Scourge of superbugs killing Malawi's babies

Malawi (CNN)In a sweltering room in the corner of the Chatinkha nursery in Queen Elizabeth Central Hospital in Blantyre, Malawi, Lilian Matchaya is expressing milk.

Her daughter, Abigail, is nearby, lying in a wooden cot with a UV light overhead keeping her at the right temperature. Her head wrapped in a bandage, Abigail has a plastic feeding tube going into her nose.

Matchaya, 38, inserts a syringe of breast milk into the tube, and it travels slowly down the translucent pipe. The sounds of infants crying, machines beeping and nurses pushing trolleys fill the ward.

Abigail Matchaya weighed just 3 pounds at birth, having been born prematurely, and soon developed sepsis.

Abigail was born prematurely at seven months and weighed just 1.8 kilograms (3 pounds) at birth, little more than a bag of flour. She needed an injection of aminophylline, which dilates the lung's cells, to help her breathe, and the day after her birth, nurses found her passed out with blood in her stool.

Babies, especially those born prematurely, are especially vulnerable to infection, as their immune systems haven't developed properly. Doctors suspected that Abigail had sepsis, a serious and potentially fatal condition in which bacteria get into the bloodstream. In response, the body's immune system goes into overdrive, and organs begin to shut down.

Abigail was given two antibiotics, penicillin and gentamicin, a combination meant to kill a wide range of bacteria. The drugs didn't seem to work, and she was soon given ceftriaxone and metronidazole, but there was still no improvement.

Her medical notes state that she then became floppy and passed out once more.

Lab results revealed that she was infected with a drug-resistant form of Klebsiella. The bacteria were resistant to most of the drugs Abigail had been given, meaning the medications were not working to kill her infection.

For four days, she had been given ineffective drugs.

For every hour that a baby in septic shock is given ineffective drugs, the chance of survival decreases by 7.6%, one study found. Dr. Kondwani Kawaza, a neonatologist at the Chatinkha nursery, said that even if the baby doesn't die, sepsis can cause disabling complications such as brain damage, meningitis and impairment to vital organs like the kidneys and the liver.

Doctors at the hospital also face another problem: The antibiotics they needed to treat Abigail's superbug are expensive and not part of Malawi's standard drug regimen, meaning they're not always available in the hospital.

On this occasion, Abigail was lucky: The pharmacy had one of the drugs they needed, amikacin, which can be given for only short periods, as it can trigger deafness as well as kidney and nerve damage.

Abigail was promptly given amikacin, after which her family faced a waiting game.

"The first thing I do when I wake up daily is to pray for my baby to get well. Then I check on her with the hope that she will be OK," said Matchaya, a soft-voiced housewife, through an interpreter. She lives with her husband, a teacher, and three sons in Nancholi, on the outskirts of Blantyre.

Lilian Matchaya holds her daughter, Abigail, praying for her to get better.

According to Kawaza, 20% to 40% of infections his team diagnoses are now resistant to antibiotics. The proportion was a lot lower five years ago, he said.

"Four patients grew Klebsiella in this ward alone in a single week, where in the past, we would say it would be for the whole month," he said. "It's becoming a bigger and bigger problem."

A nation in crisis

Malawi is one of the poorest countries in the world, ranking 170th out of 188 on the United Nations' human development index. More than 70% of its 18 million people survive on less than $1.90 a day, the international benchmark of poverty.

Most Malawians do not own televisions, cars or phones or have internet. In rural areas, people grow their own food.

And now, the country is facing an epidemic of infections causing sepsis, one of the leading causes of death among newborns. It killed nearly 20% of them in 2016; by comparison, in the UK, sepsis is responsible for less than 2% of infant deaths.

A combination of factors, all related to poverty, mean the percentage of babies dying of sepsis has barely fallen since 2000 despite improvements in the health care system.

Mothers and babies at Queen Elizabeth Central Hospital in Blantyre wait for treatment.

To make things worse, these figures are thought to be vast underestimates, as most health care facilities do not have the tests to diagnose sepsis.

Across Malawi, it is common to find mothers who have lost a child.

Malnutrition and a high burden of diseases such as HIV and malaria mean mothers and babies' immune systems are even weaker, so they catch infections a healthy body might easily quash.

This is all further fueled by the fact that the majority of Malawians don't have running water, so keeping clean is difficult, and soap is expensive. Many lack education on the importance of washing their hands, how to hygienically prepare food or how to change their baby's diaper, and not many can afford to go to a doctor when they become ill.

More than half of the country's health care facilities are also failing to meet World Health Organization standards on water and sanitation facilities, according to UNICEF. Even Queen Elizabeth hospital, Malawi's biggest, does not have running water in every room.

Many hospitals report "stockouts," periods when supplies like soap, chlorine, bleach and sterile gloves run out.

This culmination of poor hygiene means there is a constant cycle of infection and, in turn, a constant need for antibiotics, whose overuse has now fueled resistance.

For example, a three-month spike in sepsis rates from October occurred at the same time as a shortage of chlorhexidine, an antiseptic put on a baby's umbilical cord to prevent infection, said Wezi Kalumbu, an adviser on child health for the Organized Network of Services for Everyone's Health, a USAID-funded program to improve health care in 16 districts of Malawi.

Antibiotic resistance: An old problem with new ramifications

'Embarrassing' conditions

Down a sandy, potholed track near the border of Mozambique lies the Nayuchi health centre, in Machinga district. Tamandua Chirwa, 26, runs the rural hospital and remembers how delighted she was the day running water was installed in March 2017.

Before that, it was difficult to recruit staff, as there was no toilet. Buckets of water had to be carried from a borehole in the nearby village to wash hands or clean the hospital.

Nyambi health center does not have running water; instead, buckets of water must be carried from a nearby borehole to wash hands or clean the hospital.

Pregnant women would avoid coming to the center because conditions were unhygienic and they believed it was safer to give birth at home -- even though nine out of 10 people in Malawi do not have electricity, and one in three doesn't have clean water.

After WaterAid, a nonprofit organization working to improve water and sanitation, installed a borehole and solar-powered water supply system, the rooms could be cleaned properly. "It was very encouraging when we had water," Chirwa said. "We had more women delivering at the hospital. They knew, after delivery, we will have safe water to clean ourselves up."

The Nyambi health care center is 60 miles away in the same district, but has no running water. Green vats that once held rainwater from the roof now lie broken on the floor. There are six toilets, but all but one is broken, and it must be shared by roughly 300 people -- including pregnant women, families and staff.

Here, women are asked to bring candles or flashlights in case there is no power. They are also told to bring razor blades to cut their children's umbilical cords as well as a plastic sheet, called a macintosh in Malawi, on which to give birth. Such requests are common in health centers and hospitals across the country.

Women are asked to bring a plastic sheet on which to give birth and a razor blade to cut their baby's umbilical cord.

Blackouts are also a regular occurrence at Nyambi, so staffers cannot always sterilize equipment like forceps to use during labour. There is also no incinerator for placentas.

Sphiwe Kachimangha, infection prevention control lead for Machinga district, called the conditions "embarrassing." "We are in financial crisis, so it is difficult to tackle all the problems at once."

In 2013, the "cashgate" scandal was uncovered, revealing that an estimated $250 million (£150 million) worth of public money was stolen through fraudulent payments. The crisis led to the freezing of $150 million worth of international aid, which plunged the government budget into deficit.

In the cobweb-ridden waiting room in Nyambi, which has a broken sink full of dried corn and a rusty wheelchair in a corner, are young mothers-to-be Ruth White, 23, and Jenifa Lyson, 24, who are staying nearby in case their waters break. "This place is very untidy, and it stinks a lot," Lyson said through an interpreter.

They sleep on the same black plastic sheet on which they plan to give birth, risking future infection or passing an infection on to their babies.

Midwives or nurses from both health centers and Queen Elizabeth hospital also voiced concerns about cultural practices around cutting the umbilical cord. Sometimes, animal dung or the juice of pumpkin flowers is rubbed on the wound, which could cause infections that lead to sepsis. However, many said these practices are dying out due to education campaigns.

The world is running out of antibiotics, WHO says

The luxury of being clean

Simple measures like washing hands could prevent many infections, but for people in poverty, soap is a luxury.

Buying enough soap to wash hands and clean plates and clothes costs about 3,000 kwacha (£3.30 or US $4.27) a month, said Bertha Gesinao, 19, through an interpreter. She lives in the village of Khambo in Chikwawa, a poor district an hour and a half outside Blantyre. The London School of Hygiene and Tropical Medicine in the UK is running a project there to help improve sanitation practices.

News Courtesy: www.newagebd.net