Emerging public health challenges during the COVID-19 pandemic in Malawi: A review

Time to invest in cholera

The recent surge in cholera cases globally calls for urgent evaluation of current approaches to prevention and control of the disease. Malawi was one of the worst affected countries in 2022-2023 with the highest number of deaths due to cholera in the world. In this personal view, we look at Malawi as a case example to illustrate how current approaches lack sufficient investment. We review the history of cholera in Malawi and compare previous outbreaks to the 2022/23 outbreak. We discuss contributing factors to the outbreak including a lack of investment in water, sanitation and hygiene (both historically and currently), human resource constraints, and the market structures which make accessing oral cholera vaccine challenging both in the midst of an ongoing outbreak and as a preventative approach. We call for international action to address the economic and structural challenges underlying cholera persistence and propose solutions to prevent future epidemics and to eliminate cholera as a public health threat.

Towards improving district health information system data consistency, report completeness and timeliness in Neno district, Malawi

BACKGROUND

Quality data is crucial in making informed decisions regarding health services; However, the literature suggests that in many LMICs including Malawi, it remains of poor quality. Data quality is measured in terms of completeness, timeliness and consistency among other parameters. We describe the Ministry of Health's District Health Information System (DHIS2) report completeness and timeliness at three levels: National, South West Zone (SWZ) and Neno district. Further, describe data consistency following data quality assessments (DQA) in Neno district, Malawi.

METHODS

We conducted a descriptive retrospective study by extracting DHIS2 report completeness and timeliness at three levels and used DQA data in Neno district between January 2016 and December 2022. We defined report completeness as the number of reports in DHIS2 against those expected, timeliness as the number of reports entered into DHIS2 before the deadline and consistency as the level of agreement between three sources: register, report and DHIS2 system. We presented the data graphically and calculated yearly median reporting rates for weekly, monthly and quarterly reports against the national target of 85%. We utilized a verification factor (VF) of 0-200% to evaluate consistency between three sources in the Neno district. VF exceeding 100% indicated over-reporting, 100% as a perfect match, and less than 100% as under-reporting, with an acceptable 90-110% range.

RESULTS

During the study period, we found increased trends in weekly, monthly and quarterly report completeness at all three levels but were below 85%. Neno district surpassed the target from 2020 onward for weekly reports and from 2019 onward for monthly reports. Similar increased trends were observed for report timeliness with below threshold of 85% except for Neno district monthly report from 2021 onward. We found inconsistencies in data entry from the report to DHIS2 (VF: >90% - <110%) in Neno district. Similarly, under and over-reporting occurred between the register and the report (VF: <90% and > 110%) were observed. These findings should be considered when using DHIS2 for decision-making.

CONCLUSION

In general, we found increased completeness and timeliness rates at all three levels, however, less than the set target of 85%. We suggest continued support, including routine DQAs and report monitoring, towards improving DHIS2 data quality.

"Kuteteza": A community-engaged COVID-19 Prevention and Protection Initiative in Southern Malawi

Background

The COVID-19 epidemic in Malawi involved almost 90,000 recorded cases and 2,638 deaths. In response to early concerns about vulnerable older people in rural areas, we developed 'Kuteteza': a COVID-19 mitigation response project. Clinicians, public health professionals, and researchers collaborated with government and district-level staff in two Southern Malawi districts. Interventions included supported 'shielding' of older people - minimising social mixing whilst having their daily needs supported. Additional mitigation strategies included provision of masks, handwashing stations, and soap. Government partnerships allowed additional support for vulnerable groups. We present the findings of a realist project evaluation, assessing the feasibility of this approach.

Methods

We collated anonymised descriptive data on Kuteteza procedures and conducted qualitative structured observations in villages involved in the initiative. We carried out three focus groups involving community members, frontline health staff, and volunteers in each setting. These provided deeper insights into experiences of the pandemic and impacts of the intervention, including suggested opportunities during future outbreaks.

Results

The project involved 25 villages across two districts, with 1,087 people over the age of 60 voluntarily participating in 'shielding'. Supplies of food, water, and cooking fuel were mostly arranged within the family. In Kuteteza villages, the handwashing stations and soap were widely used, and there was awareness and some observance of COVID-19 prevention measures. The project, including the provision of supplies, was greatly appreciated by communities, but wider contextual constraints - namely widespread economic insecurity - presented persisting challenges. Suggestions for improvement largely concerned project enhancements and extensions.

Conclusions

Through effective stakeholder engagement and contribution to national response strategy, the Kuteteza project helped raise COVID-19 awareness and supported populations at a critical time in the pandemic. Kuteteza approaches were welcomed locally and may be incorporated in future epidemic responses. Supported 'shielding' should be paired with government-led measures to mitigate economic hardship.

"Life mapping" exploring the lived experience of COVID-19 on access to HIV treatment and care in Malawi

Background

The COVID-19 pandemic in Malawi exacerbated, existing public health challenges including access to HIV treatment and care services. "Life Mapping," a component of the Citizen Science community-led project in Malawi, documented the lived experiences and perspectives of people living with HIV in the context of COVID-19.

Methods

Citizen Science Life Maps is a three-year qualitative, longitudinal project utilizing collaborative and participatory research methods through digital storytelling to document peoples' daily lives. Twenty participants living with HIV were recruited between 2022 and 2023 in two central regional districts of Malawi and two urban areas. The participants were given mobile smart phones to document the impact of COVID-19 on HIV prevention and treatment services, HIV treatment literacy, mental health and the COVID -19 vaccine. Data was analyzed using a thematic analysis approach.

Results

Access to HIV prevention and treatment slowly recovered yet introducing multi-month anti- retroviral dispensing raised concerns. In the absence of mental health care services, participants were resourceful in seeking alternative ways to deal with mental health. However, state sponsored violence in relation to COVID-19 public health measures impacted negatively not only on mental well-being but also on HIV treatment adherence. Whilst most recognized the importance of the COVID-19 vaccine, especially for people living with HIV, myths, misinformation, and conspiracy theories around the vaccine persisted especially religious themed misinformation.

Conclusions

The relationship between misinformation and COVID-19 vaccine hesitancy is complex and medical and scientific approaches may not be sufficient to prevent misinformation. Fear and misinformation are likely attributed to global uncertainty during the pandemic and the speed at which vaccines were developed with minimal opportunity to prepare global communities.

Household costs and care seeking patterns associated with COVID-19 in Blantyre, Malawi

Economic consequences of COVID-19 illness and healthcare use for households in low income countries are not well known. We estimated costs associated with COVID-19 care-seeking and treatment from a household perspective and assessed determinants of treatment costs. A cross-sectional household survey was conducted between December 2020 and November 2021 in urban and peri-urban areas of Blantyre district. Adults (age ≥18 years) with confirmed COVID-19 were asked to report the symptoms they experienced or prompted them to seek COVID-19 tests as well as healthcare seeking behaviors preceding and following COVID-19 diagnosis. For individuals who sought healthcare, information on out-of-pocket expenditures incurred while seeking and receiving care including on transport, food etc. by both the patients and their guardians was collected. Finally, data on time use seeking, receiving care and during convalesces was recorded. Multivariate Generalized Linear Models were used to evaluate association between household COVID-19 costs and their determinants. Of 171 individuals who took part in the study, the average age was 40.7 years, standard deviation (SD) 15.0, and 50.8% were females. Most participants (85.3%) were symptomatic. Of these, 67.8% sought care at health facilities and the majority (91.7%) were treated as outpatients. The average total household cost associated with COVID-19 seeking, receiving care and convalescence was $62.81 (SD $126.02). Average costs for outpatient and inpatient cases were $52.96 (SD $54.35) and $172.39 (SD $407.08), respectively. Average out-of-pocket household expenditures were $42.62 (SD $123.10), accounting for 62% of total household costs. Being a male COVID-19 patient and engagement in formal employment were significantly associated with high COVID-19 household costs. Households face high economic burden related to COVID-19 sickness and healthcare use. Social policies that support households cope with both the direct and indirect COVID-19 cost are needed to ensure access to healthcare and protect households from COVID-19 related shocks.