Spatial distribution and determinants of tuberculosis incidence in Mozambique: A nationwide Bayesian disease mapping study.

INTRODUCTION: Mozambique is a high-burden country for tuberculosis (TB). International studies show that TB is a disease that tends to cluster in specific regions, and different risk factors (HIV prevalence, migration, overcrowding, poverty, house condition, temperature, altitude, undernutrition, urbanization, and inadequate access to TB diagnosis and treatment) are reported in the literature to be associated with TB incidence. Although Mozambique has a higher burden of TB, the spatial distribution, and determinants of TB incidence at the sub-national level have not been studied yet for the whole country. Therefore, we aimed to analyze the spatial distribution and determinants of tuberculosis incidence across all 154 districts of Mozambique and identify the hotspot areas. METHOD: We conducted an ecological study with the district as our unit of analysis, where we included all cases of tuberculosis diagnosed in Mozambique between 2016 and 2020. We obtained the data from the Mozambique Ministry of Health and other publicly available open sources. The predictor variables were selected based on the literature review and data availability at the district level in Mozambique. The parameters were estimated through Bayesian hierarchical Poisson regression models using Markov Chain Monte Carlo simulation. RESULTS: A total of 512 877 people were diagnosed with tuberculosis in Mozambique during our five-year study period. We found high variability in the spatial distribution of tuberculosis incidence across the country. Sixty-two districts out of 154 were identified as hotspot areas. The districts with the highest incidence rate were concentrated in the south and the country's central regions. In contrast, those with lower incidence rates were mainly in the north. In the multivariate analysis, we found that TB incidence was positively associated with the prevalence of HIV (RR: 1.23; 95 % CrI 1.13 to 1.34) and negatively associated with the annual average temperature (RR: 0.83; 95 % CrI 0.74 to 0.94). CONCLUSION: The incidence of tuberculosis is unevenly distributed across the country. Lower average temperature and high HIV prevalence seem to increase TB incidence. Targeting interventions in higher-risk areas and strengthening collaboration between HIV and TB programs is paramount to ending tuberculosis in Mozambique, as established by the WHO's End TB strategy and the Sustainable Development Goals.

Effect of decentralising childhood tuberculosis diagnosis to primary health centre versus district hospital levels on disease detection in children from six high tuberculosis incidence countries: an operational research, pre-post intervention study.

Background: Childhood tuberculosis (TB) remains underdiagnosed largely because of limited awareness and poor access to all or any of specimen collection, molecular testing, clinical evaluation, and chest radiography at low levels of care. Decentralising childhood TB diagnostics to district hospitals (DH) and primary health centres (PHC) could improve case detection. Methods: We conducted an operational research study using a pre-post intervention cross-sectional study design in 12 DHs and 47 PHCs of 12 districts across Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone and Uganda. The intervention included 1) a comprehensive diagnosis package at patient-level with tuberculosis screening for all sick children and young adolescents <15 years, and clinical evaluation, Xpert Ultra-testing on respiratory and stool samples, and chest radiography for children with presumptive TB, and 2) two decentralisation approaches (PHC-focused or DH-focused) to which districts were randomly allocated at country level. We collected aggregated and individual data. We compared the proportion of tuberculosis detection in children and young adolescents <15 years pre-intervention (01 August 2018-30 November 2019) versus during intervention (07 March 2020-30 September 2021), overall and by decentralisation approach. This study is registered with ClinicalTrials.gov, NCT04038632. Findings: TB was diagnosed in 217/255,512 (0.08%) children and young adolescent <15 years attending care pre-intervention versus 411/179,581 (0.23%) during intervention, (OR: 3.59 [95% CI 1.99-6.46], p-value<0.0001; p-value = 0.055 after correcting for over-dispersion). In DH-focused districts, TB diagnosis was 80/122,570 (0.07%) versus 302/86,186 (0.35%) (OR: 4.07 [1.86-8.90]; p-value = 0.0005; p-value = 0.12 after correcting for over-dispersion); and 137/132,942 (0.10%) versus 109/93,395 (0.11%) in PHC-focused districts, respectively (OR: 2.92 [1.25-6.81; p-value = 0.013; p-value = 0.26 after correcting for over-dispersion). Interpretation: Decentralising and strengthening childhood TB diagnosis at lower levels of care increases tuberculosis case detection but the difference was not statistically significant. Funding source: Unitaid, Grant number 2017-15-UBx-TB-SPEED.

Tobacco smoking clusters in households affected by tuberculosis in an individual participant data meta-analysis of national tuberculosis prevalence surveys: Time for household-wide interventions?

Tuberculosis (TB) and non-communicable diseases (NCD) share predisposing risk factors. TB-associated NCD might cluster within households affected with TB requiring shared prevention and care strategies. We conducted an individual participant data meta-analysis of national TB prevalence surveys to determine whether NCD cluster in members of households with TB. We identified eligible surveys that reported at least one NCD or NCD risk factor through the archive maintained by the World Health Organization and searching in Medline and Embase from 1 January 2000 to 10 August 2021, which was updated on 23 March 2023. We compared the prevalence of NCD and their risk factors between people who do not have TB living in households with at least one person with TB (members of households with TB), and members of households without TB. We included 16 surveys (n = 740,815) from Asia and Africa. In a multivariable model adjusted for age and gender, the odds of smoking was higher among members of households with TB (adjusted odds ratio (aOR) 1.23; 95% CI: 1.11-1.38), compared with members of households without TB. The analysis did not find a significant difference in the prevalence of alcohol drinking, diabetes, hypertension, or BMI between members of households with and without TB. Studies evaluating household-wide interventions for smoking to reduce its dual impact on TB and NCD may be warranted. Systematically screening for NCD using objective diagnostic methods is needed to understand the actual burden of NCD and inform comprehensive interventions.

Early effects of COVID-19 on maternal and child health service disruption in Mozambique

After the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths...

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

Barriers to access and adherence to tuberculosis services, as perceived by patients: A qualitative study in Mozambique

Tuberculosis (TB) continues to be a leading cause of death in Sub-Saharan Africa, including Mozambique. While diagnostic methods and total notifications are improving, significant gaps remain between total numbers of TB cases annually, and the number that are notified. The purpose of this study was to elicit Mozambican patients with drug sensitive TB (DS-TB), TB/HIV and Multi drug resistant tuberculosis (MDR-TB) understanding and assessment of the quality of care for DS-TB, HIV/TB and MDR-TB services in Mozambique, along with challenges to effectively preventing, diagnosing and treating TB. Materials and methods: Qualitative data was collected via separate focus group discussions consisting of patients with DS-TB, TB/HIV and MDR-TB at four health centers in Sofala and Manica Province, Mozambique, to describe knowledge on TB, HIV and MDR-TB, and identify barriers to access and adherence to services and their recommendations for improvement. A total of 51 patients participated in 11 discussions. Content analysis was done and main themes were identified. Results: Focus groups shared a number of prominent themes. Respondents identified numerous challenges including delays in diagnosis, stigma related with diagnosis and treatment, long waits at health facilities, the absence of nutritional support for patients with TB, the absence of a comprehensive psychosocial support program, and the lack of overall knowledge about TB or multi drug resistant TB in the community. Discussion: TB patients in central Mozambique identified many challenges to effectively preventing, diagnosing and treating tuberculosis. Awareness strengthening in the community, continuous quality monitoring and in-service training is needed to increase screening, diagnosis and treatment for TB, HIV/TB and MDR-TB

Seroepidemiologic Screening for Zoonotic Viral Infections, Maputo, Mozambique

In sub-Saharan Africa, febrile patients are often assumed to have, and are treated for, malaria, but when tested, many are malaria-negative. Because emerging diseases, such as chikungunya virus (CHIKV) and dengue virus (DENV) infections, cause outbreaks around the world (1­3), the importance of these pathogens has become more evident. However, low-income countries have limited epidemiologic data on alternative diagnoses to malaria (4,5) and poor laboratory capacity (1), which restrict further diagnostic investigations. An early study in Mozambique during the 1980s found antibodies to Rift Valley fever virus (RVFV) in 2% of pregnant women (6). More recently, a RVFV seroprevalence of 36.9% among cattle in the Maputo Province was shown in 2010­2011 (7). Furthermore, the movement of humans from rural areas to major cities, particularly to the capital of Maputo, might affect human illnesses and disease pattern of zoonotic viruses (3). We conducted a pilot study on CHIKV, DENV, hantavirus, RVFV, and West Nile virus (WNV) epidemiology in Mozambique. Ethical approval (registration no. IRB00002657) was granted by the National Bioethics Committee in Mozambique and by the Regional Ethical Review Board at Karolinska Institutet, Stockholm, Sweden (permit no. 2012/974­31/3)...

High tuberculosis burden among people living with HIV in southern Mozambique

Tuberculosis (TB) remains an important public health concern, and a leading cause of disease and death worldwide. Mozambique is one of the few high TB burden countries where TB figures have not improved in recent years, with an estimated TB incidence in 2013 of 552 cases per 100 000 population [1]. With 58% of all notified TB cases being HIV-positive, Mozambique also has one of the highest TB/HIV co-infection rates. Published data on the burden of TB or HIV disease in the country are scarce, and improving epidemiological surveillance has been identified as an urgent step to improve TB control [2]. People living with HIV (PLHIV) are at a higher risk of developing active TB, which is the main cause of death among this population, accounting for 26% of AIDS-related deaths [3, 4]. It has been estimated that in the African region, 31% of new TB cases in adults were attributable to HIV infection [5]. Most TB incidence measurements among HIV patients come from HIV cohorts [6, 7], clinical trials or mathematical modelling using various strategies described elsewhere [1]. Very few settings, especially in sub-Saharan Africa, provide population-level estimates of TB risk among PLHIV [8, 9]. We determined the incidence rate of TB among HIV-positive and ­negative individuals during 2011 in a high HIV burden setting in southern Mozambique. The study was conducted at the Manhiça Health Research Centre (CISM), located in the rural district of Manhiça, southern Mozambique [10]. This retrospective, population-based epidemiological analysis used three data sources: TB notification data were obtained from the 2011 registries of the National TB Control Program for the District of Manhiça, based on passive surveillance; the population at risk was calculated from the latest official census data (2007) for the District of Manhiça, obtained through the Mozambican National Statistics Institute, and the estimated population growth for 2007­2011, using annual data from CISM's Demographic Surveillance System; and HIV prevalence in the district population was estimated using community-based HIV seroprevalence data from a survey conducted in 2010 [11], which only included adults aged 18­47 years...

Assessment of measles immunity among infants in maputo city, mozambique

Background: The optimum age for measles vaccination varies from country to country and thus a standardized vaccination schedule is controversial. While the increase in measles vaccination coverage has produced significant changes in the epidemiology of infection, vaccination schedules have not been adjusted. Instead, measures to cut wild-type virus transmission through mass vaccination campaigns have been instituted. This study estimates the presence of measles antibodies among six- and nine-month-old children and assesses the current vaccination seroconversion by using a non invasive method in Maputo City, Mozambique. Methods: Six- and nine-month old children and their mothers were screened in a cross-sectional study for measles-specific antibodies in oral fluid. All vaccinated children were invited for a follow up visit 15 days after immunization to assess seroconversion. Results: 82.4% of the children lost maternal antibodies by six months. Most children were antibody-positive post-vaccination at nine months, although 30.5 % of nine month old children had antibodies in oral fluid before vaccination. We suggest that these pre-vaccination antibodies are due to contact with wild-type of measles virus. The observed seroconversion rate after vaccination was 84.2%. Conclusion: These data indicate a need to re-evaluate the effectiveness of the measles immunization policy in the current epidemiological scenario.

Manual para o manejo da tuberculose na criança, no adolescente e na mulher grávida / Manual for the Management of Tuberculosis in Children, Adolescents and Pregnant Women

Estima-se que um terço da população mundial esteja infectada pelo Mycobacterium tuberculosis. Segundo a Organização Mundial de Saúde (OMS) em 2017, 10 milhões de pessoas de todas idades contraíram a Tuberculose (TB) no mundo, sendo que 1 milhão de casos afectaram crianças dos 0-14 anos e destes 52% ocorreram em crianças menores de 5 anos. Ainda em 2017, a TB foi uma das 10 principais causas de morte a nível global tendo causado 1,6 milhões de mortes. Em crianças a TB causou cerca de 233 000 mortes sendo 82% em menores de 5 anos e 39 000 (17%) em crianças vivendo com HIV. Do total das mortes, 95% ocorreu em crianças que não tiveram acesso ao tratamento. No mesmo ano cerca de 75% (de 1,3 milhões) dos contatos domiciliares de pacientes com TB elegíveis (menores de 5 anos) não tiveram acesso ao Tratamento Preventivo de Tuberculose...

Manual de manejo Clínico e programático da tuberculose multirresistente / Clinical and programmatic management manual for multidrug-resistant tuberculosis

O surgimento de resistência aos fármacos usados para tratar a tuberculose (TB), particularmente a Tuberculose Multirresistente (TB-MR), tornou-se um problema de saúde pública em vários países e, um sério obstáculo na luta contra Tuberculose, razão pela qual a OMS recomenda desde o ano 2000 uma abordagem clínica e programática da TB-MR . Naquela época, o Green Light Commitee (GLC) foi estabelecido para promover o acesso a serviços de medicamentos da segunda linha de alta qualidade para uso adequado em programas de TB. Em 2002, o Fundo Global de Combate à SIDA, TB e Malária começou a financiar programas de controlo de TB, incluindo TB Multirresistente, reduzindo assim a barreira económica para a implementação dos serviços de TB Multirresistente. Desde então, os serviços Gestão Programática da Tuberculose Multirresistente (PMDT) expandiram-se rapidamente. Com base nos dados e na experiência desses projectos e práticas, a evidência científica continua a evoluir no que diz respeito aos serviços de TB-R.

Relatório da avaliação conjunta do plano estratégico e operacional, do programa nacional de controlo da tuberculose 2014-2018, do plano estratégico nacional de resposta ao hiv e sida 2016-2020 e do estabelecimento da linha de base das hepatites virais em moçambique / Report of the joint evaluation of the strategic and operational plan, the national tuberculosis control program 2014-2018, the national strategic plan for the response to hiv and aids 2016-2020 and the establishment of the viral hepatitis baseline in mozambique

O MISAU e o CNCS encomendaram uma revisão externa conjunta dos planos estratégicos dos programas nacionais de contro de ITS/HIV/SIDA e da Tuberculose (TB) bem como o estabelecimento da linha de base da resposta as hepatites virais em Moçambique. Esta avaliação foi liderada pela Organização Mundial da Saúde (OMS) em coordenação com o Ministério da Saúde (MISAU) e o Conselho Nacional de Combate ao SIDA (CNCS) e com apoio financeiro do CDC. O principal objectivo desta revisão externa, era de avaliar a Resposta Nacional às epidemias de HIV e da TB bem como o estado da resposta as hepatites virais, em direcção as metas de 2020. Com foco no Plano Estratégico de resposta ao HIV/SIDA 2016-2020 (PEN IV) e no Plano Estratégico e Operacional do Programa Nacional de Controlo da Tuberculose (PNCT) 2014-2018, foram avaliados os progressos alcançados, identificados os desafios, e destacadas as boas práticas. A Revisão recomendou estratégias e abordagens operacionais para um maior e estável progresso, melhoria da qualidade e aumento da relação custo-benefício dos principais serviços de HIV, TB e hepatites virais.

First serological evidence of hantavirus among febrile patients in Mozambique Ramalho

Objective: The occurrence of hantavirus in Sub-Saharan Africa is poorly studied and its clinical implications are unknown. This study aimed to determine the occurrence of hantavirus infection among febrile patients attending an outpatient clinic at a primary health care center located in a suburban area of the city of Maputo in Mozambique. Methods: Paired acute and convalescent samples from a total of 200 febrile patients aged >5 years who were recruited between February 2012 and October 2014 were screened for IgM and IgG antibodies against hantavirus using an ELISA. Acute samples were also screened for malaria and to determine hematological and clinical chemistry parameters. Results: Of the 200 patients enrolled, four had IgM antibodies in their acute sample and IgG antibodies in their convalescent sample, yielding a prevalence rate of 2%. Contact with rodents was higher among IgM-positive participants than IgM-negative participants (50.0% (2/4) vs. 15.3% (30/196)). IgM-positive patients presented significantly higher levels of creatinine and alanine aminotransferase and lower platelet counts than IgM-negative patients. Conclusions: The findings of this study demonstrate human exposure to hantavirus in Mozambique for the first time; however, further studies should be conducted to investigate its clinical implications. © 2017 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-

Seroprevalência do Vírus Linfotrópico T Humano Tipo I (HTLV-I) em Crianças Moçambicanas HIV 1/2 Seropositivas / Seroprevalence of Human T lymphotropic virus type I (HTLV-I) in Children Mozambican HIV 1/2 HIV-positive

Introdução: Estudos recentes realizados em Moçambique mostraram que a prevalência da coinfecção HIV/HTLV-I em pacientes adultos infetados pelo HIV é de 4.5 por cento e que a mesma cursa com dissociação entre os parâmetros clínicos e imunológicos. No entanto, até a data, não existem dados sobre a prevalência e características clínico-laboratoriais da coinfecção HIV/HTLV-I na população pediátrica, em Moçambique. Objetivo: Determinar a seroprevalência e características clínico-laboratoriais da infeção por HTLV-1 em crianças moçambicanas seropositivas para o HIV atendidas em Unidades Sanitárias da Cidade de Maputo. Métodos: Entre Novembro de 2010 e Agosto de 2011, foram estudadas de forma consecutiva, 945 crianças infetadas pelo HIV, atendidas na consulta da criança em risco (CCR) em 3 Unidades Sanitárias da Cidade de Maputo, para o rastreio da infeção pelo HTLV-I, contagem de células T CD4+ e determinação dos parâmetros hematológicos. Cada criança com coinfecção HIV/HTLV-I foi pareada com duas crianças com monoinfeção por HIV de acordo com a idade, o sexo e estadiamento clínico do HIV (OMS) para comparação de parâmetros clínicos e epidemiológicos...

Resultados: Foram recrutadas para o estudo 945 crianças, das quais 37 (3,9 por cento; IC: 2.8 - 5.4 por cento) foram positivas para o HTLV-I. A mediana da idade foi de 6 anos [Intervalo Interquartil (IQR): 4 - 9]. Não houve diferença significativa entre crianças mono e co-infectadas em relação à idade, sexo, parâmetros hematológicos, estadiamento da infecção pelo HIV e uso de antirretrovirais. Na análise dos casos pareados não foram observadas diferenças significativas entre os dois grupos relacionadas a dados epidemiológicos e clínicos. Nenhuma das crianças coinfectadas tinha manifestações clínicas do HTLV-I e apenas 4/37 apresentaram carga próviral detectável. Discussão: Nossos dados demonstram que a infecção pelo HTLV-I circula também em crianças infectadas pelo HIV em Moçambique e que a contagem de células CD4 em sangue periférico não foi alterada na coinfecção na população estudada. Estes resultados são importantes para o desenho e implementação de novas estratégias para prevenção da transmissão vertical do HTLV-I, bem como para o manuseio clínico das crianças infetadas pelo HTLV-I em Moçambique...