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We used publicly available data to describe epidemiology, genomic surveillance, and public health and social measures from the first 3 COVID-19 pandemic waves in southern Africa during April 6, 2020-September 19, 2021. South Africa detected regional waves on average 7.2 weeks before other countries. Average testing volume 244 tests/million/day) increased across waves and was highest in upper-middle-income countries. Across the 3 waves, average reported regional incidence increased (17.4, 51.9, 123.3 cases/1 million population/day), as did positivity of diagnostic tests (8.8%, 12.2%, 14.5%); mortality (0.3, 1.5, 2.7 deaths/1 million populaiton/day); and case-fatality ratios (1.9%, 2.1%, 2.5%). Beta variant (B.1.351) drove the second wave and Delta (B.1.617.2) the third. Stringent implementation of safety measures declined across waves. As of September 19, 2021, completed vaccination coverage remained low (8.1% of total population). Our findings highlight opportunities for strengthening surveillance, health systems, and access to realistically available therapeutics, and scaling up risk-based vaccination.

Introduction Bacterial bloodstream and urinary tract infections present a huge health burden especially in low-resource settings, which is worsened by the escalating burden of antimicrobial resistance (AMR). However, surveillance data on antimicrobial susceptibility profiles of pathogens remains scarce in Malawi. Therefore, this study aimed at establishing trends and patterns of AMR among common pathogens causing adult bloodstream and urinary tract infections in Malawi. Methods This was a secondary analysis of records from bacterial culture and susceptibility testing results of routinely collected adult blood and urinary tract samples from seven facilities in Malawi between January 2020 and August 2024. Antimicrobial susceptibility testing (AST) was performed using the disk diffusion method and interpreted according to EUCAST guidelines. The outcome of interest was the AST results of the bacterial isolates. Data were analyzed using SPSS version 28. Results Out of the 2787 isolates collected, 80.6% ( n  = 2246) were from urine samples and 19.4% ( n  = 541) were from blood samples. 74.1% ( n  = 2066) of the isolates were Gram-negative organisms. Escherichia coli (37.6%, n  = 1048) and Klebsiella pneumoniae (8.3%, n  = 232) were the most frequent isolates. A total of 16,696 ASTs were performed on the isolates, with 54.3% ( n  = 9,068) showing resistance to the antibiotics tested. Among Gram-positive organisms, there was increasing resistance to co-trimoxazole (71.4-83.3%), vancomycin (20.0-31.0%), with consistently high resistance rates to ciprofloxacin, erythromycin and gentamicin. Gram-negative organisms showed trends of increasing resistance to ceftriaxone (63.0-72.4%), co-trimoxazole (72.7-89.7%), and piperacillin and tazobactam (0.0-35.8%), with a notable significant increase in resistance to ciprofloxacin (66.7-81.0%, p  = 0.001). There was an increasing trend of Enterobacteriaceae resistance to third-generation cephalosporins (58.9-71.5%). Overall, pathogens with the highest resistance include Citrobacter freundii (62.1%, n  = 755/1216), Staphylococcus sp. (62.0%, n  = 163/263) and K. pneumoniae (57.1%, n  = 941/1648). Among the commonly isolated pathogens, E. coli , K. pneumoniae and Enterobacter spp. showed highest resistance to multiple antibiotics. Conclusion The study revealed high resistance levels among pathogens that cause BSIs and UTIs in public hospitals in Malawi. Most pathogens demonstrated high resistance against multiple antibiotic classes. The high AMR trends and patterns pose a significant risk to healthcare provision, calling for enhancing surveillance and upscaling efforts to address the challenge.

Background: The period of complementary feeding, starting around 6 months of age, is a time of high risk for growth faltering and morbidity. Low micronutrient density of locally available foods is a common problem in low income countries. Children of HIV-infected women are especially vulnerable. Although antiretroviral prophylaxis can reduce breast milk HIV transmission in early infancy, there are no clear feeding guidelines for after 6 months. There is a need for acceptable, feasible, affordable, sustainable and safe (AFASS by WHO terminology) foods for both HIV-exposed and unexposed children after 6 months of age. Methods and Findings: We conducted in Lusaka, Zambia, a randomised double-blind trial of two locally made infant foods: porridges made of flour composed of maize, beans, bambaranuts and groundnuts. One flour contained a basal and the other a rich level of micronutrient fortification. Infants (n = 743) aged 6 months were randomised to receive either regime for 12 months. The primary outcome was stunting (length-for-age Z<−2) at age 18 months. No significant differences were seen between trial arms overall in proportion stunted at 18 months (adjusted odds ratio 0.87; 95% CI 0.50, 1.53; P = 0.63), mean length-for-age Z score, or rate of hospital referral or death. Among children of HIV-infected mothers who breastfed <6 months (53% of HIV-infected mothers), the richly-fortified porridge increased length-for-age and reduced stunting (adjusted odds ratio 0.17; 95% CI 0.04, 0.84; P = 0.03). Rich fortification improved iron status at 18 months as measured by hemoglobin, ferritin and serum transferrin receptors. Conclusions: In the whole study population, the rich micronutrient fortification did not reduce stunting or hospital referral but did improve iron status and reduce anemia. Importantly, in the infants of HIV-infected mothers who stopped breastfeeding before 6 months, the rich fortification improved linear growth. Provision of such fortified foods may benefit health of these high risk infants.

People who inject drugs (PWID) in Zambia are an understudied population at high risk for HIV acquisition and transmission. We report here on the progress within the PWID communities of Livingstone, Lusaka, and Ndola, Zambia towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets. A biobehavioral survey used respondent-driven sampling to survey 235 PWID in Livingstone, 349 in Lusaka, and 259 in Ndola in 2021-22. Questions on HIV and injection drug use were administered, and blood was collected for HIV, syphilis, Hepatitis B, and Hepatitis C testing. Weighted prevalence and 95% confidence intervals (CIs) were calculated using Gile's sequential sampling estimator. In Livingstone, Lusaka, and Ndola, HIV prevalence among PWID was 11.9% (95% CI: 7.3, 16.5), 7.3% (95% CI: 4.5, 10.2), and 21.9% (95% CI: 14.5, 29.3), respectively. Among HIV-positive PWID in Livingstone, 70.7% (95% CI: 55.4, 85.0) were aware of their HIV status (95% is 1st UNAIDS target), 100% of those were on antiretroviral therapy (ART) (95% is 2nd UNAIDS target), and 100% of those achieved viral load suppression (VLS) (95% is 3rd UNAIDS target). In Lusaka, 66.0% (95% CI: 49.3, 82.2) were aware, 75.7% (95% CI: 51.1, 99.9) were on ART, and 66.3% (95% CI: 42.1, 90.9) achieved VLS. In Ndola, 60.2% (95% CI: 44.1, 76.0), 100%, and 90.2% (95% CI: 82.2, 98.3) were aware, on ART, and achieved VLS, respectively. Awareness of HIV status was low among PWID living in Livingstone, Lusaka, and Ndola, Zambia. Treatment and VLS progress were lacking in Lusaka and Ndola as well with Lusaka showing the least progress toward all three UNAIDS targets. Our site-level findings highlight critical gaps in PWID-specific HIV awareness, treatment, and VLS status in three major urban areas in Zambia that limit progress toward HIV epidemic control in this hard-to-reach population.

Background For years, Malawi remained at the bottom of league tables on maternal, neonatal and child health. Although maternal mortality ratios have reduced and significant progress has been made in reducing neonatal morality, many challenges in achieving universal access to maternal, newborn and child health care still exist in Malawi. In Malawi, there is still minimal, though increasing, male involvement in ANC/PMTCT/MNCH services, but little understanding of why this is the case. The aim of this paper is to explore the role and involvement of men in MNCH services, as part of the broader understanding of those community system factors. Methods This paper draws on the qualitative data collected in two districts in Malawi to explore the role and involvement of men across the MNCH continuum of care, with a focus on understanding the community systems barriers and enablers to male involvement. A total of 85 IDIs and 20 FGDs were conducted from August 2014 to January 2015. Semi-structure interview guides were used to guide the discussion and a thematic analysis approach was used for data analysis. Results Policy changes and community and health care provider initiatives stimulated men to get involved in the health of their female partners and children. The informal bylaws, the health care provider strategies and NGO initiatives created an enabling environment to support ANC and delivery service utilisation in Malawi. However, traditional gender roles in the home and the male ‘unfriendly’ health facility environments still present challenges to male involvement. Conclusion Traditional notions of men as decision makers and socio-cultural views on maternal health present challenges to male involvement in MNCH programs. Health care provider initiatives need to be sensitive and mindful of gender roles and relations by, for example, creating gender inclusive programs and spaces that aim at reducing perceptions of barriers to male involvement in MNCH services so that programs and spaces that are aimed at involving men are designed to welcome men as full partners in the overall goals for improving maternal, neonatal and child health outcomes.

Traditional leaders play a prominent role at the community level in Malawi, yet limited research has been undertaken on their role in relation to policy implementation. This article seeks to analyse the role of traditional leaders in implementing national maternal, newborn and child health (MNCH) policy and programmes at the community level. We consider whether the role of the chief embodies a top-down (utilitarian) or bottom-up (empowerment) approach to MNCH policy implementation. Primary data were collected in 2014/15, through 85 in-depth interviews and 20 focus group discussions in two districts in Malawi. We discovered that traditional leaders play a pivotal role in supporting MNCH service utilization, through mobilization for MNCH campaigns, and encouraging women to give birth at the health facility rather than at home or in the community setting. Women and their families responded to bylaws to deliver in the facility out of respect for the traditional leader, which is ingrained in Malawian culture. Fines were imposed on women for delivering at home, in the form of goats, chickens and money. Fear and coercion were often used by traditional leaders to ensure that women delivered at the health facility. Chiefs who failed to enforce these bylaws were also fined. Although the role of the traditional leader was often positive and encouraging in relation to MNCH service utilization, this was sometimes carried out in a coercive manner. Results show evidence of a utilitarian top-down model of policy implementation, where the goal of health service utilization justified the means, through encouragement, fear, punishment or coercion. Although the bottom-up approach would be associated with a more empowerment approach, it is unlikely that this would have been successful in Malawi, given the hierarchical nature of society. Further research on policy implementation in the context of community participation is needed. Les chefs traditionnels jouent un rôle de premier plan au niveau communautaire au Malawi, mais peu de recherches ont été menées sur leur rôle dans la mise en œuvre des politiques. Le présent article cherche à analyser le rôle des chefs traditionnels dans la mise en œuvre des politiques et programmes nationaux de santé maternelle, néonatale et infantile (SMNI) au niveau communautaire. Nous cherchons à savoir si le rôle du chef incarne une approche descendante (utilitaire) ou ascendante (autonomisation) de la mise en œuvre de la politique de SMNI. Des données primaires ont été recueillies en 2014/15, par le biais de 85 entretiens approfondis et de 20 discussions de groupe réalisés dans deux districts du Malawi. Nous avons découvert que les chefs traditionnels jouent un rôle central dans le soutien à l’utilisation des services de santé maternelle, néonatale et infantile par la mobilisation dans le cadre des campagnes de santé maternelle et infantile et en encourageant les femmes à accoucher dans les formations sanitaires plutôt qu’à domicile ou dans une structure communautaire. Par respect pour le chef traditionnel, inhérent à la culture du Malawi, les femmes et leurs familles ont été réceptives aux règlements municipaux leur recommandant d’accoucher dans les établissements sanitaires. Des amendes - payées sous forme de chèvres, poulets ou argent -, ont été infligées aux femmes qui accouchent à domicile. La peur et la coercition étaient souvent utilisées par les chefs traditionnels pour s’assurer que les femmes accouchent dans les formations sanitaires. Les chefs qui ne sont pas parvenus à faire respecter ces règlements ont également été sanctionnés par une amende. Bien que le rôle des chefs traditionnels ait souvent été positif et encourageant s’agissant de l’utilisation des services de santé maternelle, néonatale et infantile, ils ont parfois eu recours à des méthodes coercitives. Les résultats démontrent l’existence d’un modèle descendant - utilitaire - de mise en œuvre des politiques, dont l’objectif, à savoir, le recours à des formations sanitaires, justifie les moyens utilisés (l’encouragement, la peur, la punition ou la coercition). Bien que l’approche ascendante soit associée à une approche plus autonomisante, elle avait peu de chances d’être couronnée de succès au Malawi, étant donné la nature hiérarchique de la société. Il est nécessaire de procéder à des recherches plus approfondies sur la mise en œuvre des politiques dans le contexte de la participation communautaire. Los líderes tradicionales desempeñan un rol prominente a nivel de la comunidad en Malawi. Sin embargo, se ha llevado a cabo poca investigación sobre su rol en relación a la implementación de políticas. Este artículo tiene como objetivo analizar el rol de los lideres tradicionales en la implementación de las políticas y programas de salud maternal, neonatal e infantil (SMNI) a nivel de la comunidad. Consideramos si el rol del líder personifica un enfoque de arriba hacia abajo (utilitario) o de abajo hacia arriba (de empoderamiento) con respecto a implementación de políticas de SMNI. Datos primarios fueron recolectados en 2014/15 a través de 85 entrevistas en profundidad y 20 grupos de discusión en 2 distritos en Malawi. Descubrimos que los lideres tradicionales juegan un rol crucial en el apoyo a la utilización de servicios de SMNI, a través de la movilización de campañas de SMNI y motivando a las mujeres a dar a luz en los centros de salud y no en sus casas o entornos comunitarios. Las mujeres y sus familias responden a las instrucciones de dar a luz en los centros de salud por el respeto que tienen a sus líderes, lo cual está arraigado en la cultura de Malawi. Se impusieron multas, en forma de cabras, gallinas y dinero, a las mujeres que dieron a luz en casa. El miedo y la coerción fueron utilizadas a menudo por los lideres tradicionales para garantizar que las mujeres dieran a luz en los centros de salud. Los líderes que no hicieron cumplir estas instrucciones también fueron multados. Aunque el rol de los lideres tradicionales fue a menudo positivo y alentador en relación a la utilización de servicios, esto a veces fue llevado a cabo de manera coactiva. Los resultados muestran evidencia de un modelo de implementación de políticas utilitario de arriba hacia abajo, donde el objetivo de la utilización de servicios de salud justifica los métodos de estímulo, miedo, castigo y coerción. Aunque el enfoque de abajo hacia arriba podría ser asociadocon un enfoque de empoderamiento, es poco probable que este tuviera éxito en Malawi, dada la naturaleza jerárquica de la sociedad. Se necesita más investigación sobre la implementación de políticas en el contexto de la participación de la comunidad. 传统领袖是马拉维社群中的重要角色, 但很少有研究探讨他们 在政策实施中的作用。本文旨在分析传统领袖在社区实施国 家孕产妇、新生儿和儿童健康（MNCH）政策和项目中的 用。我们考虑族长是否体现MNCH政策实施所采取的方式, 是 自上而下还是自下而上。我们于2014至2015年在马拉维两个 地区进行了85次深度访谈和20次焦点小组讨论, 收集到一手数 据。我们发现, 传统领袖在MNCH服务利用方面发挥了关键作 用, 他们为MNCH项目动员群众, 鼓励妇女选择在医疗机构分 娩而不是在家或在社区内分娩。妇女及其家庭出于对传统领 袖的尊重而选择住院分娩, 这种尊重是马拉维文化中根深蒂固 的一部分。在家分娩的妇女则要缴纳羊、鸡、金钱等形式的 罚款。传统领袖经常利用恐惧和胁迫来使妇女到医疗机构分 娩。未能实施规则的族长也会被罚款。尽管传统领袖在 MNCH服务利用方面通常起到积极作用, 但这种作用有时是采 用胁迫的方式进行的。研究结果显示, 政策实施采取了功利性 的自上而下模式, 为达到提高卫生服务利用的目的而不择方 法, 不管是鼓励、威慑、惩罚还是强迫。尽管自下而上的模式 赋予妇女更多权力, 这种模式在马拉维这类阶级社会不大可能 奏效。需要进一步研究社区参与情境下的政策实施

ObjectivesTo evaluate the feasibility and acceptability of integrating point-of-care ultrasound scan (POCUS) by midwives into routine antenatal care (ANC) services.DesignProspective, observational, multiphase, implementation science study.Main outcome measuresPrimary outcomes included the proportion of midwives who completed training and competency checks for basic obstetric scanning using a POCUS device; the feasibility and acceptability of midwife-delivered POCUS from the perspectives of midwives and pregnant women captured on structured questionnaires; and the proportion of scans meeting predefined quality standards. Secondary outcomes included responses to acceptability-related questionnaires administered to midwives and pregnant women.SettingRural, periurban and urban health centres in Blantyre District, Malawi.ParticipantsPregnant women attending ANC and midwives providing care at participating health facilities.ResultsObstetric registrars trained and mentored 45 midwives, and 42 (93%) completed the training. Most midwives (95%, n=40) found providing POCUS during ANC was feasible and acceptable. Overall, device durability was rated positively. Of the 1499 pregnant women who received a scan, 99% (n=1484) reported that receiving an ultrasound from a midwife during ANC was acceptable. Independent assessors determined that over 70% of the subsample of reviewed scans met minimum quality standards.ConclusionsMidwife-delivered POCUS is feasible and highly acceptable in diverse antenatal settings in Malawi. These findings support task-sharing models as a means of expanding access to this essential ANC service, particularly in low-resource settings.

Background Coverage of prevention of mother-to-child transmission of HIV (PMTCT) services has expanded rapidly but approaches to ensure service delivery is patient-centered have not always kept pace. To better understand how the inclusion of women living with HIV in a collective, quality improvement process could address persistent gaps, we adapted a social accountability approach, CARE’s Community Score Card© (CSC), to the PMTCT context. The CSC process generates perception-based score cards and facilitates regular quality improvement dialogues between service users and service providers. Methods Fifteen indicators were generated by PMTCT service users and providers as part of the CSC process. These indicators were scored by each population during three sequential cycles of the CSC process which culminates in a sharing of scores in a collective meeting followed by action planning. We aggregated these scores across facilities and analyzed the differences in first and last scorings to understand perceived improvements over the course of the project (z-test comparing the significance of two proportions; one-tailed p -value ≤ .05). Data were collected over 12 months from September 2017 to August 2018. Results Fourteen of the fifteen indicators improved over the course of this project, with eight showing statistically significant improvement. Out of the indicators that showed statistically significant improvement, the majority fell within the control of local communities, local health facilities, or service providers (7 out of 8) and were related to patient or user experience and support from families and community members (6 out of 8). From first to last cycle, scores from service users’ and service providers’ perspectives converged. At the first scoring cycle, four indicators exhibited statistically significant differences ( p -value ≤ .05) between service users and service providers. At the final cycle there were no statistically significant differences between the scores of these two groups. Conclusions By creating an opportunity for mothers living with HIV, health service providers, communities, and local government officials to jointly identify issues and implement solutions, the CSC contributed to improvements in the perceived quality of PMTCT services. The success of this model highlights the feasibility and importance of involving people living with HIV in quality improvement and assurance efforts. Trial registration Trial registration: ClincalTrials.gov NCT04372667 retrospectively registered on May 1st 2020.

Objectives In order to improve maternal and neonatal outcomes, it is important to understand how to maximise the utilisation of MNCH services. The supply side (service-driven) factors affecting access to MNCH services are more commonly studied and are better understood than the demand side (community led) factors. The aim of this study was to identify demand and supply determinants of access to MNCH services in Malawi. Methods Research was conducted in two districts of the Central Region of Malawi (Nkhotakota & Mchinji). Qualitative interviews (n = 85) and focus group discussions (n = 20) were conducted with a range of community members, leaders and health workers. Data were managed in NVivo (v10) and analysed using framework analysis, using Levesque et al. (2013) access framework. Results Community members clearly recognise their need for and seek out MNCH care from the formal health system. Women experience difficulties reaching health services and when reached find them limited, characterised by many indirect costs. There are many technical and interpersonal deficits, which results in poor satisfaction and reportedly poor outcomes for women. Conclusions for practice Women are seeking and utilising MNCH services which they find under-resourced and unwelcoming. Utilising the Levesque et al. (2013) framework, a granular analysis of demand and supply factors has identified the many challenges that remain to achieving equitable access to MNCH services in Malawi. Community members experience lack of availability, acceptability and appropriateness of these essential services.