Title: Preventing Healthcare Associated Infection and Antimicrobial Resistance in Africa
Funder: Department of Health and Social Care

Abstract: Research QuestionHow 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? BackgroundIPC 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/partnersMalawi: 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.

Lay abstract: To address Healthcare Associated Infection (HAI) in Africa, I will use cutting edge molecular microbiology and mathematical modelling to investigate the implementation of the WHO framework for Infection Prevention and Control (IPC) in Malawi. Key to this will be the development of equitable partnerships with the Ministry of Health and College of Medicine. I will use the data to develop effective, acceptable and scalable interventions to reduce HAI in Africa.Background Hospitals are complex environments that offer people care for diverse life events, from minor ailments to end-of-life care. They are perceived as places of safety, however the concentration of vulnerable people, staff and visitors makes maintaining safety a major challenge that requires the involvement of multiple professional groups and which requires the collective involvement of patients, staff and visitors.Infections contracted as a result of admission to hospital, or exposure to other healthcare facilities represent the most common adverse outcome associated with healthcare settings globally. Further, the germs, specifically bacteria, associated with HAI are increasingly resistant to antibiotics, making the treatment of HAI an increasing challenge. It is therefore best to prevent HAI happening in the first place.Infection prevention and control (IPC) is the term used to describe strategies to prevent HAI and the World Health Organisation has published a substantial body of work to support the implementation of IPC in low and middle income countries (LMIC). However HAI and IPC are often not prioritised in LMIC due to lack of resources and multiple competing priorities.Design and MethodsI will work in three government hospitals in Malawi. The project will be based at the Malawi Liverpool Wellcome Programme and will run in partnership with the College of Medicine, Ministry of Health and African Institute of Development Policy (AFIDEP). I will implement my project in 4 workstrands:Implementing IPC strategy (Workstrand 1): The first priority will be to convene a national steering group to build an equitable partnership and reinvigorate existing ministry of health IPC teams. My team will investigate the success or failure of previous IPC strategies (Y1). I will conduct clinical and laboratory surveillance of HAI before implementing an IPC programme co-created with partners (Y2-4). Assessment of effectiveness of the implementation will be made and shared with policy makers (Y3-5 & WS4).Using mathematical modelling to understand the intervention (Workstrand 2): I will recruit cohorts of patients with different types of HAI and study them in-depth by capturing comprehensive patient and bacterial data before and after implementation for key HAI syndromes (Y3-5). I will use cutting edge microbiological tools and mathematical methods to analyse these data and iteratively improve the IPC programme.Health economics (Workstand 3): It will be vital to estimate the cost of HAI, and then evaluate cost effectiveness of interventions in order to enable policy makers to make recommendations about targeting efforts (Y2-4).Policy (Workstrand 4): We will actively involve MoH and CoM throughout the project and, in doing so, co-create nationally scalable IPC interventions (Y4-5).Patient and public engagementWe will involve patents and the public in co-producing IPC strategy and interventions and in doing so raise the profile of HAI, IPC and AMR in Malawi, in partnership with MLW's community advisory group. DisseminationOur findings will be shared with the WHO Infection Prevention team and more broadly to the academic community through presentation and peer-reviewed publication. We will engage with the public through MLW's communications team, which uses radio, print and social media, and share information with the hospitals through peer education meetings (i.e. Grand Round), and with the Ministry of Health through relevant technical advisory groups.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION