In Malawi, three government hospitals will become testing grounds for adapting global infection control rules to a setting where sinks are scarce, cleaners are poorly paid, and 68% of drug-resistant sepsis cases originate from recent healthcare visits. This matters because healthcare-acquired infections (HAI) and antimicrobial resistance are poorly measured and under-prioritised in African hospitals. The researcher has already shown that hospitals are likely major transmission sites for untreatable infections. Current WHO guidelines were not designed for these conditions, and no one has rigorously tested whether they work—or are worth the cost—in this context. If successful, the project will produce a nationally scalable infection control programme for Malawi, backed by hard evidence on what actually reduces infections and at what price. It will train a cadre of local infection control professionals and establish a “learning health system” that can sustain improvements beyond the grant period. The economic modelling will tell policymakers where to invest limited funds for the greatest impact. The findings could also inform infection control strategies across other low-resource settings in Africa.
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Research Question How can the WHO Infection Prevention and Control guidelines be optimally adapted to the African context, and iteratively improved by using causal inference to investigate their efficacy and economic modelling to evaluate their cost-effectiveness? Background IPC has yet to be consistently prioritised in LMIC, and the scale of the problem is poorly described. In the African context, the healthcare built environment is often inadequate, cleaners are poorly paid and equipped and there are few facilities to support hand hygiene. We recently observed that 68% of episodes of cephalosporin resistant/locally untreatable gram negative sepsis followed recent health care exposure, indicating health care facilities are highly likely to be a major site for HAI. Aim Through implementing the WHO IPC guidelines, I will investigate the efficacy and cost-effectiveness of an IPC intervention and co-create acceptable, scalable and sustainable interventions to reduce HAI in Africa. Objectives In equitable partnership with a national-level IPC steering group, to reinvigorate local IPC teams in three hospitals in Southern Malawi; Establish clinical and microbiological HAI surveillance, then implement, test and improve the WHO guidelines on IPC, investigating their effectiveness within an implementation science framework; Assess the efficacy of IPC implementation using descriptive epidemiology, high resolution molecular surveillance and causal inference; To estimate the economic burden associated with HAI, and cost-effectiveness of IPC Co-create acceptable, sustainable, and nationally generalisable guidelines, policy and protocols to mitigate HAI in Malawi in partnership with College of Medicine and Public Health Institute of Malawi. Country of work/partners Malawi: the study will operate at three government hospitals and be based at the Malawi Liverpool Wellcome Programme, running in partnership with the College of Medicine, Ministry of Health and African Institute of Development Policy (AFIDEP). Methods and timelines Implementing IPC strategy (Workstrand 1): I will convene a steering group and reinvigorate existing ministry of health IPC teams, conduct formative research to understand the success or failure of previous IPC strategies and establish an IPC training programme (Y1). Clinical and microbiological surveillance can then be established and multimodal implementation strategies devised and implemented (Y2-4). Mixed-method evaluation of effectiveness of the implementation will be made and fed back to policy makers (Y3-5 & WS4). Causal modelling (Workstrand 2): HAI cohorts will be recruited before and after implementation for key HAI syndromes and characterised using culture and molecular microbiology (Y2-4). Causal modelling will be utilised to predict efficacy of intervention and improve multimodal strategy (Y3-5). Health economics (Workstand 3): We will estimate the economic burden associated with HAI, and evaluate cost-effectiveness of IPC interventions in order to make recommendations about targeting efforts (Y2-4). Policy (Workstrand 4): We will actively involve MoH and CoM throughout the project and work with MoH to develop nationally scalable IPC interventions (Y4-5). Anticipated impact I will describe the effectiveness, efficacy and cost effectiveness of an IPC programme in Africa. Success in Malawi will entail the development of a cadre of IPC professionals that will establish a learning health system capable of sustaining an effective IPC programme.
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