Maternal death and delays in accessing emergency obstetric care in Mozambique.

BACKGROUND: Despite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique. METHODS: Secondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility. RESULTS: Data were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa. CONCLUSIONS: The delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.

The magnitude and factors related to facility-based maternal mortality in Mozambique.

Facility-based maternal mortality remains an important public health problem in Mozambique. A number of factors associated with health system functioning can be described behind the occurrence of these deaths. This paper aimed to evaluate the magnitude of the health facility-based maternal mortality, its geographical distribution and to assess the health facility factors implicated in the occurrence of these deaths. A secondary analysis was done on data from the survey on maternal health needs performed by the Ministry of Health of Mozambique in 2008. During the study period 2.198 maternal deaths occurred out of 312.537 deliveries. According to the applied model the availability of Maternal and Child Health (MCH) nurses performing Emergency Obstetric Care functions was related to the reduction of facility-based maternal mortality by 40%. No significant effects were observed for the availability of medical doctors, surgical technicians and critical delivery room equipment. Impact statement Is largely known that the availability of skilled attendants assisting every delivery and providing Emergency Obstetric Care services during the pregnancy, labor and Childbirth is key for maternal mortality reduction. This study add the differentiation on the impact of different cadres of health services providers working on maternal and child health services on the facility based maternal mortality. In this setting the study proven the high impact of the midlevel skilled maternal and child health nurses on the reduction of maternal mortality. Another important add from this study is the use of facility based maternal mortality data to inform the management process of maternal healthcare services. The findings from this study have potential to impact on the decision of staffing prioritization in setting like the study setting. The findings support the policy choice to improve the availability of maternal and child health nurses.

eSIP-Saúde: Mozambique's novel approach for a sustainable human resources for health information system.

INTRODUCTION: Over the past decade, governments and international partners have responded to calls for health workforce data with ambitious investments in human resources information systems (HRIS). However, documentation of country experiences in the use of HRIS to improve strategic planning and management has been lacking. The purpose of this case presentation is to document for the first time Mozambique's novel approach to HRIS, sharing key success factors and contributing to the scant global knowledge base on HRIS. CASE PRESENTATION: Core components of the system are a Government of Mozambique (GOM) registry covering all workers in the GOM payroll and a "health extension" which adds health-sector-specific data to the GOM registry. Separate databases for pre-service and in-service training are integrated through a business intelligence tool. The first aim of the HRIS was to identify the following: who and where are Mozambique's health workers? As of July 2015, 95 % of countrywide health workforce deployment information was populated in the HRIS, allowing the identification of health professionals' physical working location and their pay point. HRIS data are also used to quantify chronic issues affecting the Ministry of Health (MOH) health workforce. Examples include the following: HRIS information was used to examine the deployment of nurses trained in antiretroviral therapy (ART) vis-à-vis the health facilities where ART is being provided. Such results help the MOH align specialized skill sets with service provision. Twenty-five percent of the MOH health workforce had passed the 2-year probation period but had not been updated in the MOH information systems. For future monitoring of employee status, the MOH established a system of alerts in semi-monthly reports. As of August 2014, 1046 health workers were receiving their full salary but no longer working at the facilities. The MOH is now analyzing this situation to improve the retirement process and coordination with Social Security. CONCLUSION: The Mozambican system is an important example of an HRIS built on a local platform with local staff. Notable models of strategic data use demonstrate that the system is empowering the MOH to improve health services delivery, health workforce allocation, and management. Combined with committed country leadership and ownership of the program, this suggests strong chances of sustainability and real impact on public health equity and quality.

The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique.

BACKGROUND: Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented. METHODS: t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula. RESULTS: Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs. CONCLUSIONS: Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.

A pragmatic randomised controlled trial on routine iron prophylaxis during pregnancy in Maputo, Mozambique (PROFEG): rationale, design, and success.

The effects of prophylactic iron during pregnancy on maternal and child health in developing settings with endemic malaria and high prevalence of HIV remain unclear. This paper describes the rationale, implementation and success of a pragmatic randomised controlled trial comparing routine iron supplementation vs. screening and treatment for anaemia during pregnancy. The setting was two health centres in Maputo, Mozambique. Pregnant women (≥ 12-week gestation; ≥ 18 years old; and not with a high-risk pregnancy, n=4326) were recruited. The main outcomes are preterm delivery and low birthweight. The women were randomly assigned to one of two iron administration policies: a routine iron group (n=2184) received 60 mg of ferrous sulphate plus 400 µg of folic acid daily while a selective iron group (n=2142) had screening and treatment for anaemia and a daily intake of 1 mg of folic acid. The recruitment, follow-up, and collection of follow-up data were successful; both groups were similar to each other in all the trial stages. Collection of delivery data was challenging and data on about 40% of births is missing. These are currently being traced through different hospitals and health centres. The compliance of the study personnel and the women with regard to regular measurement of haemoglobin and intake of the iron and folic acid tablets was high and similar in both trial arms. Taking into account the various constraints encountered, the stages of the present trial prior to delivery were carried out well.

Assessment of the nursing skill mix in Mozambique using a task analysis methodology.

BACKGROUND: The density of the nursing and maternal child health nursing workforce in Mozambique (0.32/1000) is well below the WHO minimum standard of 1 nurse per 1000. Two levels of education were being offered for both nurses and maternal child health nurses, in programmes ranging from 18 to 30 months in length. The health care workforce in Mozambique also includes Medical Technicians and Medical Agents, who are also educated at either basic or mid-level. The Ministry of Health determined the need to document the tasks that each of the six cadres was performing within various health facilities to identify gaps, and duplications, in order to identify strategies for streamlining workforce production, while retaining highest educational and competency standards. The methodology of task analysis (TA) was used to achieve this objective. This article provides information about the TA methodology, and selected outcomes of the very broad study. METHODS: A cross-sectional descriptive task analysis survey was conducted over a 15 month period (2008-2009). A stratified sample of 1295 individuals was recruited from every type of health facility in all of Mozambique's 10 provinces and in Maputo City. Respondents indicated how frequently they performed any of 233 patient care tasks. Data analysis focused on identifying areas where identical tasks were performed by the various cadres. Analyses addressed frequency of performance, grouped by level of educational preparation, within various types of health facilities. RESULTS: Task sharing ranged from 74% to 88% between basic and general nurse cadres and from 54% to 88% between maternal and child health nurse cadres, within various health facility types. Conversely, there was distinction between scope of practice for nursing and maternal/child health nursing cadres. CONCLUSION: The educational pathways to general nursing and maternal/child health nursing careers were consolidated into one 24 month programme for each career. The scopes of practice were affirmed based on task analysis survey data.

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience.

Mozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions' strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.

Prevalence and predictors of maternal peripheral malaria parasitemia in central Mozambique.

Malaria infection during pregnancy (MiP) is heterogeneously distributed even in malaria-endemic countries. Program planners require data to facilitate identification of highest-priority populations for MiP control. Using data from two cross-sectional studies of 5,528 pregnant women in 8 neighboring sites in Mozambique, we described factors associated with maternal peripheral parasitemia by using logistic regression. Principal multivariate predictors of maternal peripheral parasitemia were gravidity (odds ratio [OR] = 2.29, 95% confidence interval [CI] = 1.60-3.26 for primigravidae and OR = 1.61, 95% CI = 1.29-2.01 for secundigravidae compared with gravidity > or = 3); age (OR = 0.96 per year, 95% CI = 0.94-0.99); study site (OR = 1.45, 95% CI = 1.34-1.56 to 5.32, 95% CI = 4.92-5.75) for comparison with the reference site; and no maternal education (OR = 1.38, 95% CI = 1.15-1.66) compared with any education. Other predictors (in subgroups) were bed net use (OR = 0.49, 95% CI = 0.48-0.50); preventive sulfadoxine-pyrimethamine doses (OR = 0.25, 95% CI = 0.24-0.25); and infection with human immunodeficiency virus (HIV) (OR = 1.49, 95% CI = 1.11-2.00). Programmatic priorities should respond to heterogeneous distribution of multiple risk factors, including prevalence of malaria and infection with HIV, and maternal socioeconomic status.

The epidemiology of malaria in adults in a rural area of southern Mozambique.

BACKGROUND: Epidemiological studies of malaria in adults who live in malaria endemic areas are scarce. More attention to the natural history of malaria affecting adults is needed to understand the dynamics of malaria infection and its interaction with the immune system. The present study was undertaken to investigate the clinical, parasitological and haematological status of adults exposed to malaria, and to characterize parasites in these individuals who progressively acquire protective immunity. METHODS: A cross-sectional survey of 249 adults was conducted in a malaria endemic area of Mozambique. Clinical, parasitological and haematological status of the study population was recorded. Sub-microscopic infections and multiplicity of infections were investigated using polymerase chain reaction (PCR) and restriction fragment length polymorphism of Plasmodium falciparum merozoite surface protein 2 (msp2). RESULTS: Prevalence of P. falciparum infection by microscopy (14%) and PCR (42%) decreased progressively during adulthood, in parallel with an increase in the prevalence of sub-microscopic infections. Anaemia was only related to parasitaemia as detected by PCR. Multiplicity of infection decreased with age and was higher in subjects with high P. falciparum densities, highlighting density-dependent constraints upon the PCR technique. CONCLUSION: Adults of Manhiça progressively develop non-sterile, protective immunity against P. falciparum malaria. The method of parasite detection has a significant effect on the observed natural history of malaria infections. A more sensitive definition of malaria in adults should be formulated, considering symptoms such as diarrhoea, shivering and headache, combined with the presence of parasitaemia.

Intermittent preventive treatment for malaria control administered at the time of routine vaccinations in Mozambican infants: a randomized, placebo-controlled trial.

BACKGROUND: There is an urgent need to deploy and develop new control tools that will reduce the intolerable burden of malaria. Intermittent preventive treatment in infants (IPTi) has the potential to become an effective tool for malaria control. METHODS: We performed a randomized, double-blind, placebo-controlled trial of sulfadoxine-pyrimethamine (SP) treatment in 1503 Mozambican children. Doses of SP or placebo were given at 3, 4, and 9 months of age. The intervention was administered alongside routine vaccinations delivered through the Expanded Program on Immunization (EPI). Hematological and biochemical tests were done when infants were 5 months old. Morbidity monitoring through a hospital-based passive case-detection system was complemented by cross-sectional surveys when infants were 12 and 24 months old. RESULTS: IPTi was well tolerated, and no adverse events associated with SP were documented. During the first year of life, intermittent SP treatment reduced the incidence of clinical malaria by 22.2% (95% confidence interval [CI], 3.7%-37.0%; P=.020) and the rate of hospital admissions by 19% (95% CI, 4.0%-31.0%; P=.014). Although the incidence of severe anemia (packed cell volume of <25%) did not differ significantly between the 2 groups (protective effect, 12.7% [95% CI, -17.3% to 35.1%]; P=.36), there was a significant reduction in hospital admissions for anemia during the month after dosing for both the first and second dose. The serological responses to EPI vaccines were not modified by the intervention. CONCLUSIONS: IPTi with SP has been shown to moderately reduce the incidence of clinical malaria in Mozambican infants without evidence of rebound after stopping the intervention or of interactions with EPI vaccines. Its recommendation as a malaria control strategy in Mozambique needs to be balanced against the scarcity of affordable control tools and the burden of malaria in children.

Assessing women's satisfaction with family planning services in Mozambique.

BACKGROUND: The contraceptive prevalence rate in Mozambique was estimated as 11.3% in the last Demographic and Health Survey. The impact of family planning (FP) on women's health and on the reduction of maternal mortality is well known. METHODS: Acknowledging the importance of user satisfaction in the utilisation of health services, exit interviews were used to assess women's satisfaction with FP services in Mozambique. The survey, conducted in 174 health facilities, was representative at the national level, covered all provinces, and both urban and rural areas. RESULTS: Overall, 86% of respondents were satisfied with FP services, but issues such as insufficient supplies of oral contraceptives and the low quality of healthcare provider/client interactions were given as reasons for women's dissatisfaction. CONCLUSION: Defined actions at the level of health service provision are needed to tackle the identified issues and ensure improved satisfaction with, and better utilisation of, FP services in Mozambique.

Is selective prenatal iron prophylaxis better than routine prophylaxis: final results of a trial (PROFEG) in Maputo, Mozambique.

OBJECTIVE: To compare routine versus selective (ie, screening and treatment for anaemia) prenatal iron prophylaxis in a malaria-endemic and HIV-prevalent setting, an extended analysis including previously missing data. DESIGN: A pragmatic randomised controlled clinical trial. SETTING: 2 health centres in Maputo, Mozambique. PARTICIPANTS: Pregnant women (≥18 years old; non-high-risk pregnancy) were randomly allocated to routine iron (n=2184) and selective iron (n=2142) groups. INTERVENTIONS: In the routine group, women received 60 mg ferrous sulfate plus 400 µg folic acid daily. In the selective group, women received 1 mg of folic acid daily and haemoglobin (Hb) screening at each visit; with low Hb (cut-off 9 g/dL) treatment (120 mg+800 µg of folic acid daily) for a month. PRIMARY OUTCOMES: preterm birth, low birth weight; secondary outcomes: self-reported malaria, labour complications, caesarean section, perinatal death, woman's death. Nurses collected pregnancy data. Birth data were abstracted from hospital records for 52% of women and traced using various methods and linked with probabilistic matching for 24%. Women's deaths were collected from death registers. RESULTS: Birth data were available for 3301 (76%) of the women. Outcomes were similar in the two groups: preterm births (27.1% in the selective vs 25.3% in the routine group), low birthweight infants (11.0% vs 11.7%), perinatal deaths (2.4% vs 2.4%) and caesarean sections (4.0% vs 4.5%). Women's deaths during pregnancy or <42 days postpartum were more common in the selective group (0.8% among the two best matched women) than in the routine group (0.4%). Extra deaths could not be explained by the cause of death, Hb level or HIV status at recruitment. CONCLUSIONS: Birth outcomes were similar in the two iron groups. There might have been more women's deaths in the selective iron group, but it is unclear whether this was due to the intervention, other factors or chance finding. TRIAL REGISTRATION NUMBER: NCT00488579.

Malaria in southern Mozambique: malariometric indicators and malaria case definition in Manhiça district.

A total of 2057 children aged <10 years were selected at random from a demographic surveillance system and enrolled in 4 malariometric cross-sectional surveys in different seasons in Manhiça district in southern Mozambique. Plasmodium falciparum accounted for 90% of all malaria infections and the prevalence of asexual P. falciparum ranged from 13.7-21.7% at the end of the dry season to 30.5-34.0% at the end of rainy season. In order to determine the malaria attributable fraction (MAF) of fever, 1021 children from a nearby hospital acted as fever cases and from this separate case-control study the crude MAF was 36%, showing a marked age dependency. Plasmodium falciparum is the most common malaria species in Manhiça. This malaria-mesoendemic area has year-round transmission. The importance of other non-malarial fever-causing conditions among infants was highlighted. Malaria appeared to be a major contributory factor to anaemia in the area.

Malaria in southern Mozambique: incidence of clinical malaria in children living in a rural community in Manhiça district.

We estimated the incidence of clinical malaria episodes by weekly home-based active case detection between December 1996 and July 1999 in 2 groups of children in Manhiça district in southern Mozambique. Cohort 1 comprised a random sample of children aged <10 years at recruitment and cohort 2 comprised newborns. A blood slide was taken if the axillary temperature was 7.5 degrees C or if the child was reported to have been febrile over the previous 24 h. A total of 1966 children were followed-up. Malaria occurred all year round. The number of clinical malaria episodes ranged from 0 to 6 per child. No clinical malaria episodes were detected in 71% of children or in children aged <2 months. Those aged 6 months to <4 years showed the highest incidence ranging from 0.65 to 0.74 episodes per 100 person-weeks at risk, indicating that infants and young children were at highest risk. Malaria transmission is perennial in this district of Mozambique with some seasonality. Significant differences were observed in the spatial incidence of malaria episodes in regions just a few miles apart with a higher incidence in children living near the river or in swampy areas. These findings strengthen the need for improved control measures targeted at infancy and early childhood.

Mid-level healthcare personnel training: an evaluation of the revised, nationally-standardized, pre-service curriculum for clinical officers in Mozambique.

INTRODUCTION: Mozambique suffers from a critical shortage of healthcare workers. Mid-level healthcare workers, (Tecnicos de Medicina Geral (TMG)), in Mozambique require less money and time to train than physicians. From 2009-2010, the Mozambique Ministry of Health (MoH) and the International Training and Education Center for Health (I-TECH), University of Washington, Seattle, revised the TMG curriculum. To evaluate the effect of the curriculum revision, we used mixed methods to determine: 1) if TMGs meet the MoH's basic standards of clinical competency; and 2) do scores on measurements of clinical knowledge, physical exam, and clinical case scenarios differ by curriculum? METHODS: T-tests of differences in means examined differences in continuous score variables between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related and demographic factors associated with assessment scores on each of the three evaluation methods at the p<0.05 level. Qualitative interviews and focus groups inform interpretation. RESULTS: We found no significant differences in sex, marital status and age between the 112 and 189 TMGs in initial and revised curriculum, respectively. Mean scores at graduation of initial curriculum TMGs were 56.7%, 63.5%, and 49.1% on the clinical cases, knowledge test, and physical exam, respectively. Scores did not differ significantly from TMGs in the revised curriculum. Results from linear regression models find that training institute was the most significant predictor of TMG scores on both the clinical cases and physical exam. CONCLUSION: TMGs trained in either curriculum may be inadequately prepared to provide quality care. Curriculum changes are a necessary, but insufficient, part of improving TMG knowledge and skills overall. A more comprehensive, multi-level approach to improving TMG training that includes post-graduation mentoring, strengthening the pre-service internship training, and greater resources for training institute faculty may result in improvements in TMG capacity and patient care over time.

Comparison of routine prenatal iron prophylaxis and screening and treatment for anaemia: pregnancy results and preliminary birth results from a pragmatic randomised controlled trial (PROFEG) in Maputo, Mozambique.

OBJECTIVE: To present the pregnancy results and interim birth results of a pragmatic randomised controlled trial comparing routine iron prophylaxis with screening and treatment for anaemia during pregnancy in a setting of endemic malaria and HIV. DESIGN: A pragmatic randomised controlled trial. SETTING: Two health centres (1° de Maio and Machava) in Maputo, Mozambique, a setting of endemic malaria and high prevalence of HIV. PARTICIPANTS: Pregnant women (≥18-year-olds; non-high-risk pregnancy, n=4326) attending prenatal care consultation at the two health centres were recruited to the trial. INTERVENTIONS: The women were randomly allocated to either Routine iron (n=2184; 60 mg ferrous sulfate plus 400 µg of folic acid daily throughout pregnancy) or Selective iron (n=2142; screening and treatment for anaemia and daily intake of 1 mg of folic acid). OUTCOME MEASURES: The primary outcomes were preterm delivery (delivery <37 weeks of gestation) and low birth weight (<2500 g). The secondary outcomes were symptoms suggestive of malaria and self-reported malaria during pregnancy; birth length; caesarean section; maternal and child health status after delivery. RESULTS: The number of follow-up visits was similar in the two groups. Between the first and fifth visits, the two groups were similar regarding the occurrence of fever, headache, cold/chills, nausea/vomiting and body aches. There was a suggestion of increased incidence of self-reported malaria during pregnancy (OR 1.37, 95% CI 0.98 to1.92) in the Routine iron group. Birth data were available for 1109 (51%) in the Routine iron group and for 1149 (54%) in the Selective iron group. The birth outcomes were relatively similar in the two groups. However, there was a suggestion (statistically non-significant) of poorer outcomes in the Routine iron group with regard to long hospital stay after birth (relative risk (RR) 1.43, 95% CI 0.97 to 1.26; risk difference (RD) 0.02, 95% CI -0.00 to 0.03) and unavailability of delivery data (RR 1.06, 95% CI 1.00 to 1.13; RD 0.03, 95% CI -0.01 to 0.07). CONCLUSIONS: These interim results suggest that routine iron prophylaxis during pregnancy did not confer advantage over screening and treatment for anaemia regarding maternal and child health. Complete data on birth outcomes are being collected for firmer conclusions. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov, number NCT00488579 (June 2007). The first women were randomised to the trial proper April 2007-March 2008. The pilot was November 2006-March 2008. The 3-month lag was due to technical difficulties in completing trial registration.

Impact of vaccination on the incidence of measles in Mozambique in the period 2000 to 2011.

The aim of this study was to contribute to the better planning of measles elimination actions in Mozambique, by considering the impact of vaccination actions over the period 2000 to 2011. Descriptive and ecological studies and case records made available by the Ministry of Health were used to analyze measles vaccination coverage. Statistical analysis was performed using time series and spatial analysis. Vaccine coverage rates ranged from 82% to 99%. Coverage rates in Maputo city were under 70% and in Niassa province they were over 100%. Coverage showed a clustered pattern in the districts. The measles incidence rate was 1.58 per 100,000 inhabitants (0.00-40.08 per 100,000 inhabitants); districts bordering neighboring countries presented high incidence rates. Although measles morbidity and mortality has decreased in Mozambique, vaccine coverage has been insufficient to interrupt measles transmission. Enhanced surveillance, including investigation of cases and outbreaks, and improvements in measles vaccination are recommended in order to achieve a homogenous coverage rate of ≥ 95% for both routine and mass vaccination campaigns.

Impact of vaccination on the incidence of measles in Mozambique in the period 2000 to 2011 / Impacto da vacinação sobre a incidência de sarampo em Moçambique no período de 2000-2011 / Impacto de la vacunación sobre la incidencia del sarampión en Mozambique durante el período de 2000-2011

The aim of this study was to contribute to the better planning of measles elimination actions in Mozambique, by considering the impact of vaccination actions over the period 2000 to 2011. Descriptive and ecological studies and case records made available by the Ministry of Health were used to analyze measles vaccination coverage. Statistical analysis was performed using time series and spatial analysis. Vaccine coverage rates ranged from 82% to 99%. Coverage rates in Maputo city were under 70% and in Niassa province they were over 100%. Coverage showed a clustered pattern in the districts. The measles incidence rate was 1.58 per 100,000 inhabitants (0.00-40.08 per 100,000 inhabitants); districts bordering neighboring countries presented high incidence rates. Although measles morbidity and mortality has decreased in Mozambique, vaccine coverage has been insufficient to interrupt measles transmission. Enhanced surveillance, including investigation of cases and outbreaks, and improvements in measles vaccination are recommended in order to achieve a homogenous coverage rate of ≥ 95% for both routine and mass vaccination campaigns.

O objetivo deste estudo foi analisar as ações de eliminação do sarampo em Moçambique, considerando o impacto do programa de vacinação ao longo do período de 2000-2011. Foram revisados os dados de vacinação e os casos de sarampo disponíveis no Ministério da Saúde. Análise de séries temporais e técnicas estatísticas de análise espacial foram aplicadas. As coberturas variaram entre 82% e 99%. Nas províncias, a cidade de Maputo teve as coberturas abaixo de 70%, e a província de Niassa teve as coberturas acima de 100%. As coberturas apresentaram um padrão espacial que se modificou com o tempo. A taxa de incidência de sarampo no país foi de 1,58 (0,00-40,08 distritos) por 100 mil habitantes. Os distritos que fazem fronteiras com os países vizinhos tiveram as elevadas taxas de incidência. As coberturas de rotina são insuficientes, e a circulação de sarampo continua em Moçambique. O país necessita alcançar coberturas homogêneas e maiores que 95% em crianças menores de um ano, manter as campanhas de vacinação e melhorar a vigilância e o tratamento de casos.

El objetivo de este artículo fue analizar las acciones de eliminación del sarampión en Mozambique, considerando el impacto del programa de vacunación a lo largo del período de 2000-2011. Se revisaron los datos de vacunación y casos de sarampión, disponibles en el Ministerio de Salud. Se aplicaron análisis de series temporales y técnicas estadísticas de análisis espacial. Las coberturas variaron entre un 82% y un 99% por nivel. En las provincias, la Ciudad de Maputo tuvo coberturas por debajo de un 70%, mientras que la provincia de Niassa tuvo coberturas por encima de un 100%. Las coberturas presentaron un patrón espacial que se modificó con el tiempo. La tasa de incidencia de sarampión en el país fue de un 1,58 (0,00-40,08 distritos) por 100 mil habitantes. Los distritos que tienen fronteras con países vecinos tuvieron una elevadas tasas de incidencia. Las coberturas de rutina son insuficientes y la propagación del sarampión continúa en Mozambique. El país necesita alcanzar coberturas > 95% en niños menores de un año y que sean homogéneas, mantener las campañas de vacunación, mejorar la vigilancia y el tratamiento de casos.

Intermittent preventive treatment of malaria during pregnancy in central Mozambique.

PROBLEM: New WHO strategies for control of malaria in pregnancy (MiP) recommend intermittent preventive treatment (IPTp), bednet use and improved case management. APPROACH: A pilot MiP programme in Mozambique was designed to determine requirements for scale-up. LOCAL SETTING: The Ministry of Health worked with a nongovernmental organization and an academic institution to establish and monitor a pilot programme in two impoverished malaria-endemic districts. RELEVANT CHANGES: Implementing the pilot programme required provision of additional sulfadoxine-pyrimethamine (SP), materials for directly observed SP administration, bednets and a modified antenatal card. National-level formulary restrictions on SP needed to be waived. The original protocol required modification because imprecision in estimation of gestational age led to missed SP doses. Multiple incompatibilities with other health initiatives (including programmes for control of syphilis, anaemia and HIV) were discovered and overcome. Key outputs and impacts were measured; 92.5% of 7911 women received at least 1 dose of SP, with the mean number of SP doses received being 2.2. At the second antenatal visit, 13.5% of women used bednets. In subgroups (1167 for laboratory analyses; 2600 births), SP use was significantly associated with higher haemoglobin levels (10.9 g/dL if 3 doses, 10.3 if none), less malaria parasitaemia (prevalence 7.5% if 3 doses, 39.3% if none), and fewer low-birth-weight infants (7.3% if 3 doses, 12.5% if none). LESSONS LEARNED: National-level scale-up will require attention to staffing, supplies, bednet availability, drug policy, gestational-age estimation and harmonization of vertical initiatives.

Plasmodium falciparum multiple infections in Mozambique, its relation to other malariological indices and to prospective risk of malaria morbidity.

We describe the frequency of Plasmodium falciparum clones infecting individuals living in a rural area of southern Mozambique and analyse the relationship between multiplicity of infection, age and other malariometric indices, including prospective risk of clinical malaria. The genotyping was based on the use of restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR) analysis of P. falciparum merozoite surface protein 2 (msp2). We analysed 826 samples collected during five cross-sectional surveys from residents of Manhiça ranging in age from 4 months to 83 years. We also determined the multiplicity of infection in samples obtained from 6-month-old infants (n = 79) and children <10 years (n = 158) who were then treated and followed prospectively for 1 year or 75 weeks, respectively. Multiplicity of infection did not vary significantly during the first year of life, but increased thereafter, and decreased during adulthood to the levels found in infants. With increasing multiplicity of infection, there was a statistically significant decrease in the risk of submicroscopic infections. There was also a significant correlation between multiplicity of infection and parasite density in infants, children <4 years of age and adults, suggesting that high densities increase the probability of discriminating more clones in complex infections. We found that the relationship between multiple infections and malaria morbidity is age-dependent. In infants, the risk of subsequent episodes of clinical malaria was related to the parasite density but not to baseline multiplicity of infection. In older children, however, the more clones a child carried, the more likely they were to have a clinical malaria episode, and this was true after adjusting for parasite densities. This change in the association between multiplicity and risk of clinical malaria may indicate a shift in the host response to P. falciparum.