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.
Severe anaemia is a major cause of morbidity and mortality in HIV-infected adults living in resource-limited countries. Comprehensive data on the aetiology are lacking but are needed to improve ...outcomes.
HIV-infected adults with severe (haemoglobin ≤70g/l) or very severe anaemia (haemoglobin ≤ 50 g/l) were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifteen potential causes and associations with anaemia severity and mortality were explored.
199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on ART. More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI<20: 49.7%), TB infection (41.2%) and unsuppressed HIV infection (viral load >1000 copies/ml) (73.9%). EBV/CMV co-infection (16.5%) was associated with very severe anaemia (OR 2.8 95% CI 1.1-6.9). Overall mortality was high (53%; 100/199) with a median time to death of 17.5 days (IQR 6-55) days. Death was associated with folate deficiency (HR 2.2; 95% CI 1.2-3.8) and end stage renal disease (HR 3.2; 95% CI 1.6-6.2).
Mortality among severely anaemic HIV-infected adults is strikingly high. Clinicians should be aware of the urgent need for a multifactorial approach including starting or optimising HIV treatment, considering TB treatment, nutritional support and optimising renal management.
Iron deficiency is a treatable cause of severe anaemia in low-and-middle-income-countries (LMIC). Diagnosing it remains challenging as peripheral blood markers poorly reflect bone-marrow iron ...deficiency (BM-ID), especially in the context of HIV-infection.
Severely anaemic (haemoglobin ≤70g/l) HIV-infected adults were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. BM-ID was evaluated. Accuracy of blood markers (including hepcidin, mean corpuscular volume, mean cellular haemoglobin concentration, serum iron, serum ferritin, soluble transferrin receptor (sTfR), sTfR index, sTfR-ratio) to detect BM-ID was evaluated by ROC area under the curve (AUCROC).
Seventy-three patients were enrolled and 35 (48.0%) had BM-ID. Although hepcidin and MCV performed best (AUCROC of 0.593 and 0.545 respectively) all markers performed poorly in identifying BM-ID (ROC<0.6). The AUCROC of hepcidin in males was 0.767 (sensitivity 80%, specificity 78%) and in women 0.490 (sensitivity 60%, specificity 61%).
BM-ID deficiency was common in severely anaemic HIV-infected patients. It is an important and potential treatable contributor to severe anaemia but lack of definitive biomarkers makes it difficult to accurately assess iron status in these patients. Further investigation of the potential of hepcidin is needed, including exploration of the differences in hepcidin results between males and females.
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.
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.
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.
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.
Dyslipidaemia drives the process of atherosclerosis, and hence a significant modifiable risk factor complicating hypertension and diabetes. In Malawi, the prevalence, screening and management of ...dyslipidaemia among persons with diabetes mellitus have not been reported. This study aimed to investigate the prevalence, biochemical characteristics, screening and management practices for dyslipidaemia among persons with diabetes mellitus, hypertension, and diabetes mellitus and hypertension comorbidity at Queen Elizabeth Central hospital in Blantyre, Malawi.
This was a cross-sectional study conducted in 2021. A total of 256 adult participants (diabetes mellitus = 100); hypertension = 100; both conditions = 56) were included. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were also assessed.
Dyslipidaemia was prevalent in 58%, 55%, and 70% of participants with diabetes mellitus, hypertension, and both conditions. Low-density lipoprotein cholesterol (LDL-C) dyslipidaemia was the most common in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2-4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p < 0.02). Being overweight or obese and age over 30 years were risk factors for dyslipidaemia in participants with diabetes mellitus alone (OR 1.3 (95% CI 1.1-1.6), p < 0.04, and OR 2.2 (95% CI 1.2-4.7) (p < 0.01), respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (OR 3.5 (95% CI 1.2-9.9) p < 0.001). Poorly controlled hypertension and the use of beta-blockers and thiazide diuretics predicted dyslipidaemia among patients with both diabetes mellitus and hypertension (OR 6.50 CI 1.45-29.19; and OR 5.20 CI 1.16-23.36 respectively). None of the participants had a lipogram performed before the study or were on lipid-lowering therapy.
Dyslipidaemia with LDL-C derangement was highly prevalent, especially in individuals with both diabetes mellitus and hypertension, and there was absent use of lipid-lowering therapy. Screening and managing dyslipidaemia should be reinforced to reduce the risk of cardiovascular complications in this population at increased risk.
To assess the impact of the COVID-19 pandemic impact on hemodialysis (HD) centers, The Dialysis Outcomes and Practice Patterns Study and ISN collaborated on a web-survey of centers.
A combined ...approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centers in 78 countries and all 10 ISN regions.
In 8 regions, rates of SARS-CoV-2 infection were <20% in most centers, but in North East Asia (NE Asia) and Newly Independent States and Russia (NIS & Russia), rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centers in 8 regions, although lower in North America and Caribbean (N America & Caribbean) and NE Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centers in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centers in NE Asia to ≥50% in 63% of centers in the Middle East and 68% of centers in NIS & Russia. In most centers, <10% of staff died, but in Africa and South Asia (S Asia), 2% and 6% of centers reported ≥50% mortality, respectively.
There has been wide global variation in SARS-CoV-2 infection rates among HD patients and staff, personal protective equipment (PPE) availability, and testing, and the ways in which services have been redesigned in response to the pandemic.
Background
: In low-income countries, like Malawi, important public health measures including social distancing or a lockdown have been challenging to implement owing to socioeconomic constraints, ...leading to predictions that the COVID-19 pandemic would progress rapidly. However, due to limited capacity to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, there are no reliable estimates of the true burden of infection and death. We, therefore, conducted a SARS-CoV-2 serosurvey amongst health care workers (HCWs) in Blantyre city to estimate the cumulative incidence of SARS-CoV-2 infection in urban Malawi.
Methods
: We recruited 500 otherwise asymptomatic HCWs from Blantyre City (Malawi) from 22
nd
May 2020 to 19
th
June 2020 and serum samples were collected from all participants. A commercial ELISA was used to measure SARS-CoV-2 IgG antibodies in serum.
Results
: A total of 84 participants tested positive for SARS-CoV-2 antibodies. The HCWs with positive SARS-CoV-2 antibody results came from different parts of the city. The adjusted seroprevalence of SARS-CoV-2 antibodies was 12.3% CI 8.2 - 16.5. Using age-stratified infection fatality estimates reported from elsewhere, we found that at the observed adjusted seroprevalence, the number of predicted deaths was eight times the number of reported deaths.
Conclusions
: The high seroprevalence of SARS-CoV-2 antibodies among HCWs and the discrepancy in the predicted versus reported deaths suggests that there was early exposure but slow progression of COVID-19 epidemic in urban Malawi. This highlights the urgent need for development of locally parameterised mathematical models to more accurately predict the trajectory of the epidemic in sub-Saharan Africa for better evidence-based policy decisions and public health response planning.
Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life ...expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country’s Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.
Dyslipidaemia is a significant risk factor for cardiovascular events but is often neglected in most resource-poor settings.
We aimed to investigate the prevalence, biochemical characteristics, ...screening and management practice for dyslipidaemia among patients with DM, hypertension, and both DM and hypertension at a tertiary teaching hospital in Southern Malawi, Africa.
A total of 256 adult participants (DM=100; hypertension =100; both condition = 56) were included in the cross-sectional study in 2021. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were assessed.
Dyslipidaemia was prevalent in 73.5%, 71.8%, and 76.7% of participants with DM, hypertension, and both conditions. High low-density lipoprotein cholesterol (LDL-C) was the most common dyslipidaemia type in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2 - 4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p=0.02). Overweight or obesity, and age over 30 years were risks for dyslipidaemia in patients with DM alone (RR 1.3 (95% CI 1.1 – 1.6), p=0.04, and RR 2.2 (95% CI 1.2 – 4.7) (p<0.01) respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (RR 3.492 (95% CI 1.234 - 9.884) p <0.001). Poorly controlled hypertension was associated with a 1.8 times risk (95% CI 1.06 – 2.7) of dyslipidaemia in patients with both DM and hypertension (p<0.01). Only 1% of the participants ever had a lipogram performed before the study and were on lipid-lowering therapy.
Dyslipidaemia was highly prevalent, especially in individuals with both DM and hypertension. Screening and managing dyslipidaemia should be reinforced to reduce the risk of major cardiovascular events in this population at high risk.
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