An evaluation of LLIN physical integrity and population attitudes towards net use, care and handling during the Magude project in southern Mozambique

BACKGROUND

The Magude Project assessed the feasibility of eliminating malaria in Magude district, a low transmission setting in southern Mozambique, using a package of interventions, including long-lasting insecticidal nets (LLINs). As the efficacy of LLINs depends in part on their physical integrity, this metric was quantified for Olyset® Nets post mass-distribution, in addition to net use, care and handling practices and other risk factors associated with net physical integrity.

METHODS

Nets were collected during a cross-sectional net evaluation, nine months after the Magude project commenced, which was 2 years after the nets were distributed by the National Malaria Control Programme (NMCP). The physical integrity of the nets was assessed by counting and sizing the holes at different positions on each net. A structured questionnaire was administered to assess how the selected net was used and treated (care, wash and repair). Net bio-efficacy was assessed following the standard World Health Organization (WHO) cone bioassay procedures.

RESULTS

Out of the 170 Olyset® Nets included in the analysis, 63.5% had been used the night before. The main reason for not using a net was the notion that there were no mosquitoes present. The average number of people using each net was 1.79. Two thirds of the nets had only been washed once or twice since distribution. Most nets (80.9%) were holed and 18% were torn, but none of the risk factors were significantly associated with net integrity, except for presence of mice in the household. Less than half of the participants noticed holes in holed nets, and of those only 38.6% attempted to repair those. None of the six nets that were tested for bio-efficacy passed the WHO threshold of 80% mosquito mortality.

CONCLUSION

Overall the majority of Olyset® Nets were in serviceable condition two years post-distribution, but their insecticidal effect may have been lost. This study-together with previous evidence on suboptimal access to and use of LLINs in Magude district-highlights that LLINs as an intervention could have been optimized during the Magude project to achieve maximum intervention impact.

Associations between landscape fires and child morbidity in southern Mozambique: a time-series study

BACKGROUND

Epidemiological evidence linking exposure to landscape fires to child health remains scarce. We assessed the association between daily landscape fire smoke and child hospital visits and admissions in the Manhiça district, Mozambique, an area characterised by frequent forest and cropland fires.

METHODS

In this time-series analysis (2012-20), our primary metric for exposure to landscape fires was fire-originated PM2·5 from smoke dispersion hindcasts. We also assessed total and upwind fire exposure using daily satellite-derived fire density data. Daily numbers of hospital visits and admissions were extracted from an ongoing paediatric morbidity surveillance system (children aged ≤15 years). We applied quasi-Poisson regression models controlling for season, long-term trend, day of the week, temperature, and rainfall, and offsetting by annual population-time at risk to examine lag-specific association of fires on morbidity.

FINDINGS

A 10 μg/m3 increase in fire-originated PM2·5 was associated with a 6·12% (95% CI 0·37-12·21) increase in all-cause and a 12·43% (5·07-20·31) increase in respiratory-linked hospital visits on the following day. Positive associations were also observed for lag 0 and the cumulative lag of 0-1 days. Null associations were observed for hospital admissions. Landscape fires mostly occurred in forested areas; however, associations with child morbidity were stronger for cropland than for forest fires.

INTERPRETATION

Landscape fire smoke was associated with all-cause and respiratory-linked morbidity in children. Improved exposure assessment is needed to better quantify the contribution of landscape fire smoke to child health in regions with scarce air pollution monitoring.

FUNDING

H2020 project EXHAUSTION, Academy of Finland, Spanish Ministry of Science and Innovation, Generalitat de Catalunya, and Government of Mozambique and Spanish Agency for International Cooperation and Development.

Comprehensive profiling of social mixing patterns in resource poor countries: a mixed methods research protocol

Background

Low-and-middle-income countries (LMICs) bear a disproportionate burden of communicable diseases. Social interaction data inform infectious disease models and disease prevention strategies. The variations in demographics and contact patterns across ages, cultures, and locations significantly impact infectious disease dynamics and pathogen transmission. LMICs lack sufficient social interaction data for infectious disease modeling.

Methods

To address this gap, we will collect qualitative and quantitative data from eight study sites (encompassing both rural and urban settings) across Guatemala, India, Pakistan, and Mozambique. We will conduct focus group discussions and cognitive interviews to assess the feasibility and acceptability of our data collection tools at each site. Thematic and rapid analyses will help to identify key themes and categories through coding, guiding the design of quantitative data collection tools (enrollment survey, contact diaries, exit survey, and wearable proximity sensors) and the implementation of study procedures.We will create three age-specific contact matrices (physical, nonphysical, and both) at each study site using data from standardized contact diaries to characterize the patterns of social mixing. Regression analysis will be conducted to identify key drivers of contacts. We will comprehensively profile the frequency, duration, and intensity of infants' interactions with household members using high resolution data from the proximity sensors and calculating infants' proximity score (fraction of time spent by each household member in proximity with the infant, over the total infant contact time) for each household member.

Discussion

Our qualitative data yielded insights into the perceptions and acceptability of contact diaries and wearable proximity sensors for collecting social mixing data in LMICs. The quantitative data will allow a more accurate representation of human interactions that lead to the transmission of pathogens through close contact in LMICs. Our findings will provide more appropriate social mixing data for parameterizing mathematical models of LMIC populations. Our study tools could be adapted for other studies.

Knowledge of COVID-19 symptoms, transmission, and prevention: Evidence from health and demographic surveillance in Southern Mozambique

Understanding community members' knowledge of SARS-CoV-2 transmission and prevention is essential for directing public health interventions to reduce disease spread and improve vaccination coverage. Here, we describe knowledge of COVID-19 transmission, prevention, and symptoms among community residents in Mozambique. We conducted a cross-sectional survey among 33,087 households in a Health and Demographic Surveillance System in Manhiça, Mozambique. Participants were recruited in April 2021 before the Delta variant wave to the peak of Omicron cases in February 2022. Principal components analysis was used to create scores representing knowledge of COVID-19 symptoms, transmission, and prevention. Multiple imputation and quasi-Poisson regression were used to examine associations between demographic characteristics and sources of COVID-19 information, and knowledge of COVID-19 symptoms, transmission, and prevention. We examined whether sources of COVID-19 information mediated the relationship between educational attainment and knowledge of symptoms, transmission, and prevention. Across this rural community, 98.2%, 97.0%, and 85.1% of respondents reported knowing how COVID-19 could be prevented, that SARS-CoV-2 can cause disease, and how SARS-CoV-2 is transmitted, respectively. The most recognized COVID-19 symptoms were cough (51.2%), headaches (44.9%), and fever (44.5%); transmission mechanisms were saliva droplets (50.5%) or aerosol (46.9%) from an infected person; and prevention measures were handwashing (91.9%) and mask-wearing (91.8%). Characteristics associated with greater knowledge of symptoms, transmission, and prevention included having at least primary education, older age, employment, higher wealth, and Christian religion. Respondents who had experienced COVID-19 symptoms were also more likely to possess knowledge of symptoms, transmission, and prevention. Receiving information from television, WhatsApp, radio, and hospital, mediated the relationship between educational attainment and knowledge scores. These findings support the need for outreach and for community-engaged messaging to promote prevention measures, particularly among people with low education.

Prevalence of molecular markers of resistance to sulfadoxine-pyrimethamine before and after community delivery of intermittent preventive treatment of malaria in pregnancy in sub-Saharan Africa: a multi-country evaluation

BACKGROUND

The effectiveness of community delivery of intermittent preventive treatment (C-IPT) of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine has been evaluated in selected areas of the Democratic Republic of the Congo, Madagascar, Mozambique, and Nigeria. We aimed to assess the effect of C-IPTp on the potential development of Plasmodium falciparum resistance to sulfadoxine-pyrimethamine, since it could threaten the effectiveness of this strategy.

METHODS

Health facility-based cross-sectional surveys were conducted at baseline and 3 years after C-IPTp implementation in two neighbouring areas per country, one with C-IPTp intervention, and one without, in the four project countries. Dried blood spots from children under five years of age with clinical malaria were collected. Sulfadoxine-pyrimethamine resistance-associated mutations of the P falciparum dhfr (Asn51Ile/Cys59Arg/Ser108Asn/Ile164Leu) and dhps (Ile431Val/Ser436Ala/Ala437Gly/Lys540Glu/Ala581Gly/Ala613Ser) genes were analysed.

FINDINGS

2536 children were recruited between June 19 and Oct 10, 2018, during baseline surveys. Endline surveys were conducted among 2447 children between July 26 and Nov 30, 2021. In the Democratic Republic of the Congo, the dhfr/dhps IRNI/ISGEAA inferred haplotype remained lower than 10%, from 2% (5 of 296) at baseline to 8% (24 of 292) at endline, and from 3% (9 of 300) at baseline to 6% (18 of 309) at endline surveys in intervention and non-intervention areas respectively with no significant difference in the change between the areas. In Mozambique, the prevalence of this haplotype remained stable at over 60% (194 [64%] of 302 at baseline to 194 [64%] of 303 at endline, and 187 [61%] of 306 at baseline to 183 [61%] of 301 in endline surveys, in non-intervention and intervention areas respectively). No isolates harbouring the dhps ISGEAA genotype were found in Nigeria. In Madagascar, only five isolates with this haplotype were found in the non-intervention area (2 [>1%] of 300 at baseline and 3 [1%] of 300 at endline surveys). No isolates were found carrying the dhps ISGEGA genotype.

INTERPRETATION

C-IPTp did not increase the prevalence of molecular markers associated with sulfadoxine-pyrimethamine resistance after three years of programme implementation. These findings reinforce C-IPTp as a strategy to optimise the control of malaria during pregnancy, and support the WHO guidelines for prevention of malaria in pregnancy.

FUNDING

UNITAID [2017-13-TIPTOP].

Burden and risk factors of snakebite in Mopeia, Mozambique: Leveraging larger malaria trials to generate data of this neglected tropical disease

BACKGROUND

Snakebite is a neglected disease that disproportionally affects the rural poor. There is a dearth of evidence regarding incidence and risk factors in snakebite-endemic countries. Without this basic data, it will be impossible to achieve the target of a 50% reduction of snakebite morbidity and mortality by 2030 as set by the World Health Organization.

METHODS

This was a descriptive analysis nested in a 2021 community-based demographic survey of over 70,000 individuals conducted in Mopeia, Mozambique, in preparation for a cluster randomized trial to test an intervention for malaria. We describe the incidence rate, demographics, socioeconomic indicators and outcomes of snakebite in this population.

FINDINGS

We found the incidence of self-reported snakebite in Mopeia to be 393 bites per 100,000 person-years at risk, with 2% of households affected in the preceding 12 months. Whilst no fatalities were recorded, over 3,000 days of work or school days were lost with an individual household economic impact higher than that of uncomplicated malaria. 1 in 6 of those affected did not fully recover at the time of the study. We found significant relationships between age older than 15, use of firewood for household fuel, and animal possession with snakebite.

CONCLUSIONS

This study exposes higher than expected incidence and burden of snakebite in rural Mozambique. Whilst snakebite elimination in Mozambique seems unattainable today, it remains a preventable disease with manageable sequelae. We have shown that snakebite research is particularly easy to nest in larger studies, making this a practical and cost-effective way of estimating its incidence.

Alternative approaches for creating a wealth index: the case of Mozambique

INTRODUCTION

The wealth index is widely used as a proxy for a household's socioeconomic position (SEP) and living standard. This work constructs a wealth index for the Mopeia district in Mozambique using data collected in year 2021 under the BOHEMIA (Broad One Health Endectocide-based Malaria Intervention in Africa) project.

METHODS

We evaluate the performance of three alternative approaches against the Demographic and Health Survey (DHS) method based wealth index: feature selection principal components analysis (PCA), sparse PCA and robust PCA. The internal coherence between four wealth indices is investigated through statistical testing. Validation and an evaluation of the stability of the wealth index are performed with additional household income data from the BOHEMIA Health Economics Survey and the 2018 Malaria Indicator Survey data in Mozambique.

RESULTS

The Spearman's rank correlation between wealth index ventiles from four methods is over 0.98, indicating a high consistency in results across methods. Wealth rankings and households' income show a strong concordance with the area under the curve value of ~0.7 in the receiver operating characteristic analysis. The agreement between the alternative wealth indices and the DHS wealth index demonstrates the stability in rankings from the alternative methods.

CONCLUSIONS

This study creates a wealth index for Mopeia, Mozambique, and shows that DHS method based wealth index is an appropriate proxy for the SEP in low-income regions. However, this research recommends feature selection PCA over the DHS method since it uses fewer asset indicators and constructs a high-quality wealth index.

Cost-effectiveness of community-based distribution of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria, and the Democratic Republic of Congo

INTRODUCTION

Malaria in pregnancy is a major driver of maternal and infant mortality in sub-Saharan Africa. The WHO recommends the administration of intermittent preventive treatment with sulfadoxine pyrimethamine (IPTp-SP) at antenatal care (ANC) visits. Despite being a highly cost-effective strategy, IPTp-SP coverage and uptake remains low. A pilot project was conducted to assess the cost-effectiveness (CE) of community-based delivery of IPTp (C-IPTp) in addition to ANC delivery to increase IPTp uptake in the Democratic Republic of Congo (DRC), Madagascar (MDG), Mozambique (MOZ) and Nigeria (NGA).

METHODS

Costs and CE estimates of C-IPTp were calculated according to two scenarios: (1) costs in 'programmatic mode' (ie, costs if C-IPTp was to be implemented by national health systems) and (2) costs from the pilot project. The effectiveness of C-IPTp was obtained through estimates of the averted disability-adjusted life-years (DALYs) associated with maternal clinical malaria and anaemia, low birth weight and neonatal mortality.

RESULTS

Net incremental costs of C-IPTp ranged between US$6138-US$47 177 (DRC), US$5552-US$31 552 (MDG), US$10 202-US$53 221 (MOZ) and US$667-US$28 645 (NGA) per 1000 pregnant women, under scenarios (1) and (2), respectively. Incremental cost-effectiveness ratios (ICERs) ranged between US$15-US$119 in DRC, US$9-US$53 in MDG, US$104-US$543 in MOZ and US$2-US$66 in NGA per DALY averted, under scenarios (1) and (2), respectively. ICERs fall below the WHO recommended CE threshold based on the gross domestic product per capita.

CONCLUSION

Findings suggest that C-IPTp is a highly cost-effective intervention. Results can inform policy decisions on adopting and optimising effective interventions for preventing malaria in pregnancy.

BOHEMIA a cluster randomized trial to assess the impact of an endectocide-based one health approach to malaria in Mozambique: baseline demographics and key malaria indicators

BACKGROUND

Many geographical areas of sub-Saharan Africa, especially in rural settings, lack complete and up-to-date demographic data, posing a challenge for implementation and evaluation of public health interventions and carrying out large-scale health research. A demographic survey was completed in Mopeia district, located in the Zambezia province in Mozambique, to inform the Broad One Health Endectocide-based Malaria Intervention in Africa (BOHEMIA) cluster randomized clinical trial, which tested ivermectin mass drug administration to humans and/or livestock as a potential novel strategy to decrease malaria transmission.

METHODS

The demographic survey was a prospective descriptive study, which collected data of all the households in the district that accepted to participate. Households were mapped through geolocation and identified with a unique identification number. Basic demographic data of the household members was collected and each person received a permanent identification number for the study.

RESULTS

25,550 households were mapped and underwent the demographic survey, and 131,818 individuals were registered in the district. The average household size was 5 members and 76.9% of households identified a male household head. Housing conditions are often substandard with low access to improved water systems and electricity. The reported coverage of malaria interventions was 71.1% for indoor residual spraying and 54.1% for universal coverage of long-lasting insecticidal nets. The median age of the population was 15 years old. There were 910 deaths in the previous 12 months reported, and 43.9% were of children less than 5 years of age.

CONCLUSIONS

The study showed that the district had good coverage of vector control tools against malaria but sub-optimal living conditions and poor access to basic services. The majority of households are led by males and Mopeia Sede/Cuacua is the most populated locality in the district. The population of Mopeia is young (< 15 years) and there is a high childhood mortality. The results of this survey were crucial as they provided the household and population profiles and allowed the design and implementation of the cluster randomized clinical trial. Trial registration NCT04966702.

The economic costs of malaria in pregnancy: evidence from four sub-Saharan countries

Background Malaria in pregnancy is a major public health problem in sub-Saharan Africa (SSA), which imposes a significant economic burden. We provide evidence on the costs of malaria care in pregnancy to households and the health system in four high-burden countries in SSA.  Methods Household and health system economic costs associated with malaria control in pregnancy were estimated in selected areas of the Democratic Republic of Congo (DRC), Madagascar (MDG), Mozambique (MOZ) and Nigeria (NGA). An exit survey was administered to 2,031 pregnant women when leaving the antenatal care (ANC) clinic from October 2020 to June 2021. Women reported the direct and indirect costs associated to malaria prevention and treatment in pregnancy. To estimate health system costs, we interviewed health workers from 133 randomly selected health facilities. Costs were estimated using an ingredients-based approach. Results Average household costs of malaria prevention per pregnancy were USD6.33 in DRC, USD10.06 in MDG, USD15.03 in MOZ and USD13.33 in NGA. Household costs of treating an episode of uncomplicated/complicated malaria were USD22.78/USD46 in DRC, USD16.65/USD35.65 in MDG, USD30.54/USD61.25 in MOZ and USD18.92/USD44.71 in NGA, respectively. Average health system costs of malaria prevention per pregnancy were USD10.74 in DRC, USD16.95 in MDG, USD11.17 in MOZ and USD15.64 in NGA. Health system costs associated with treating an episode of uncomplicated/complicated malaria were USD4.69/USD101.41 in DRC, USD3.61/USD63.33 in MDG, USD4.68/USD83.70 in MOZ and USD4.09/USD92.64 in NGA. These estimates resulted in societal costs of malaria prevention and treatment per pregnancy of USD31.72 in DRC, USD29.77 in MDG, USD31.98 in MOZ and USD46.16 in NGA. Conclusions Malaria in pregnancy imposes a high economic burden on households and the health system. Findings emphasize the importance of investing in effective strategies that improve access to malaria control and reduce the burden of the infection in pregnancy.

The economic costs of malaria in pregnancy: evidence from four sub-Saharan countries

Background Malaria in pregnancy is a major public health problem in sub-Saharan Africa (SSA), which imposes a significant economic burden. We provide evidence on the costs of malaria care in pregnancy to households and the health system in four high-burden countries in SSA.  Methods Household and health system economic costs associated with malaria control in pregnancy were estimated in selected areas of the Democratic Republic of Congo (DRC), Madagascar (MDG), Mozambique (MOZ) and Nigeria (NGA). An exit survey was administered to 2,031 pregnant women when leaving the antenatal care (ANC) clinic from October 2020 to June 2021. Women reported the direct and indirect costs associated to malaria prevention and treatment in pregnancy. To estimate health system costs, we interviewed health workers from 133 randomly selected health facilities. Costs were estimated using an ingredients-based approach. Results Average household costs of malaria prevention per pregnancy were USD6.33 in DRC, USD10.06 in MDG, USD15.03 in MOZ and USD13.33 in NGA. Household costs of treating an episode of uncomplicated/complicated malaria were USD22.78/USD46 in DRC, USD16.65/USD35.65 in MDG, USD30.54/USD61.25 in MOZ and USD18.92/USD44.71 in NGA, respectively. Average health system costs of malaria prevention per pregnancy were USD10.74 in DRC, USD16.95 in MDG, USD11.17 in MOZ and USD15.64 in NGA. Health system costs associated with treating an episode of uncomplicated/complicated malaria were USD4.69/USD101.41 in DRC, USD3.61/USD63.33 in MDG, USD4.68/USD83.70 in MOZ and USD4.09/USD92.64 in NGA. These estimates resulted in societal costs of malaria prevention and treatment per pregnancy of USD31.72 in DRC, USD29.77 in MDG, USD31.98 in MOZ and USD46.16 in NGA. Conclusions Malaria in pregnancy imposes a high economic burden on households and the health system. Findings emphasize the importance of investing in effective strategies that improve access to malaria control and reduce the burden of the infection in pregnancy.

Choosing blood pressure thresholds to inform pregnancy care in the community: An analysis of cluster trials

OBJECTIVE

To inform digital health design by evaluating diagnostic test properties of antenatal blood pressure (BP) outputs and levels to identify women at risk of adverse outcomes.

DESIGN

Planned secondary analysis of cluster randomised trials.

SETTING

India, Pakistan, Mozambique.

POPULATION

Women with in-community BP measurements and known pregnancy outcomes.

METHODS

Blood pressure was defined by its outputs (systolic and/or diastolic, systolic only, diastolic only or mean arterial pressure [calculated]) and level: normotension-1 (<135/85 mmHg), normotension-2 (135-139/85-89 mmHg), non-severe hypertension (140-149/90-99 mmHg; 150-154/100-104 mmHg; 155-159/105-109 mmHg) and severe hypertension (≥160/110 mmHg). Dose-response (adjusted risk ratio [aRR]) and diagnostic test properties (negative [-LR] and positive [+LR] likelihood ratios) were estimated.

MAIN OUTCOME MEASURES

Maternal/perinatal composites of mortality/morbidity.

RESULTS

Among 21 069 pregnancies, different BP outputs had similar aRR, -LR, and +LR for adverse outcomes. No BP level (even normotension-1) was associated with low risk (all -LR ≥0.20). Across outcomes, risks rose progressively with higher BP levels above normotension-1. For each of maternal central nervous system events and stillbirth, BP ≥155/105 mmHg showed at least good diagnostic test performance (+LR ≥5.0) and BP ≥135/85 mmHg at least fair performance, similar to BP ≥140/90 mmHg (+LR 2.0-4.99).

CONCLUSIONS

In the community, normal BP values do not provide reassurance about subsequent adverse outcomes. Given the similar performance of BP cut-offs of 135/85 and 140/90 mmHg for hypertension, and 155/105 and 160/110 mmHg for severe hypertension, digital decision support for women in the community should consider using these lower thresholds.

BOHEMIA: Broad One Health Endectocide-based Malaria Intervention in Africa-a phase III cluster-randomized, open-label, clinical trial to study the safety and efficacy of ivermectin mass drug administration to reduce malaria transmission in two African settings

BACKGROUND

Residual malaria transmission is the result of adaptive mosquito behavior that allows malaria vectors to thrive and sustain transmission in the presence of good access to bed nets or insecticide residual spraying. These behaviors include crepuscular and outdoor feeding as well as intermittent feeding upon livestock. Ivermectin is a broadly used antiparasitic drug that kills mosquitoes feeding on a treated subject for a dose-dependent period. Mass drug administration with ivermectin has been proposed as a complementary strategy to reduce malaria transmission.

METHODS

A cluster randomized, parallel arm, superiority trial conducted in two settings with distinct eco-epidemiological conditions in East and Southern Africa. There will be three groups: human intervention, consisting of a dose of ivermectin (400 mcg/kg) administered monthly for 3 months to all the eligible population in the cluster (>15 kg, non-pregnant and no medical contraindication); human and livestock intervention, consisting human treatment as above plus treatment of livestock in the area with a single dose of injectable ivermectin (200 mcg/kg) monthly for 3 months; and controls, consisting of a dose of albendazole (400 mg) monthly for 3 months. The main outcome measure will be malaria incidence in a cohort of children under five living in the core of each cluster followed prospectively with monthly RDTs DISCUSSION: The second site for the implementation of this protocol has changed from Tanzania to Kenya. This summary presents the Mozambique-specific protocol while the updated master protocol and the adapted Kenya-specific protocol undergo national approval in Kenya. BOHEMIA will be the first large-scale trial evaluating the impact of ivermectin-only mass drug administration to humans or humans and cattle on local malaria transmission TRIAL REGISTRATION: ClinicalTrials.gov NCT04966702 . Registered on July 19, 2021. Pan African Clinical Trials Registry PACTR202106695877303.

Child Health and Mortality Prevention Surveillance (CHAMPS): Manhiça site description, Mozambique

The Manhiça Health Research Centre (Manhiça HDSS) was established in 1996 in Manhiça, a rural district at Maputo Province in the southern part of Mozambique with approximately 49,000 inhabited households, a total population of 209.000 individuals, and an annual estimated birth cohort of about 5000 babies. Since 2016, Manhiça HDSS is implementing the Child Health and Mortality Prevention Surveillance (CHAMPS) program aiming to investigate causes of death (CoD) in stillbirths and children under the age of 5 years using, among other tools, the innovative post-mortem technique known as Minimally Invasive Tissue sampling (MITS). Both in-hospital and community pediatric deaths are investigated using MITS. For this, community-wide socio-demographic approaches (notification of community deaths by key informants, formative research involving several segments of the community, availability of free phone lines for notification of medical emergencies and deaths, etc.) are conducted alongside to foster community awareness, involvement and adherence as well as to compute mortality estimates and collect relevant information of health and mortality determinants. The main objective of this paper is to describe the Manhiça Health and Demographic Surveillance System (HDSS) site and the CHAMPS research environment in place including the local capacities among its reference hospital, laboratories, data center and other relevant areas involved in this ambitious surveillance and research project, whose ultimate aim is to improve child survival through public health actions derived from credible estimates and understanding of the major causes of childhood mortality in Mozambique.

An evaluation of LLIN ownership, access, and use during the Magude project in southern Mozambique

The Magude Project assessed the feasibly of eliminating malaria in a low transmission setting in southern Mozambique using a package of interventions. This study measured the ownership, access and use of long-lasting insecticide treated nets (LLINs) and inequalities in these indicators across household wealth, size and population subgroups, to understand the protection that LLINs provided during the project. Data were obtained from various household surveys. At least 31% of the nets distributed during the 2014 and 2017 campaigns were lost during the first year post-distribution. Most nets (77.1%) present in the district were Olyset Nets. LLIN access never exceeded 76.3% and use varied seasonally between 40% and 76.4%. LLIN access limited LLIN use during the project, especially during the high transmission season. LLIN ownership, access and use were lower in harder-to-reach localities, in poorer and larger households. Children and women below 30 had poorer access to LLINs than the overall population. Net use was lowest among school-aged children and young adults, especially among young males, and highest in children under 5, pregnant women, in older adults and in households that received indoor residual spraying (IRS). This study revealed that LLIN mass-distribution campaigns alone are not sufficient to achieve the high level of net protection needed during elimination programs and that reviewing the LLIN allocation scheme, top-up distributions and/or community engagement campaigns is needed, also to reduce inequalities in populations' access to LLINs.

The social dimensions of community delivery of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria and the Democratic Republic of the Congo

INTRODUCTION

Intermittent preventive treatment in pregnancy with sulphadoxine pyrimethamine (IPTp) is a key malaria prevention strategy in sub-Saharan African countries. We conducted an anthropological study as part of a project aiming to evaluate a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in four countries (the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria), to understand the social context in order to identify key factors that could influence C-IPTp acceptability.

METHODS

A total of 796 in-depth interviews and 265 focus group discussions were undertaken between 2018 and 2021 in the four countries with pregnant women, women of reproductive age, traditional and facility-based healthcare providers, community leaders, and relatives of pregnant women. These were combined with direct observations (388) including both community-based and facility-based IPTp delivery. Grounded theory guided the overall study design and data collection, and data were analysed following a combination of content and thematic analysis.

RESULTS

A series of key factors were found to influence acceptability, delivery and uptake of C-IPTp in project countries. Cross-cutting findings include the alignment of the strategy with existing social norms surrounding pregnancy and maternal health-seeking practices, the active involvement of influential and trusted actors in implementation activities, existing and sustained trust in CHWs, the influence of husbands and other relatives in pregnant women's care-seeking decision-making, the working conditions of CHWs, pregnant women's perceptions of SP for IPTp and persistent barriers to facility-based antenatal care access.

CONCLUSIONS

The findings provide evidence on the reported acceptability of C-IPTp among a wide range of actors, as well as the barriers and facilitators for delivery and uptake of the intervention. Overall, C-IPTp was accepted by the targeted communities, supporting the public health value of community-based interventions, although the barriers identified should be examined if large-scale implementation of the intervention is considered.

Single-Nucleotide Polymorphisms in the Beta-Tubulin Gene and Its Relationship with Treatment Response to Albendazole in Human Soil-Transmitted Helminths in Southern Mozambique

Soil-transmitted helminth (STH) cornerstone control strategy is mass drug administration (MDA) with benzimidazoles. However, MDA might contribute to selection pressure for anthelmintic resistance, as occurred in livestock. The aim of this study is to evaluate the treatment response to albendazole and the relationship with the presence of putative benzimidazole resistance single-nucleotide polymorphisms (SNPs) in the β-tubulin gene of STH in Southern Mozambique. After screening 819 participants, we conducted a cohort study with 184 participants infected with STH in Manhiça district, Southern Mozambique. A pretreatment and a posttreatment stool samples were collected and the STH infection was identified by duplicate Kato-Katz and quantitative polymerase chain reaction (qPCR). Cure rate and egg reduction rates were calculated. Putative benzimidazole resistance SNPs (F167Y, F200T, and E198A) in Trichuris trichiura and Necator americanus were assessed by pyrosequencing. Cure rates by duplicate Kato-Katz and by qPCR were 95.8% and 93.6% for Ascaris lumbricoides, 28% and 7.8% for T. trichiura, and 88.9% and 56.7% for N. americanus. Egg reduction rate by duplicate Kato-Katz was 85.4% for A. lumbricoides, 34.9% for T. trichiura, and 40.5% for N. americanus. Putative benzimidazole resistance SNPs in the β-tubulin gene were detected in T. trichiura (23%) and N. americanus (21%) infected participants at pretreatment. No statistical difference was observed between pretreatment and posttreatment frequencies for none of the SNPs. Although treatment response to albendazole was low, particularly in T. trichiura, the putative benzimidazole resistance SNPs were not higher after treatment in the population studied. New insights are needed for a better understanding and monitoring of human anthelmintic resistance.

Evaluation of antibody serology to determine current helminth and Plasmodium falciparum infections in a co-endemic area in Southern Mozambique

Background

Soil-transmitted helminths (STH), Schistosoma spp. and Plasmodium falciparum are parasites of major public health importance and co-endemic in many sub-Saharan African countries. Management of these infections requires detection and treatment of infected people and evaluation of large-scale measures implemented. Diagnostic tools are available but their low sensitivity, especially for low intensity helminth infections, leaves room for improvement. Antibody serology could be a useful approach thanks to its potential to detect both current infection and past exposure.

Methodology

We evaluated total IgE responses and specific-IgG levels to 9 antigens from STH, 2 from Schistosoma spp., and 16 from P. falciparum, as potential markers of current infection in a population of children and adults from Southern Mozambique (N = 715). Antibody responses were measured by quantitative suspension array Luminex technology and their performance was evaluated by ROC curve analysis using microscopic and molecular detection of infections as reference.

Principal findings

IgG against the combination of EXP1, AMA1 and MSP2 (P. falciparum) in children and NIE (Strongyloides stercoralis) in adults and children had the highest accuracies (AUC = 0.942 and AUC = 0.872, respectively) as markers of current infection. IgG against the combination of MEA and Sm25 (Schistosoma spp.) were also reliable markers of current infection (AUC = 0.779). In addition, IgG seropositivity against 20 out of the 27 antigens in the panel differentiated the seropositive endemic population from the non-endemic population, suggesting a possible role as markers of exposure although sensitivity could not be assessed.

Conclusions

We provided evidence for the utility of antibody serology to detect current infection with parasites causing tropical diseases in endemic populations. In addition, most of the markers have potential good specificity as markers of exposure. We also showed the feasibility of measuring antibody serology with a platform that allows the integration of control and elimination programs for different pathogens.

Parasitic worms and Plasmodium falciparum, the causal agent of malaria, are among the most relevant parasitic diseases of our time and efforts are under way for their control and, ultimately, elimination. An accurate diagnosis is relevant for case management, but also allows calculating the prevalence and evaluating the effectiveness of treatment and control measures. Unfortunately, current diagnostic methods for parasitic worms are not optimal and many infections remain undetected. As for P. falciparum, current diagnostic techniques are satisfactory but do not allow for ascertaining exposure, which is relevant for evaluating control measures. Here we investigated the utility of measuring antibodies to these parasites as a diagnostic method. Our results indicate that it is possible to detect current infection with parasitic worms and P. falciparum using antibody detection with a moderate to high accuracy. We also show that antibodies against the antigens in this study have potential as markers of exposure. Importantly, we used a platform that allows for the simultaneous detection of immunoglobulins to different parasites, which would be extremely useful as a tool to integrate control and elimination programs for several pathogens.

Local mortality impacts due to future air pollution under climate change scenarios

The health impacts of global climate change mitigation will affect local populations differently. However, most co-benefits analyses have been done at a global level, with relatively few studies providing local level results. We aimed to quantify the local health impacts due to fine particles (PM_2.5) under the governance arrangements embedded in the Shared Socioeconomic Pathways (SSPs1-5) under two greenhouse gas concentration scenarios (Representative Concentration Pathways (RCPs) 2.6 and 8.5) in local populations of Mozambique, India, and Spain. We simulated the SSP-RCP scenarios using the Global Change Analysis Model, which was linked to the TM5-FASST model to estimate PM_2.5 levels. PM_2.5 levels were calibrated with local measurements. We used comparative risk assessment methods to estimate attributable premature deaths due to PM_2.5 linking local population and mortality data with PM_2.5-mortality relationships from the literature, and incorporating population projections under the SSPs. PM_2.5 attributable burdens in 2050 differed across SSP-RCP scenarios, and sensitivity of results across scenarios varied across populations. Future attributable mortality burden of PM_2.5 was highly sensitive to assumptions about how populations will change according to SSP. SSPs reflecting high challenges for adaptation (SSPs 3 and 4) consistently resulted in the highest PM_2.5 attributable burdens mid-century. Our analysis of local PM_2.5 attributable premature deaths under SSP-RCP scenarios in three local populations highlights the importance of both socioeconomic development and climate policy in reducing the health burden from air pollution. Sensitivity of future PM_2.5 mortality burden to SSPs was particularly evident in low- and middle- income country settings due either to high air pollution levels or dynamic populations.

Neighbors' use of water and sanitation facilities can affect children's health: a cohort study in Mozambique using a spatial approach

BACKGROUND

Impact evaluation of most water, sanitation and hygiene (WASH) interventions in health are user-centered. However, recent research discussed WASH herd protection - community WASH coverage could protect neighboring households. We evaluated the effect of water and sanitation used in the household and by household neighbors in children's morbidity and mortality using recorded health data.

METHODS

We conducted a retrospective cohort including 61,333 children from a district in Mozambique during 2012-2015. We obtained water and sanitation household data and morbidity data from Manhiça Health Research Centre surveillance system. To evaluate herd protection, we estimated the density of household neighbors with improved facilities using a Kernel Density Estimator. We fitted negative binomial adjusted regression models to assess the minimum children-based incidence rates for every morbidity indicator, and Cox regression models for mortality.

RESULTS

Household use of unimproved water and sanitation displayed a higher rate of outpatient visit, diarrhea, malaria, and anemia. Households with unimproved water and sanitation surrounded by neighbors with improved water and sanitation high coverage were associated with a lower rate of outpatient visit, malaria, anemia, and malnutrition.

CONCLUSION

Household and neighbors' access to improve water and sanitation can affect children's health. Accounting for household WASH and herd protection in interventions' evaluation could foster stakeholders' investment and improve WASH related diseases control. Distribution of main water and sanitation facilities used during study period.

Household modifications after the indoor residual spraying (IRS) campaign in Mozambique reduce the actual spray coverage and efficacy

Indoor residual spraying of insecticides (IRS) is a key malaria vector control strategy. Whilst human attitude towards IRS is monitored before or shortly after implementation, human activities leading to the modification of insecticide-treated walls post-IRS are not. This could inadvertently reduce the protective effects of IRS. We monitored the extent of modifications to the sprayed indoor wall surfaces by household owners for six months post-IRS campaigns in two districts targeted for malaria elimination in southern Mozambique. In parallel, we assessed building of any additional rooms onto compounds, and mosquito net use. We quantified the contribution of wall modifications, added rooms, prolonged spray campaigns, and product residual efficacies on actual IRS coverage and relative mosquito bite reduction, using a mechanistic approach. Household owners continually modified insecticide-treated walls and added rooms onto compounds. Household surveys in southern Mozambique showed frequent modification of indoor walls (0-17.2% of households modified rooms monthly) and/or added rooms (0-16.2% of households added rooms monthly). Actual IRS coverage reduced from an assumed 97% to just 39% in Matutuine, but only from 96% to 91% in Boane, translating to 43% and 5.8% estimated increases in relative daily mosquito bites per person. Integrating post-IRS knowledge, attitude, and practice (KAP) surveys into programmatic evaluations to capture these modification and construction trends can help improve IRS program efficiency and product assessment.

Acceptability and perceived facilitators and barriers to the usability of biometric registration among infants and children in Manhiça district, Mozambique: A qualitative study

In low-and middle-income countries, many infants and children remain unregistered in both civil registration and healthcare records, limiting their access to essential rights-based services, including healthcare. A novel biometric registration prototype, applying a non-touch platform using smart phones and tablets to capture physical characteristics of infants and children for electronic registration, was tested in rural Mozambique. This study assessed acceptability and perceived barriers and facilitators to the usability of this biometric registration prototype in Manhiça district, southern Mozambique. The study followed a qualitative design consisting of 5 semi-structured interviews with healthcare providers, 7 focus group discussions with caregivers of infants aged between 0 and 5 years old, and 2 focus group discussions with data collectors involved in the implementation of the biometric registration pilot project. Data were thematically analysed. The results of this study show that there is wide acceptability of the biometric registration prototype among healthcare providers and caregivers. Participants were aware of the benefits of the biometric registration prototype. The perceived benefits included that the biometric registration prototype would solve the inefficiency of paper-based registration, and the perception of biometric registration as “healthcare norm”. Perceived potential barriers to the implementation of the biometric registration prototype included: myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers. In conclusion, the biometric prototype was widely accepted due to its perceived usefulness. However, there is a need to address the perceived barriers, and involvement of children’s fathers and/or other relevant family members in the process of biometric registration.

The impact of the caregiver mobility on child HIV care in the Manhiça District, Southern Mozambique: A clinical based study

Introduction

Manhiça District, in Southern Mozambique harbors high HIV prevalence and a long history of migration. To optimize HIV care, we sought to assess how caregiver’s mobility impacts children living with HIV (CLHIV)´s continuation in HIV care and to explore the strategies used by caregivers to maintain their CLHIV on antiretroviral treatment (ART).

Methods

A clinic-based cross-sectional survey conducted at the Manhiça District Hospital between December-2017 and February-2018. We enrolled CLHIV with a self-identified migrant caregiver (moved outside of Manhiça District ≤12 months prior to survey) and non-migrant caregiver, matched by the child age and sex. Survey data were linked to CLHIV clinical records from the HIV care and treatment program.

Results

Among the 975 CLHIV screened, 285 (29.2%) were excluded due to absence of an adult at the appointment. A total of 232 CLHIV-caregiver pairs were included. Of the 41 (35%) CLHIV migrating with their caregivers, 38 (92.6%) had access to ART at the destination because either the caregivers travelled with it 24 (63%) or it was sent by a family member 14 (36%). Among the 76 (65%) CLHIV who did not migrate with their caregivers, for the purpose of pharmacy visits, 39% were cared by their grandfather/grandmother, 28% by an aunt/uncle and 16% by an adult brother/sister. CLHIV of migrant caregivers had a non-statistically significant increase in the number of previous reported sickness episodes (OR = 1.38, 95%CI: 0.79–2.42; p = 0.257), ART interruptions (OR = 1.73; 95%CI: 0.82–3.63; p = 0.142) and lost-to-follow-up episodes (OR = 1.53; 95%CI: 0.80–2.94; p = 0.193).

Conclusions

Nearly one third of the children attend their HIV care appointments unaccompanied by an adult. The caregiver mobility was not found to significantly affect child’s retention on ART. Migrant caregivers adopted strategies such as the transportation of ART to the mobility destination to avoid impact of mobility on the child’s HIV care. However this may have implications on ART stability and effectiveness that should be investigated in rural areas.

Towards soil-transmitted helminths transmission interruption: The impact of diagnostic tools on infection prediction in a low intensity setting in Southern Mozambique

World Health Organization goals against soil-transmitted helminthiases (STH) are pointing towards seeking their elimination as a public health problem: reducing to less than 2% the proportion of moderate and heavy infections. Some regions are reaching WHO goals, but transmission could rebound if strategies are discontinued without an epidemiological evaluation. For that, sensitive diagnostic methods to detect low intensity infections and localization of ongoing transmission are crucial. In this work, we estimated and compared the STH infection as obtained by different diagnostic methods in a low intensity setting. We conducted a cross-sectional study enrolling 792 participants from a district in Mozambique. Two stool samples from two consecutive days were collected from each participant. Samples were analysed by Telemann, Kato-Katz and qPCR for STH detection. We evaluated diagnostic sensitivity using a composite reference standard. By geostatistical methods, we estimated neighbourhood prevalence of at least one STH infection for each diagnostic method. We used environmental, demographical and socioeconomical indicators to account for any existing spatial heterogeneity in infection. qPCR was the most sensitive technique compared to composite reference standard: 92% (CI: 83%- 97%) for A. lumbricoides, 95% (CI: 88%- 98%) for T. trichiura and 95% (CI: 91%- 97%) for hookworm. qPCR also estimated the highest neighbourhood prevalences for at least one STH infection in a low intensity setting. While 10% of the neighbourhoods showed a prevalence above 20% when estimating with single Kato-Katz from one stool and Telemann from one stool, 86% of the neighbourhoods had a prevalence above 20% when estimating with qPCR. In low intensity settings, STH estimated prevalence of infection may be underestimated if based on Kato-Katz. qPCR diagnosis outperformed the microscopy methods. Thus, implementation of qPCR based predictive maps at STH control and elimination programmes would disclose hidden transmission and facilitate targeted interventions for transmission interruption.

Effect of wall type, delayed mortality and mosquito age on the residual efficacy of a clothianidin-based indoor residual spray formulation (SumiShield™ 50WG) in southern Mozambique

Indoor residual spraying (IRS) is one of the main malaria vector control strategies in Mozambique alongside the distribution of insecticide treated nets. As part of the national insecticide resistance management strategy, Mozambique introduced SumiShield™ 50WG, a third generation IRS product, in 2018. Its residual efficacy was assessed in southern Mozambique during the 2018-2019 malaria season. Using a susceptible Anopheles arabiensis strain, residual efficacy was assessed on two different wall surfaces, cement and mud-plastered walls, using standard WHO (World Health Organization) cone bioassay tests at three different heights. Female mosquitoes of two age groups (2-5 and 13-26 day old) were exposed for 30 minutes, after which mortality was observed 24h, 48h, 72h, and 96h and 120h post-exposure to assess (delayed) mortality. Lethal times (LT) 90, LT50 and LT10 were estimated using Bayesian models. Mortality 24h post exposure was consistently below 80%, the current WHO threshold value for effective IRS, in both young and old mosquitoes, regardless of wall surface type. Considering delayed mortality, residual efficacies (mosquito mortality equal or greater than 80%) ranged from 1.5 to ≥12.5 months, with the duration depending on mortality time post exposure, wall type and mosquito age. Looking at mortality 72h after exposure, residual efficacy was between 6.5 and 9.5 months, depending on wall type and mosquito age. The LT50 and LT10 (i.e. 90% of the mosquitoes survive exposure to the insecticides) values were consistently higher for older mosquitoes (except for LT10 values for 48h and 72h post-exposure mortality) and ranged from 0.9 to 5.8 months and 0.2 to 7.8 months for LT50 and LT10, respectively. The present study highlights the need for assessing mosquito mortality beyond the currently recommended 24h post exposure. Failure to do so may lead to underestimation of the residual efficacy of IRS products, as delayed mortality will lead to a further reduction in mosquito vector populations and potentially negatively impact disease transmission. Monitoring residual efficacy on relevant wall surfaces, including old mosquitoes that are ultimately responsible for malaria transmission, and assessing delayed mortalities are critical to provide accurate and actionable data to guide vector control programmes.

Coverage of intermittent preventive treatment of malaria in pregnancy in four sub-Saharan countries: findings from household surveys

Background

Intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) is a key malaria prevention strategy in areas with moderate to high transmission. As part of the TIPTOP (Transforming IPT for Optimal Pregnancy) project, baseline information about IPTp coverage was collected in eight districts from four sub-Saharan countries: Democratic Republic of Congo (DRC), Madagascar, Mozambique and Nigeria.

Methods

Cross-sectional household surveys were conducted using a multistage cluster sampling design to estimate the coverage of IPTp and antenatal care attendance. Eligible participants were women of reproductive age who had ended a pregnancy in the 12 months preceding the interview and who had resided in the selected household during at least the past 4 months of pregnancy. Coverage was calculated using percentages and 95% confidence intervals.

Results

A total of 3911 women were interviewed from March to October 2018. Coverage of at least three doses of IPTp (IPTp3+) was 22% and 24% in DRC project districts; 23% and 12% in Madagascar districts; 11% and 16% in Nigeria local government areas; and 63% and 34% in Mozambique districts. In DRC, Madagascar and Nigeria, more than two-thirds of women attending at least four antenatal care visits during pregnancy received less than three doses of IPTp.

Conclusions

The IPTp3+ uptake in the survey districts was far from the universal coverage. However, one of the study districts in Mozambique showed a much higher coverage of IPTp3+ than the other areas, which was also higher than the 2018 average national coverage of 41%. The reasons for the high IPTp3+ coverage in this Mozambican district are unclear and require further study.

Molecular Detection of Soil-Transmitted Helminths and Enteric Protozoa Infection in Children and Its Association with Household Water and Sanitation in Manhiça District, Southern Mozambique

Intestinal parasite infections can have detrimental health consequences in children. In Mozambique, soil-transmitted helminth (STH) infections are controlled through mass drug administration since 2011, but no specific control program exists for enteric protozoa. This study evaluates STH and protozoan infections in children attending healthcare in Manhiça district, Southern Mozambique, and its association with water and sanitation conditions. We conducted a cross-sectional study in children between 2 and 10 years old in two health centers (n = 405). A stool sample and metadata were collected from each child. Samples were analyzed by multi-parallel real-time quantitative PCR (qPCR). We fitted logistic regression-adjusted models to assess the association between STH or protozoan infection with household water and sanitation use. Nineteen percent were infected with at least one STH and 77.5% with at least one enteric protozoon. qPCR detected 18.8% of participants with intestinal polyparasitism. Protected or unprotected water well use showed a higher risk for at least one protozoan infection in children (OR: 2.59, CI: 1.01-6.65, p-value = 0.010; OR: 5.21, CI: 1.56-17.46, p-value = 0.010, respectively) compared to household piped water. A high proportion of children had enteric protozoan infections. Well consumable water displayed high risk for that.

Economic and cost-effectiveness analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials in India, Pakistan and Mozambique

Background

The Community-Level Interventions for Pre-eclampsia (CLIP) trials (NCT01911494) in India, Pakistan and Mozambique (February 2014–2017) involved community engagement and task sharing with community health workers for triage and initial treatment of pregnancy hypertension. Maternal and perinatal mortality was less frequent among women who received ≥8 CLIP contacts. The aim of this analysis was to assess the incremental costs and cost-effectiveness of the CLIP intervention overall in comparison to standard of care, and by PIERS (Pre-eclampsia Integrated Estimate of RiSk) On the Move (POM) mobile health application visit frequency.

Methods

Included were all women enrolled in the three CLIP trials who had delivered with known outcomes by trial end. According to the number of POM-guided home contacts received (0, 1–3, 4–7, ≥8), costs were collected from annual budgets and spending receipts, with inclusion of family opportunity costs in Pakistan. A decision tree model was built to determine the cost-effectiveness of the intervention (vs usual care), based on the primary clinical endpoint of years of life lost (YLL) for mothers and infants. A probabilistic sensitivity analysis was used to assess uncertainty in the cost and clinical outcomes.

Results

The incremental per pregnancy cost of the intervention was US$12.66 (India), US$11.51 (Pakistan) and US$13.26 (Mozambique). As implemented, the intervention was not cost-effective due largely to minimal differences in YLL between arms. However, among women who received ≥8 CLIP contacts (four in Pakistan), the probability of health system and family (Pakistan) cost-effectiveness was ≥80% (all countries).

Conclusion

The intervention was likely to be cost-effective for women receiving ≥8 contacts in Mozambique and India, and ≥4 in Pakistan, supporting WHO guidance on antenatal contact frequency.

Trial registration number

NCT01911494.

Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men

BACKGROUND

HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique.

METHODS

This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI).

RESULTS

Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women.

CONCLUSION

The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out

Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.

Health and Demographic Surveillance Systems Within the Child Health and Mortality Prevention Surveillance Network

Health and demographic surveillance systems (HDSSs) provide a foundation for characterizing and defining priorities and strategies for improving population health. The Child Health and Mortality Prevention Surveillance (CHAMPS) project aims to inform policy to prevent child deaths through generating causes of death from surveillance data combined with innovative diagnostic and laboratory methods. Six of the 7 sites that constitute the CHAMPS network have active HDSSs: Mozambique, Mali, Ethiopia, Kenya, Bangladesh, and South Africa; the seventh, in Sierra Leone, is in the early planning stages. This article describes the network of CHAMPS HDSSs and their role in the CHAMPS project. To generate actionable health and demographic data to prevent child deaths, the network depends on reliable demographic surveillance, and the HDSSs play this crucial role.

The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis

BACKGROUND

To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries.

METHODS

In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014-17. Consenting pregnant women, aged 12-49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564.

FINDINGS

Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22-30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90-1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility.

INTERPRETATION

The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening.

FUNDING

University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.

VAR2CSA Serology to Detect Plasmodium falciparum Transmission Patterns in Pregnancy

Pregnant women constitute a promising sentinel group for continuous monitoring of malaria transmission. To identify antibody signatures of recent Plasmodium falciparum exposure during pregnancy, we dissected IgG responses against VAR2CSA, the parasite antigen that mediates placental sequestration. We used a multiplex peptide-based suspension array in 2,354 samples from pregnant women from Mozambique, Benin, Kenya, Gabon, Tanzania, and Spain. Two VAR2CSA peptides of limited polymorphism were immunogenic and targeted by IgG responses readily boosted during infection and with estimated half-lives of <2 years. Seroprevalence against these peptides reflected declines and rebounds of transmission in southern Mozambique during 2004–2012, reduced exposure associated with use of preventive measures during pregnancy, and local clusters of transmission that were missed by detection of P. falciparum infections. These data suggest that VAR2CSA serology can provide a useful adjunct for the fine-scale estimation of the malaria burden among pregnant women over time and space.

Community-level interventions for pre-eclampsia (CLIP) in Mozambique: A cluster randomised controlled trial

OBJECTIVES

Pregnancy hypertension is the third leading cause of maternal mortality in Mozambique and contributes significantly to fetal and neonatal mortality. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment.

STUDY DESIGN

The Mozambique Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 administrative posts (clusters) in Maputo and Gaza Provinces. The CLIP intervention (6 clusters) consisted of community engagement, community health worker-provided mobile health-guided clinical assessment, initial treatment, and referral to facility either urgently (<4hrs) or non-urgently (<24hrs), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of CLIP contacts.

MAIN OUTCOME MEASURES

20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity.

RESULTS

15,013 women (15,123 pregnancies) were recruited in intervention (N = 7930; 2·0% loss to follow-up (LTFU)) and control (N = 7190; 2·8% LTFU) clusters. The primary outcome did not differ between intervention and control clusters (adjusted odds ratio (aOR) 1·31, 95% confidence interval (CI) [0·70, 2·48]; p = 0·40). Compared with intervention arm women without CLIP contacts, those with ≥8 contacts experienced fewer primary outcomes (aOR 0·79 (95% CI 0·63, 0·99); p = 0·041), primarily due to improved maternal outcomes (aOR 0·72 (95% CI 0·53, 0·97); p = 0·033).

INTERPRETATION

As generally implemented, the CLIP intervention did not improve pregnancy outcomes; community implementation of the WHO eight contact model may be beneficial.

FUNDING

The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).

Demographic and health community-based surveys to inform a malaria elimination project in Magude district, southern Mozambique

OBJECTIVES

A Demographic and Health Platform was established in Magude in 2015, prior to the deployment of a project aiming to evaluate the feasibility of malaria elimination in southern Mozambique, named the Magude project. This platform aimed to inform the design, implementation and evaluation of the Magude project, through the identification of households and population; and the collection of demographic, health and malaria information.

SETTING

Magude is a rural district of southern Mozambique which borders South Africa. It has nine peripheral health facilities and one referral health centre with an inpatient ward.

INTERVENTION

A baseline census enumerated and geolocated all the households, and their resident and non-resident members, collecting demographic and socio-economic information, and data on the coverage and usage of malaria control tools. Inpatient and outpatient data during the 5 years (2010 to 2014) before the survey were obtained from the district health authorities. The demographic platform was updated in 2016.

RESULTS

The baseline census conducted in 2015 reported 48 448 (92.1%) residents and 4133 (7.9%) non-residents, and 10 965 households. Magude's population is predominantly young, half of the population has no formal education and the main economic activities are agriculture and fishing. Houses are mainly built with traditional non-durable materials and have poor sanitation facilities. Between 2010 and 2014, malaria was the most common cause of all-age inpatient discharges (representing 20% to 40% of all discharges), followed by HIV (12% to 22%) and anaemia (12% to 15%). In early 2015, all-age bed-net usage was between 21.8% and 27.1% and the reported coverage of indoor residual spraying varied across the district between 30.7% and 79%.

CONCLUSION

This study revealed that Magude has limited socio-economic conditions, poor access to healthcare services and low coverage of malaria vector control interventions. Thus, Magude represented an area where it is most pressing to demonstrate the feasibility of malaria elimination.

TRIAL REGISTRATION NUMBER

NCT02914145; Pre-results.

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study

Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

Predictors of personal exposure to black carbon among women in southern semi-rural Mozambique

Sub-Saharan Africa (SSA) has the highest proportion of people using unclean fuels for household energy, which can result in products of incomplete combustion that are damaging for health. Black carbon (BC) is a useful marker of inefficient combustion-related particles; however, ambient air quality data and temporal patterns of personal exposure to BC in SSA are scarce. We measured ambient elemental carbon (EC), comparable to BC, and personal exposure to BC in women of childbearing age from a semi-rural area of southern Mozambique. We measured ambient EC over one year (2014-2015) using a high-volume sampler and an off-line thermo-optical-transmission method. We simultaneously measured 5-min resolved 24-h personal BC using a portable MicroAeth (AE51) in 202 women. We used backwards stepwise linear regression to identify predictors of log-transformed 24-h mean and peak (90th percentile) personal BC exposure. We analyzed data from 187 non-smoking women aged 16-46 years. While daily mean ambient EC reached moderate levels (0.9 μg/m³, Standard Deviation, SD: 0.6 μg/m³), daily mean personal BC reached high levels (15 μg/m³, SD: 19 μg/m³). Daily patterns of personal exposure revealed a peak between 6 and 7 pm (>35 μg/m³), attributable to kerosene-based lighting. Key determinants of mean and peak personal exposure to BC were lighting source, kitchen type, ambient EC levels, and temperature. This study highlights the important contribution of lighting sources to personal exposure to combustion particles in populations that lack access to clean household energy.

Differential expression of var subgroups and PfSir2a genes in afebrile Plasmodium falciparum malaria: a matched case-control study

Background

Poor knowledge on the afebrile Plasmodium falciparum biology limits elimination approaches to target asymptomatic malaria. Therefore, the association of parasite factors involved in cytoadhesion, parasite multiplication and gametocyte maturation with afebrile malaria was assessed.

Methods

Plasmodium falciparum isolates were collected from febrile (axillary temperature ≥ 37.5 °C or a reported fever in the previous 24 h) and afebrile (fever neither at the visit nor in the previous 24 h) individuals residing in Southern Mozambique. var, PfSir2a and Pfs25 transcript levels were determined by reverse transcriptase quantitative PCRs (RT-qPCRs) and compared among 61 pairs of isolates matched by parasite density, age and year of sample collection.

Results

The level of varC and PfSir2a transcripts was higher in P. falciparum isolates from afebrile individuals (P ≤ 0.006), while varB and DC8 genes (P ≤ 0.002) were higher in isolates from individuals with febrile infections. After adjusting the analysis by area of residence, doubling the relative transcript unit (RTU) of varC and PfSir2a was associated with a 29.7 (95% CI 4.6–192.3) and 8.5 (95% CI 1.9–32.2) fold increases, respectively, of the odds of being afebrile. In contrast, doubling the RTU of varB and DC8 was associated with a 0.8 (95% CI 0.05–0.6) and 0.2 (95% CI 0.04–0.6) fold changes, respectively, of the odds of being afebrile. No significant differences were found for Pfs25 transcript levels in P. falciparum isolates from afebrile and febrile individuals.

Conclusions

var and gametocyte-specific transcript patterns in febrile and afebrile infections from southern Mozambique matched by age, parasite density and recruitment period suggest similar transmissibility but differential expression of variant antigens involved in cytoadhesion and immune-evasion.

Mothers' satisfaction with care during facility-based childbirth: a cross-sectional survey in southern Mozambique

Background

Client satisfaction is an essential component of quality of care. Health system factors, processes of care as well as mothers’ characteristics influence the extent to which care meets the expectations of mothers and families. In our study, we specifically aimed to address the mothers’ experiences of, and satisfaction with, care during childbirth.

Methods

A population-based cross-sectional study, using structured interviews with published sequences of questions assessing satisfaction, including 4358 mothers who gave birth during the 12 months before June 2016 to estimate satisfaction with childbirth care. Regression analysis was used to determine the predictors of client satisfaction.

Results

Most mothers (92.5%) reported being satisfied with care during childbirth and would recommend that a family member to deliver at the same facility. Specifically, 94.7% were satisfied with the cleanliness of the facility, 92.0% reported being satisfied with the interaction with the healthcare providers, but only 49.8% felt satisfied with the assistance to feed their baby. Mothers who had negative experiences during the process of care, such as being abandoned when needing help, disrespect, humiliation, or physical abuse, reported low levels of satisfaction when compared to those who had not had such experiences (68.5% vs 93.5%). Additionally, they reported higher levels of dissatisfaction (20.1% vs 2.1%). Regression analysis revealed that mothers who gave birth in primary level facilities tended to be more satisfied than those who gave birth in hospitals, and having a companion increased, on average, the overall satisfaction score, with 0.06 in type II health centres (CI 0.03–0.10) and with 0.05 in type I health centres (CI − 0.02 – 0.13), compared to − 0.01(CI -0.08 – 0.07) in the hospitals, irrespective of age, education and socio-economic background.

Conclusion

Childbirth at the primary level facilities contributes to the level of satisfaction. The provision of childbirth care should consider women’s preferences and needs, including having a companion of choice. We highlight the challenge in balancing safety of care versus satisfaction with care and in developing policies on the optimum configuration of childbirth care. Interventions to improve the interaction with providers and the provision of respectful care are recommended.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2449-6) contains supplementary material, which is available to authorized users.

How accurate are modelled birth and pregnancy estimates? Comparison of four models using high resolution maternal health census data in southern Mozambique

Background

Existence of inequalities in quality and access to healthcare services at subnational levels has been identified despite a decline in maternal and perinatal mortality rates at national levels, leading to the need to investigate such conditions using geographical analysis. The need to assess the accuracy of global demographic distribution datasets at all subnational levels arises from the current emphasis on subnational monitoring of maternal and perinatal health progress, by the new targets stated in the Sustainable Development Goals.

Methods

The analysis involved comparison of four models generated using Worldpop methods, incorporating region-specific input data, as measured through the Community Level Intervention for Pre-eclampsia (CLIP) project. Normalised root mean square error was used to determine and compare the models’ prediction errors at different administrative unit levels.

Results

The models’ prediction errors are lower at higher administrative unit levels. All datasets showed the same pattern for both the live birth and pregnancy estimates. The effect of improving spatial resolution and accuracy of input data was more prominent at higher administrative unit levels.

Conclusion

The validation successfully highlighted the impact of spatial resolution and accuracy of maternal and perinatal health data in modelling estimates of pregnancies and live births. There is a need for more data collection techniques that conduct comprehensive censuses like the CLIP project. It is also imperative for such projects to take advantage of the power of mapping tools at their disposal to fill the gaps in the availability of datasets for populated areas.

Place-specific factors associated with adverse maternal and perinatal outcomes in Southern Mozambique: a retrospective cohort study

OBJECTIVES

To identify and measure the place-specific determinants that are associated with adverse maternal and perinatal outcomes in the southern region of Mozambique.

DESIGN

Retrospective cohort study. Choice of variables informed by literature and Delphi consensus.

SETTING

Study conducted during the baseline phase of a community level intervention for pre-eclampsia that was led by community health workers.

PARTICIPANTS

A household census identified 50 493 households that were home to 80 483 women of reproductive age (age 12-49 years). Of these women, 14 617 had been pregnant in the 12 months prior to the census, of which 9172 (61.6%) had completed their pregnancies.

PRIMARY AND SECONDARY OUTCOME MEASURES

A combined fetal, maternal and neonatal outcome was calculated for all women with completed pregnancies.

RESULTS

A total of six variables were statistically significant (p≤0.05) in explaining the combined outcome. These included: geographic isolation, flood proneness, access to an improved latrine, average age of reproductive age woman, family support and fertility rates. The performance of the ordinary least squares model was an adjusted R²=0.69. Three of the variables (isolation, latrine score and family support) showed significant geographic variability in their effect on rates of adverse outcome. Accounting for this modest non-stationary effect through geographically weighted regression increased the adjusted R² to 0.71.

CONCLUSIONS

The community exploration was successful in identifying context-specific determinants of maternal health. The results highlight the need for designing targeted interventions that address the place-specific social determinants of maternal health in the study area. The geographic process of identifying and measuring these determinants, therefore, has implications for multisectoral collaboration.

TRIAL REGISTRATION NUMBER

NCT01911494.

Postdischarge Mortality Prediction in Sub-Saharan Africa

BACKGROUND

Although the burden of postdischarge mortality (PDM) in low-income settings appears to be significant, no clear recommendations have been proposed in relation to follow-up care after hospitalization. We aimed to determine the burden of pediatric PDM and develop predictive models to identify children who are at risk for dying after discharge.

METHODS

Deaths after hospital discharge among children aged <15 years in the last 17 years were reviewed in an area under demographic and morbidity surveillance in Southern Mozambique. We determined PDM over time (up to 90 days) and derived predictive models of PDM using easily collected variables on admission.

RESULTS

Overall PDM was high (3.6%), with half of the deaths occurring in the first 30 days. One primary predictive model for all ages included young age, moderate or severe malnutrition, a history of diarrhea, clinical pneumonia symptoms, prostration, bacteremia, having a positive HIV status, the rainy season, and transfer or absconding, with an area under the curve of 0.79 (0.75-0.82) at day 90 after discharge. Alternative models for all ages including simplified clinical predictors had a similar performance. A model specific to infants <3 months old was used to identify as predictors being a neonate, having a low weight-for-age z score, having breathing difficulties, having hypothermia or fever, having oral candidiasis, and having a history of absconding or transfer to another hospital, with an area under the curve of 0.76 (0.72-0.91) at day 90 of follow-up.

CONCLUSIONS

Death after discharge is an important although poorly recognized contributor to child mortality. A simple predictive algorithm based on easily recognizable variables could readily be used to identify most infants and children who are at a high risk of dying after discharge.

The role of HIV infection in the etiology and epidemiology of diarrheal disease among children aged 0-59 months in Manhiça District, Rural Mozambique

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HIV prevalence was higher among cases with moderate-to-severe diarrhea (MSD) than controls.

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Mortality was higher among HIV-infected children with diarrhea than HIV-uninfected ones.

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HIV-infected children were more likely to have MSD.

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Cryptosporidium was the most common pathogen in HIV-infected children with MSD.

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Escherichia coli producing heat-stable toxin (enterotoxigenic Escherichia coli, any sequence type) was the most common pathogen in HIV-infected children with less severe diarrhea.

Background

Diarrhea is an important health problem among HIV-infected patients. This study evaluated the role of HIV in the epidemiology, etiology, and severity of diarrheal disease among children.

Methods

The Global Enteric Multicenter Study enrolled children with moderate-to-severe diarrhea (MSD) and less-severe diarrhea (LSD) between December 2007 and November 2012. One to three controls for MSD cases and one per LSD case were enrolled and matched by age, sex, and neighborhood. All children were tested for HIV. Clinical data, anthropometric data, and stool samples were collected. Follow-up was performed at 60 days.

Results

Two hundred and fourteen MSD cases and 418 controls, together with 349 LSD cases and 214 controls were tested. HIV prevalence was 25% among MSD cases (4% for matched controls) and 6% among LSD cases (6% among matched controls). HIV-infected children were more likely to have MSD (odds ratio 5.6, p < 0.0001).

Mortality rates were higher among HIV-infected children than among the uninfected (34 vs. 5 per 1000 child-weeks at risk; p = 0.0039). Cryptosporidium, Giardia, and enteroaggregative Escherichia coli (aatA only) were more prevalent among HIV-infected MSD cases than among uninfected ones.

Conclusion

HIV is an important risk factor for MSD. The high mortality rate implies that children with MSD should be screened for HIV and managed accordingly.

Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re-test during HIV-testing campaigns in rural Mozambique

INTRODUCTION

Awareness of HIV-infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV-care. We aimed to characterize the HIV-positive population that underwent repeat HIV-testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target.

METHODS

This analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV-testing modalities: voluntary counselling and testing (VCT), provider-initiated counselling and testing (PICT) and home-based testing (HBT). Participants were given the opportunity to self-report their status to lay counsellors and HIV-positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV-diagnosis, were defined as non-disclosures. Venue-stratified descriptive analyses were performed and factors associated with non-disclosure were estimated through log-binomial regression.

RESULTS

In the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self-reported their HIV-positivity. Of those tested with a positive result, 38.9% were found to be non-disclosures. Similar prevalence of non-disclosures was found in clinical-testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non-disclosure as compared to patients who self-reported. When considering non-disclosures as people living with HIV (PLWHIV) aware of their HIV-status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6).

CONCLUSION

More than one-third of individuals testing HIV-positive did not disclose their previous positive HIV-diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non-anonymous tracking system for HIV-testers, repeat testing of non-disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources.

BCG vaccination in southern rural Mozambique: an overview of coverage and its determinants based on data from the demographic and health surveillance system in the district of Manhiça

Background

Over the past four decades, the World Health Organization established the Expanded Programme on Immunization (EPI) to foster universal access to all relevant vaccines for all children at risk. The success of this program has been undeniable, but requires periodic monitoring to ensure that coverage rates remain high. The aim of this study was to measure the BCG vaccination coverage in Manhiça district, a high TB burden rural area of Southern Mozambique and to investigate factors that may be associated with BCG vaccination.

Methods

We used data from the Health and Demographic Surveillance System (HDSS) run by the Manhiça Health Research Centre (CISM) in the district of Manhiça. A questionnaire was added in the annual HDSS round visits to retrospectively collect the vaccination history of children under the age of 3 years. Vaccinations are registered in the National Health Cards which are universally distributed at birth. This information was collected for children born from 2011 to 2014. Data on whether a child was vaccinated for BCG were collected from these National Health Cards and/or BCG scar assessment.

Results

A total of 10,875 number of children were eligible for the study and 7903 presented the health card. BCG coverage was 97.4% for children holding a health card. A BCG-compatible scar was observed in 99.0% of all children and in 99.6% of children with recorded BCG in the card. A total of 93.4% of children had been vaccinated with BCG within their first 28 days of life. None of the factors analysed were found to be associated with lack of BCG vaccination except for living in the municipality of Maluana compared to living in the municipality of Manhiça; (OR = 1.89, 95% CI: 1.18-3.00). Coverage for other EPI vaccines during the first year of life was similarly high, but decreased for subsequent doses.

Conclusions

BCG coverage is high and timely administered. Almost all vaccinated infants develop scar, which is a useful proxy for monitoring BCG vaccine implementation.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1003-4) contains supplementary material, which is available to authorized users.

Health and socio-demographic profile of women of reproductive age in rural communities of southern Mozambique

Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12–49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20–24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20–24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities.