COVID-19 in Malawi: lessons in pandemic preparedness from a tertiary children's hospital.

The COVID-19 pandemic curve in Africa has lagged behind that of Europe. The first case of SARS-CoV-2 in Malawi was confirmed on 2 April.1 Malawi closed schools and airports, but no ‘lockdown’ was enforced in recognition of the risk to a population vulnerable to economic and health service disruption.2 Although overall ascertainment was low, detection of cases nationwide confirmed community transmission by July. Nonetheless, the number of acute cases presenting to hospital remained less than expected. The current total number of confirmed COVID-19 cases nationwide is just over 60001 with Blantyre district contributing one-third of the nationwide total.3 Queen Elizabeth Central Hospital (QECH) in Blantyre is the tertiary referral hospital for the Southern Region of Malawi. The pandemic heightened existing challenges related to limited human and material resources. Public fear and healthcare worker (HCW) sit-ins associated with concerns around inadequate personal protective equipment (PPE) disrupted services and contributed to delayed patient presentation. We established a multidisciplinary COVID-19 task force to work with hospital, district and national leaders in the coordination of activities aimed at mitigating the direct and indirect risks of the COVID-19 pandemic on staff and paediatric patients. We now reflect and share our initial lessons in pandemic preparedness in the Department of Paediatrics at QECH. In the early months of the pandemic, there was mounting evidence that the risk of nosocomial transmission and occupational exposure was high.4 5 In response, the Ministry of Health of Malawi developed COVID-19 treatment centres separate from central hospitals. This policy was challenging for paediatrics as the WHO clinical case definition used for isolation overlaps with the majority of in-patient paediatric diagnoses. Limited diagnostics led to a risk of inappropriate isolation, unnecessary exposure of high-risk children and guardians to COVID-19 and a reduced level of specialty care for …