SARS-CoV-2 in Mozambican primary school-aged children at Maputo City and Province: a cross-sectional study from a low-income country.

BACKGROUND: Seroprevalence studies provide information on the true extent of infection and capture demographic and geographic differences, indicating the level of immunity against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We sought to provide local evidence of SARS-CoV-2 exposure in school-aged children during in-class teaching in Maputo City and Province, Mozambique. METHODS: Between August and November 2022, we performed a cross-sectional study in school-aged children in four schools in rural, peri-urban, and urban areas of Maputo City and Province. A point-of-care test was used to evaluate SARS-CoV-2 antigens and anti-SARS-CoV-2-specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. Descriptive statistics were used to estimate the prevalence of the antigens and antibodies. Multiple logistic regression models were used to estimate the adjusted odds ratio (AOR) for the factors associated with anti-SARS-CoV-2 antibodies. RESULTS: A total of 736 school-aged children were analyzed. The prevalence of the SARS-CoV-2 antigen was 0.5% (4/736). The prevalence of SARS-CoV-2 antigens was 0.0% (0/245), 0.8% (2/240) and 0.8% (2/251), in the rural, peri-urban and urban areas respectively. The overall seroprevalence of the anti-SARS-CoV-2 antibodies (IgG or IgM) was 80.7% (594/736). In rural area anti-SARS-CoV-2 IgG or IgM antibodies were detected in 76.7% (188/245), while in peri-urban area they were detected in 80.0% (192/240) and in urban area they were detected in 85.3% (214/251). In the adjusted logistic regression model, school-aged children from the urban area were more likely to have anti-SARS-CoV-2 IgG or IgM antibodies than were school-aged children from the rural area (adjusted odds ratio: 1.679; 95% CI: 1.060-2.684; p-value = 0.028). CONCLUSIONS: During the in-class teaching period, active SARS-CoV-2 cases in school-aged children were observed. More than half of the school-aged children were exposed to SARS-CoV-2, and SARS-CoV-2 was significantly more common in the schools at the urban area than in the school in the rural area at Maputo City and Province.

Immunogenicity of Reduced-Dose Monovalent Type 2 Oral Poliovirus Vaccine in Mocuba, Mozambique.

BACKGROUND: The monovalent type 2 oral poliovirus vaccine (mOPV2) stockpile is low. One potential strategy to stretch the existing mOPV2 supply is to administer a reduced dose: 1 drop instead of 2. METHODS: We conducted a randomized, controlled, open-label, noninferiority trial (10% margin) to compared immunogenicity after administration of 1 versus 2 drops of mOPV2. We enrolled 9-22-month-old infants from Mocuba district of Mozambique. Poliovirus neutralizing antibodies were measured in serum samples collected before and 1 month after mOPV2 administration. Immune response was defined as seroconversion from seronegative (<1:8) at baseline to seropositive (≥1:8) after vaccination or boosting titers by ≥4-fold for those with titers between 1:8 and 1:362 at baseline. The trial was registered at anzctr.org.au (no. ACTRN12619000184178p). RESULTS: We enrolled 378 children, and 262 (69%) completed per-protocol requirements. The immune response of mOPV2 was 53.6% (95% confidence interval, 44.9%-62.1%) and 60.6% (52.2%-68.4%) in 1-drop and 2-drop recipients, respectively. The noninferiority margin of the 10% was not reached (difference, 7.0%; 95% confidence interval, -5.0% to 19.0%). CONCLUSION: A small loss of immunogenicity of reduced mOPV2 was observed. Although the noninferiority target was not achieved, the Strategic Advisory Group of Experts on Immunization recommended the 1-drop strategy as a dose-sparing measure if mOPV2 supplies deteriorate further.

Rotavirus A infection in children under five years old with a double health problem: undernutrition and diarrhoea - a cross-sectional study in four provinces of Mozambique.

BACKGROUND: Mozambique has a high burden of group A rotavirus (RVA) infection and chronic undernutrition. This study aimed to determine the frequency and potential risk factors for RVA infection in undernourished children under 5 years old with diarrhoea in Mozambique. METHODS: The analysis was conducted using data from March 2015 to December 2017, regarding children under 5 years old with at least one type of undernutrition. Anthropometric measures were used to calculate indices of weight-for-age, weight-for-height and height-for-age through the Z-Scores. RVA results were extracted from the National Diarrhoea Surveillance database. Descriptive statistics, chi-square test was used for qualitative variables and organized in contingency tables and 95% Confidence Intervals (CI) were considered for the calculation of RVA infection proportion and in the multiple logistic regression models to estimate the adjusted odds ratios (AOR). RESULTS: Of the 842 undernourished children included in the analysis, 27.2% (95% CI: 24.3-30.3%) were positive for RVA. The rate of RVA infection was 42.7% (95% CI: 38.0-47.5%) in the pre-vaccine period, with great reduction to 12.2% (95% CI: 9.4-15.6%) in the post-vaccine period. Most of the RVA undernourished children had severe wasting (33.3%) and severe stunting (32.0%). The risk of infection was significantly high in children from 0 to 11 months (p-value < 0.001) when compared to the age group of 24-59 months. A higher proportion of RVA infection was detected in households with five or more members (p-value = 0.029). Similar proportions of RVA were observed in children fed only by breast milk (34.9%) and breast milk with formula (35.6%). A higher proportion of undernourished HIV-positive children co-infected with RVA (7.4%) was observed. CONCLUSIONS: The frequency of RVA infection in undernourished children declined following the introduction of the vaccine in Mozambique. Beyond the temporal variation, Maputo province, age and crowded households were also associated to RVA infection. A high proportion of RVA infection was observed in children with severe wasting and a triple burden of disease: undernutrition, RVA and HIV, highlighting the need to conduct follow-up studies to understand the long-term impact of these conditions on children's development.

Intestinal protozoa in hospitalized under-five children with diarrhoea in Nampula - a cross-sectional analysis in a low-income setting in northern Mozambique.

BACKGROUND: In Mozambique, infection by intestinal parasites is reported all over the country. However, infection in children with diarrhoea is mostly focused in the southern region of Mozambique. This work aims to determine the frequency and potential risk factors for infection by Cryptosporidium spp., Giardia lamblia, and Entamoeba histolytica in children under-five years hospitalized with diarrhoea in Hospital Central de Nampula, northern Mozambique. METHODS: A cross-sectional hospital-based surveillance was conducted between March 2015 and January 2018 in children admitted with diarrhoea in Hospital Central de Nampula. Sociodemographic information was obtained through semi-structured interviews applied to the children's caregivers. A single stool sample was collected from each child to detect antigens from Cryptosporidium spp., G. lamblia, and E. histolytica using an immune-enzymatic technique. Crude and adjusted odds ratios (with 95% Confidence Intervals) were obtained by logistic regression models to identify factors associated with infection by Cryptosporidium spp. and G. lamblia. RESULTS: The median age and interquartile intervals of our sample population was 12 months (8-20). Intestinal protozoa were detected in 21.4% (59/276). Cryptosporidium spp. was the most common protozoa (13.9% - 38/274), followed by G. lamblia (9.1% - 25/274) and E. histolytica (0.4% - 1/275). Children with illiterate caregiver's (p-value = 0.042) and undernourished (p-value = 0.011) were more likely to be infected by Cryptosporidium spp. G. lamblia was more common in children living in households with more than four members (p-value = 0.039). E. histolytica was detected in an eleven month's child, co-infected with Cryptosporidium spp. and undernourished. CONCLUSION: Cryptosporidium spp. and Giardia lamblia were the most common pathogenic intestinal protozoa detected in children with diarrhoea hospitalized in the Hospital Central de Nampula. Our findings obtained highlight the importance of exploring the caregiver's education level, children's nutritional status for infections with Cryptosporidium spp., and living conditions, namely crowded households for infections with G. lamblia in children younger than five years.

Whole-genome characterization of G12 rotavirus strains detected in Mozambique reveals a co-infection with a GXP[14] strain of possible animal origin.

A high prevalence of G12 rotavirus strains has previously been reported in southern Mozambique. In this study, the full genomes of five Mozambican G12 strains were determined directly from stool using an Illumina Miseq platform. One sample (0060) contained an intergenogroup co-infection of a G12P[8] Wa-like strain and a GXP[14] DS-1-like strain. The sequences of seven genome segments, detected for the GXP[14] strain, clustered with a diverse group of mostly animal strains, suggesting co-infection with a strain of possible animal origin. The stool samples contained G12P[6] rotavirus strains with Wa-like backbones. Phylogenetic analyses of the VP4 and VP7 encoding segments of the G12P[6] strains suggested that they were reassortants containing backbones that are similar to that of the G12P[8] strain. The study confirms previous observations of interspecies transmission and emphasizes the importance of whole-genome sequencing in order to evaluate rotavirus co-infections and reassortants.

Rotavirus A strains obtained from children with acute gastroenteritis in Mozambique, 2012-2013: G and P genotypes and phylogenetic analysis of VP7 and partial VP4 genes.

In Mozambique rotavirus (RV) was shown to be the greatest cause of acute diarrhoea in infants from 0 to 11 months, and in 2015, national rotavirus vaccination was introduced. As with other developing countries, there is very limited active strain characterisation. Rotavirus positive clinical specimens, collected between 2012 and 2013, have now provided information on the genotypes circulating in southern Mozambique prior to vaccine introduction. Genotypes G2 (32.4%), G12 (28.0%), P[4] (41.4%) and P[6] (22.9%) (n = 157) strains were commonly detected with G2P[4] (42.3%) RVs being predominant, specifically during 2013. Phylogenetic evaluation of the VP7 and VP8* encoding genes showed, for the majority of the Mozambican strains, that they clustered with other African strains based on genotype. RVA/Human-wt/MOZ/0153/2013/G2P[4], RVA/Human-wt/MOZ/0308/2012/G2P[4] and RVA/Human-wt/MOZ/0288/2012/G12P[8] formed separate clusters from the other Mozambican strains with similar genotypes, suggesting possible reassortment. Amino acid substitutions in selected epitope regions also supported phylogenetic clustering. As expected, the VP7 and VP8* genes from the Mozambican strains differed from both the RotaTeq® (SC2-9) G2P[5] and Rotarix® (A41CB052A) G1P[8] genes. This study provides information on the genetic diversity of rotavirus strains prior to vaccine introduction and generates baseline data for future monitoring of any changes in rotavirus strains in response to vaccine pressure.

Bio-efficacy of new long-lasting insecticide-treated bed nets against Anopheles funestus and Anopheles gambiae from central and northern Mozambique.

BACKGROUND: Long-lasting insecticide-treated nets (LLINs) are one of the main methods used for controlling malaria transmission in Mozambique. The proliferation of several types of LLINs and the re-emergence of insecticide resistance in the local vector populations poses challenges to the local malaria control programme on selecting suitable insecticide-based vector control products. Therefore, this study evaluated the insecticide susceptibility and bio-efficacy of selected new LLINs against wild populations of Anopheles funestus sensu lato and A. gambiae s.l. from Northern and Central Mozambique. The study also investigated whether the insecticide contents on the LINNs fabrics were within the WHOPES recommended target range. METHODS: The susceptibility of 2-5 day old wild female A. funestus and A. gambiae sensu stricto against the major classes of insecticides used for vector control, viz: deltamethrin (0.05 %), permethrin (0.75 %), propoxur (0.1 %), bendiocarb (0.1 %) and DDT (4 %), was determined using WHO cylinder susceptibility tests. WHO cone bioassays were conducted to determine the bio-efficacy of both pyrethroid-only LLINs (Olyset(®), Permanet 2.0(®), NetProtect(®) and Interceptor(®)) and, Permanet 3.0(®) a combination LLIN against A. funestus s.s, from Balama, Mocuba and Milange districts, respectively. The bio-efficacy of LLINs against the insectary-susceptible A. arabiensis (Durban strain) was assessed, as well. Untreated bed net swatches were used as negative controls. Chemical analyses, by high performance liquid chromatography, were undertaken to assess whether the insecticide contents on the LLINs fabrics fell within recommended target dose ranges. The frequency of kdr gene mutations was determined from a random sample of A. gambiae s.s. from both WHO susceptibility and cone bioassay experiments. RESULTS: Anopheles funestus from Balama district showed resistance to deltamethrin and possible resistance to permethrin, propoxur and bendiocarb, whilst A. gambiae from Mocuba district was susceptible to deltamethrin, bendiocarb and propoxur. There were no kdr mutants found in the sample of 256 A. gambiae tested. Overall, 186 LLIN swatches were tested. Mosquitoes exposed to Olyset(®) had the lowest knockdown (±standard error) and mortality rate (±standard error) in all studied sites regardless of vectors species tested. Permanet 3.0 showed the highest bio-efficacy independent of vector species tested and level of insecticide resistance detected. All types of LLINs effectively killed susceptible A. arabiensis Durban strain. The insecticide content of Olyset(®) and Permanet 2.0(®) was higher than the target dose but NetProtect(®) had a lower insecticide content than the target dose. CONCLUSION: The study shows evidence of considerable heterogeneity in both insecticide susceptibility and the level of bio-efficacy of commonly available types of LLINs against wild A. funestus and A. gambiae from Balama, Mocuba and Milange districts, located in north and centre of Mozambique. The findings suggest that vector control approaches combining different types of insecticides might help to tackle the apparent problem of pyrethroid resistance in the vector populations from these three sites. Results from bioassays on laboratory-susceptible A. arabiensis strongly suggest that LLINs can offer some protection against susceptible malaria vectors.

Impact of elevated maternal HIV viral load at delivery on T-cell populations in HIV exposed uninfected infants in Mozambique.

BACKGROUND: HIV-uninfected infants born to HIV-infected mothers (HIV-exposed uninfected, HEU) have been described to have immune alterations as compared to unexposed infants. This study sought to characterize T-cell populations after birth in HEU infants and unexposed infants living in a semirural area in southern Mozambique. METHODS: Between August 2008 and June 2009 mother-infant pairs were enrolled at the Manhiça District Hospital at delivery into a prospective observational analysis of immunological and health outcomes in HEU infants. Infants were invited to return at one month of age for a clinical examination, HIV DNA-PCR, and immunophenotypic analyses. The primary analysis sought to assess immunological differences between HEU and unexposed groups, whereas the secondary analysis assessed the impact of maternal HIV RNA viral load in the HEU group. Infants who had a positive HIV DNA-PCR test were not included in the analysis. RESULTS: At one month of age, the 74 HEU and the 56 unexposed infants had similar median levels of naïve, memory and activated CD8 and CD4 T-cells. Infant naïve and activated CD8 T-cells were found to be associated with maternal HIV-RNA load at delivery. HEU infants born to women with HIV-RNA loads above 5 log10 copies/mL had lower median levels of naïve CD8 T-cells (p = 0.04), and higher median levels of memory CD8 T-cells, (p = 0.014). CONCLUSIONS: This study suggests that exposure to elevated maternal HIV-RNA puts the infant at higher risk of having early T-cell abnormalities. Improving prophylaxis of mother to child HIV programs such that more women have undetectable viral load is crucial to decrease vertical transmission of HIV, but may also be important to reduce the consequences of HIV virus exposure in HEU infants.

Post-independence health research productivity in Portuguese-speaking African countries: A bibliometric analysis of 43 years of research and higher education in Mozambique.

Background: Africa has a high double burden of infectious and non-communicable diseases underscoring the critical need for robust scientific research. However, it is also associated with low scientific research productivity. Mozambique, which gained independence in 1975, serves as a poignant example. However, there remains a notable scarcity of evidence evaluating the country's trajectory in scientific and academic development. This study aims to evaluate 43 years of health-related scientific knowledge production through bibliometric analysis, focusing on key indicators. Additionally, it seeks to characterize the higher education institutions within the country. Methods: The data was retrieved from the Web of Science Core Collection using an advanced search tool with Boolean research strategies, covering the period from 1976 to 2022 for all PALOP and 1976 to 2019 for Mozambique. To map Mozambican higher institutions, information was sourced from the Ministry of Science Technology and Higher Education database. Descriptive statistics were employed to summarize the findings, while the VOSviewer program version 1.6.19 was utilized to visualize distance-based bibliometric networks, focusing on co-authorship among institutions and keyword co-occurrence. Results: Portuguese-speaking African countries (PALOP) contribute 2.5 % (10,933 out of 442,309) to Africa's total scientific output, with Mozambique leading at 63.6 % (6,951 publications) followed by Angola at 16.6 % (1,811 publications). All PALOP countries experienced decreased scientific productivity during the third year of the COVID-19 pandemic. In Mozambique, over 70 % (1,710 out of 2,380) of health-related publications from 2011 to 2019 were concentrated in this period. Key journals for health sciences include PLOS ONE, Malaria Journal, and Tropical Medicine & International Health, focusing on HIV, malaria, and tuberculosis. Higher education institutions in Mozambique show regional disparities, with 67.9 % in the South and only 8.9 % in the North, indicating significant inequality in their distribution across the country. Conclusion: This study highlights Mozambique's significant progress in health research productivity over 43 years, establishing it as a leader among PALOP countries. The substantial increase in publications, particularly after 2008, underscores the nation's growing research capacity and commitment to addressing critical health challenges such as HIV, malaria, and tuberculosis. However, regional disparities in higher education access and limited research contributions from private universities remain high in Mozambique.

Profile of Children with Undernutrition Admitted in Two Secondary-Level Hospitals in Maputo City, Mozambique.

Mozambique has one of the highest child undernutrition rates in Sub-Saharan Africa. The aim of this study was to characterize the profile of children from 1 to 14 years old hospitalized for undernutrition and to explore associated risk factors. Clinical, demographic, socioeconomic, and environmental data were collected. Anthropometric measurements and stool samples were collected from a child and their caretaker. The wealth index was determined using Principal Components Analysis. A total of 449 children and their caretakers were enrolled. The children had a median age of 1.0 year [IQR: 1.0-2.0], and 53.9% (242/449) were male. Most were admitted with severe undernutrition (35.7%, 159/449 kwashiorkor and 82.0%, 368/449 with -3SD Z-score indexes). The most common co-morbidities were HIV (30.0%, 120/400), diarrhea (20.0%; 80/400), and anemia (12.5%; 50/400). Among the caretakers, 9.5% (39/409) were underweight, 10.1% (40/397) were overweight, and 14.1% (56/397) were obese. Intestinal parasites were found in 24.8% (90/363) children and in 38.5% (77/200) caretakers. The majority of children (60.7%, 85/140) came from low- to middle-wealth households. Most were severely undernourished, suggesting that they seek medical care too late. The finding of overweight/obese caretakers in combination with undernourished children confirms that Mozambique is facing a double burden of malnutrition.

Safety of incidental exposure to the novel oral poliovirus vaccine type 2 in pregnancy: A longitudinal observational study in Mozambique, 2022-2023.

BACKGROUND: To minimize the risk of vaccine-derived poliovirus emergences, the novel oral poliovirus vaccine type 2 (nOPV2), was bioengineered to have increased genetic stability compared to Sabin OPV and recommended for outbreak response Emergency Use Listing by WHO. Although pregnant women are not a target population for this vaccine, a theoretical risk of incidental exposure exists via pharyngeal or faecal shedding from vaccinated children in the household or close community. METHODS: This was an observational study of pregnant women conducted in Nampula (exposed cohort) and Maputo (non-exposed cohort) in Mozambique from August 2022 to June 2023. Two nOPV2 campaigns were conducted in Nampula and none in Maputo. Women were followed-up during routine prenatal consultation, delivery, and 28-day neonate visits for obstetric anomalies and pregnancy outcomes. Sociodemographic, medical, and obstetric history was captured. RESULTS: Three hundred twenty-six pregnant women were enrolled from Nampula and 940 from Maputo City. Stillbirth prevalence (2·3% vs 1·6%, p = 0·438), low birth weight (8·9% vs 8·2%, p = 0·989), congenital anomalies (1 % vs 0·5%, p = 0·454), neonatal death (2·3% vs 1·6%, p = 0·08), and maternal death (0 % vs 0·2%, p = 0·978) did not differ amongst exposed and non-exposed cohorts. There was an increased rate of pre-term delivery in the exposed cohort (18·4% vs 11·0%, p = 0·011). CONCLUSION: We did not observe an increased frequency of adverse pregnancy outcomes due to passive nOPV2 exposure. A higher frequency of preterm delivery needs to be further investigated. The data reported herein support the continued use of nOPV2 for poliovirus outbreak response and full licensure of the vaccine.

Whole-Genome Characterization of Rotavirus G9P[6] and G9P[4] Strains That Emerged after Rotavirus Vaccine Introduction in Mozambique.

Mozambique introduced the Rotarix® vaccine into the National Immunization Program in September 2015. Following vaccine introduction, rotavirus A (RVA) genotypes, G9P[4] and G9P[6], were detected for the first time since rotavirus surveillance programs were implemented in the country. To understand the emergence of these strains, the whole genomes of 47 ELISA RVA positive strains detected between 2015 and 2018 were characterized using an Illumina MiSeq-based sequencing pipeline. Of the 29 G9 strains characterized, 14 exhibited a typical Wa-like genome constellation and 15 a DS-1-like genome constellation. Mostly, the G9P[4] and G9P[6] strains clustered consistently for most of the genome segments, except the G- and P-genotypes. For the G9 genotype, the strains formed three different conserved clades, separated by the P type (P[4], P[6] and P[8]), suggesting different origins for this genotype. Analysis of the VP6-encoding gene revealed that seven G9P[6] strains clustered close to antelope and bovine strains. A rare E6 NSP4 genotype was detected for strain RVA/Human-wt/MOZ/HCN1595/2017/G9P[4] and a genetically distinct lineage IV or OP354-like P[8] was identified for RVA/Human-wt/MOZ/HGJM0644/2015/G9P[8] strain. These results highlight the need for genomic surveillance of RVA strains detected in Mozambique and the importance of following a One Health approach to identify and characterize potential zoonotic strains causing acute gastroenteritis in Mozambican children.

Quality of routine data for monitoring nutrition and diarrhoea indicators of children under 5 in Mozambique: an ecological study over a 5-year period.

BACKGROUND: Undernutrition and diarrhoea have a high burden in children under 5 in low/middle-income countries. Having data-driven quality health services for these two diseases is key in order to address the high burden of diseases; therefore, health systems must provide data to monitor, manage, plan and decide on policies at all levels of health services. OBJECTIVE: We aimed to assess the quality of nutrition and diarrhoea routine data on children under 5 in Mozambique. DESIGN: A longitudinal ecological study was implemented. Secondary data were used to assess the quality of moderate acute malnutrition (MAM), deworming and rotavirus vaccine indicators based on the data's completeness, presence of outliers and consistency, and seasonality analysis in the form of time series analysis was performed. SETTING: We used monthly district-level count data from 2017 to 2021, from all health facilities, from the Mozambican health information system (Sistema de Informação de Saúde para Monitoria e Avaliação, or District Health Information System version 2). RESULTS: The rotavirus vaccine indicators presented better completeness when compared with other indicators under analysis. Extreme outliers were observed for deworming and rotavirus vaccines, with a higher number of outliers in the Zambezia and Nampula Provinces. Better consistency over time was observed when analysing the period before the COVID-19 pandemic, for all of the indicators and across provinces. Indicators of MAM and MAM-recovered showed more consistency issues over time in both periods of 2017-2019 and 2018-2021. In terms of seasonality analysis, for the MAM and MAM-recovered indicators, lower variation was observed, and heterogeneous patterns were seen across provinces for the rotavirus vaccine, which had the most pronounced negative seasonality components in Maputo City. CONCLUSION: Major deficits regarding the analysed quality indicators were observed for Cabo Delgado, Nampula, Zambezia, Tete, Manica, and Maputo City and Province.

Examining comorbidities in children with diarrhea across four provinces of Mozambique: A cross-sectional study (2015 to 2019).

Comorbidities are defined as the simultaneous occurrence of two or more diseases within the same individual. Comorbidities can delay a patient's recovery and increase the costs of treatment. Assessing comorbidities can provide local health care policy-makers with evidence of the most common multi-health impairments in children. This could aid in redirecting and integrating care and treatment services by increasing health facilities the awareness and readiness of health facilities. The present analysis aims to determine the frequency and associated factors of comorbidities in children with diarrhea in Mozambique. A cross-sectional hospital-based analysis was conducted between January 2015 and December 2019 in children up to 59 months of age who were admitted with diarrhea in six reference hospitals in Mozambique. These hospitals are distributed across the country's three regions, with at least one hospital in each province from each region. Sociodemographic and clinical data were obtained through semi-structured interviews and by reviewing the child clinical process. Descriptive statistics, and Mann-Whitney-U tests were used. Crude and adjusted logistics regression models were built. P-values < 0.05 were considered statistically significant. Comorbidities were observed in 55.5% of patients (389/701; 95%CI: 51.8-59.1). Wasting was the most common comorbidity (30.2%; 212/701) and pneumonia was the least common (1.7%; 12/701). Children born with a low birth weight were 2.420 times more likely to have comorbidities, adjusted odds ratio: 2.420 (95% CI: 1.339-4374). The median (interquartile range) duration of hospitalization was significantly higher in children with comorbidities than without comorbidities, 5 days (3-7) and 4 days (3-6), respectively (p-value < 0.001). One in every two children with diarrhea in Mozambique has an additional health impairment, and this increases the length of their hospital stay.

Trends and Determinants of Full Immunisation among Children Aged 12-23 Months: Analysis of Pooled Data from Mozambican Household Surveys between 1997 and 2015.

The 1974 Expanded Program on Immunisation has saved millions of children worldwide by promoting full immunisation coverage (FIC). However, forty years later, many sub-Saharan African countries remain well below its target of 90% FIC. This study analysed the level, trends and determinants of FIC in 4322 Mozambican children aged 12-23 months from pooled data from four national surveys between 1997 and 2015. Descriptive statistics and multivariable logistic regression models were performed to analyse the factors associated with full immunisation coverage. Overall, the coverage of fully immunised children increased from 47.9% in 1997 to 66.5% in 2015, corresponding to a 1.8% yearly increase. The needed FIC growth rate post-2015 was 4.3 times higher. Increased maternal education and a higher household wealth index were associated with higher odds of FIS. Furthermore, attending antenatal care (ANC) visits, institutional delivery and living in southern provinces were also associated with increased odds of FIS. Between 1997 and 2015, FIC among 12-23-month-old children made modest annual gains but remained well below international targets. Factors related to access to healthcare, educational level, socioeconomic status and geographical location were associated with improved FIC. Targeted interventions to expand these factors will improve immunisation coverage among Mozambican children.

Impact and Cost-Effectiveness of Alternative Human Papillomavirus Vaccines for Preadolescent Girls in Mozambique: A Modelling Study.

Mozambique has one of the highest rates of cervical cancer in the world. Human papillomavirus (HPV) vaccination was introduced in 2021. This study evaluated the health and economic impact of the current HPV vaccine (GARDASIL® hereafter referred to as GARDASIL-4) and two other vaccines (CECOLIN® and CERVARIX®) that could be used in the future. A static cohort model was used to estimate the costs and benefits of vaccinating girls in Mozambique over the period 2022-2031. The primary outcome measure was the incremental cost per disability-adjusted life-year averted from a government perspective. We conducted deterministic and probabilistic sensitivity analyses. Without cross-protection, all three vaccines averted approximately 54% cervical cancer cases and deaths. With cross-protection, CERVARIX averted 70% of cases and deaths. Without Gavi support, the discounted vaccine program costs ranged from 60 million to 81 million USD. Vaccine program costs were approximately 37 million USD for all vaccines with Gavi support. Without cross-protection, CECOLIN was dominant, being cost-effective with or without Gavi support. With cross-protection and Gavi support, CERVARIX was dominant and cost-saving. With cross-protection and no Gavi support, CECOLIN had the most favorable cost-effectiveness ratio. Conclusions: At a willingness-to-pay (WTP) threshold set at 35% of Gross Domestic Product (GDP) per capita, HPV vaccination is cost-effective in Mozambique. The optimal vaccine choice depends on cross-protection assumptions.

Enterovirus detection in stool samples from Mozambican children with acute gastroenteritis.

Enteroviruses (EV) are predominantly enteric viruses, present in all parts of the world causing disease in humans with a broad spectrum of clinical presentations. The purpose of this study was to identify non-polio enteroviruses (NPEV) in stool samples collected from children with acute gastroenteritis (AGE) symptoms of unknown etiology in four provinces (Maputo, Nampula, Sofala and Zambézia) of Mozambique. From June 2014 to March 2018, 327 stool samples were collected from children hospitalized with AGE in health care units. NPEVs were detected in 52 samples (52/327; 15.9%) and were more frequent in children under 5 years of age. The age group from 12 to 23 months was the most affected and showed more severity of disease. We also identified 26 different EV-types with the following detection pattern EV-B>EV-C>EV-A. The major EV-types were EV-A119 (9/52; 17.3%) and EV-C99 (8/52; 15.4%), accounting for 32.7% of the total. In addition to EV-A119, other uncommon EV-types were also identified, such as EV-B75, EV-B97 and EV-C113. The current study shows a high heterogeneity of EV types circulating in children with AGE in Mozambique as well as the identification of rarely described enteroviruses.

Association between Intestinal Parasite Infections and Proxies for Body Composition: A Scoping Review.

It has long been recognized that intestinal parasite infections and undernutrition are closely linked. However, little is known about the role of intestinal parasite infections (IPIs), or parasite clearance, in these processes. The aim of this scoping review was to summarize published evidence on the association between IPIs and body composition. PRISMA guidelines, PubMed/MEDLINE, EMBASE and Cochrane Library databases were searched up until June 2021. Studies reporting on IPIs in relation to (proxies for) body composition were eligible. Study quality and risk of bias were assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Twenty-four studies were included, two Randomized Control Trials (RCTs) and 22 observational. Most observational studies showed IPIs to be associated with lower Body Mass Index (BMI) or being underweight as proxies for body composition. One RCT showed no effect of antiparasitic treatment on body composition, while the other one showed a significant post-treatment increase in body fat, as measured by BMI z-scores and skinfolds. This review lends support to distinct associations between IPIs and body composition. More longitudinal studies are needed using direct measures of body composition to investigate whether weight gained after antiparasitic treatment concerns an increase in body fat or healthy weight gain.

Intestinal Parasites in Children up to 14 Years Old Hospitalized with Diarrhea in Mozambique, 2014-2019.

Diarrhea remains a public health problem in Mozambique, even with control strategies being implemented. This analysis aimed to determine the proportion and factors associated with intestinal parasitic infection (IPI) in children up to 14 years old with diarrheal disease, in the southern, central and northern regions of Mozambique. A single diarrheal sample of 1424 children was collected in hospitals and examined using the formol-ether concentration and modified Ziehl−Neelsen techniques to identify intestinal parasites using optical microscopy. Sociodemographic characteristics were obtained by questionnaires. Descriptive statistics and cross-tabulation were performed, and p-values <0.05 were considered statistically significant. A single IPI was detected in 19.2% (273/1424) of the children. Cryptosporidium spp. was the most common parasite (8.1%; 115/1424). Polyparasitism was seen in 26.0% (71/273), with the co-infection of Ascaris lumbricoides and Trichuris trichiura (26.8%; 19/71) being the most common. Age and province were related to IPI (p-value < 0.05). The highest occurrence of IPI was observed in the wet period (October to March), with 21.9% (140/640), compared to the dry period (April to September), with 16.9% (131/776) (p-value = 0.017). Cryptosporidium spp. and the combination of A. lumbricoides/T. trichiura were the main intestinal parasites observed in children hospitalized with diarrhea in Mozambique.

Environmental Monitoring for Enteroviruses in Maputo, Mozambique-2018.

Due to the possibility of wild poliovirus importation from endemic regions and the high circulation of vaccine-derived poliovirus type 2 in the African region, Mozambique implemented a surveillance program to monitor the circulation of enteroviruses in the environment. From January to November 2018, a period that immediately preceded the cVDPV outbreak in Africa, 63 wastewater samples were collected from different areas in Maputo city. A total of 25 samples (39.7%) were positive based on cell culture isolation. Non-polio enteroviruses were found in 24 samples (24/25; 96%), whereas 1 Sabin-related poliovirus was isolated. Neither wild nor vaccine-derived poliovirus was detected. High circulation of EVB species was detected. Environmental surveillance in the One Health approach, if effectively applied as support to acute flaccid paralysis, can be a powerful aid to the public health system to monitor poliovirus besides non-polio enteroviruses in polio-free areas.