There are not sample-based or specimen-based severe disease and mortality surveillance studies underway yet in Malawi, and is an urgent need for empirical data on all-cause and cause-specific mortality in all ages and populations. An estimated three quarters of all deaths occur at home, most of which are not being captured in routine data collection, and the causes of which are often not confirmed. The changing epidemiology of HIV in a context of high treatment coverage and the increasing non-communicable disease burden in the general population imposes a pressing need for data on causes of mortality and severe disease in both PLHIV and general population. 

We propose to implement a phased approach to comprehensive population-based severe disease and mortality surveillance (SDMS) in urban Lilongwe and rural Salima districts, in order to rapidly fill the data gap identified by both the Ministry of Health (MOH) and the National Registration Bureau (NRB). This will include capacity-building in-country to diagnose severe disease using state of the art diagnostics, and to collect, process and interpret postmortem minimally-invasive tissue specimens. While primarily for research purposes, any laboratory findings on admitted patients will be shared immediately with the health care provider to improve clinical care.  Once established, we will expand SDMS to a nationally-representative sample of sites and their catchment areas to generate more complete data on the distribution and burden of diseases and causes of death across the nation. Using a population-based approach for SDMS will guarantee our ability to calculate precise all-cause and cause-specific rates, as the frequency and intensity of data collection will ensure we have a data ‘island of completeness’.  With accurate denominators to complement the rigorously collected numerators, we will be able to rapidly ascertain accurate estimates of the burden of mild and severe diseases, and cause-specific mortality rates.