FIEBRE has recently finished recruiting patients in Malawi following delays due to a series of challenges which has included flooding, cyclone Idai and of course the COVID-19 pandemic.
The FIEBRE (Febrile Illness Evaluation in a Broad Range of Endemicities) is led by the London School of Hygiene and Tropical Medicine (LSHTM) and is funded by the UK Foreign, Commonwealth and Development Office. The study aims to reveal leading causes of fever in sub-Saharan Africa and southeast Asia. LSTM and the Malawi Liverpool Wellcome Trust (MLW) Clinical Research Programme are undertaking the work in both Blantyre and Chikwawa in Malawi.
The first patient was enrolled on 4 July 2018 at Chikwawa District Hospital (CDH). In total, 1765 patients were recruited (over 6200 screened) and the team reached the outpatient recruitment target of 600 for both adults and children. Control recruitment was very effective at 98% and 28-day follow up was high at 91%. This reflects the dedication of the community engagement team.
Initially, FIEBRE started at CDH and second site opened at St Montfort Mission hospital (SMH) in May 2019 in order to help increase inpatient recruitment.
Community engagement was integral to the study. FIEBRE was helped by long-established community sensitisation work to research in the area. There's been particular interest and concern about the amount of blood taken. These issues are addressed by the team through their continued commitment to working with the local community.
The team faced many challenges such as flooding, cyclone Idai in March 2020, the COVID-19 pandemic and a high number of eligible patients declining to participate for a variety of reasons including:
- Concern about donating blood/large volume when anaemic (severe anaemia is commonplace in Chikwawa)
- Traditional beliefs about losing and sharing blood
- Wanting to seek consent from husband or elder
These sensitive issues were addressed over the course of the study by many staff and patient education and sensitisation sessions explaining the safety and desirability of blood testing in patients who might be suffering from infections. On the whole, these efforts were bearing fruit with increased inpatient recruitment until the arrival of COVID-19 in the spring of 2020.
The COVID-19 pandemic had a considerable impact on the study’s activities; national and institutional restrictions were imposed which slowed down enrolment and limited activities. Although personal protective equipment was available for staff, and infection control measures were in place, with masks and screening at the hospital entrance, people were reluctant to seek healthcare due to a fear of COVID-19 transmission in health centres and of being diagnosed and being sent to a COVID-19 treatment centre.
Despite all the challenges, the FIEBRE team have been able to help support and add to the overall level of care and treatment in the area by providing clinical microbiology services in CDH and SMH for the first time and diagnosing HIV and TB in patients who might otherwise have slipped through the net. FIEBRE staff followed up any positive blood cultures immediately and advised clinicians on antibiotic choice and length of treatment. The study hopes to leave a legacy whereby this service will be continued by the MLW core team.
Many of the FIEBRE team members in Malawi were undertaking their first research role. It has been rewarding to see the team develop and no surprise to see team members grow into more senior roles or be taken up by other studies, research support units or research institutions in Malawi.