BackgroundLittle is known about the pattern or risk factors for deaths from external causes in sub-Saharan Africa: there is a lack of reliable data, and public health priorities have been focussed on other causes. This study assessed the prevalence and risk factor for deaths from external causes in rural Malawi.MethodsWe analysed data from 2002–2012 from the Karonga demographic surveillance site which covers ~35,000 people in rural northern Malawi. Verbal autopsies with clinician coding are used to assign cause of death. Repeated annual surveys capture data on socio-economic factors. Using Poisson regression models we calculated age, sex and cause-specific rates and rate ratios of external deaths. We used a nested case–control study, matched on age, sex and time period, to investigate risk factors for these deaths, using conditional logistic regression.ResultsIn 315,580 person years at risk (pyar) there were 2673 deaths, including 143 from external causes. The mortality rate from external causes was 47.1/100,000 pyar (95 % CI 32.5-68.2) among under-fives; 20.1/100,000 pyar (95 % CI 13.1–32.2) among 5–14 year olds; 46.3/100,000 pyar (95 % CI 35.8–59.9) among 15–44 year olds; and 98.7/100,000 pyar (95 % CI 71.8–135.7) among those aged ≥45 years. Drowning (including four deaths in people with epilepsy), road injury and suicide were the leading external causes. Adult males had the highest rates (100.7/100,000 pyar), compared to 21.8/100,000pyar in adult females, and the rate continued to increase with increasing age in men. Alcohol contributed to 21 deaths, all in adult males. Children had high rates of drowning (9.2/100,000 pyar, 95 % CI 5.5-15.6) but low rates of road injury (2.6/100,000 pyar, 95 % CI 1.0–7.0). Among 5–14 year olds, attending school was associated with fewer deaths from external causes than among those who had never attended school (adjusted OR 0.15, 95 % CI 0.08-0.81). Fishermen had increased risks of death from drowning and suicide compared to farmers.DiscussionIn this population the rate of deaths from external causes was lowest at age 5–14 years. Adult males had the highest rate of death from external causes, 5 times the rate in adult females. Drowning, road injury and suicide were the leading causes of death; alcohol consumption contributed to more than one quarter of the deaths in menConclusionsThe high proportion of alcohol-related deaths in men, the predominance of drowning, deaths linked to uncontrolled epilepsy, and the possible protective effect of school attendance suggest areas for intervention.

Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death; however, worldwide incidence and mortality rates do not reflect the geographic variations in the occurrence of this disease. In recent years, increased attention has been focused on the high incidence of esophageal squamous cell carcinoma (ESCC) throughout the eastern corridor of Africa, extending from Ethiopia to South Africa. Nascent investigations are underway at a number of sites throughout the region in an effort to improve our understanding of the etiology behind the high incidence of ESCC in this region. In 2017, these sites established the African Esophageal Cancer Consortium. Here, we summarize the priorities of this newly established consortium: to implement coordinated multisite investigations into etiology and identify targets for primary prevention; to address the impact of the clinical burden of ESCC via capacity building and shared resources in treatment and palliative care; and to heighten awareness of ESCC among physicians, at-risk populations, policy makers, and funding agencies.

HighlightsWe conducted a review and meta-analysis of esophageal cancer sex ratios in mainland Africa using data from 197 populations in 36 countries.We observed a consistent male excess in incidence rates overall and in the high-risk Eastern and Southern African regions.A male excess was evident in 30–39 year olds in high-risk Eastern and Southern African regions.Our findings suggest that a substantial fraction of the African EC burden could be avoided by targeting gender-specific exposures.

Background With antiretroviral therapy (ART), AIDS-defining cancer incidence has declined and non-AIDS–defining cancers (NADCs) are now more frequent among human immunodeficiency virus (HIV)–infected populations in high-income countries. In sub-Saharan Africa, limited epidemiological data describe cancer burden among ART users. Methods We used probabilistic algorithms to link cases from the population-based cancer registry with electronic medical records supporting ART delivery in Malawi’s 2 largest HIV cohorts from 2000–2010. Age-adjusted cancer incidence rates (IRs) and 95% confidence intervals were estimated by cancer site, early vs late incidence periods (4–24 and >24 months after ART start), and World Health Organization (WHO) stage among naive ART initiators enrolled for at least 90 days. Results We identified 4346 cancers among 28 576 persons. Most people initiated ART at advanced WHO stages 3 or 4 (60%); 12% of patients had prevalent malignancies at ART initiation, which were predominantly AIDS-defining eligibility criteria for initiating ART. Kaposi sarcoma (KS) had the highest IR (634.7 per 100 000 person-years) followed by cervical cancer (36.6). KS incidence was highest during the early period 4–24 months after ART initiation. NADCs accounted for 6% of new cancers. Conclusions Under historical ART guidelines, NADCs were observed at low rates and were eclipsed by high KS and cervical cancer burden. Cancer burden among Malawian ART users does not yet mirror that in high-income countries. Integrated cancer screening and management in HIV clinics, especially for KS and cervical cancer, remain important priorities in the current Malawi context.

Background The contribution of alcohol to the large burden of oesophageal squamous cell carcinoma (ESCC) in east Africa remains uncertain and difficult to assess owing to complex consumption patterns of traditional and commercial drinks. We aimed to assess whether alcohol drinking, overall and at specific intake levels, contributes to ESCC risk in east Africa. MethodsWe did a hospital-based case-control study in Kenya, Tanzania, and Malawi, which included comprehensive assessment of a variety of locally consumed alcohol that we used to classify drinkers as exclusively low alcohol-byvolume (ABV; <30% ABV) drinkers or drinkers of some high-ABV drinks, as well as the number of drinks consumed, average weekly ethanol intake, and the contribution of each drink type to overall ethanol consumption. Cases were patients aged 18 years and older with incident primary ESCC, confirmed histologically for the majority of cases, and a clinical diagnosis for the remainder. Controls were frequency-matched on age and sex in a 1:1 ratio with cases. The controls were recruited from the same hospitals as cases and included outpatients, inpatients, and hospital visitors who did not have cancer or any other digestive disease. Consenting participants took part in face-to-face interviews in which they were asked whether they had ever consumed alcohol (the primary exposure variable); those who had were asked follow-up questions about their consumption habits for different alcoholic drinks. Findings 1279 cases and 1346 controls were recruited between Aug 5, 2013, and May 24, 2020, including 430 cases and 440 controls from Kenya, 310 cases and 313 controls from Tanzania, and 539 cases and 593 controls from Malawi. 65 (4•8%) of 1344 cases were excluded. Consistent positive associations with ESCC risk were found for ever having consumed alcohol in Kenyan men and Tanzanian men, and for daily number of drinks and estimated ethanol intake in Kenya, Tanzania (both sexes) and Malawian women. Corresponding population-attributable fractions of ESCC for those reporting ever drinking alcohol (vs never drinking) were 65% (95% CI 52-78) in Kenyan men and 23% (<1-45) in Kenyan women, and 56% (95% CI 36-76) in Tanzanian men and 5% (0-42) in Tanzanian women. Increased risk and population-attributable fractions were almost entirely due to risks in high-ABV drinkers.Interpretation Alcohol appears to be a substantial contributor to ESCC risk in east Africa, particularly among men, and a large fraction of ESCC could be prevented by cessation or reduction of alcohol consumption. Future studies should consider independent ascertainment of alcohol intake to assess the potential of under-reporting in Malawi.

In this paper, we present incidence rates of different cancers calculated for the population of Blantyre, Malawi for the period 2008–2010, using data from the Malawi Cancer Registry. Active methods were used for case finding, with standard checks for accuracy and validity performed in CanReg 4. During this 3-year period, a total of 3,711 cases were registered comprising 1,643 men (an estimated age-standardized incidence rate (ASR) of 169.8 per 100,000) and 2,068 women (ASR 238.7 per 105). Kaposi sarcoma (KS) was the most common cancer in men (40.5% of all cancers in men; ASR 54.0 per 105) while cervical cancer was the commonest in women (33.3%; ASR 88.6 per 105). The incidence rates for esophageal cancer remain one of the highest in the world (ASR 30.9 per 100,000 in men, 22.1 per 100,000 in women). Incidence of cancer of the prostate is relatively low in Blantyre (5.1%; ASR 16.4 per 105), compared with elsewhere in Africa. In childhood, the cancer spectrum is dominated by Burkitt lymphoma (32.5% ASR 90.9 per 106) followed by Wilms tumor (11.3%; ASR 35.9 per 106) and pediatric KS (11.0%; ASR 31.1 per 106). The overall percentage of cases with histological verification was 47.5%, a slight improvement from 42.4% in late 1990s also indicating successful case finding outside laboratories.

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Background This paper describes cancer burden and compares characteristics of cancer patients enrolled at 2 palliative care facilities of contrasting resources and geographical locations in Malawi. It also assesses the extent of differences in service delivery and the impact these might have on outcomes. Methods Data on all cancer patients registered between October 2010 and October 2015 at Tiyanjane Clinic (at Queen Elizabeth Central Hospital, Blantyre) and Mzuzu Central Hospital (MCH) palliative care clinics were extracted and analysed. Key informant in-depth interviews were carried out at both sites. Thematic analysis was used for qualitative data and Excel 2010 and Stata 12 were used for analysis of quantitative data. Results Quantitative: There were 1362 and 633 cancer patients at Tiyanjane and MCH, respectively. Overall, females predominated over males (55.8% vs 42.8%); however, Tiyanjane had more males (52.2% vs 45.8%), which was contrary to Mzuzu (77.4% females vs 22.6% males). The 35- to 54-year age group was predominant at both Tiyanjane (43.1%) and Mzuzu (40.1%).Overall, the most common cancers were Kaposi's sarcoma (26.9%), cervical cancer (26.8%), oesophageal cancer (14.2%), hepatocellular carcinoma (4.9%), and bladder cancer (3.0%). Histologically confirmed diagnoses accounted for 13% of cases at Tiyanjane, whereas all patients from MCH were diagnosed clinically. Qualitative: Palliative care services were free of charge at both facilities, and owing to the expansion of services to district hospitals, the workload at central hospitals had been reduced. Between the 2 sites, there were differences in follow-up procedures, drug availabilities, as well as human resource capacity, with Mzuzu palliative care facility facing more extensive challenges. Conclusions The characteristics of patients seen at each site varied according to services available. Quality of care was assessed as superior at Tiyanjane, demonstrating the importance of multiple stakeholder involvement in the delivery of palliative care services.