Prevalence and Associated Factors of Chronic Obstructive Pulmonary Disease Among Adults in Neno District, Malawi: A Cross-Sectional Analytical Study

Introduction

Chronic obstructive pulmonary disease (COPD) continues to pose a global public health challenge. However, literature is scarce on the burden of COPD in Malawi. We assessed the prevalence and risk factors for COPD among adults in Neno, Malawi.

Methodology

We conducted a population-based analytical cross-sectional study in Neno District between December 2021 and November 2022. Using a multi-stage sampling technique, we included 525 adults aged≥40 years. All participants underwent spirometry according to the American Thoracic Society (ATS) guidelines and were interviewed using the IMPALA questionnaire. For this study, we utilized the definition of COPD as a post-bronchodilator FEV1/FVC <0.70. We collected data using Kobo collect, exported to Microsoft Excel, and analysed using R software. We used descriptive statistics and logistic regression analysis; a p-value of <0.05 was considered statistically significant.

Results

Out of 525 participants, 510 participants were included in the final analysis. Fifty-eight percent of the participants were females (n=296), and 62.2% (n=317) were between 40 and 49 years with a median (IQR) age of 46 (40-86). For patient characteristics, 15.1% (n=77) were current smokers, and 4.1% (n=21) had a history of pulmonary tuberculosis (PTB). Cough was the most commonly reported respiratory symptom (n=249, 48.8%). The prevalence of COPD was 10.0% (n=51) and higher (15.0%) among males compared to females (6.4%). Factors significantly associated with COPD were age 60 years and above (adjusted odds ratio [aOR] = 3.27, 95% CI: 1.48-7.34, p<0.004), ever smoked (aOR = 6.17, 95% CI:1.89-18.7, p<0.002), current smoker (aOR = 17.6, 95% CI: 8.47-38.4, p<0.001), and previous PTB (aOR = 4.42, 95% CI: 1.16-15.5, p<0.023).

Conclusion

The cross-sectional prevalence of COPD in rural Malawi is high, especially among males. Factors significantly associated were older age (60 years and above), cigarette smoking, and previous PTB. Longitudinal studies are needed to better understand disease etiology and progression in this setting.

Screening for post-TB lung disease at TB treatment completion: Are symptoms sufficient?

Pulmonary TB survivors face a high burden of post-TB lung disease (PTLD) after TB treatment completion. In this secondary data analysis we investigate the performance of parameters measured at TB treatment completion in predicting morbidity over the subsequent year, to inform programmatic approaches to PTLD screening in low-resource settings. Cohort data from urban Blantyre, Malawi were used to construct regression models for five morbidity outcomes (chronic respiratory symptoms or functional limitation, ongoing health seeking, spirometry decline, self-reported financial impact of TB disease, and death) in the year after PTB treatment, using three modelling approaches: logistic regression; penalised regression with pre-selected predictors; elastic net penalised regression using the full parent dataset. Predictors included demographic, clinical, symptom, spirometry and chest x-ray variables. The predictive performance of models were examined using the area under the receiver-operator curve (ROC AUC) values. Key predictors were identified, and their positive and negative predictive values (NPV) determined. The presence of respiratory symptoms at TB treatment completion was the strongest predictor of morbidity outcomes. TB survivors reporting breathlessness had higher odds of spirometry decline (aOR 20.5, 95%CI:3-199.1), health seeking (aOR 10.2, 2.4-50), and symptoms or functional limitation at 1-year (aOR 16.7, 3.3-133.4). Those reporting activity limitation were more likely to report symptoms or functional limitation at 1-year (aOR 4.2, 1.8-10.3), or severe financial impact of TB disease (aOR2.3, 1.0-5.0). Models were not significantly improved by including spirometry or imaging parameters. ROC AUCs were between 0.65-0.77 for the morbidity outcomes. Activity limitation at treatment completion had a NPV value of 78-98% for adverse outcomes. Our data suggest that whilst challenging to predict the development of post-TB morbidity, the use of symptom screening tools at TB treatment completion to prioritise post-TB care should be explored. We identified little benefit from the additional use of spirometry or CXR imaging.

Implementing health worker training on sepsis in South Eastern Nigeria using innovative digital strategies: an interventional study

Background

Sepsis is a leading cause of morbidity and mortality especially in low- and middle-income countries such as Nigeria. Training of health workers using digital platforms may improve knowledge and lead to better patient outcomes.

Objectives

To assess the effectiveness of a digital health educational module on sepsis in improving the knowledge of medical doctors in Cross River State Nigeria on the diagnosis and management of patients presenting with sepsis.

Design

Quasi-experimental analytical study.

Methods

We developed and deployed a sepsis module through an innovative application (Sepsis tutorial app) to doctors in Calabar, Nigeria. We assessed quantitative pre- and post-intervention knowledge scores for those completing the tutorial on sepsis between both assessments. A user satisfaction survey evaluated the content of the tutorial and the usability of the app.

Results

One hundred and two doctors completed the course. There were more males than females (58.8% versus 41.2%). Over half (52%) were junior doctors, a minority were general practitioners and house officers (3% and 5%, respectively), and 72.6% had practiced for periods ranging from 1 to 15 years post-qualification. Gender and age appeared to have no significant association with pre- and post-test scores. The oldest age group (61-70) had the lowest mean pre- and post-test scores, while general practitioners had higher mean pre- and post-test scores than other cadres. The majority (95%) of participants recorded higher post-test than pre-test scores with a significant overall increase in mean scores (25.5 ± 14.7%, p < 0.0001). Participants were satisfied with the content and multimodal delivery of the material and found the app usable.

Conclusion

Digital training using context-responsive platforms is feasible and may be used to close the critical knowledge gap required to respond effectively to medical emergencies such as sepsis in low- to middle-income settings.

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

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.

Use of hospital services by patients with chronic conditions in sub-Saharan Africa: a systematic review and meta-analysis

Objective

To estimate the prevalence of individual chronic conditions and multimorbidity among adults admitted to hospital in countries in sub-Saharan Africa.

Methods

We systematically searched MEDLINE®, Embase®, Global Index Medicus, Global Health and SciELO for publications reporting on patient cohorts recruited between 1 January 2010 and 12 May 2023. We included articles reporting prevalence of pre-specified chronic diseases within unselected acute care services (emergency departments or medical inpatient settings). No language restrictions were applied. We generated prevalence estimates using random-effects meta-analysis alongside 95% confidence intervals, 95% prediction intervals and I2 statistics for heterogeneity. To explore associations with age, sex, country-level income status, geographical region and risk of bias, we conducted pre-specified meta-regression, sub-group and sensitivity analyses.

Findings

Of 6976 identified studies, 61 met the inclusion criteria, comprising data from 20 countries and 376 676 people. None directly reported multimorbidity, but instead reported prevalence for individual conditions. Among medical admissions, the highest prevalence was human immunodeficiency virus infection (36.4%; 95% CI: 31.3-41.8); hypertension (24.4%; 95% CI: 16.7-34.2); diabetes (11.9%; 95% CI: 9.9-14.3); heart failure (8.2%; 95% CI: 5.6-11.9); chronic kidney disease (7.7%; 95% CI: 3.9-14.7); and stroke (6.8%; 95% CI: 4.7-9.6).

Conclusion

Among patients seeking hospital care in sub-Saharan Africa, multimorbidity remains poorly described despite high burdens of individual chronic diseases. Prospective public health studies of multimorbidity burden are needed to generate integrated and context-specific health system interventions that act to maximize patient survival and well-being.

A health systems approach to critical care delivery in low-resource settings: a narrative review

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.

Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi

Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.

Tools for measuring client experiences and satisfaction with healthcare in low- and middle-income countries: a systematic review of measurement properties

BACKGROUND

Perspectives of patients as clients on healthcare offer unique insights into the process and outcomes of care and can facilitate improvements in the quality of services. Differences in the tools used to measure these perspectives often reflect differences in the conceptualization of quality of care and personal experiences. This systematic review assesses the validity and reliability of instruments measuring client experiences and satisfaction with healthcare in low- and middle-income countries (LMICs).

METHODS

We performed a systematic search of studies published in PubMed, SCOPUS, and CINAHL. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies describing the development and psychometric properties of client experience and satisfaction with general health care were included in the review. Critical appraisal of study design was undertaken using the Appraisal tool for Cross-Sectional Studies (AXIS). The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and Terwee's criteria were used to appraise the psychometric properties of the included studies. A narrative synthesis approach was used in the interpretation of the findings.

RESULTS

Of the 7470 records identified, 12 studies with 14 corresponding instruments met the inclusion criteria and were included in the final review. No study assessed all the psychometric properties highlighted by the COSMIN criteria. In most instruments, we found evidence that initial development work incorporated client participation. The most evaluated measurement properties were content validity, internal consistency, and structural validity. Measurement error and responsiveness were not reported in any study.

CONCLUSION

Reliability and validity should be considered important elements when choosing or developing an instrument for professionals seeking an effective instrument for use within the population. Our review identified limitations in the psychometric properties of patient experience and satisfaction instruments, and none met all methodological quality standards. Future studies should focus on further developing and testing available measures for their effectiveness in clinical practice. Furthermore, the development of new instruments should incorporate clients' views and be rigorously tested or validated in studies with high methodological quality.

TRIAL REGISTRATION

CRD42020150438.

A comparison of four epidemic waves of COVID-19 in Malawi; an observational cohort study

BACKGROUND

Compared to the abundance of clinical and genomic information available on patients hospitalised with COVID-19 disease from high-income countries, there is a paucity of data from low-income countries. Our aim was to explore the relationship between viral lineage and patient outcome.

METHODS

We enrolled a prospective observational cohort of adult patients hospitalised with PCR-confirmed COVID-19 disease between July 2020 and March 2022 from Blantyre, Malawi, covering four waves of SARS-CoV-2 infections. Clinical and diagnostic data were collected using an adapted ISARIC clinical characterization protocol for COVID-19. SARS-CoV-2 isolates were sequenced using the MinION™ in Blantyre.

RESULTS

We enrolled 314 patients, good quality sequencing data was available for 55 patients. The sequencing data showed that 8 of 11 participants recruited in wave one had B.1 infections, 6/6 in wave two had Beta, 25/26 in wave three had Delta and 11/12 in wave four had Omicron. Patients infected during the Delta and Omicron waves reported fewer underlying chronic conditions and a shorter time to presentation. Significantly fewer patients required oxygen (22.7% [17/75] vs. 58.6% [140/239], p < 0.001) and steroids (38.7% [29/75] vs. 70.3% [167/239], p < 0.001) in the Omicron wave compared with the other waves. Multivariable logistic-regression demonstrated a trend toward increased mortality in the Delta wave (OR 4.99 [95% CI 1.0-25.0 p = 0.05) compared to the first wave of infection.

CONCLUSIONS

Our data show that each wave of patients hospitalised with SARS-CoV-2 was infected with a distinct viral variant. The clinical data suggests that patients with severe COVID-19 disease were more likely to die during the Delta wave.

Ultrasound appearance of the kidney among radiology department attendees of a tertiary centre in Malawi

Background: Diagnostic and therapeutic decisions in nephrology in low-resource settings are frequently based on ultrasound assessment of kidney size. An understanding of reference values is critical, particularly given the rise of non-communicable disease and the expanding availability of point-of-care ultrasound. However, there is a paucity of normative data from African populations. We determined estimates of kidney ultrasound measures, including kidney size based on age, sex, and HIV status, among apparently healthy outpatient attendees of Queen Elizabeth Central hospital radiology department, Blantyre, Malawi. Methods: We performed a cross-sectional cohort study of 320 adults attending the radiology department between October 2021 and January 2022. Bilateral kidney ultrasound was performed on all participants using a portable Mindray DP-50 machine and a 5MHz convex probe. The sample was stratified by age, sex, and HIV status. Predictive linear modelling was used to construct reference ranges for kidney size estimating the central 95 percentiles of 252 healthy adults. Exclusion criteria for the healthy sample were known kidney disease, hypertension, diabetes, BMI > 35, heavy alcohol intake, smoking and ultrasonographic abnormalities. Results: There were 162/320 (51%) male participants. The median age was 47 (interquartile range [IQR] 34-59). Among people living with HIV 134/138 (97%) were receiving antiretroviral therapy. Men had larger average kidney sizes: mean 9.68 cm (SD 0.80 cm), compared to 9.46 cm (SD 0.87 cm) in women ( p = 0.01). Average kidney sizes in people living with HIV were not significantly different from those who were HIV-negative, 9.73 cm (SD 0.93 cm) versus 9.58 cm (SD 0.93 cm) ( p = 0.63). Conclusions: This is the first report of the apparently healthy kidney size in Malawi. Predicted kidney size ranges may be used for reference in the clinical assessment of kidney disease in Malawi.

Ultrasound appearance of the kidney among radiology department attendees of a tertiary centre in Malawi

Background: Diagnostic and therapeutic decisions in nephrology in low-resource settings are frequently based on ultrasound assessment of kidney size. An understanding of reference values is critical, particularly given the rise of non-communicable disease and the expanding availability of point-of-care ultrasound. However, there is a paucity of normative data from sub-Saharan Africa (SSA). We determined estimates of kidney ultrasound measures, including kidney size based on age, sex, and HIV status, among apparently healthy outpatient attendees of Queen Elizabeth Central hospital radiology department, Blantyre, Malawi. Methods: We performed a cross-sectional cohort study of 320 adults attending the radiology department between October 2021 and January 2022. Bilateral kidney ultrasound was performed on all participants using a portable Mindray DP-50 machine and a 5MHz convex probe. The sample was stratified by age, sex, and HIV status. Predictive linear modelling was used to construct reference ranges for kidney size estimating the central 95 percentiles of 252 healthy adults. Exclusion criteria for the healthy sample were known kidney disease, hypertension, diabetes, BMI > 35, heavy alcohol intake, smoking and ultrasonographic abnormalities. Results: There were 162/320 (51%) male participants. The median age was 47 (interquartile range [IQR] 34-59). Of those whose HIV status was known and positive, 138/308 (45%), 134/138 (97%) were receiving antiretroviral therapy. Men had larger average kidney sizes: mean 9.68 cm (SD 0.80 cm), compared to 9.46 cm (SD 0.87 cm) in women ( p = 0.01). Average kidney sizes in HIV-positive participants were not significantly different from those who were HIV-negative, 9.73 cm (SD 0.93 cm) versus 9.58 cm (SD 0.93 cm) ( p = 0.63). Conclusions: This is the first report of the apparently healthy kidney size in Malawi. Predicted kidney size ranges may be used for reference in the clinical assessment of kidney disease in Malawi.

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors

Knowing the target oxygen saturation (SpO₂) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO₂ targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO₂ targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO₂ ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO₂ values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO₂ range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO₂ target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

Comprehensive review of safety in Experimental Human Pneumococcal Challenge

INTRODUCTION

Experimental Human Pneumococcal Challenge (EHPC) involves the controlled exposure of adults to a specific antibiotic-sensitive Streptococcus pneumoniae serotype, to induce nasopharyngeal colonisation for the purpose of vaccine research. The aims are to review comprehensively the safety profile of EHPC, explore the association between pneumococcal colonisation and frequency of safety review and describe the medical intervention required to undertake such studies.

METHODS

A single-centre review of all EHPC studies performed 2011-2021. All recorded serious adverse events (SAE) in eligible studies are reported. An unblinded meta-analysis of collated anonymised individual patient data from eligible EHPC studies was undertaken to assess the association between experimental pneumococcal colonisation and the frequency of safety events following inoculation.

RESULTS

In 1416 individuals (median age 21, IQR 20-25), 1663 experimental pneumococcal inoculations were performed. No pneumococcal-related SAE have occurred. 214 safety review events were identified with 182 (12.85%) participants presenting with symptoms potentially in keeping with pneumococcal infection, predominantly in pneumococcal colonised individuals (colonised = 96/658, non-colonised = 86/1005, OR 1.81 (95% CI 1.28-2.56, P = <0.001). The majority were mild (pneumococcal group = 72.7% [120/165 reported symptoms], non-pneumococcal = 86.7% [124/143 reported symptoms]). 1.6% (23/1416) required antibiotics for safety.

DISCUSSION

No SAEs were identified directly relating to pneumococcal inoculation. Safety review for symptoms was infrequent but occurred more in experimentally colonised participants. Most symptoms were mild and resolved with conservative management. A small minority required antibiotics, notably those serotype 3 inoculated.

CONCLUSION

Outpatient human pneumococcal challenge can be conducted safely with appropriate levels of safety monitoring procedures in place.

Prospective cohort study to identify prevalence, risk factors and outcomes of infection associated kidney disease in a regional hospital in Malawi

OBJECTIVES

Acute kidney injury (AKI) is a common and severe complication of community acquired infection, but data on impact in sub-Saharan Africa (SSA) are lacking. We determined prevalence, risk factors and outcomes of infection associated kidney disease in adults in Malawi.

DESIGN

A prospective cohort study of adults admitted to hospital with infection, from February 2021 to June 2021, collecting demographic, clinical, laboratory and ultrasonography data.

SETTING

Adults admitted to a regional hospital in Southern Region, Malawi.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were prevalence of kidney disease and mortality by Cox proportional hazard model. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Secondary outcomes were risk factors for AKI identified by logistic regression and prevalence of chronic kidney disease at 3 months.

RESULTS

We recruited 101 patients presenting to hospital with infection. Median age was 38 years (IQR: 29-48 years), 88 had known HIV status of which 53 (60%) were living with HIV, and of these 42 (79%) were receiving antiretroviral therapy. AKI was present in 33/101 at baseline, of which 18/33 (55%) cases were severe (KDIGO stage 3). At 3 months, 28/94 (30%) participants had died, while 7/61 (11%) of survivors had chronic kidney disease. AKI was associated with older age (age: 60 years vs 40 years, OR: 3.88, 95% CI 1.82 to 16.64), and HIV positivity (OR: 4.08, 95% CI 1.28 to 15.67). Living with HIV was independently associated with death (HR: 3.97, 95% CI 1.07 to 14.69).

CONCLUSIONS

Kidney disease is common among hospitalised adults with infection in Malawi, with significant kidney impairment identified at 3 months. Our study highlights the difficulty in diagnosing acute and chronic kidney disease, and the need for more accurate methods than creatinine based estimated glomerular filtration rate (eGFR) equations for populations in Africa. Patients with kidney impairment identified in hospital should be prioritised for follow-up.

Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi

Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m 3 (IQR: 22.9-482.0), vs 7.6μg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7μg/m 3 [IQR: 5.2-30.0] vs 3.3μg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.

Airway-resident T cells from unexposed individuals cross-recognize SARS-CoV-2

T cells can contribute to clearance of respiratory viruses that cause acute-resolving infections such as SARS-CoV-2, helping to provide long-lived protection against disease. Recent studies have suggested an additional role for T cells in resisting overt infection: pre-existing cross-reactive responses were preferentially enriched in healthcare workers who had abortive infections¹, and in household contacts protected from infection². We hypothesize that such early viral control would require pre-existing cross-reactive memory T cells already resident at the site of infection; such airway-resident responses have been shown to be critical for mediating protection after intranasal vaccination in a murine model of SARS-CoV³. Bronchoalveolar lavage samples from the lower respiratory tract of healthy donors obtained before the COVID-19 pandemic revealed airway-resident, SARS-CoV-2-cross-reactive T cells, which correlated with the strength of human seasonal coronavirus immunity. We therefore demonstrate the potential to harness functional airway-resident SARS-CoV-2-reactive T cells in next-generation mucosal vaccines.

A comparison of four epidemic waves of COVID-19 in Malawi; an observational cohort study

Background

Compared to the abundance of clinical and genomic information available on patients hospitalised with COVID-19 disease from high-income countries, there is a paucity of data from low-income countries. Our aim was to explore the relationship between viral lineage and patient outcome.

Methods

We enrolled a prospective observational cohort of adult patients hospitalised with PCR-confirmed COVID-19 disease between July 2020 and March 2022 from Blantyre, Malawi, covering four waves of SARS-CoV-2 infections. Clinical and diagnostic data were collected using an adapted ISARIC clinical characterization protocol for COVID-19. SARS-CoV-2 isolates were sequenced using the MinIONâ"¢ in Blantyre.

Results

We enrolled 314 patients, good quality sequencing data was available for 55 patients. The sequencing data showed that 8 of 11 participants recruited in wave one had B.1 infections, 6/6 in wave two had Beta, 25/26 in wave three had Delta and 11/12 in wave four had Omicron. Patients infected during the Delta and Omicron waves reported fewer underlying chronic conditions and a shorter time to presentation. Significantly fewer patients required oxygen (22.7% [17/75] vs. 58.6% [140/239], p<0.001) and steroids (38.7% [29/75] vs. 70.3% [167/239], p<0.001) in the Omicron wave compared with the other waves. Multivariable logistic-regression demonstrated a trend toward increased mortality in the Delta wave (OR 4.99 [95% CI 1.0-25.0 p=0.05) compared to the first wave of infection.

Conclusions

Our data show that each wave of patients hospitalised with SARS-CoV-2 was infected with a distinct viral variant. The clinical data suggests that patients with severe COVID-19 disease were more likely to die during the Delta wave.

Summary

We used genome sequencing to identify the variants of SARS-CoV-2 causing disease in Malawi, and found that each of the four waves was caused by a distinct variant. Clinical investigation suggested that the Delta wave had the highest mortality.

"We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi

Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.

On prioritising global health's triple crisis of sepsis, COVID-19 and antimicrobial resistance: a mixed-methods study from Malawi

Sepsis causes 20% of global deaths, particularly among children and vulnerable populations living in developing countries. This study investigated how sepsis is prioritised in Malawi’s health system to inform health policy. In this mixed-methods study, twenty multisectoral stakeholders were qualitatively interviewed and asked to quantitatively rate the likelihood of sepsis-related medium-term policy outcomes being realised. Respondents indicated that sepsis is not prioritised in Malawi due to a lack of local sepsis-related evidence and policies. However, they highlighted strong linkages between sepsis and maternal health, antimicrobial resistance and COVID-19, which are already existing national priorities, and offers opportunities for sepsis researchers as policy entrepreneurs. To address the burden of sepsis, we recommend that funding should be channelled to the generation of local evidence, evidence uptake, procurement of resources and treatment of sepsis cases, development of appropriate indicators for sepsis, adherence to infection prevention and control measures, and antimicrobial stewardship.

TB morbidity estimates overlook the contribution of post-TB disability: evidence from urban Malawi

INTRODUCTION

Despite growing evidence of the long-term impact of tuberculosis (TB) on quality of life, Global Burden of Disease (GBD) estimates of TB-related disability-adjusted life years (DALYs) do not include post-TB morbidity, and evaluations of TB interventions typically assume treated patients return to pre-TB health. Using primary data, we estimate years of life lost due to disability (YLDs), years of life lost due to premature mortality (YLL) and DALYs associated with post-TB cardiorespiratory morbidity in a low-income country.

METHODS

Adults aged ≥15 years who had successfully completed treatment for drug-sensitive pulmonary TB in Blantyre, Malawi (February 2016-April 2017) were followed-up for 3 years with 6-monthly and 12-monthly study visits. In this secondary analysis, St George's Respiratory Questionnaire data were used to match patients to GBD cardiorespiratory health states and corresponding disability weights (DWs) at each visit. YLDs were calculated for the study period and estimated for remaining lifespan using Malawian life table life expectancies. YLL were estimated using study mortality data and aspirational life expectancies, and post-TB DALYs derived. Data were disaggregated by HIV status and gender.

RESULTS

At treatment completion, 222/403 (55.1%) participants met criteria for a cardiorespiratory DW, decreasing to 15.6% after 3 years, at which point two-thirds of the disability burden was experienced by women. Over 90% of projected lifetime-YLD were concentrated within the most severely affected 20% of survivors. Mean DWs in the 3 years post-treatment were 0.041 (HIV-) and 0.025 (HIV+), and beyond 3 years estimated as 0.025 (HIV-) and 0.010 (HIV+), compared with GBD DWs of 0.408 (HIV+) and 0.333 (HIV-) during active disease. Our results imply that the majority of TB-related morbidity occurs post-treatment.

CONCLUSION

TB-related DALYs are greatly underestimated by overlooking post-TB disability. The total disability burden of TB is likely undervalued by both GBD estimates and economic evaluations of interventions, particularly those aimed at early diagnosis and prevention.

Influence of sex, season and environmental air quality on experimental human pneumococcal carriage acquisition: a retrospective cohort analysis

Streptococcus pneumoniae (pneumococcus) is the most commonly identified bacterial cause of pneumonia and the leading infectious cause of death in children under 5 years of age worldwide. Pneumococcal disease follows a seasonal pattern with increased incidence during winter. Pneumonia burden is also associated with poor air quality. Nasopharyngeal carriage of the bacterium is a pre-requisite of invasive disease. We aimed to determine if susceptibility to nasopharyngeal pneumococcal carriage varied by season and which environmental factors might explain such variation. We also evaluated the influence of sex on susceptibility of carriage. We collated data from five studies in which human volunteers underwent intranasal pneumococcal challenge. Generalised linear mixed-effects models were used to identify factors associated with altered risk of carriage acquisition, specifically climate and air-quality data. During 2011-2017, 374 healthy adults were challenged with type 6B pneumococcus. Odds of carriage were significantly lower in males (OR, 0.61; 95% CI, 0.40-0.92; p=0.02), and higher with cooler temperatures (OR, 0.79; 95% CI, 0.63-0.99; p=0.04). Likelihood of carriage was also associated with lower concentrations of local fine particulate matter concentrations (PM2.5) and increased local rainfall. In contrast to epidemiological series, experimental challenge allowed us to test propensity to acquisition during controlled exposures; immunological explanations for sex and climatic differences should be sought.

Household food insecurity, maternal nutrition, environmental risks and infants' health outcomes: protocol of the IMPALA birth cohort study in Uganda

INTRODUCTION

In low- and middle-income countries (LMICs), food insecurity and undernutrition disproportionately affect women of reproductive age, infants and young children. The disease burden from undernutrition in these vulnerable sections of societies remains a major concern in LMICs. Biomass fuel use for cooking is also common in LMICs. Empirical evidence from high-income countries indicates that early life nutritional and environmental exposures and their effect on infant lung function are important; however, data from sub-Saharan Africa are scarce.

AIM

To estimate the association between infant lung function and household food insecurity, energy poverty and maternal dietary diversity.

METHODS AND ANALYSIS

Pregnant women will be recruited in an existing Health and Demographic Surveillance Site in South-West Uganda. Household food insecurity, sources and uses of energy, economic measures and maternal dietary diversity will be collected during pregnancy and after birth. Primary health outcomes will be infant lung function determined by tidal breath flow and volume analysis at 6-10 weeks of age. Infant weight and length will also be collected.A household Food Consumption Score and Minimum Dietary Diversity for Women (MDD-W) indicator will be constructed. The involved cost of dietary diversity will be estimated based on MDD-W. The association between household level and mothers' food access indicators and infant lung function will be evaluated using regression models. The Multidimensional Energy Poverty Index (MEPI) will be estimated and used as an indicator of households' environmental exposures. The association between household MEPI and infant lung function will be assessed using econometric models.

ETHICS AND DISSEMINATION

Ethical approvals have been obtained from Liverpool School of Tropical Medicine (18-059), the Uganda Virus Research Institute Ethics Committee (097/2018) and Uganda National Council for Science and Technology (SS 4846). Study results will be shared with participants, policy-makers, other stakeholders and published in peer-reviewed journals.

"We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi

Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.

“My life is not going to be the same, my health is going to improve”: a cross-sectional qualitative study of patients’ experiences of living with chronic respiratory symptoms and their views on a proposed pulmonary rehabilitation program at Queen Elizabeth Central Hospital, Blantyre, Malawi

Background: Malawi’s population has a substantial burden of chronic respiratory symptoms. Elsewhere, patients with these symptoms have benefited from pulmonary rehabilitation (PR), a program of exercise training, education, and behaviour management. Practically, PR in Malawi may not be delivered in the same format as elsewhere due to substantial contextual differences. These differences necessitate adaptation of the intervention to Malawi’s setting to be acceptable and effective. This study explored patients’ experiences of living with chronic respiratory symptoms and their views on a proposed PR program at Queen Elizabeth Central Hospital, Blantyre, Malawi, to inform the design of an individualized and culturally adapted PR program. Methods: This was a cross-sectional qualitative study. Face-to-face, one-to-one semi-structured in-depth interviews were undertaken to data saturation. Interviews were audio-recorded, transcribed verbatim, and Chichewa transcripts were translated into English. The transcripts were anonymized and thematically analysed using an inductive approach. Results: We recruited 10 patients (five males and five females) with functionally limiting chronic respiratory symptoms, with documented causes including chronic obstructive pulmonary disease, asthma, post-tuberculosis lung disease, and bronchiectasis. Symptoms most frequently included dyspnoea, with associated functional limitations including the reduced performance of activities of daily living. Participants’ coping strategies most frequently included the use of inhalers. Participants were motivated to undertake the PR program owing to its anticipated benefits including improved health. They perceived transport costs and competing commitments as barriers to participation. The participant group gender mix and public nature of the program were considered socio-culturally sensitive by some participants. Conclusions: The functionally limiting dyspnoea most frequently experienced by the study participants would be amenable to a PR program. To ensure participation by eligible patients, pre-program assessments should consider patient access to transport, suitability of the timing for the program’s sessions, and patient views on organizational aspects of the program considered social-culturally sensitive.

"We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi

Background: Exposure to air pollution is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally made clay cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into cooking and non-cooking ('baseline') periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention  involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9μg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8μg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, 'baseline' exposures were found to be reduced post-intervention (from 8.2μg/m 3 [2.5-22.0] to 4.6μg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Most cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in baseline exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.

“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

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.

Protocol for a single-centre mixed-method pre-post single-arm feasibility trial of a culturally appropriate 6-week pulmonary rehabilitation programme among adults with functionally limiting chronic respiratory diseases in Malawi

INTRODUCTION

Malawi has a substantial burden of chronic respiratory diseases (CRDs) which cause significant morbidity and loss of economic productivity, affecting patients, families and health systems. Pulmonary rehabilitation (PR) is a highly recommended non-pharmacological intervention in the clinical management of people with CRDs. However, Malawi lacks published evidence on the implementation of PR for people with CRDs. This trial will test the feasibility and acceptability of implementing a culturally appropriate hospital-based PR programme among adults with functionally limiting CRDs at Queen Elizabeth Central Hospital in Blantyre, Malawi.

METHODS AND ANALYSIS

This is a single-centre mixed-methods pre-post single-arm feasibility trial. Ten patients aged ≥18 years, with a spirometry confirmed diagnosis of a CRD and breathlessness of ≥2 on the modified Medical Research Council dyspnoea scale, will be consecutively recruited. Their baseline lung function, exercise tolerance and health status will be assessed; including spirometry, Incremental Shuttle Walk Test and Chronic Obstructive Pulmonary Disease Assessment Test, respectively. Pretrial semistructured in-depth interviews will explore their experiences of living with CRD and potential enablers and barriers to their PR uptake. Along with international PR guidelines, these data will inform culturally appropriate delivery of PR. We initially propose a 6-week, twice-weekly, supervised centre-based PR programme, with an additional weekly home-based non-supervised session. Using combination of researcher observation, interaction with the participants, field notes and informal interviews with the participants, we will assess the feasibility of running the programme in the following areas: participants' recruitment, retention, engagement and protocol adherence. Following programme completion (after 6 weeks), repeat assessments of lung function, exercise tolerance and health status will be conducted. Quantitative changes in clinical outcomes will be described in relation to published minimal clinically important differences. Post-trial semistructured interviews will capture participants' perceived impact of the PR programme on their quality of life, enablers, and barriers to fully engaging with the programme, and allow iteration of its design.

ETHICS AND DISSEMINATION

Ethical approval for this trial was obtained from University of Malawi College of Medicine Research and Ethics Committee (COMREC), Blantyre, Malawi (protocol number: P.07/19/2752) and University of Leicester Research Ethics Committee, Leicester, UK (ethics reference: 31574). The results of the trial will be disseminated through oral presentations at local and international scientific conferences or seminars and publication in a peer-reviewed journal. We will also engage the participants who complete the PR trial and the Science Communication Department at Malawi-Liverpool-Wellcome Trust Clinical Research Programme to organise community outreach activities within Blantyre to educate communities about CRDs and PR. We will also broadcast our trial results through national radio station programmes such as the weekly "Thanzi la Onse" (Health of All) programme by Times Radio Malawi. We will formally present our trial results to Blantyre District Health Office and Malawi Ministry of Health.

TRIAL REGISTRATION NUMBER

ISRCTN13836793.

Facilitating high quality acute care in resource-constrained environments: Perspectives of patients recovering from sepsis, their caregivers and healthcare workers in Uganda and Malawi

Sepsis is a major global health problem, especially in sub-Saharan Africa. Improving patient care requires that healthcare providers understand patients' priorities and provide quality care within the confines of the context they work. We report the perspectives of patients, caregivers and healthcare workers regarding care quality for patients admitted for sepsis to public hospitals in Uganda and Malawi. This qualitative descriptive study in two hospitals included face-to face semi-structured interviews with purposively selected patients recovering from sepsis, their caregivers and healthcare workers. In both Malawi and Uganda, sepsis care often occurred in resource-constrained environments which undermined healthcare workers' capacity to deliver safe, consistent and accessible care. Constraints included limited space, strained; water, sanitation and hygiene (WASH) amenities and practices, inadequate human and material resources and inadequate provision for basic needs including nutrition. Heavy workloads for healthcare workers strained relationships, led to poor communication and reduced engagement with patients and caregivers. These consequences were exacerbated by understaffing which affected handover and continuity of care. All groups (healthcare workers, patients and caregivers) reported delays in care due to long queues and lack of compliance with procedures for triage, treatment, stabilization and monitoring due to a lack of expertise, supervision and context-specific sepsis management guidelines. Quality sepsis care relies on effective severity-based triaging, rapid treatment of emergencies and individualised testing to confirm diagnosis and monitoring. Hospitals in resource-constrained systems contend with limitations in key resources, including for space, staff, expertise, equipment and medicines, in turn contributing to gaps in areas such as WASH and effective care delivery, as well as communication and other relational aspects of care. These limitations are the predominant challenges to achieving high quality care.

Respiratory symptoms and lung function in patients treated for pulmonary tuberculosis in Malawi: a prospective cohort study

Rationale

Pulmonary tuberculosis (PTB) can cause post-TB lung disease (PTLD) associated with respiratory symptoms, spirometric and radiological abnormalities. Understanding of the predictors and natural history of PTLD is limited.

Objectives

To describe the symptoms and lung function of Malawian adults up to 3 years following PTB-treatment completion, and to determine the evolution of PTLD over this period.

Methods

Adults successfully completing PTB treatment in Blantyre, Malawi were followed up for 3 years and assessed using questionnaires, post-bronchodilator spirometry, 6 min walk tests, chest X-ray and high-resolution CT. Predictors of lung function at 3 years were identified by mixed effects regression modelling.

Measurement and main results

We recruited 405 participants of whom 301 completed 3 years follow-up (mean (SD) age 35 years (10.2); 66.6% males; 60.4% HIV-positive). At 3 years, 59/301 (19.6%) reported respiratory symptoms and 76/272 (27.9%) had abnormal spirometry. The proportions with low FVC fell from 57/285 (20.0%) at TB treatment completion to 33/272 (12.1%), while obstruction increased from and 41/285 (14.4%) to 43/272 (15.8%) at 3 years. Absolute FEV₁ and FVC increased by mean 0.03 L and 0.1 L over this period, but FEV₁ decline of more than 0.1 L was seen in 73/246 (29.7%). Higher spirometry values at 3 years were associated with higher body mass index and HIV coinfection at TB-treatment completion.

Conclusion

Spirometric measures improved over the 3 years following treatment, mostly in the first year. However, a third of PTB survivors experienced ongoing respiratory symptoms and abnormal spirometry (with accelerated FEV₁ decline). Effective interventions are needed to improve the care of this group of patients.

A comparison of different scores for diagnosis and mortality prediction of adults with sepsis in Low-and-Middlencome Countries: a systematic review and meta-analysis

BACKGROUND

Clinical scores for sepsis have been primarily developed for, and applied in High-Income Countries. This systematic review and meta-analysis examined the performance of the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), Modified Early Warning Score (MEWS), and Universal Vital Assessment (UVA) scores for diagnosis and prediction of mortality in patients with suspected infection in Low-and-Middle-Income Countries.

METHODS

PubMed, Science Direct, Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched until May 18, 2021. Studies reporting the performance of at least one of the above-mentioned scores for predicting mortality in patients of 15 years of age and older with suspected infection or sepsis were eligible. The Quality Assessment of Diagnostic Accuracy Studies tool was used for risk-of-bias assessment. PRISMA guidelines were followed (PROSPERO registration: CRD42020153906). The bivariate random-effects regression model was used to pool the individual sensitivities, specificities and areas-under-the-curve (AUC).

FINDINGS

Twenty-four articles (of 5669 identified) with 27,237 patients were eligible for inclusion. qSOFA pooled sensitivity was 0·70 (95% confidence interval [CI] 0·60-0·78), specificity 0·73 (95% CI 0·67-0·79), and AUC 0·77 (95% CI 0·72-0·82). SIRS pooled sensitivity, specificity and AUC were 0·88 (95% CI 0·79 -0·93), 0·34 (95% CI 0·25-0·44), and 0·69 (95% CI 0·50-0·83), respectively. MEWS pooled sensitivity, specificity and AUC were 0·70 (95% CI 0·57 -0·81), 0·61 (95% CI 0·42-0·77), and 0·72 (95% CI 0·64-0·77), respectively. UVA pooled sensitivity, specificity and AUC were 0·49 (95% CI 0·33 -0·65), 0·91(95% CI 0·84-0·96), and 0·76 (95% CI 0·44-0·93), respectively. Significant heterogeneity was observed in the pooled analysis.

INTERPRETATION

Individual score performances ranged from poor to acceptable. Future studies should combine selected or modified elements of different scores.

FUNDING

Partially funded by the UK National Institute for Health Research (NIHR) (17/63/42).

Changing lung function and associated health-related quality-of-life: A five-year cohort study of Malawian adults

BACKGROUND

In Sub-Saharan Africa cross-sectional studies report a high prevalence of abnormal lung function indicative of chronic respiratory disease. The natural history and health impact of this abnormal lung function in low-and middle-income countries is largely unknown.

METHODS

A cohort of 1481 adults representative of rural Chikwawa in Malawi were recruited in 2014 and followed-up in 2019. Respiratory symptoms and health-related quality of life (HRQoL) were quantified. Lung function was measured by spirometry.

FINDINGS

1232 (83%) adults participated; spirometry was available for 1082 (73%). Mean (SD) age 49.5 (17.0) years, 278(23%) had ever smoked, and 724 (59%) were women. Forced expiratory volume in one second (FEV₁) declined by 53.4 ml/year (95% CI: 49.0, 57.8) and forced vital capacity (FVC) by 45.2 ml/year (95% CI: 39.2, 50.5) . Chronic airflow obstruction increased from 9.5% (7.6, 11.6%) in 2014 to 17.5% (15.3, 19.9%) in 2019. There was no change in diagnosed asthma or in spirometry consistent with asthma or restriction. Rate of FEV₁ decline was not associated with diagnosed Chronic obstructive pulmonary disease (COPD), asthma, or spirometry consistent with asthma, COPD, or restriction. HRQoL was adversely associated with respiratory symptoms (dyspnoea, wheeze, cough), previous tuberculosis, declining FEV₁ and spirometry consistent with asthma or restriction. These differences exceeded the minimally important difference.

INTERPRETATION

In this cohort, the increasing prevalence of COPD is associated with the high rate of FEV₁ decline and lung function deficits present before recruitment. Respiratory symptoms and sub-optimal lung function are independently associated with reduced HRQoL.

Incidence of HIV-positive admission and inpatient mortality in Malawi (2012-2019)

OBJECTIVE

To investigate trends in population incidence of HIV-positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi.

DESIGN

Population cohort study using an existing electronic health information system ('SPINE') at Queen Elizabeth Central Hospital and Blantyre census data.

METHODS

We used multiple imputation and negative binomial regression to estimate population age-specific and sex-specific admission rates over time. We used a log-binomial model to investigate trends in risk of in-hospital death.

RESULTS

Of 32 814 adult medical admissions during Q4 2012--Q3 2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV-positive admissions were highest in Q3 2013 (173 per 100 000 adult Blantyre residents) and lowest in Q3 2019 (53 per 100 000 residents). An estimated 10 818 fewer than expected people with HIV (PWH) [95% confidence interval (CI) 10 068-11 568] were admitted during 2012-2019 compared with the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2264 fewer HIV-positive admissions, 95% CI 2002-2526). In-hospital mortality for PWH was 23.5%, with no significant change over time in any age-sex group, and no association with antiretroviral therapy (ART) use at admission.

CONCLUSION

Rates of admission for adult PWH decreased substantially, likely because of large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PWH.

The burden and determinants of post-TB lung disease

BACKGROUND: Post-TB lung disease (PTLD) is an important but under-recognised chronic respiratory disease in high TB burden settings such as Tanzania.METHODS: This was a cross-sectional survey of adults within 2 years of completion of TB treatment in Kilimanjaro, Tanzania. Data were collected using questionnaires (symptoms and exposures), spirometry and chest radiographs to assess outcome measures, which were correlated with daily life exposures, including environment and diet.RESULTS: Of the 219 participants enrolled (mean age: 45 years ± 10; 193 88% males), 98 (45%) reported chronic respiratory symptoms; 46 (22%) had received treatment for TB two or more times; and HIV prevalence was 35 (16%). Spirometric abnormalities were observed in 146 (67%). Chest X-ray abnormalities occurred in 177 (86%). A diagnosis of PTLD was made in 200 (91%), and half had clinically relevant PTLD. The prevalence of mMRC ≥Grade 3 chronic bronchitis and dyspnoea was respectively 11% and 26%. Older age, multiple episodes of TB and poverty indicators were linked with clinically relevant PTLD.CONCLUSIONS: We found a substantial burden of PTLD in adults who had recently completed TB treatment in Tanzania. There is a pressing need to identify effective approaches for both the prevention and management of this disease.

A feasibility study of controlled human infection with Streptococcus pneumoniae in Malawi

Background

Persistent carriage of pneumococcal vaccine serotypes has occurred after introduction of PCV13 vaccination in Africa but the mechanisms are unclear. We tested the feasibility of using a human pneumococcal challenge model in Malawi to understand immune correlates of protection against carriage and to trial alternative vaccine candidates. We aimed to identify a dose of Streptococcus pneumoniae serotype 6B sufficient to establish nasopharyngeal carriage in 40% of those nasally inoculated and evaluate nasal mucosal immunity before and after experimental inoculation.

Methods

Healthy student volunteers were recruited and inoculated with saline, 20,000 CFU/naris or 80,000 CFU/naris of Streptococcus pneumoniae serotype 6B Post inoculation carriage was determined by nasal sampling for bacterial culture and lytA PCR. Immunological responses were measured in serum and nasal mucosal biopsies before and after bacterial inoculation.

Findings

Twenty-four subjects completed the feasibility protocol with minimal side effects. pneumococcal carriage was established in 0/6, 3/9 and 4/9 subjects in the saline, 20,000 CFU/naris and 80,000 CFU/naris groups, respectively. Incidental (natural) serotype carriage was common (7/24 participants carried non-6B strains, 29.2%. Experimentally induced type 6B pneumococcal carriage was associated with pro-inflammatory nasal mucosal responses prior to inoculation and altered mucosal recruitment of immune cells post bacterial challenge. There was no association with serum anti-capsular antibody.

Interpretation

The serotype 6B experimental human pneumococcal carriage model is feasible in Malawi and can now be used to determine the immunological correlates of protection against carriage and vaccine efficacy in this population.

The nose is the best niche for detection of experimental pneumococcal colonisation in adults of all ages, using nasal wash

Previous studies have suggested that the pneumococcal niche changes from the nasopharynx to the oral cavity with age. We use an Experimental Human Pneumococcal Challenge model to investigate pneumococcal colonisation in different anatomical niches with age. Healthy adults (n = 112) were intranasally inoculated with Streptococcus pneumoniae serotype 6B (Spn6B) and were categorised as young 18-55 years (n = 57) or older > 55 years (n = 55). Colonisation status (frequency and density) was determined by multiplex qPCR targeting the lytA and cpsA-6A/B genes in both raw and culture-enriched nasal wash and oropharyngeal swab samples collected at 2-, 7- and 14-days post-exposure. For older adults, raw and culture-enriched saliva samples were also assessed. 64% of NW samples and 54% of OPS samples were positive for Spn6B in young adults, compared to 35% of NW samples, 24% of OPS samples and 6% of saliva samples in older adults. Many colonisation events were only detected in culture-enriched samples. Experimental colonisation was detected in 72% of young adults by NW and 63% by OPS. In older adults, this was 51% by NW, 36% by OPS and 9% by saliva. The nose, as assessed by nasal wash, is the best niche for detection of experimental pneumococcal colonisation in both young and older adults.

Essential Emergency and Critical Care: a consensus among global clinical experts

BACKGROUND

Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.

METHODS

In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements.

RESULTS

The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19.

CONCLUSION

The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

A longitudinal observational study of aetiology and long-term outcomes of sepsis in Malawi revealing the key role of disseminated tuberculosis

Background

Sepsis protocols in sub-Saharan Africa are typically extrapolated from high-income settings, yet sepsis in sub-Saharan Africa is likely caused by distinct pathogens and may require novel treatment strategies. Data to guide such strategies are lacking. We aimed to define causes and modifiable factors associated with sepsis outcomes in Blantyre, Malawi, in order to inform the design of treatment strategies tailored to sub-Saharan Africa.

Methods

We recruited 225 adults who met a sepsis case definition defined by fever and organ dysfunction in an observational cohort study at a single tertiary center. Etiology was defined using culture, antigen detection, serology, and polymerase chain reaction. The effect of treatment on 28-day outcomes was assessed using Bayesian logistic regression.

Results

There were 143 of 213 (67%) participants living with human immunodeficiency virus (HIV). We identified a diagnosis in 145 of 225 (64%) participants, most commonly tuberculosis (TB; 34%) followed by invasive bacterial infections (17%), arboviral infections (13%), and malaria (9%). TB was associated with HIV infection, whereas malaria and arboviruses with the absence of HIV infection. Antituberculous chemotherapy was associated with survival (adjusted odds ratio for 28-day death, 0.17; 95% credible interval, 0.05–0.49 for receipt of antituberculous therapy). Of those with confirmed etiology, 83% received the broad-spectrum antibacterial ceftriaxone, but it would be expected to be active in only 24%.

Conclusions

Sepsis in Blantyre, Malawi, is caused by a range of pathogens; the majority are not susceptible to the broad-spectrum antibacterials that most patients receive. HIV status is a key determinant of etiology. Novel antimicrobial strategies for sepsis tailored to sub-Saharan Africa, including consideration of empiric antituberculous therapy in individuals living with HIV, should be developed and trialed.

Exploring smoke: an ethnographic study of air pollution in rural Malawi

Air pollution adversely affects human health, and the climate crisis intensifies the global imperative for action. Low-/middle-income countries (LMIC) suffer particularly high attributable disease burdens. In rural low-resource settings, these are linked to cooking using biomass. Proposed biomedical solutions to air pollution typically involve ‘improved cooking technologies’, often introduced by high-income country research teams. This ethnography, set in a rural Malawian village, aimed to understand air pollution within its social and environmental context. The results provide a multifaceted account through immersive participant observations with concurrent air quality monitoring, interviews and participatory workshops. Data included quantitative measures of individuals’ air pollution exposures paired with activity, qualitative insights into how smoke is experienced in daily life throughout the village, and participants’ reflections on potential cleaner air solutions. Individual air quality monitoring demonstrated that particulate levels frequently exceeded upper limits recommended by the WHO, even in the absence of identified sources of biomass burning. Ethnographic findings revealed the overwhelming impact of economic scarcity on individual air pollution exposures. Scarcity affected air pollution exposures through three pathways: daily hardship, limitation and precarity. We use the theory of structural violence, as described by Paul Farmer, and the concept of slow violence to interrogate the origins of this scarcity and global inequality. We draw on the ethnographic findings to critically consider sustainable approaches to cleaner air, without re-enacting existing systemic inequities.

Knowledge of health workers relating to sepsis awareness and management in Lambaréné, Gabon

Background In 2016, the third international consensus definitions for sepsis and septic shock (Sepsis-3) task force provided revised definitions for sepsis and septic shock. This study explores knowledge regarding sepsis among health workers in Lambaréné, Gabon. Methods We conducted a self-administered questionnaire-based survey about sepsis among health workers from the referral regional hospital, the research center, and primary care health facilities in the Lambaréné region. Participants were from the referral regional hospital, the research center, and primary health care facilities. A score of one was given to each correct answer. The global score out of a possible score of twenty was calculated, and the proportion of correct responses was determined. Results A total of 115 health workers (physicians, nurses and assistant nurses) completed the questionnaire, of which 48.7% (56/115) provided a valid definition of sepsis, but 74% (85/115) had never heard about the quick Sequential Organ Failure Assessment (qSOFA) score. The proportion of correct answers was comparable across the three health profession categories. The median global score across all health workers was 11 [IQR, 9-14.5] out of 20. Physicians attained higher global scores [14 (IQR, 11-15)] than assistant nurses [11 (IQR, 8-13), P=0.007]; their global score was comparable to that of nurses. Conclusion There are considerable knowledge gaps regarding sepsis among health workers in Lambaréné, potentially impairing the prompt recognition and management of sepsis. There is a need to establish periodic up-to-date training to improve sepsis knowledge.

Distinct clinical and immunological profiles of patients with evidence of SARS-CoV-2 infection in sub-Saharan Africa

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.

Supplemental oxygen in Queen Elizabeth Central Hospital Malawi: a prospective cohort study of patients admitted to medical wards

Background: Oxygen is designated an essential drug by the World Health Organisation, and reduces mortality in hypoxic patients. In low-resource settings the provision of oxygen seldom meets its demand. This study explores predictors and observed time-course of hypoxaemia in order to help inform needs assessments for oxygen in hospitals in low- and middle-income countries. Methods: A prospective cohort study of adults with hypoxaemia admitted to medical wards of a teaching hospital in Malawi between February and March 2020. Vital signs and oxygen therapy were recorded daily. We analysed outcomes (death, discharge from hospital or ongoing inpatient care at 14 days after admission) using Kaplan-Meier and Cox regression time-to-event analysis. Results: 33 patients were recruited with median age 45 years (IQR 33-61). 13 (39%) were female. Median pre-treatment oxygen saturations were 84% (IQR 76-87%). Oxygen delivery devices were often shared with other patients (n=10, 33%) and the flow rate was often unknown (n=14, 47%), mostly because of broken equipment (n=8, 57%). Median duration of oxygen therapy was 3 days (IQR 1-7). Death occurred in 16 (49%). Hazard ratios for short oxygen therapy were reduced in patients who had a chest radiograph performed (HR 0.08, 95% CI 0.02–0.30), in ex-smokers (HR 0.01, 95% CI 0.00-0.22) and in never smokers (HR 0.03, 95% CI 0.00 – 0.78). Conclusions: Delivering oxygen therapy in lower-middle income countries is challenging; broken equipment and shared delivery devices prevented titration of flow rates. Patients were relatively young and at a high risk of death. Patients with a chest radiograph received oxygen for longer than those without. This hypothesis generating study can be used to build a more comprehensive understanding of oxygen supply need at the hospital level.

Population Incidence and Mortality of Sepsis in an Urban African Setting, 2013-2016

BACKGROUND

Sepsis is an important cause of mortality globally, although population incidence estimates from low-income settings, including sub-Saharan Africa, are absent. We aimed to estimate sepsis incidence burden using routinely available data from a large urban hospital in Malawi.

METHODS

We linked routine-care databases at Queen Elizabeth Central Hospital, Blantyre, Malawi, to provide admission and discharge data for 217 149 adults from 2013-2016. Using a definition of sepsis based on systemic inflammatory response syndrome criteria and Blantyre census population data, we calculated population incidence estimates of sepsis and severe sepsis and used negative binomial regression to assess for trends over time. Missing data were multiply imputed with chained equations.

RESULTS

We estimate that the incidence rate of emergency department-attending sepsis and severe sepsis in adults was 1772 per 100 000 person-years (95% confidence interval [CI], 1754-1789) and 303 per 100 000 person-years (95% CI, 295-310), respectively, between 2013 and 2016, with a year-on-year decrease in incidence. In-hospital mortality for patients admitted to the hospital with sepsis and severe sepsis was 23.7% (95% CI, 22.7-24.7%) and 28.1% (95% CI, 26.1 - 30.0%), respectively, with no clear change over time.

CONCLUSIONS

Sepsis incidence is higher in Blantyre, Malawi, than in high-income settings, from where the majority of sepsis incidence data are derived. Worldwide sepsis burden is likely to be underestimated, and data from low-income countries are needed to inform the public health response.

Evidence for pulmonary rehabilitation in chronic respiratory diseases in sub-Saharan Africa: a systematic review

BACKGROUND: Pulmonary rehabilitation (PR) is a highly effective non-pharmacological treatment for patients with chronic respiratory diseases.OBJECTIVE: To synthesise the evidence for PR practice and efficacy in sub-Saharan Africa.METHODS: We searched in PubMed and Scopus for relevant studies and scanned reference lists of relevant studies from these databases for additional studies. Articles meeting the inclusion criteria were included. Pre-determined data were extracted independently by two reviewers. A narrative synthesis approach was used in the interpretation of findings.RESULTS: Six studies were included, totalling 275 participants. Indications for PR were chronic obstructive pulmonary disease, asthma, pulmonary tuberculosis and post-tuberculosis lung disease. Programmes ran for 6-12 weeks, universally incorporated exercise, and variously used home-based and hospital-based delivery models. All were interventional studies, of which two were randomised controlled trials, and primarily reported pulmonary function and exercise tolerance endpoints. Evidence for individualising the exercise regimen was available in three studies.CONCLUSIONS: There is limited evidence on PR design and efficacy in sub-Saharan Africa, but available data support its use in a variety of chronic respiratory conditions. Future studies should report core outcome sets and their individualised exercise and education regimens.

Experimental Human Pneumococcal Colonization in Older Adults Is Feasible and Safe, Not Immunogenic

Rationale: Pneumococcal colonization is key to the pathogenesis of invasive disease but is also immunogenic in young adults, protecting against recolonization. Colonization is rarely detected in older adults, despite high rates of pneumococcal disease.Objectives: To establish experimental human pneumococcal colonization in healthy adults aged 50-84 years, to measure the immune response to pneumococcal challenge, and to assess the protective effect of prior colonization against autologous strain rechallenge.Methods: Sixty-four participants were inoculated with Streptococcus pneumoniae (serotype 6B; 80,000 cfu in each nostril). Colonization was determined by bacterial culture of nasal wash, and humoral immune responses were assessed by anticapsular and antiprotein IgG concentrations.Measurements and Main Results: Experimental colonization was established in 39% of participants (25/64) with no adverse events. Colonization occurred in 47% (9/19) of participants aged 50-59 compared with 21% (3/14) in those aged ≥70 years. Previous pneumococcal polysaccharide vaccination did not protect against colonization. Colonization did not confer serotype-specific immune boosting, with a geometric mean titer (95% confidence interval) of 2.7 μg/ml (1.9-3.8) before the challenge versus 3.0 (1.9-4.7) 4 weeks after colonization (P = 0.53). Furthermore, pneumococcal challenge without colonization led to a drop in specific antibody concentrations from 2.8 μg/ml (2.0-3.9) to 2.2 μg/ml (1.6-3.0) after the challenge (P = 0.006). Antiprotein antibody concentrations increased after successful colonization. Rechallenge with the same strain after a median of 8.5 months (interquartile range, 6.7-10.1) led to recolonization in 5/16 (31%).Conclusions: In older adults, experimental pneumococcal colonization is feasible and safe but demonstrates different immunological outcomes compared with younger adults in previous studies.

Persistent chronic respiratory symptoms despite TB cure is poorly correlated with lung function

BACKGROUND: Persistent respiratory symptoms and lung function deficits are common after patients with TB. We aimed to define the burden of post-TB lung disease (PTLD) and assess associations between symptoms and impairment in two high TB incidence communities.METHODS: This was a cross-sectional survey of adults in Cape Town, South Africa who completed TB treatment 1-5 years previously. Questionnaires, spirometry and 6-minute walking distance (6MWD) were used to assess relationships between outcome measures and associated factors.RESULTS: Of the 145 participants recruited (mean age: 42 years, range: 18-75; 55 [38%] women), 55 (38%) had airflow obstruction and 84 (58%) had low forced vital capacity (FVC); the mean 6MWD was 463 m (range: 240-723). Respiratory symptoms were common: chronic cough (n = 27, 19%), wheeze (n = 61, 42%) and dyspnoea (modified MRC dyspnoea score 3 or 4: n = 36, 25%). There was poor correlation between FVC or obstruction and 6MWD. Only low body mass index showed consistent association with outcomes on multivariable analyses. Only 19 (13%) participants had a diagnosis of respiratory disease, and 16 (11%) currently received inhalers.CONCLUSION: There was substantial burden of symptoms and physiological impairment in this "cured" population, but poor correlation between objective outcome measures, highlighting deficits in our understanding of PTLD.

An Improvised Pulmonary Telerehabilitation Program for Postacute COVID-19 Patients Would Be Feasible and Acceptable in a Low-Resource Setting

ABSTRACT

Postacute COVID-19 patients are at risk of long-term functional impairment, and the rehabilitation community is calling for action preparing for a "tsunami of rehabilitation needs" in this patient population. In the absence of standard guidelines and local evidence, a 3-wk pulmonary telerehabilitation program was successfully delivered to a postacute severe COVID-19 patient in Malawi. The patient experienced persistent dyspnea and fatigue, with a remarkable impact on his health status. On the final assessment, all his respiratory severity scores had fallen by more than their thresholds for clinical significance. He reported no continued or new complaints, was walking longer distances, had returned to work, and was discharged from follow-up. Our case shows that an improvised pulmonary telerehabilitation program for postacute COVID-19 patients could be feasible and acceptable in a low-resource setting. Benefits include reducing risk of transmission and use of personal protective equipment.

Pneumococcal colonization impairs mucosal immune responses to live attenuated influenza vaccine

Influenza virus infections affect millions of people annually, and current available vaccines provide varying rates of protection. However, the way in which the nasal microbiota, particularly established pneumococcal colonization, shape the response to influenza vaccination is not yet fully understood. In this study, we inoculated healthy adults with live Streptococcuspneumoniae and vaccinated them 3 days later with either tetravalent-inactivated influenza vaccine (TIV) or live attenuated influenza vaccine (LAIV). Vaccine-induced immune responses were assessed in nose, blood, and lung. Nasal pneumococcal colonization had no impact upon TIV-induced antibody responses to influenza, which manifested in all compartments. However, experimentally induced pneumococcal colonization dampened LAIV-mediated mucosal antibody responses, primarily IgA in the nose and IgG in the lung. Pulmonary influenza-specific cellular responses were more apparent in the LAIV group compared with either the TIV or an unvaccinated group. These results indicate that TIV and LAIV elicit differential immunity to adults and that LAIV immunogenicity is diminished by the nasal presence of S. pneumoniae. Therefore, nasopharyngeal pneumococcal colonization may affect LAIV efficacy.

In depth analysis of patients with severe SARS-CoV-2 in sub-Saharan Africa demonstrates distinct clinical and immunological profiles

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 comprehensively characterise patients hospitalised with suspected or confirmed COVID-19, and healthy community controls. PCR-confirmed COVID-19 participants were more likely to receive dexamethasone and a beta-lactam antibiotic, and survive to hospital discharge than PCR-/IgG+ and PCR-/IgG-participants. PCR-/IgG+ participants exhibited a nasal and systemic cytokine signature analogous to PCR-confirmed COVID-19 participants, but increased propensity for Staphylococcus aureus and Streptococcus pneumoniae colonisation. We did not find evidence that HIV co-infection in COVID-19 participants was associated with mortality or altered cytokine responses. The nasal immune signature in PCR-/IgG+ and PCR-confirmed COVID-19 participants was distinct and predominated by chemokines and neutrophils. In addition, PCR-/IgG+ 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.