventive treatment, which led to blindness. We draw attention to preventive measures that can potentially reduce permanent ocular damage from SJS.

Uptake of diabetic retinopathy screening at a secondary level facility in Malawi

Diabetic retinopathy (DR) is a common microvascular complication of long-standing diabetes mellitus (DM). DR screening is a cost-effective intervention for preventing blindness from DR. We conducted a cross-sectional study to investigate the uptake and the predictors of uptake of annual DR screening in an opportunistic DR screening programme at a secondary-level diabetes clinic in Southern Malawi. Consecutive patients were interviewed using a structured questionnaire to record their demographic characteristics, medical details and data regarding; the frequency of clinic visits, knowledge of existence of DR screening services and a history of referral for DR screening in the prior one year. Univariate binary logistic regression was used to investigate predictors of DR screening uptake over the prior one year. Explanatory variables that had a P-value of < 0.1 were included into a multivariate logistic regression model. All variables that had a p-value of <0.05 were considered to be statistically significant. We recruited 230 participants over three months with a median age of 52.5 years (IQR 18-84) and a median duration of diabetes of 4 years (IQR 1-7). The average interval of clinic visits was 1.2 months (SD ± 0.43) and only 59.1% (n = 139) of the participants were aware of the existence of diabetic retinopathy screening services at the facility. The uptake for DR screening over one year was 20% (n = 46). The strongest predictors of uptake on univariate analysis were awareness of the existence of DR screening services (OR 10.05, P <0.001) and a history of being referred for DR screening (OR 9.02, P <0.001) and these remained significant on multivariable analysis. Interventions to improve uptake for DR screening should promote referral of patients for DR screening and strengthen knowledge about the need and availability of DR screening services.

Ocular surface squamous neoplasia as the first apparent manifestation of HIV infection in Malawi

PURPOSE

To evaluate the prevalence of undiagnosed and asymptomatic HIV infection in patients with ocular surface squamous neoplasia (OSSN) in an urban patient population in Malawi.

METHODS

A consecutive series of patients presenting with OSSN was evaluated in an African academic centre. A detailed history and physical examination in 53 consecutive patients with conjunctival squamous cell carcinoma and conjunctival intraepithelial neoplasia were performed. Thirty eight (72%) patients agreed to undergo serological HIV testing.

RESULTS

Seventy-nine per cent (30 of 38) patients were HIV positive. None of the patients had previous HIV testing or was aware of having symptoms of HIV. Seventy per cent (n = 21) of the HIV-positive patients had no other symptoms suggestive of HIV infection or any other disease. Patients were far more likely to refuse HIV testing if they were married and male.

CONCLUSIONS

The conjunctival tumour may be the primary and only apparent manifestation of HIV in patients presenting with OSSN in Sub-Saharan Africa.

Management of diabetic retinopathy

Sub-Saharan Africa faces an epidemic of diabetes. Visual loss from diabetic retinopathy (DR) is both preventable and treatable. This article reviews the epidemiology and clinical features of DR and current evidence-based interventions in three areas: primary prevention of retinopathy by optimum medical management, early detection of pre-symptomatic disease and management of established retinopathy to prevent or mitigate visual loss. There are significant challenges to DR care in resource poor environments. Appropriate provision of effective interventions by health services can reduce social and economic costs associated with patient care.

Predicting Acute and Post-Recovery Outcomes in Cerebral Malaria and Other Comas by Optical Coherence Tomography (OCT in CM) - A protocol for an observational cohort study of Malawian children

Cerebral malaria (CM) remains a significant global health challenge with high morbidity and mortality. Malarial retinopathy has been shown to be diagnostically and prognostically significant in the assessment of CM. The major mechanism of death in paediatric CM is brain swelling. Long term morbidity is typically characterised by neurological and neurodevelopmental sequelae. Optical coherence tomography can be used to quantify papilloedema and macular ischaemia, identified as hyperreflectivity. Here we describe a protocol to test the hypotheses that quantification of optic nerve head swelling using optical coherence tomography can identify severe brain swelling in CM, and that quantification of hyperreflectivity in the macula predicts neurodevelopmental outcomes post-recovery. Additionally, our protocol includes the development of a novel, low-cost, handheld optical coherence tomography machine and artificial intelligence tools to assist in image analysis.

Ocular infection from Staphylococcus aureus bacteraemia in a sero-positive HIV patient from Queen Elizabeth Central Hospital, Blantyre, Malawi

Ocular involvement in Staphylococcus aureus bacteraemia occurs with metastatic infection and has been identified as an independent risk factor for mortality. It manifests as either endophthalmitis or chorioretinitis and often leads to visual loss, particularly with delayed diagnosis. We present a case report of endogenous endophthalmitis and chorioretinitis in the background of methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia in a 23-year-old HIV-positive woman.

Evaluation of Tele-Education in Malawi for Detection of Macular Features Using Optical Coherence Tomography

PURPOSE

The study aimed to assess the reliability of tele-education in training a Malawian ophthalmology resident to interpret optical coherence tomography (OCT) images of patients with macular conditions.

METHODS

This was a retrospective analysis of 1000 macula-centered OCT image series from 1000 eyes of 1000 consecutive patients from Malawi, which involved initial interpretation by a German retina specialist (observer 1) (T0). Observer 1 then trained a Malawian resident (observer 2) via email, and observer 2 independently interpreted images at T1, followed by face-to-face training in Malawi and reinterpretation at T2 and T3 (3-month intervals). The observers had to recognize, on OCT imaging, the normal macular structure, vitreofoveal traction (VFT), absent fovea depression (FD), epiretinal membrane (ERM), lamellar macular hole (LMH), full-thickness macular hole (FTMH), foveoschisis, intraretinal pseudocyst (IPC), intraretinal hyperreflective foci (IHF), subretinal fluid (SRF), pigment epithelial detachment (PED), and drusen. Cohen's Kappa statistic measured inter-observer agreement.

RESULTS

At T1 post-tele-education, almost perfect agreement (κ = 0.86; 99.6% agreement) was observed for FTMH. Agreement remained high at T2 post-face-to-face training (κ = 0.9; 99.7%) and decreased substantially at T3 (κ = 0.77; 99.4%). Following tele-education (T1), substantial agreement (κ range: 0.77 - 0.86) was found for IPC, PED, IHF, and FD, while ERM showed fair agreement (κ = 0.33; 81%). Face-to-face training notably improved agreement for SRF (T1 κ = 0.6, T2 κ = 0.63), LMH (T1 κ = 0.6, T2 κ = 0.67), and normal macular structure (T1 κ = 0.6, T2 κ = 0.62).

CONCLUSION

There was good agreement in the detection of the majority of the OCT features seen in most of the macular pathologies following training through tele-education and the results did not change significantly following face-to-face teaching. Tele-education could reliably complement training in vitreoretinal diagnostic skills in resource-limited settings.