| dc.description.abstract | Introduction: The global burden of musculoskeletal disease in low and middle-income countries is large, growing, and neglected. While there is considerable funding for the control of communicable disease, there has been little attention paid to either the prevention or the treatment of musculoskeletal impairment (MSI) in developing countries. Musculoskeletal disease is one of the major causes of physical disability globally, yet data regarding the magnitude of this burden in developing countries is scarce or lacking. Several studies have shown that the vast majority of those living with disability are children residing in Lower Middle-Income Countries (LMICs), but again, little research has been done in Malawi to establish the the actual burden of MSI in the population.
Musculoskeletal disease encompasses a wide range of conditions that vary from traumatic injury to congenital malformations, disabling arthritis to chronic low back pain, many of which benefit from surgical intervention. They affect a large portion of the world’s population in one form or another, with non-traumatic musculoskeletal disease estimated to account for 6.8% of all disability adjusted life years lost according to the latest Global Burden of Disease studies. However, this 6.8% of disability adjusted life years does not include those lost owing to musculoskeletal trauma.
Each year 5.1 million people worldwide die from injuries. 1.35 million of these deaths are due to road traffic accidents and ninety percent occur in developing countries. Africa has the highest rate of road traffic injuries (RTIs) in the world, despite being the least motorized of the world's 6 regions with only 2% of the world's registered vehicles. According to Global status Report on road safety 2018, there has been no reduction in number of road traffic deaths in any low-income country (LIC) since 2013. RTIs are the 8th leading cause of death for people of all age but are now the leading cause of death for children and young adults aged 5-29 years. For each person who dies from trauma, three to eight persons are permanently disabled and at least 20 persons survive with injuries that need treatment. WHO estimates suggest Malawi has one of the highest mortality rates due to road traffic injuries (RTIs) in the world, but very little research has been done to map the actual situation on the ground. Whereas WHO estimates of road traffic mortality in Malawi have remained relatively static over the last years, as clinicians we have had the impression that there is a rapidly increasing burden of RTIs in Malawi.
The overall aim of this thesis was to assess the burden of MSI and to report the prevalence, causes, and treatment need among both adults and children, to evaluate the quality of life among people with MSI in Malawi and map the trend of RTIs in Lilongwe, Malawi.
Methods: This thesis is based on 3 papers. Paper I assessed the trend over 7 years (from January 2009 to December 2015) of the burden of road traffic related trauma presented to Kamuzu Central Hospital (KCH) in Lilongwe, one of the main referral hospitals in Malawi. This was an analysis of prospectively collected data from the KCH Trauma Registry. Paper II assessed the prevalence, impact, causes, and service implications of MSIs in Malawi. To achieve this we used a validated survey tool to randomly select clusters across the whole country that matched the national distribution of the population. Then adult individuals were screened and examined for MSI by survey field teams. The questionnaire and Rapid Assessment of Musculoskeletal Impairment (RAM 1 & RAM 2) tools were installed on 17 tablet computers for data collection. Quality of life was measured using EQ-5D. Paper III critically analysed the same survey data to estimate the prevalence of MSI and the need for different treatment modalities among children aged 16 years or less in Malawi, and described the causes of MSI in Malawian children.
Results: Paper I: The prospectively collected data from the KCH Trauma Registry showed that there was a 62.4% rise in the number of RTI victims treated at KCH from 2,447 in 2009 to 3,975 in 2015. If this trend continues, 7,997 patients will be expected to need treatment for RTIs at KCH in 2030, doubling the numbers seen in 2015 in just 15 years. The highest number of injuries occurred in pedestrians (32.3%) and cyclists (28.2%) and continually rose over the years studied. The length of hospital stay for RTIs increased from 6.4 (SD 9.1) days in 2009 to 15.0 (SD 19.4) days in 2015. Paper II: During our national survey of MSI in Malawi, we travelled the whole country for 2 months. We enumerated 8,548 people and found that 810 were living with MSI, representing 9.5% of the population. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic noninfective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the International Classification of Functioning (ICF) class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress, or unable to perform usual daily activities. Paper III: We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6,000-33,000) children in need of orthopaedic surgery. Low parents’ educational level was one factor associated with an increased risk of MSI.
Conclusion: Paper I: There was a rapidly growing burden of RTIs at KCH in Lilongwe, Malawi, between 2009 and 2015, and projections based on our data show that this burden is likely to continue to rise, and could double by 2030. The absence of a clear strategy to meet the growing epidemic of injuries in Malawi will come at a huge cost to an already strained economy, and the largest portion of the burden of injury will continue to be borne by the poorest segment of the population. However, 7 years down the line new data is urgently needed to assess the trend of RTIs. Observing the current situation on the ground, RTIs continue to rise and the hospital is struggling to cope up with the number of road traffic victims. Paper II: Our study showed that a huge burden of musculoskeletal impairment in Malawi is mostly unattended and has a profound impact on a large proportion of the population. The prevalence of MSI in the country was found to be high, revealing an urgent need to scale up surgical and rehabilitation services in the country. Increasing age was one of the factors that was associated with an increased risk of having MSI. The quality of life of a large proportion of patients with moderate and severe MSI was considerably affected. Paper III: This study also uncovered a large burden of MSI among children aged 16 and under in the country with an immense unmet need for treatment (P & O devices, physical & occupational therapy, and surgical services) of those affected children. A clear strategy should be made by policy makers to cope up with this burden of MSI in both adults and children and give the necessary support to those in need. | en_US |
