Improving brain infection diagnostics in Malawi

By Dr Gareth D Lipunga Malawi Study Physician, Brain Infections Global Intervention Study, Study Physician, Malawi-Liverpool-Wellcome Trust Clinical Research Programme & Queen Elizabeth Central Hospital, Blantyre, Malawi. To view the full paper click here (external link).

In an effort to improve timely diagnosis and early management of patients with suspected brain infections, we implemented a series of targeted interventions.

A key takeaway from this project was the significant impact that well-executed, practical measures can have on patient outcomes, clinical workflows, and laboratory support. Rather than focusing on complex solutions, our approach prioritized essential but often overlooked aspects of care, particularly in resource-limited settings.

Key Interventions Implemented in Malawi

In Malawi, our efforts targeted critical gaps in brain infection diagnosis and management. Specific interventions included:

• Training Laboratory Technicians: Hands-on training in performing essential cerebrospinal fluid (CSF) microscopic tests, such as Gram stain and cell counts, improved diagnostic accuracy and speed.
• Enhanced TB Diagnosis with GeneXpert: Incorporating GeneXpert testing facilitated quicker and more reliable detection of tuberculosis meningitis, allowing for timely treatment.
• Motorbike-Based Sample Transport: To address logistical barriers, we introduced a motorbike-based system for transporting samples to reference laboratories efficiently.
• Developing Brain Infection Champions: Local clinicians were trained as “brain infection champions” who could further train others, ensuring sustainability and long-term impact.
• A Practical Lumbar Puncture Handbook: A structured guide was developed to support clinicians in performing lumbar punctures (LPs) effectively, addressing a common barrier to accurate diagnosis.
• Clinical Algorithms: These served as aids to prompt appropriate action with regards to pertinent management points and the importance of timely diagnostics.

Lessons Learned and Future Directions

One of the most valuable lessons we gained from this project is the importance of getting the basics right. While healthcare systems are inherently complex, with multiple interdependent components, our experience reinforced the idea that each element must function effectively for the system to deliver optimal patient care.

Through our interventions, we were able to highlight the resources that healthcare centres already have—such as lumbar puncture equipment—and find ways to use them more efficiently and in a timely manner. This need for efficiency led to the introduction of a standardised lumbar puncture pack, designed to streamline the process and ensure that essential procedures are performed promptly when needed.

No intervention, no matter how well-designed, can be successful without the people who implement it. Healthcare improvements rely not only on equipment and protocols but also on the dedication and expertise of the professionals on the ground. Malawi already has a well-established system of training trainers to implement critical interventions for key disease processes. Building on this approach, we developed a network of Brain Infection Champions—healthcare workers who advocate for the rapid identification and appropriate management of neurological infections. By equipping and empowering these champions, we hope to create a sustainable system where knowledge is passed on, and best practices are reinforced across different regions. These champions are instrumental in ensuring that interventions are not just introduced but embedded into daily practice, leading to long-term improvements in patient outcomes.

A crucial aspect of any healthcare intervention is ensuring that it is sustainable in the long run. This means allowing healthcare workers the flexibility to adapt and implement changes in a way that aligns with their local context. Rather than imposing rigid, one-size-fits-all solutions, we focused on context-driven delivery—encouraging teams to integrate best practices into their existing workflows in a way that makes sense for them.

By emphasising practical, sustainable implementation and empowering frontline healthcare workers, we believe this approach has the potential to create lasting change. The ultimate goal is not just to introduce new interventions but to foster a culture of continuous improvement, ensuring that essential procedures are consistently performed with efficiency, accuracy, and timeliness.

These interventions reinforced the importance of optimising fundamental clinical and laboratory practices. While these strategies have already demonstrated success in Malawi, our goal is to adapt and scale them in other settings facing similar challenges. Ongoing data collection and stakeholder feedback will help refine these approaches, ensuring their effectiveness across different healthcare environments.

This study highlights that addressing brain infections doesn’t always require advanced or costly interventions. Strengthening core clinical and laboratory processes can lead to meaningful and sustainable improvements in healthcare delivery.