Prevalence of sexually transmitted infections (STIs), associations with sociodemographic and behavioural factors, and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique.

In Mozambique, sexually transmitted infections (STIs) are estimated to be prevalent, but diagnosis and treatment of curable STIs rely only on syndromic management. We examined the prevalence of four non-viral STIs and HIV-1/2, based on etiological diagnosis, associations with sociodemographic and behavioural factors, and the STI diagnostic accuracy of the vaginal discharge syndromic management in women with urogenital complaints in Maputo, Mozambique. A cross-sectional study was performed in Maputo, Mozambique, February 2018-January 2019, enrolling 924 women of reproductive age with urogenital complaints. Endocervical/vaginal swabs were sampled and chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium infections were diagnosed using a multiplex real-time PCR (AmpliSens; InterLabServices). Serological testing was performed for HIV-1/2. A structured questionnaire collected metadata. All data were analyzed in STATA/IC 12.1 using descriptive statistics, chi-square tests and logistic regression model. About 40% of the women were less than 24 years old, 50.8% were single, 62.1% had their sexual debut between 12 and 17 years of age, and the main complaint was vaginal discharge syndrome (85%). The prevalence of chlamydia was 15.5%, trichomoniasis 12.1%, gonorrhoea 4.0%, M. genitalium 2.1%, and HIV-1/2 22.3%. The vaginal discharge syndrome flowchart had a sensitivity of 73.0%-82.5% and a specificity of 14%-15% for the detection of any individual non-viral STI in women with urogenital complaints. In total, 19.2% of the symptomatic women with chlamydia, trichomoniasis or gonorrhoea would not be detected and accordingly treated using the vaginal discharge syndromic management (missed treatment) and 70.0% of the women would be treated despite not being infected with any of these three STIs (overtreatment). In conclusion, a high prevalence of especially chlamydia, trichomoniasis, and HIV-1/2 was found in women of childbearing age with urogenital complaints in Maputo, Mozambique. Syndromic management of vaginal discharge revealed low accuracy in the detection of STIs in symptomatic women, especially low specificity, which resulted in under-treatment of STI-positive cases and incorrect or over-treatment of women with urogenital complaints, many of whom were negative for all the non-viral STIs. Etiological diagnosis is imperative for effective management of STIs in symptomatic and asymptomatic women.

Laboratory-based evaluation of the 4th-generation AlereTM HIV Combo rapid point-of-care test.

BACKGROUND: Mozambique is a high-prevalence country for HIV and early detection of new HIV infections is crucial for control of the epidemic. We aimed to evaluate the accuracy of the 4th-generation rapid diagnostic test (RDT) AlereTM HIV Combo in detecting acute and seroconverted HIV-infection, among sexually-active women attending three clinical health centers in Maputo, Mozambique. METHODS: Women aged 14-55 years (n = 920) seeking care at the Mavalane Health Area, Maputo (February 2018-January 2019) were included, and blood specimens sampled. Sociodemographic and sexual behavior data were collected. Point-of-care HIV testing was performed using Alere DetermineTM HIV-1/2 and Uni-GoldTM HIV-1/2. All samples were also tested using Enzygnost® HIV Integral 4 and Innotest® HIV Antigen mAb in laboratory. The 4th-generation RDT AlereTM HIV Combo was evaluated on serum samples in the laboratory. Finally, Innotest® HIV Antigen mAb, Enzygnost® HIV Integral 4 (Ag/Ab), and HIV RNA quantification acted as gold standard assays in the evaluation of AlereTM HIV Combo test for HIV antigen detection (in clinical samples and in three HIV-1 seroconversion panels). RESULTS: The antibody component of the 4th generation AlereTM HIV Combo RDT demonstrated a sensitivity and specificity of 100% examining clinical samples. However, the test did not detect HIV p24 antigen in any clinical samples, while Innotest® HIV Antigen mAb, verified by Enzygnost® HIV Integral 4 (Ag/Ab) and/or HIV RNA quantification, detected HIV antigen in six clinical samples. Furthermore, the AlereTM HIV Combo RDT had a low sensitivity in the detection of HIV p24 antigen in seroconversion panels. The HIV prevalence among the examined women was 17.8%. CONCLUSIONS: The 4th-generation RDT AlereTM HIV Combo showed similar sensitivity to the 3rd-generation RDTs to detect seroconverted HIV-infections. However, the sensitivity for detection of HIV p24 antigen and diagnosing acute HIV infections, before seroconversion, was low. There is an urgent need to develop and evaluate simple and affordable POC tests with high sensitivity and specificity for diagnosing individuals with acute HIV infection in resource-limited settings with high HIV prevalence.

A Cross Sectional Study on the Bidirectional Interactions Between Leptospirosis and HIV Infection Among Patients from Maputo Central Hospital, Mozambique.

Introduction: This study aims to determine the baseline seroprevalence of leptospirosis, a zoonotic and neglected disease, in people living with HIV (PWH) in Maputo, Mozambique, and to evaluate the relationship between selected HIV-related factors that might influence risk of coinfection with leptospirosis, such as degree of immunosuppression, as assessed by CD4 cell count, World Health Organization (WHO) HIV/AIDS clinical stage and antiretroviral therapy (ART) intake. Methods: This was a descriptive cross-sectional analysis of 157 PWH, aged over 18 years old, admitted to the Maputo Central Hospital, in Maputo, Mozambique, between March 2020 and October 2021. The study participants were recruited as a convenience sample regardless of the reasons for their admission. We collected sociodemographic and clinical data, including ART and WHO HIV/AIDS clinical stage, and blood for CD4 cell count and detection of Leptospira IgG antibodies using a commercial Kit ab247199 Leptospira IgG ELISA (www.abcam.com/ab247199) with sensitivity and specificity of 100% and 97.3%, respectively. Laboratory testing was performed at the Faculty of Medicine, Eduardo Mondlane University and Laboratory of Clinical Analysis, in Maputo. Results: Participants were aged 18 to 72 years (median age 39 years; SD ± 10.5), the majority were female 100 (63.7%), from urban areas 138 (87.9%), with secondary-level education 80 (51%). The overall seroprevalence of Leptospira IgG antibodies was 40.1%. The median CD4 cell count was 385 cells/µl (02 to 2297; SD ± 378.47). Higher seroprevalence of Leptospira antibodies was found among participants with CD4 cell counts <250 cells/µl (54.8%), WHO HIV/AIDS stage IV (70.2%) and those on ART (92%), though there were no statistically significant differences between groups with and without Leptospira antibodies. Conclusion: Our study confirmed that Leptospira antibodies are highly prevalent in PWH in Maputo; however, Leptospira infection was not associated with the degree of immunosuppression, WHO HIV/AIDS clinical stage, or the use of ART. Our data support the need for routine screening for leptospirosis in PWH in Mozambique. Future studies are warranted to characterize the incidence and outcomes of symptomatic leptospirosis in this patient population and to identify circulating serovars and species in the country and region, as well as the implicated reservoirs.

RTS,S/AS02A Malaria Vaccine-Induced IgG Responses Equally Recognize Native-Like Fucosylated and Nonfucosylated Plasmodium falciparum Circumsporozoite Proteins.

The RTS,S/AS02A malaria vaccine is based on the Plasmodium falciparum circumsporozoite protein (PfCSP), which is O-fucosylated on the sporozoite surface. We determined whether RTS,S/AS02A-induced immunoglobulin G (IgG) antibodies recognize vaccine-like nonfucosylated PfCSP better than native-like fucosylated PfCSP. Similar to previous vaccine trials, RTS,S/AS02A vaccination induced high anti-PfCSP IgG levels associated with malaria protection. IgG recognition of nonfucosylated and fucosylated PfCSP was equivalent, suggesting that PfCSP fucosylation does not affect antibody recognition. Clinical Trials Registration. NCT00197041.

Communication strategies used by medical physicians when delivering bad news at the Maputo Central Hospital, Mozambique: a cross-sectional study.

BACKGROUND: Physicians' communication with patients and their families is important during both the disease diagnosis and prognosis stages and through the follow-up process. Effective physician communication improves patients' quality of life and satisfaction with care and helps reduce suffering for those newly diagnosed with advanced progressive illnesses. This study aims to identify the communication strategies physicians use in the transition to palliative care and how these professionals perceive their academic and clinical preparation concerning this task. METHODS: A cross-sectional and quantitative study. Physicians providing palliative care at the Maputo Central Hospital, Mozambique, were invited to complete a 17-question questionnaire. This questionnaire was based on a Brazilian adaptation of the Setting-Perception-Invitation-Knowledge-Emotions-Strategy (SPIKES) tool, the P-A-C-I-E-N-T-E protocol, with additional questions regarding socio-demographic details and the integration of "communication of bad news" into hospital training. RESULTS: Of the 121 participants, 62 (51.2%) were male, and 110 (90.9%) were general practitioners, with a median age of 36 years old. They had worked in clinical practice for a median of 8 years and in their current department for three years. The majority of the participants considered that they have an acceptable or good level of bad news communication skills and believed that they do it in a clear and empathic way, paying attention to the patient's requests and doubts; however, most were not aware of the existing tools to assist them in this task and suggested that delivering bad news ought to be integrated into the undergraduate medical course and included in hospital training. CONCLUSIONS: This study adds to our understanding of physicians' strategies when communicating bad news in the context of palliative care at one Mozambique hospital. As palliative care is not fully implemented in Mozambique, it is important to use protocols suitable to the country's healthcare level to improve how doctors deal with patients and their family members.

First-Line Antituberculosis Drug Concentrations in Infants With HIV and a History of Recent Admission With Severe Pneumonia.

Optimal antituberculosis therapy is essential for favorable clinical outcomes. Peak plasma concentrations of first-line antituberculosis drugs in infants with living HIV receiving WHO-recommended dosing were low compared with reference values for adults, supporting studies on increased doses of first-line TB drugs in infants.

Polyclonal Multidrug ESBL-Producing Klebsiella pneumoniae and Emergence of Susceptible Hypervirulent Klebsiella pneumoniae ST23 Isolates in Mozambique.

Globally, antibiotic-resistant Klebsiella spp. cause healthcare-associated infections with high mortality rates, and the rise of hypervirulent Klebsiella pneumoniae (hvKp) poses a significant threat to human health linked to community-acquired infections and increasing non-susceptibility. We investigated the phenotypic and genetic features of 36 Klebsiella isolates recovered from invasive infections at Hospital Central of Maputo in Mozambique during one year. The majority of the isolates displayed multidrug resistance (MDR) (29/36) to cephalosporins, gentamicin, ciprofloxacin, and trimethoprim-sulfamethoxazole but retained susceptibility to amikacin, carbapenems, and colistin. Most isolates were ESBLs-producing (28/36), predominantly carrying the blaCTX-M-15 and other beta-lactamase genes (blaSHV, blaTEM-1, and blaOXA-1). Among the 16 genomes sequenced, multiple resistance genes from different antibiotic classes were identified, with blaCTX-M-15, mostly in the ISEcp1-blaCTX-M-15-orf477 genetic environment, co-existing with blaTEM-1 and aac(3)-IIa in five isolates. Our results highlight the presence of polyclonal MDR ESBL-producing K. pneumoniae from eight sequence types (ST), mostly harbouring distinct yersiniabactin within the conjugative integrative element (ICE). Further, we identified susceptible hvKp ST23, O1-K1-type isolates carrying yersiniabactin (ybt1/ICEKp10), colibactin, salmochelin, aerobactin, and hypermucoid locus (rmpADC), associated with severe infections in humans. These findings are worrying and underline the importance of implementing surveillance strategies to avoid the risk of the emergence of the most threatening MDR hvKp.

Molecular detection of Helicobacter pylori and its genotypic antimicrobial resistance patterns in dyspeptic Mozambican patients.

BACKGROUND: Helicobacter pylori strains show a high level of genotypic diversity and express several genes that contribute to their pathogenicity and resistance. In Mozambique, there is lack of information regarding its resistance pattern to antibiotics. In this study, we aimed to investigate the prevalence of H. pylori and its genotypic resistance to clarithromycin, metronidazole, and fluoroquinolones in Mozambican dyspeptic patients. Since appropriate eradication should be based on the local resistance rate, our data will guide clinicians in choosing the best drugs for the effective treatment of H. pylori-infected patients. METHODS: This is a cross-sectional descriptive study conducted between June 2017 and June 2020, in which 171 dyspeptic patients were recruited, and through upper gastrointestinal endoscopy, gastric biopsies were collected from those patients. Polymerase chain reaction was performed for the detection of H. pylori and its resistance mechanisms to clarithromycin (23S rRNA), metronidazole (rdxA), and fluoroquinolones (gyrA); mutations conferring resistance to these antibiotics were investigated by sequencing 23S rRNA, rdxA, and gyrA genes. RESULTS: Of the 171 samples tested, H. pylori was detected in 56.1% (96/171). The clarithromycin resistance rate was 10.4% (the responsible mutations were A2142G and A2143G), the metronidazole resistance rate was 55.2% (4 types of mutations responsible for metronidazole resistance were identified which include, D59N, R90K, H97T, and A118T. However, in many cases, they appeared in combination, with D59N + R90K + A118T being the most frequent combination), and the fluoroquinolones resistance rate was 20% (the responsible mutations were N87I and D91G). CONCLUSION: H. pylori infection remains common in dyspeptic Mozambican patients. High resistance to metronidazole and fluoroquinolones requires continuous monitoring of antibiotic resistance and adaptation of therapy to eradicate this infection.

Diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa: a continent-wide survey.

BACKGROUND: Fungal infections are common causes of death and morbidity in those with advanced HIV infection. Data on access to diagnostic tests in Africa are scarce. We aimed to evaluate the diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa. METHODS: We did a continent-wide survey by collecting data from 48 of 49 target countries across Africa with a population of more than 1 million; for Lesotho, only information on the provision of cryptococcal antigen testing was obtained. This survey covered 99·65% of the African population. We did the survey in six stages: first, questionnaire development, adaptation, and improvement; second, questionnaire completion by in-country respondents; third, questionnaire review and data analysis followed by video conference calls with respondents; fourth, external validation from public or private sources; fifth, country validation by video conference with senior figures in the Ministry of Health; and sixth, through five regional webinars led by the Africa Centres for Disease Control and Prevention with individual country profiles exchanged by email. Data was compiled and visualised using the Quantum Geographic Information System software and Natural Earth vectors to design maps showing access. FINDINGS: Data were collected between Oct 1, 2020, and Oct 31, 2022 in the 48 target countries. We found that cryptococcal antigen testing is frequently accessible to 358·39 million (25·5%) people in 14 African countries. Over 1031·49 million (73·3%) of 1·4 billion African people have access to a lumbar puncture. India ink microscopy is frequently accessible to 471·03 million (33·5%) people in 23 African countries. About 1041·62 million (74·0%) and 1105·11 million (78·5%) people in Africa do not have access to histoplasmosis and Pneumocystis pneumonia diagnostics in either private or public facilities, respectively. Fungal culture is available in 41 countries covering a population of 1·289 billion (94%) people in Africa. MRI is routinely accessible to 453·59 million (32·2%) people in Africa and occasionally to 390·58 million (27·8%) people. There was a moderate correlation between antiretroviral therapy usage and external expenditure on HIV care (R2=0·42) but almost none between external expenditure and AIDS death rate (R2=0·18), when analysed for 40 African countries. INTERPRETATION: This survey highlights the enormous challenges in the diagnosis of HIV-associated Pneumocystis pneumonia, cryptococcal disease, histoplasmosis, and other fungal infections in Africa. Urgent political and global health leadership could improve the diagnosis of fungal infections in Africa, reducing avoidable deaths. FUNDING: Global Action For Fungal Infections.

A systematic review and meta-analysis of the epidemiology of Leptospirosis in HIV uninfected and in people living with HIV from the Southern African Development Community.

BACKGROUND: Leptospirosis is an occupational, neglected febrile disease of bacterial origin transmitted between humans and animals. In this manuscript we summarize available data on Leptospira infection in HIV uninfected and in people living with HIV from the Southern African Development Community (SADC) countries, identifying gaps in knowledge and recommend future research priorities. METHODOLOGY: Articles published between 1990 and 2021 were accessed by an online search of Google Scholar and Medline/PubMed performed between February 2020 and July 2022. The STATA program was used for the Meta-analysis. Pooled prevalence values with 95% confidence intervals and heterogeneity were determined. RESULTS: Thirty studies from eight SADC countries, reporting the prevalence on Leptospira were reviewed. A pooled prevalence of 19% (CI: 13-25%), a heterogeneity level of 96% and index score ranging from 2 to 9 was determined. Only four (4) studies reported HIV co-infection status. Three species of Leptospira (Leptospira interrogans (4), L. kirschneri (3), Leptospira borgpetersenii (1) and 23 serogroups were identified. The most frequently reported serogroups were Icterohaemorrhagiae (13), Grippotyphosa and Australis (10) followed by Sejroe (8). CONCLUSION: Studies on human leptospirosis in the SADC region are scarce, especially in people living with HIV. Additional studies aimed at determining the prevalence and the role of the pathogen in people living with HIV, including detailed clinical, molecular and demographic data are recommended.

Environmental bacterial and fungal contamination in high touch surfaces and indoor air of a paediatric intensive care unit in Maputo Central Hospital, Mozambique in 2018.

Background: The hospital environment serves as a reservoir of microorganisms which may be associated with healthcare-associated infections (HCAI). The study of environmental contamination with microorganisms is a method for the assessment of hospital environmental hygiene. We sought to evaluate the environmental colonisation of a national reference hospital unit, using the total aerobic colony count (ACC) and the isolated microorganisms, as assessment tools. Methods: A cross-sectional study was conducted in the Paediatric Intensive Care Unit (PICU) of the Hospital Central de Maputo during a four-week period in 2018. Surfaces and air were sampled before and after room cleaning, using swabs and passive air method. Those samples were processed at the microbiology laboratory where total ACC levels were evaluated, and microorganisms were isolated, identified and assessed for antibiotic susceptibility. Discussion: Comparison of the total median ACC of the indoor air (287 cfu/m3 before and 195 cfu/m3 after) and surfaces (0.38 cfu/cm2 before and 0.33 cfu/cm2 after) before and after room cleaning did not show significant differences (P>0.05). Microorganisms of epidemiological importance, including coagulase negative staphylococci (CoNS), Klebsiella pneumoniae and Serratia odorifera were isolated and all of these three were multi-drug resistant (MDR). Conclusion: The results showed controlled contamination levels on high touch surfaces in the patient environment and a high level of contamination of the indoor air suggesting deficiencies in the PICU environmental decontamination process. There was evidence of the presence of fungi and MDR species of epidemiological importance in the context of HCAI.

Evaluation of the Mozambique Antiretroviral Therapy (MozART) database as an antiretroviral therapy patient surveillance system, 2017-2018.

Introduction: Mozambique antiretroviral therapy is a database used to monitor patients receiving antiretroviral treatment (ART). This study's objective was to evaluate the system for the purpose to monitor patients receiving ART. Methods: data from 287,052 patients who started ART from January to December 2017 were verified, and retention in care was assessed for 2018 in Mozambique. The Centers for Disease Control and Prevention guidelines for evaluating public health surveillance systems were used to conduct the evaluation. Simplicity, flexibility, data quality, representativeness and stability attributes were evaluated. Results: a total of 93% (266,880/287,052) of patients on ART were adults ≥15 years old, and 65% (186,677/287,052) were female. The system was complex, it involved four organisations and its management was online. Data quality was moderate with 19% (1,533,885/8,037,456) of empty variable fields, 0.04% (123/287,052) observations with birth date later than the initial ART date, 0.2% (424/287,052) and 23% (68,039/287,052) with initial ART date and diagnosis date, later than the next ART pickup date. Nationally, 19%(31/161) of the districts did not have data in the information system. MozART cover health facilities with electronic patient tracking systems. Hence did not represent all patients on ART. While it was not possible to add variables of the electronic patient tracking, the system was stable as neither data or server interruptions were reported. Conclusion: the system was useful, stable, with moderate data quality, complex, not flexible and not representative. We recommend to health facilities and partners to develop and distribute procedures for data validation and completeness and report all patient tracking variables in the system.

Induction, decay, and determinants of functional antibodies following vaccination with the RTS,S malaria vaccine in young children.

BACKGROUND: RTS,S is the first malaria vaccine recommended for implementation among young children at risk. However, vaccine efficacy is modest and short-lived. Antibodies play the major role in vaccine-induced immunity, but knowledge on the induction, decay, and determinants of antibody function is limited, especially among children. Antibodies that promote opsonic phagocytosis and other cellular functions appear to be important contributors to RTS,S immunity. METHODS: We studied a phase IIb trial of RTS,S/AS02 conducted in young children in malaria-endemic regions of Mozambique. We evaluated the induction of antibodies targeting the circumsporozoite protein (CSP, vaccine antigen) that interact with Fcγ-receptors (FcRγs) and promote phagocytosis (neutrophils, monocytes, THP-1 cells), antibody-dependent respiratory burst (ADRB) by neutrophils, and natural killer (NK) cell activity, as well as the temporal kinetics of responses over 5 years of follow-up (ClinicalTrials.gov registry number NCT00197041). RESULTS: RTS,S vaccination induced CSP-specific IgG with FcγRIIa and FcγRIII binding activity and promoted phagocytosis by neutrophils, THP-1 monocytes, and primary human monocytes, neutrophil ADRB activity, and NK cell activation. Responses were highly heterogenous among children, and the magnitude of neutrophil phagocytosis by antibodies was relatively modest, which may reflect modest vaccine efficacy. Induction of functional antibodies was lower among children with higher malaria exposure. Functional antibody magnitude and the functional activity of antibodies largely declined within a year post-vaccination, and decay were highest in the first 6 months, consistent with the decline in vaccine efficacy over that time. Decay rates varied for different antibody parameters and decay was slower for neutrophil phagocytosis. Biostatistical modelling suggested IgG1 and IgG3 contribute in promoting FcγR binding and phagocytosis, and IgG targeting the NANP-repeat and C-terminal regions CSP were similarly important for functional activities. CONCLUSIONS: Results provide new insights to understand the modest and time-limited efficacy of RTS,S in children and the induction of antibody functional activities. Improving the induction and maintenance of antibodies that promote phagocytosis and cellular functions, and combating the negative effect of malaria exposure on vaccine responses are potential strategies for improving RTS,S efficacy and longevity.

High-risk lineages among extended-spectrum ß-lactamase-producing Escherichia coli from extraintestinal infections in Maputo Central Hospital, Mozambique.

Extended-spectrum ß-lactamase (ESBL)-producing extraintestinal pathogenic Escherichia coli (ExPEC), particularly high-risk lineages, are responsible for severe infections and increased mortality and hospital costs worldwide, with a major burden in low-income countries. Here we determined the antimicrobial susceptibility and performed whole-genome sequencing of E. coli isolates from extraintestinal infections of patients during 2017-2018 at Maputo Central Hospital (Mozambique). Multidrug resistance was displayed by 71% of isolates (17/24). All isolates resistant to cefotaxime and ceftazidime were positive for ESBL genes (16/24; 67%) and were co-resistant to amoxicillin/clavulanate (14/16; 88%), piperacillin/tazobactam (8/16; 50%), gentamicin (12/16; 75%), trimethoprim/sulfamethoxazole (15/16; 94%) and ciprofloxacin (11/16; 69%). Several major high-risk ExPEC lineages were identified, such as H30Rx-ST131, fimH41-ST131, H24Rx-ST410, ST617, ST361 and ST69 harbouring blaCTX-M-15, and H30R-ST131, ST38 and ST457 carrying blaCTX-M-27. Dissemination of CTX-M transposition units (ISEcp1-blaCTX-M-15-orf477 and ISEcp1-blaCTX-M-27-IS903B) among different sequence types could be occurring through the mobility of IncF plasmids. Additionally, all H24Rx-ST410 isolates carried ISEcp1-mediated blaCMY-2 AmpC and specific mutations in PBP3/OmpC proteins, potentially contributing to carbapenem resistance even in the absence of carbapenemase genes. Genome analysis highlighted a high assortment of ExPEC/UPEC virulence-associated genes mainly involved in adhesion, invasion, iron uptake and secretory systems among isolates, and an ExPEC/EAEC hybrid pathotype (fimH27-ST131_O18-ac:H4) showing the highest virulence gene content. cgMLST showed clonality and closely related isolates, particularly among ST131 and ST410, suggesting hospital-acquired infections and long-term ward persistence. Our study provides new insights into ExPEC clones, urging measures to prevent and contain their diffusion in this hospital and Mozambique.

Coping Strategies Used by Patients After Diagnosis Disclosure in the Transition to Palliative Care: A Cross-Sectional Study.

Objectives: The objectives of this study were to identify the coping strategies used by cancer and non-cancer patients with palliative needs, and to verify if there were differences in the coping strategies adopted between sociodemographic groups. Methods: This is a cross-sectional study carried out from September to November 2019, at Maputo Central Hospital, in the units of Medicine, Surgery, Orthopedics, Gynecology and Obstetrics. Eligible patients (n = 94) were included in the study and answered a self-completion scale adapted from the Coping Strategies Inventory by Folkman and Lazarus together with a sociodemographic questionnaire. Results: Our study demonstrates that the most used coping strategies were Social Support, followed by Planful Problem Solving, Escape-Avoidance, and Positive Reappraisal strategies. In addition, significant differences were observed between religious beliefs, with Christians resorting more to coping strategies related to Social Support, Accepting Responsibility and Escape-Avoidance than Evangelicals, and between different levels of education, with greater resort to Social Support, Accepting Responsibility, Planful Problem Solving, and Positive Reappraisal in patients with high education. Conclusions: The results indicate that most of the respondents in this study used more adaptive coping strategies, such as Social Support and Positive Reappraisal, and less avoidant strategies, such as Distancing and Confrontation. There is a need to reinforce positive strategies from health professionals to increase satisfaction, autonomy, and promote patient's quality of life.

Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study.

BACKGROUND: Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique. METHODS: Prospective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women-up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance). RESULTS: We included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups. CONCLUSION: The prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of  COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

Evaluation of the multidrug-resistant tuberculosis surveillance system in Maputo City, Mozambique in the period 2017-2018.

Introduction: multidrug-resistant tuberculosis (MDR-TB) remains a public health problem worldwide. In Mozambique, cases of MDR-TB have increased annually. In 2018, 1,206 cases were reported, as compared to 943 cases in 2017. The aim of this study was to assess the surveillance system for multidrug-resistant tuberculosis in Maputo City. Methods: an extract from the national database was considered for a cut-out of the City of Maputo in the period 2017-2018; the study was conducted per the guidelines of the Centers for Disease Control and Prevention, where the description of the system was carried out, and evaluation of the attributes. Each attribute was evaluated according to the established criteria and parameters. Results: the surveillance system is based on the collection of data in health centers. Four hundred and six cases of MDR-TB were notified, of which 56.8% (231/406) were male and 95.9% (386/406) were ≥15 years. The system was complex with 4 levels of information transmission. With regard to flexibility, there was no changing the variables in the database. Acceptability was good. The quality of the data was regular with discrepancy of data of 14.5%. The system was considered stable as there was no system interruption. Timeliness with case notification monthly. The system sensitivity was 72.9%, the positive predictive value (PPV) was 2.3% and regarding utility the system has fulfilled its objectives. Conclusion: the system was not flexible, the data quality was regular, had moderate sensitivity and low positive predictive value. Continuous assessment of data and scale up the diagnosis for the detection of cases of MDR-TB is recommended.

Empirical treatment against cytomegalovirus and tuberculosis in HIV-infected infants with severe pneumonia: study protocol for a multicenter, open-label randomized controlled clinical trial.

BACKGROUND: Pneumonia is the primary cause of death among HIV-infected children in Africa, with mortality rates as high as 35-40% in infants hospitalized with severe pneumonia. Bacterial pathogens and Pneumocystis jirovecii are well known causes of pneumonia-related death, but other important causes such as cytomegalovirus (CMV) and tuberculosis (TB) remain under-recognized and undertreated. The immune response elicited by CMV may be associated with the risk of developing TB and TB disease progression, and CMV may accelerate disease caused both by HIV and TB. Minimally invasive autopsies confirm that CMV and TB are unrecognized causes of death in children with HIV. CMV and TB may also co-infect the same child. The aim of this study is to compare the impact on 15-day and 1-year mortality of empirical treatment against TB and CMV plus standard of care (SoC) versus SoC in HIV-infected infants with severe pneumonia. METHODS: This is a Phase II-III, open-label randomized factorial (2 × 2) clinical trial, conducted in six African countries. The trial has four arms. Infants from 28 to 365 days of age HIV-infected and hospitalized with severe pneumonia will be randomized (1:1:1:1) to (i) SoC, (ii) valganciclovir, (iii) TB-T, and (iv) TB-T plus valganciclovir. The primary endpoint of the study is all-cause mortality, focusing on the short-term (up to 15 days) and long-term (up to 1 year) mortality. Secondary endpoints include repeat hospitalization, duration of oxygen therapy during initial admission, severe and notable adverse events, adverse reactions, CMV and TB prevalence at enrolment, TB incidence, CMV viral load reduction, and evaluation of diagnostic tests such as GeneXpert Ultra on fecal and nasopharyngeal aspirate samples and urine TB-LAM. DISCUSSION: Given the challenges in diagnosing CMV and TB in children and results from previous autopsy studies that show high rates of poly-infection in HIV-infected infants with respiratory disease, this study aims to evaluate a new approach including empirical treatment of CMV and TB for this patient population. The potential downsides of empirical treatment of these conditions include toxicity and medication interactions, which will be evaluated with pharmacokinetics sub-studies. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03915366, Universal Trial Number U111-1231-4736, Pan African Clinical Trial Registry PACTR201994797961340.

Demographic, endoscopic and histological profile of esophageal cancer at the Gastroenterology Department of Maputo Central Hospital from January 2016 to December 2018.

Introduction: esophageal cancer is a major public health problem in Mozambique. It is the nineth most common cancer worldwide in terms of incidence (604.000 new cases/year), and sixth in overall mortality (544.076 deaths/year). In Mozambique esophageal cancer was the seventh most common cancer in males and the fifth in females between 1991 and 2008. Methods: it was done a cross-sectional hospital-based epidemiological study, using secondary demographics endoscopic and pathologic features data. A retrospective analysis of the existing information of patients classified as esophageal cancer diagnosed with upper gastrointestinal endoscopy observed from January 1st, 2016 to December 31st, 2018 at the Gastroenterology Service of Maputo Central Hospital. A coding sheet was created a priori, and data analysed in SPSS version 20. Results: of the 205 cases with complete records where included in the analysis, there was a higher frequency of females with 56.6% (116/205). The average age was 59.5 years with standard deviation of ± 12.9 years. Most of the patients were native of southern Mozambique, with 92.7% (190/205), of which Maputo made up 53.2% (109/205). Regarding race, 99.5% (204/205) were black. The most affected endoscopic location was the middle third with 48.8% (100/205), followed by the lower third with 29.8% (61/205) and the upper third with 21.5% (44/205). Squamous cell carcinoma was the most frequent, with 92.7% (190/205), followed by adenocarcinoma with 4.9% (10/205). Conclusion: due to the high number of observed cases of esophageal cancer, a high degree of clinical suspicion is needed for timely diagnosis and more effective treatment. Updated prevalent studies are needed throughout the country to understand the true impact of esophageal cancer on the Mozambican population.

Evaluation of the HIV drug resistance surveillance system in Mozambique, 2017-2018.

In the past ten years, the prevalence of primary Human Immunodeficiency Virus (HIV) drug resistance has ranged from zero to 25%, with higher and increasing rates in countries with access to antiretroviral therapy (ART), a specific case in Mozambique. World Health Organization (WHO) recommended that countries implement and routinely evaluate representative HIV drug resistance (HIVDR) research to monitor the emergency and transmission of HIV drug resistance mutations. This study aimed to describe the functioning of the system and also to identify gaps in the sensitivity, representativeness and quality of the data using the WHO methodology for Pre-Treatment and Acquired Approaches. We conducted a descriptive evaluation of the information system for surveillance of HIVDR in Mozambique in 2017-2018, based on updated guidelines for evaluating of public health surveillance systems from the Center for Disease Control and Prevention (CDC). The evaluation was conducted in all provinces using secondary data extracted from a cross-sectional survey database on HIVDR, with HIV positive cases at the beginning of ART aged ≥15 years. The system was described through informal conversations with HIVDR stakeholders and the simplicity, data quality and representativeness attributes were evaluated. With 322 positive cases at the beginning of ART (mean age=32.5 years, SD±11.1), about 63.0% (203/322) cases were women and 37.6% (121/322) men. The system was implemented in 25 health facilities distributed across all 11 Mozambican provinces and was considered representative. The system used two data collection instruments, the ART book and the form accompanying samples sent to the reference laboratory. The ART form, with 27 variables, was sent offline at two levels (health facility and National Institute of Health (NHI)), accompanied by dried blood spot samples for viral load testing and genotyping in the NHI virology laboratory, and was considered simple according to the standardized criteria. The system´s data quality was considered regular at 79.9%, with about 59.8% (1156/1932) of variable fields completed and 100% (1932/1932) consistency. The system used a single national laboratory to measure the prevalence of resistance to HIV drugs and was considered simple, with regular quality and representative data. We recommended public health efforts such as conducting genotyping tests be expanded to the provincial level, and periodic monitoring of system´s data collection procedures using forms.