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BackgroundThe high global prevalence of mental disorders justifies the need to quantify their burden in the sub-Saharan Africa where there is a dearth of information. These mental disorders are linked to different socio-demographic factors.ObjectiveTo determine the prevalence of, and factors associated with mental disorders among children and adolescents in Blantyre City, Malawi.Methods Children and adolescents aged 6 to 17 years were interviewed to determine their socio-demographic characteristics and assess their mental health status using the Strengths and Difficulties Questionnaire (SDQ) and Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Associations between mental disorders and socio-demographic characteristics were tested using Chi-square and logistic regression analysis.ResultsThe prevalence of symptoms of psychopathology on the SDQ was 7.3% (95%CI 4.8-10.5%) while for the K-SADS was 5.9% (95% CI 3.7%-8.9%). The prevalence of mental disorders across the age ranges of 6 to 12 years and 13 to 17 years was 5.4% and 7.9 % respectively. Males had a higher prevalence (7.1%) compared to females (4.7%). Conduct disorder was most prevalent (3.4%), followed by either type of ADHD- Attention Deficit Hyperactive Disorders (2.0%). Having a single parent (p

Background: There has been a decline in childhood vaccination uptake, with reports indicating that 25 million children missed out on one or more doses in 2021 . There is a need to understand the socio-behavioural drivers of vaccination uptake and to identify contextual and emerging factors that can inform demand-creation interventions. Objective: This review examined the social and behavioural factors influencing childhood vaccination intentions and uptake globally. Methods: A comprehensive search was carried out for published studies that presented data on patterns of association between socio-behavioural factors and vaccination intentions and uptake in children under five years. Studies were screened for eligibility by two reviewers, and information was collected using a standard data abstraction form. Findings: Out of 4462 records identified in the search, 82 studies were included. Emerging factors influencing vaccination uptake included gender-based factors like the mother’s financial autonomy, the number of social and formal messengers recommending vaccination, the proportion of non-conforming social network members, and the role of decisional balance and conflict as a moderator of the vaccination intention and action pathway. Conclusion: The review identified multiple behavioural and social constructs influencing vaccination intentions and uptake. The diversity of influences underscores the complexity of relationships between social-behavioural factors and vaccination uptake, which may be contributing to low vaccination uptake. More context-specific research is required to extend the geographical base and depth of evidence and to evaluate highly localised socio-behavioural interventions.

Adverse events may be a cause of observed poor completion of isoniazid preventive therapy (IPT) among people living with HIV in high tuberculosis burden areas. Data on IPT-related adverse events (AE) from sub-Saharan Africa are scarce. We report IPT-related AEs, associated clinical characteristics, and IPT discontinuations in adults who were stable on antiretroviral therapy (ART) when they initiated IPT. Cohort study nested within a randomized, controlled, clinical trial of cotrimoxazole and chloroquine prophylaxis in Malawians aged ≥ 18 years and virologically suppressed on ART. Eight hundred sixty-nine patients were followed for a median of 6 months after IPT initiation. IPT relatedness of AEs was determined retrospectively with the World Health Organization case-causality tool. Frailty survival regression modeling identified factors associated with time to first probably IPT-related AE. The overall IPT-related AE incidence rate was 1.1/person year of observation. IPT relatedness was mostly uncertain and few AEs were severe. Most common were liver and hematological toxicities. Higher age increased risk of a probably IPT-related AE (aHR = 1.02; 95% CI 1.00-1.06; P = .06) and higher weight reduced this risk (aHR = 0.98; 95% CI 0.96-1.00; P = .03). Of 869 patients, 114 (13%) discontinued IPT and 94/114 (82%) discontinuations occurred at the time of a possibly or probably IPT-related AE. We observed a high incidence of mostly mild IPT-related AEs among individuals who were stable on ART. More than 1 in 8 persons discontinued IPT. These findings inform strategies to improve implementation of IPT in adults on ART, including close monitoring of groups at higher risk of IPT-related AEs.

Background: Malawi's National Malaria Control Programme (NMCP) is developing a new strategic plan for 2023-2030 to combat malaria and recognizes that a blanket approach to malaria interventions is no longer feasible. To inform this new strategy, the NMCP set up a task force comprising 18 members from various sectors, which convened a meeting to stratify the malaria burden in Malawi and recommend interventions for each stratum. Methods: The burden stratification workshop took place from November 29 to December 2, 2022, in Blantyre, Malawi, and collated essential data on malaria burden indicators, such as incidence, prevalence, and mortality. Workshop participants reviewed the malaria burden and intervention coverage data to describe the current status and identified the districts as a appropriate administrative level for stratification and action. Two scenarios were developed for the stratification, based on composites of three variables. Scenario 1 included incidence, prevalence, and under-five all-cause mortality, while Scenario 2 included total malaria cases, prevalence, and under-five all-cause mortality counts. The task force developed four burden strata (highest, high, moderate, and low) for each scenario, resulting in a final list of districts assigned to each stratum. Results: The task force concluded with 10 districts in the highest-burden stratum (Nkhotakota, Salima, Mchinji, Dowa, Ntchisi, Mwanza, Likoma, Lilongwe, Kasungu and Mangochi) 11 districts in the high burden stratum (Chitipa, Rumphi, Nkhata Bay, Dedza, Ntcheu, Neno, Thyolo, Nsanje, Zomba, Mzimba and Mulanje) and seven districts in the moderate burden stratum (Karonga, Chikwawa, Balaka, Machinga, Phalombe, Blantyre, and Chiradzulu). There were no districts in the low-burden stratum. Conclusion: The next steps for the NMCP are to review context-specific issues driving malaria transmission and recommend interventions for each stratum. Overall, this burden stratification workshop provides a critical foundation for developing a successful malaria strategic plan for Malawi.

There is a substantial typhoid burden in sub-Saharan Africa, and TCV has been introduced in two African countries to date. Decision-makers in Malawi decided to introduce TCV and applied for financial support from Gavi, the Vaccine Alliance in 2020. The current plan is to introduce TCV as part of the national immunization program in late 2022. The introduction will include a nationwide campaign targeting all children aged 9 months to 15 years. Following the campaign, TCV will be provided through routine immunization at 9 months. This study aims to estimate the cost of TCV introduction and recurrent delivery as part of the national immunization program.This costing analysis is conducted from the government's perspective and focuses on projecting the incremental cost of TCV introduction and delivery for Malawi's existing immunization program before vaccine introduction. The study uses a costing tool developed by LevinMorgan through a partnership between the International Vaccine Institute and the World Health Organization and leverages primary and secondary data collected through key informant interviews with representatives of the Malawi Expanded Programme on Immunization team at various levels.The total financial and economic costs of TCV introduction over three years in Malawi are projected to be US$8.5 million and US$29.8 million, respectively. More than two-thirds of the total cost is made up of recurrent costs. Major cost drivers include the procurement of vaccines and injection supplies and service delivery costs. Without vaccine cost, we estimate the cost per child immunized to be substantially lower than US$1.Findings from this analysis may be used to assess the economic implications of introducing TCV in Malawi. Major cost drivers highlighted by the analysis may also inform decision-makers in the region as they assess the value and feasibility of TCV introduction in their national immunization program.

Background: The RTS,S/AS01E malaria vaccine is being assessed in Malawi, Ghana and Kenya as part of a large-scale pilot implementation programme. Even if impactful, its incorporation into immunisation programmes will depend on demonstrating cost-effectiveness. We analysed the cost-effectiveness and public health impact of the RTS,S/AS01E malaria vaccine use in Malawi. Methods: We calculated the Incremental Cost Effectiveness Ratio (ICER) per disability-adjusted life year (DALY) averted by vaccination and compared it to Malawi’s mean per capita Gross Domestic Product. We used a previously validated Markov model, which simulated malaria progression in a 2017 Malawian birth cohort for 15 years. We used a 46% vaccine efficacy, 75% vaccine coverage, USD5 estimated cost per vaccine dose, published local treatment costs for clinical malaria and Malawi specific malaria indicators for interventions such as bed net and antimalarial use. We took a healthcare provider, household and societal perspective. Costs were discounted at 3% per year, no discounting was applied to DALYs. For public health impact, we calculated the DALYs, and malaria events averted. Results: The ICER/DALY averted was USD115 and USD109 for the health system perspective and societal perspective respectively, lower than GDP per capita of USD398.6 for Malawi. Sensitivity analyses exploring the impact of variation in vaccine costs, vaccine coverage rate and coverage of four doses showed vaccine implementation would be cost-effective across a wide range of different outcomes. RTS,S/AS01 was predicted to avert a median of 93,940 (range 20,490–126,540) clinical cases and 394 (127–708) deaths for the three-dose schedule, or 116,480 (31,450–160,410) clinical cases and 484 (189–859) deaths for the four-dose schedule, per 100 000 fully vaccinated children. Conclusions: We predict the introduction of the RTS,S/AS01 vaccine in the Malawian expanded programme of immunisation (EPI) likely to be highly cost effective.

BACKGROUND: The GMZ2/alum candidate malaria vaccine had an efficacy of 14% (95% confidence interval [CI]: 3.6%, 23%) against clinical malaria over 6 months of follow-up in a phase2b multicentre trial in children 1-5 years of age. Here we report the extended follow up of safety and efficacy over 2 years.METHODS: A total of 1849 (GMZ2 = 926, rabies = 923) children aged 12-60 months were randomized to receive intramuscularly, either 3 doses of 100 μg GMZ2/alum or 3 doses of rabies vaccine as control 28 days apart. The children were followed-up for 24 months for clinical malaria episodes and adverse events. The primary endpoint was documented fever with parasitaemia of at least 5000/μL.RESULTS: There were 2,062 malaria episodes in the GMZ2/alum group and 2,115 in the rabies vaccine group in the intention-to-treat analysis, vaccine efficacy (VE) of 6.5% (95%: CI -1.6%, 14.0%). In children aged 1-2 years at enrolment, VE was 3.6% (95 %CI: -9.1%, 14.8%) in the first year and -4.1% (95 %CI: -18.7%, 87%) in the second year. In children aged 3-5 years at enrolment VE was 19.9% (95 %CI: 7.7%, 30.4%) in the first year and 6.3% (95 %CI: -10.2%, 20.3%) in the second year (interaction by year, P = 0.025, and by age group, P = 0.085). A total of 187 (GMZ2 = 91, rabies = 96) serious adverse events were recorded in 167 individuals over the entire period of the study. There were no GMZ2 vaccine related serious adverse events.CONCLUSIONS: GMZ2/alum was well tolerated. Follow-up over 2 years confirmed a low level of vaccine efficacy with slightly higher efficacy in older children, which suggests GMZ2 may act in concert with naturally acquired immunity.

Background Malaria remains a significant cause of morbidity and mortality in the paediatric population in Malawi. Insecticide-treated bed nets are a key vector malaria control intervention, however, advancement towards universal access is progressing slowly. Malawi Malaria indicator surveys (MMIS) show diverse user preferences of bed net shape and colour. The objective of this work was to understand if bed net shape and colour preferences affect usage. Methods This is a secondary analysis of data from households that participated in the 2016–2017 MMIS. The main outcome variable was net usage defined, at net level, whether someone slept under a particular net on the night before the survey. The main exposure variables were preference attributes, whether a particular net is of a preferred colour or shape as defined by the household respondent. Both bivariate and multivariate logistic regression analyses were done to determine the association between the exposure and outcome variables. Results A total of 3729 households with 16,755 individuals were included in this analysis. There were a total 7710 bed nets in households that participated in the survey of which 5435 (70.5%) of these nets had someone sleep under them the previous night before the survey. Bed nets that are of a preferred shape have 3.55 times higher odds of being used than those not preferred [AOR 3.55 (95% CI 2.98, 4.23; p value p value Conclusions The results indicate that if a bed net is of a preferred colour or shape, it is more likely to be used. Bed net purchase by malaria stakeholders need to balance more factors on top of preferences such as price and efficacy.

IntroductionMalawi has the highest rates of mortality directly or indirectly associated with burn injuries in Southern Africa. There is however no published literature on risk factors of mortality among adult patients.MethodsWe conducted a retrospective cross sectional audit records of patients admitted at the burns unit of Queen Elizabeth Central Hospital (QECH) between the years 2007 and 2017. Death due to burns was our outcome of interest. We collected patient data including demographic information, details of the burn injury and its management and determined how these factors were associated with the risk of death using Person Chi square tests in a univariate analysis and likelihood ratio tests in a multivariate logistic regression model. We also determined the odds ratios of death within the categories of the risk factors after adjusting for important variables using a logistic regression model.ResultsAn analysis of 500 burns patient records showed that 132(26.4%) died during the 10-year period. The lethal area for 50% of burns (LA50) was 28.75% and mortality reached 100% at 40% total burn surface area. The following variables were found to be significantly associated with mortality after controlling for confounders: scalds (OR 0.13; 95% CI 0.05-0.33; ConclusionsRisk factors for mortality are connected by their association with post-burn hypermetabolism. Further studies to are needed to identify the best and cost-effective ways of preventing death in burn patients.

IntroductionInfections are responsible for up to 85% of deaths in patients with burn injuries. Proper management of infections in patients with burns requires knowledge of local microbial landscape and antimicrobial resistance patterns. Most burns units in low to middle income countries lack this data to guide patient management.Methods and resultsWe conducted a retrospective audit of adult (≥17 years) patient records admitted between at 1st June 2007 and May 2017 at Queen Elizabeth Central Hospital Burns unit in Blantyre Malawi with an index complaint of burn injury. Descriptive statistical analysis was performed to determine antibiotic prescription patterns, microbial isolates and antimicrobial resistance patterns on the 500 patient files that met the inclusion criteria. Cephalosporin’s and Penicillin’s constituted 72.3% of the 328 antibiotic prescriptions given to 212 patients and 84% of all prescriptions were potentially inappropriate. A total of 102 bacterial isolates were identified and a majority (30.4%; n=31) were resistant to Aminoglycosides and Aminocyclitols (23.5%; n=24); seconded by Penicillin’s at 19.6% (n=20). Pseudomonas, staphylococcus and streptococcus species constituted 36.1%, 25% and 16.7% of all resistant bacteria that were isolated and they were thus the most common bacterial isolates. Drug resistance was more common among gram negative bacteria (48.8% versus 26.2%) and a greater proportion of patients (74.1%) that had antibiotic sensitivity testing were affected by drug resistant gram negative bacteria which appear on the World Health Organisation list of priority pathogens.ConclusionThe results of our preliminary study point towards nosocomial gram negative bacteria which appear on the World Health Organisations list of priority pathogens as the more common sources of antibiotic resistance. This scenario is potentially driven by inappropriate antibiotic prescriptions as well as clinical and laboratory diagnostic imprecision in addition to the universally recognised post burn pathophysiological changes of hypermetabolism and immunosuppression. Improvements in the areas of antimicrobial stewardship, diagnostic capacity and burns related research are needed in order to achieve optimal therapeutic outcomes and resource utilisation.

Background: The prevalence of malaria infection in time and space provides important information on the likely sub-national epidemiology of malaria burdens and how this has changed following intervention. Model-based geostatitics (MBG) allow national malaria control programmes to leverage multiple data sources to provide predictions of malaria prevalance by district over time. These methods are used to explore the possible changes in malaria prevalance in Malawi from 2010 to 2017. Methods: Plasmodium falciparum parasite prevalence (PfPR) surveys undertaken in Malawi between 2000 and 2017 were assembled. A spatio-temporal geostatistical model was fitted to predict annual malaria risk for children aged 2–10 years (PfPR2–10) at 1×1 km spatial resolutions. Parameter estimation was carried out using the Monte Carlo maximum likelihood methods. Population-adjusted prevalence and populations at risk by district were calculated for 2010 and 2017 to inform malaria control program priority setting. Results: 2,237 surveys at 1,834 communities undertaken between 2000 and 2017 were identified, geo-coded and used within the MBG framework to predict district malaria prevalence properties for 2010 and 2017. Nationally, there was a 47.2% reduction in the mean modelled PfPR2-10 from 29.4% (95% confidence interval (CI) 26.6 to 32.3%) in 2010 to 15.2% (95% CI 13.3 to 18.0%) in 2017. Declining prevalence was not equal across the country, 25 of 27 districts showed a substantial decline ranging from a 3.3% reduction to 79% reduction. By 2017, 16% of Malawi’s population still lived in areas that support PfPR2-10 ≥ 25%. Conclusions: Malawi has made substantial progress in reducing the prevalence of malaria over the last seven years. However, Malawi remains in meso-endemic malaria transmission risk. To sustain the gains made and continue reducing the transmission further, universal control interventions need to be maintained at a national level.