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Mwale D, Manda-Taylor L, Langton J, Likumbo A, van Hensbroek MB, Calis J, Janssens W, Pell C. The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi. BMC Health Serv Res 2024; 24:595. [PMID: 38714998 PMCID: PMC11077805 DOI: 10.1186/s12913-024-11050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.
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Affiliation(s)
- Daniel Mwale
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training Research Unit of Excellence, Blantyre, Malawi.
| | - Lucinda Manda-Taylor
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training Research Unit of Excellence, Blantyre, Malawi
| | | | - Alice Likumbo
- Training Research Unit of Excellence, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
| | - Job Calis
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciencies, Blantyre, Malawi
| | - Wendy Janssens
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Schade AT, Sabawo M, Jaffry Z, Nyamulani N, Mpanga CC, Ngoie LB, Metcalfe AJ, Lalloo DG, Harrison WJ, Leather A, MacPherson P. Improving the management of open tibia fractures, Malawi. Bull World Health Organ 2024; 102:255-264. [PMID: 38562195 PMCID: PMC10976873 DOI: 10.2471/blt.23.290755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/21/2023] [Accepted: 01/10/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures. Methods We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and-after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention. Findings The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice. Conclusion Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle.
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Affiliation(s)
- Alexander Thomas Schade
- Public Health Department, Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, P.O. Box 30096, Blantyre, Malawi
| | - Maureen Sabawo
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Zahra Jaffry
- Trauma and Orthopaedic Department, Bart’s Health NHS Trust, London, England
| | - Nohakhelha Nyamulani
- Trauma and Orthopaedic Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Leonard Banza Ngoie
- Trauma and Orthopaedic Department, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | | | - Andrew Leather
- King's Global Health Partnerships, King’s College London, London, England
| | - Peter MacPherson
- School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
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Njoki C, Simiyu N, Kaddu R, Mwangi W, Sulemanji D, Oduor P, Dona DG, Otieno D, Abonyo TT, Wangeci P, Kabanya T, Mutuku S, Kioko A, Muthoni J, Kamau PM, Beane A, Haniffa R, Dondorp A, Misango D, Pisani L, Waweru-Siika W. EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study. Crit Care Explor 2024; 6:e1036. [PMID: 38356864 PMCID: PMC7615640 DOI: 10.1097/cce.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Objective to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya. Design prospective registry-based observational study. Setting three HDUs and eight ICUs in Kenya. Patients consecutive adult patients admitted between January 2021 and June 2022. Interventions none. Measurements and main results data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality. Conclusions We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients. Study registration Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).
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Affiliation(s)
- Carolyne Njoki
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Nabukwangwa Simiyu
- Department of Anesthesia and Intensive Care, Kisii Hospital, Kisii, Kenya
| | - Ronnie Kaddu
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Wambui Mwangi
- Intensive Care Unit, Nyeri County Hospital, Nyeri, Kenya
| | - Demet Sulemanji
- Department of Anesthesia and Intensive Care, MP Shah Hospital, Nairobi, Kenya
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Peter Oduor
- Department of Anesthesia and Intensive Care, Nakuru referral Hospital, Nakuru, Kenya
| | | | | | | | - Patricia Wangeci
- Department of Anesthesia and Intensive Care, Nakuru referral Hospital, Nakuru, Kenya
| | - Thomas Kabanya
- Intensive Care Unit, Nyeri County Hospital, Nyeri, Kenya
| | - Selina Mutuku
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Annastacia Kioko
- Department of Anesthesia and Intensive Care, Kisii Hospital, Kisii, Kenya
| | - Joy Muthoni
- Intensive Care Unit, Aga Khan Mombasa Hospital (AKM), Mombasa, Kenya
| | - Peter Mburu Kamau
- Department of Anesthesia and Intensive Care, MP Shah Hospital, Nairobi, Kenya
| | - Abigail Beane
- Nat Intensive Care Surveillance-MORU, Colombo, Sri Lanka
- Critical Care Society of Kenya, Nairobi, Kenya
| | - Rashan Haniffa
- Nat Intensive Care Surveillance-MORU, Colombo, Sri Lanka
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | - Arjen Dondorp
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
| | - David Misango
- Department of Anesthesia, Aga Khan University, Nairobi, Kenya
| | - Luigi Pisani
- Mahidol Oxford Tropical Research Unit, Bangkok, Thailand
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Connolly E, Kasomekera N, Sonenthal PD, Nyirenda M, Marsh RH, Wroe EB, Scott KW, Bukhman A, Minyaliwa T, Katete M, Banda G, Mukherjee J, Rouhani SA. Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study. BMC Health Serv Res 2023; 23:1062. [PMID: 37798681 PMCID: PMC10557270 DOI: 10.1186/s12913-023-10014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.
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Affiliation(s)
- Emilia Connolly
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi.
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
- Division of Hospital Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Noel Kasomekera
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
- Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Paul D Sonenthal
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Brigham & Women's Hospital, Division of Pulmonary & Critical Care, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Mulinda Nyirenda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
- University of Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Regan H Marsh
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Emily B Wroe
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Division of Global Health Equity, 75 Francis St, Boston, MA, 02115, USA
| | - Kirstin W Scott
- Department of Emergency Medicine, University of Washington, Seattle, USA
| | - Alice Bukhman
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
| | - Tadala Minyaliwa
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Martha Katete
- , Abwenzi Pa Za Umoyo/Partners In Health, PO Box 56, Neno, Malawi
| | - Grace Banda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
| | - Joia Mukherjee
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Shada A Rouhani
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Brigham & Women's Hospital, Department of Emergency Medicine, 75 Francis St, Boston, MA, 02115, USA
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5
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Dula D, Morton B, Chikaonda T, Chirwa AE, Nsomba E, Nkhoma V, Ngoliwa C, Sichone S, Galafa B, Tembo G, Chaponda M, Toto N, Kamng'ona R, Makhaza L, Muyaya A, Thole F, Kudowa E, Howard A, Kenny-Nyazika T, Ndaferankhande J, Mkandawire C, Chiwala G, Chimgoneko L, Banda NPK, Rylance J, Ferreira D, Jambo K, Henrion MYR, Gordon SB. Effect of 13-valent pneumococcal conjugate vaccine on experimental carriage of Streptococcus pneumoniae serotype 6B in Blantyre, Malawi: a randomised controlled trial and controlled human infection study. THE LANCET. MICROBE 2023; 4:e683-e691. [PMID: 37659418 PMCID: PMC10469263 DOI: 10.1016/s2666-5247(23)00178-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND The effect of childhood pneumococcal conjugate vaccine implementation in Malawi is threatened by absence of herd effect. There is persistent vaccine-type pneumococcal carriage in both vaccinated children and the wider community. We aimed to use a human infection study to measure 13-valent pneumococcal conjugate vaccine (PCV13) efficacy against pneumococcal carriage. METHODS We did a double-blind, parallel-arm, randomised controlled trial investigating the efficacy of PCV13 or placebo against experimental pneumococcal carriage of Streptococcus pneumoniae serotype 6B (strain BHN418) among healthy adults (aged 18-40 years) from Blantyre, Malawi. We randomly assigned participants (1:1) to receive PCV13 or placebo. PCV13 and placebo doses were prepared by an unmasked pharmacist to maintain research team and participant masking with identification only by a randomisation identification number and barcode. 4 weeks after receiving either PCV13 or placebo, participants were challenged with 20 000 colony forming units (CFUs) per naris, 80 000 CFUs per naris, or 160 000 CFUs per naris by intranasal inoculation. The primary endpoint was experimental pneumococcal carriage, established by culture of nasal wash at 2, 7, and 14 days. Vaccine efficacy was estimated per protocol by means of a log-binomial model adjusting for inoculation dose. The trial is registered with the Pan African Clinical Trials Registry, PACTR202008503507113, and is now closed. FINDINGS Recruitment commenced on April 27, 2021 and the final visit was completed on Sept 12, 2022. 204 participants completed the study protocol (98 PCV13, 106 placebo). There were lower carriage rates in the vaccine group at all three inoculation doses (0 of 21 vs two [11%] of 19 at 20 000 CFUs per naris; six [18%] of 33 vs 12 [29%] of 41 at 80 000 CFUs per naris, and four [9%] of 44 vs 16 [35%] of 46 at 160 000 CFUs per naris). The overall carriage rate was lower in the vaccine group compared with the placebo group (ten [10%] of 98 vs 30 [28%] of 106; Fisher's p value=0·0013) and the vaccine efficacy against carriage was estimated at 62·4% (95% CI 27·7-80·4). There were no severe adverse events related to vaccination or inoculation of pneumococci. INTERPRETATION This is, to our knowledge, the first human challenge study to test the efficacy of a pneumococcal vaccine against pneumococcal carriage in Africa, which can now be used to establish vaccine-induced correlates of protection and compare alternative strategies to prevent pneumococcal carriage. This powerful tool could lead to new means to enhance reduction in pneumococcal carriage after vaccination. FUNDING Wellcome Trust.
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Affiliation(s)
- Dingase Dula
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | - Ben Morton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Critical Care Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
| | | | | | - Edna Nsomba
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Clara Ngoliwa
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Simon Sichone
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Godwin Tembo
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Neema Toto
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Lumbani Makhaza
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | - Alfred Muyaya
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | - Faith Thole
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Ashleigh Howard
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tinashe Kenny-Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Gift Chiwala
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | | | - Ndaziona P K Banda
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; School of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jamie Rylance
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi
| | - Daniela Ferreira
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of Paediatrics, University of Oxford, Oxford, UK
| | - Kondwani Jambo
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Marc Y R Henrion
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephen B Gordon
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Sethi SM, Ahmed AS, Iqbal M, Riaz M, Mushtaq MZ, Almas A. Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan. Int J Crit Illn Inj Sci 2023; 13:97-103. [PMID: 38023573 PMCID: PMC10664031 DOI: 10.4103/ijciis.ijciis_83_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/16/2023] [Accepted: 04/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality. Methods A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses. Results Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]). Conclusions Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.
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Affiliation(s)
- Sher Muhammad Sethi
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Amber Sabeen Ahmed
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Madiha Iqbal
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Mehmood Riaz
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Muhammad Zain Mushtaq
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Aysha Almas
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
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7
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Spencer SA, Adipa FE, Baker T, Crawford AM, Dark P, Dula D, Gordon SB, Hamilton DO, Huluka DK, Khalid K, Lakoh S, Limbani F, Rylance J, Sawe HR, Simiyu I, Waweru-Siika W, Worrall E, Morton B. A health systems approach to critical care delivery in low-resource settings: a narrative review. Intensive Care Med 2023; 49:772-784. [PMID: 37428213 PMCID: PMC10354139 DOI: 10.1007/s00134-023-07136-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023]
Abstract
There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.
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Affiliation(s)
- Stephen A Spencer
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Queen Marys University of London, London, UK
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Paul Dark
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Dingase Dula
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - David Oliver Hamilton
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sulaiman Lakoh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Jamie Rylance
- Health Care Readiness Unit, World Health Organisation, Geneva, Switzerland
| | - Hendry R Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ibrahim Simiyu
- Liverpool School of Tropical Medicine, Liverpool, UK
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Eve Worrall
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, Liverpool, UK.
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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8
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Buowari DY, Owoo C, Gupta L, Schell CO, Baker T. Essential Emergency and Critical Care: A Priority for Health Systems Globally. Crit Care Clin 2022; 38:639-656. [PMID: 36162903 DOI: 10.1016/j.ccc.2022.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided, and the potential for reversibility. An estimated 45 million adults become critically ill each year. While some are treated in emergency departments or intensive care units, most are cared for in general hospital wards. We outline a priority for health systems globally: the first-tier care that all critically ill patients should receive in all parts of all hospitals: Essential Emergency and Critical Care. We describe its relation to other specialties and care and opportunities for implementation.
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Affiliation(s)
- Dabota Yvonne Buowari
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Along East West Road, Alakahia, Port Harcourt, Rivers State 23401, Nigeria
| | - Christian Owoo
- Department of Anaesthesia, University of Ghana Medical School, College of Health Sciences, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Department of Anaesthesia, Korle Bu Teaching Hospital, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Ghana Infectious Disease Centre, Kwabenya, Ga East, Municipal Hospital, GE-255-9501 (PQ47+FGV), Accra, Ghana; University of Ghana Medical Centre, Indian Ocean Link, University of Ghana, GA-337-6980 (JRJ7+WJP) Accra, Ghana
| | - Lalit Gupta
- Department of Anaesthesia and Critical Care, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, New Delhi 110002, India
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Sveavägen entré 9 Mälarsjukhuset, Eskilstuna, 631 88 Sweden; Department of Medicine, Nyköping Hospital, Nyköping 61185, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, P.O. Box 65001, Tanzania; Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Ifakara Health Institute, 5 Ifakara Street, Plot 463 Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
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Yalan Q, Jin T. Impact of establishing a respiratory high dependency unit for SCAP patients on the therapeutic effect, prognosis, and expenditure: a retrospective case-control study. Sci Rep 2022; 12:10703. [PMID: 35739221 PMCID: PMC9223268 DOI: 10.1038/s41598-022-14705-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/10/2022] [Indexed: 11/09/2022] Open
Abstract
To explore the effects of establishing a high dependency unit (HDU) on the prognosis, outcome, and expenditure of patients with severe community-acquired pneumonia (SCAP). 108 SCAP patients were recruited from the respiratory intensive care unit (RICU) of the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Of these, 87 qualified the study-selection criteria and were divided into HDU group (treated in HDU after discharge from RICU prior to transfer to normal unit) (n = 40) and normal group (not treated in the HDU) (n = 47). In the 87 patients, 40 were divided into HDU group, which meant they transferring to HDU when got stable while another 47 were divided into normal group which meant they staying longer in RICU and transferring to normal unit when got stable. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, duration of mechanical ventilation, hospital infection, intensive care unit syndrome, length of stay, and expenditure were compared between the two groups. The primary outcome was discharging from hospital while the secondary outcome was length of stay. There was no significant difference with respect to noninvasive ventilation time, oxygenation index, or APACHE II and SOFA scores at admission or discharge from RICU (P > 0.05). The mean invasive ventilation time (176 ± 160 h) of the HDU group was not significantly different from that in the normal group (206 ± 179 h). The period of sequential noninvasive ventilation in the HDU group (135 ± 82 h) was significantly shorter than that in the normal group (274 ± 182 h, P < 0.05). The HDU group had a shorter length of stay in hospital and RICU, and incurred lesser expenditure than patients in the normal group (P < 0.05). Patients in HDU group had almost the same therapeutic effect with shorter length of stay in hospital and RICU, and lesser expenditure.
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Affiliation(s)
- Qin Yalan
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Tong Jin
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, 76# Linjiang Road, Yuzhong district, Chongqing, 400010, China.
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Stahlschmidt A, Passos SC, Cardoso GR, Schuh GJ, Gutierrez CS, Castro SMJ, Caumo W, Pearse RM, Stefani LC. Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study. Anaesthesia 2022; 77:416-427. [PMID: 35167136 DOI: 10.1111/anae.15671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 01/02/2023]
Abstract
Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.
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Affiliation(s)
- A Stahlschmidt
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - S C Passos
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - G R Cardoso
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - G J Schuh
- School of Medicine, Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - C S Gutierrez
- Department of Surgery, Anaesthesia and Peri-operative Medicine Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - S M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - W Caumo
- Pain and Palliative Care Service, Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - L C Stefani
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Limbani F, Kapumba BM, Mzinganjira H, Phiri T, Mwandumba HC, Rylance J, Morton B, Desmond N. “An increase in COVID-19 patients would be overwhelming”: A qualitative description of healthcare workers’ experiences during the first wave of COVID-19 (March 2020 to October 2020) at Malawi’s largest referral hospital. Wellcome Open Res 2022; 7:40. [PMID: 36969720 PMCID: PMC10036953 DOI: 10.12688/wellcomeopenres.17368.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
Background COVID-19 is currently a global health threat. Healthcare workers are on the front-line of the COVID-19 outbreak response and therefore at heightened risk of infection. There is a dearth of evidence from Sub-Saharan Africa about healthcare worker experiences in managing COVID-19. We have reported on healthcare worker responses, experiences, and perspectives on epidemic response strategies at Queen Elizabeth Central Hospital, Malawi’s largest referral hospital. Methods We conducted 39 face-to-face in-depth interviews with a purposively selected sample of healthcare workers during the first wave of COVID-19 in Malawi (March 2020 to October 2020). The study included healthcare workers who provided direct and indirect patient care. Results During the early phase of the first wave (March to May 2020), healthcare workers expressed concerns with inadequate working space, unconducive infrastructure, delayed and rushed training on the management of COVID-19, and lack of incentives. Additionally, the hospital had staff shortages and limited essential resources such as piped oxygen and personal protective equipment. This increased healthcare worker fears of contracting COVID-19 and they were less willing to volunteer at COVID-19 isolation units. Resource constraints and limited preparedness compromised the care pathway particularly with increased numbers of COVID-19 patients. By the peak of the first wave (June to August 2020) many of these issues had been resolved. The hospital provided refresher training courses, personal protective equipment became available, incentives were offered to healthcare workers working in COVID-19 units and piped oxygen was installed. Staff morale was boosted, and more staff were willing to work at the COVID-19 isolation centres. Conclusion Experiences of healthcare workers during the first wave of COVID-19 are critical for improving care in future COVID-19 waves. Response strategies in resource-constrained areas should prioritise timely training of staff, creation of adequate isolation areas, provision of adequate medical supplies and strengthening leadership.
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Affiliation(s)
- Felix Limbani
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, PO Box 30096, Chichiri, Blantyre, BT3, Malawi
| | - Blessings M Kapumba
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, PO Box 30096, Chichiri, Blantyre, BT3, Malawi
| | | | - Tamara Phiri
- Queen Elizabeth Central Hospital, Blantyre, BT3, Malawi
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, PO Box 30096, Chichiri, Blantyre, BT3, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Jamie Rylance
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, PO Box 30096, Chichiri, Blantyre, BT3, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Ben Morton
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, PO Box 30096, Chichiri, Blantyre, BT3, Malawi
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Nicola Desmond
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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Aukrust CG, Kamalo PD, Prince RJ, Sundby J, Mula C, Manda‐Taylor L. Improving competencies and skills across clinical contexts of care: a qualitative study on Malawian nurses' experiences in an institutional health and training programme. Nurs Open 2021; 8:3170-3180. [PMID: 34355870 PMCID: PMC8510767 DOI: 10.1002/nop2.1030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/15/2021] [Accepted: 07/25/2021] [Indexed: 11/21/2022] Open
Abstract
AIM To explore what competencies and skills Malawian nurses gained after participating in an institutional health and training programme in Norway and how they viewed these competencies applicable upon return to Malawi. Furthermore, to examine facilitators and challenges experienced on the exchange programme and opportunities and obstacles to make the competencies usable in own local hospital context. DESIGN Qualitative study with an explorative design. METHODS Fourteen interviews and one focus group discussion were conducted at Queen Elizabeth Central Hospital, Blantyre, Malawi, from August to September 2018. RESULTS Competencies gained in Norway included clinical skills, teamwork, coordination and strengthened professionalism. The main finding was that the exchange programme was a transformative experience. Upon return to Malawi, the competencies gained on the exchange were helpful. However, the return was characterized by mixed emotions due to the considerable difference between the two clinical settings.
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Affiliation(s)
- Camilla Grøver Aukrust
- Department of Community Medicine and Global HealthInstitute of Health and SocietyFaculty of MedicineUniversity of OsloOsloNorway
- Department of NeurosurgeryOslo University HospitalOsloNorway
| | | | - Ruth Jane Prince
- Department of Community Medicine and Global HealthInstitute of Health and SocietyFaculty of MedicineUniversity of OsloOsloNorway
| | - Johanne Sundby
- Department of Community Medicine and Global HealthInstitute of Health and SocietyFaculty of MedicineUniversity of OsloOsloNorway
| | - Chimwemwe Mula
- Kamuzu College of NursingClinical Nursing DepartmentUniversity of MalawiBlantyreMalawi
| | - Lucinda Manda‐Taylor
- Department of Health Systems and PolicySchool of Public Health and Family MedicineCollege of MedicineUniversity of MalawiBlantyreMalawi
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Morton B, Barnes KG, Anscombe C, Jere K, Matambo P, Mandolo J, Kamng'ona R, Brown C, Nyirenda J, Phiri T, Banda NP, Van Der Veer C, Mndolo KS, Mponda K, Rylance J, Phiri C, Mallewa J, Nyirenda M, Katha G, Kambiya P, Jafali J, Mwandumba HC, Gordon SB, Cornick J, Jambo KC. Distinct clinical and immunological profiles of patients with evidence of SARS-CoV-2 infection in sub-Saharan Africa. Nat Commun 2021; 12:3554. [PMID: 34117221 PMCID: PMC8196064 DOI: 10.1038/s41467-021-23267-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
Although the COVID-19 pandemic has left no country untouched there has been limited research to understand clinical and immunological responses in African populations. Here we characterise patients hospitalised with suspected (PCR-negative/IgG-positive) or confirmed (PCR-positive) COVID-19, and healthy community controls (PCR-negative/IgG-negative). PCR-positive COVID-19 participants were more likely to receive dexamethasone and a beta-lactam antibiotic, and survive to hospital discharge than PCR-negative/IgG-positive and PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants exhibited a nasal and systemic cytokine signature analogous to PCR-positive COVID-19 participants, predominated by chemokines and neutrophils and distinct from PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants had increased propensity for Staphylococcus aureus and Streptococcus pneumoniae colonisation. PCR-negative/IgG-positive individuals with high COVID-19 clinical suspicion had inflammatory profiles analogous to PCR-confirmed disease and potentially represent a target population for COVID-19 treatment strategies.
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Affiliation(s)
- Ben Morton
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
| | - Kayla G Barnes
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Harvard School of Public Health, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- University of Glasgow MRC Centre for Virus Research, Glasgow, UK
| | - Catherine Anscombe
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Khuzwayo Jere
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- University of Malawi-College of Medicine, Blantyre, Malawi
| | - Prisca Matambo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan Mandolo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Raphael Kamng'ona
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Comfort Brown
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - James Nyirenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tamara Phiri
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Charlotte Van Der Veer
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Kwazizira S Mndolo
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Kelvin Mponda
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chimota Phiri
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Jane Mallewa
- University of Malawi-College of Medicine, Blantyre, Malawi
| | - Mulinda Nyirenda
- University of Malawi-College of Medicine, Blantyre, Malawi
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Grace Katha
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Paul Kambiya
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - James Jafali
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- University of Malawi-College of Medicine, Blantyre, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jennifer Cornick
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Kondwani C Jambo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
- University of Malawi-College of Medicine, Blantyre, Malawi.
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