Targeted and whole-genome sequencing reveal a north-south divide in P. falciparum drug resistance markers and genetic structure in Mozambique.

Mozambique is one of the four African countries which account for over half of all malaria deaths worldwide, yet little is known about the parasite genetic structure in that country. We performed P. falciparum amplicon and whole genome sequencing on 2251 malaria-infected blood samples collected in 2015 and 2018 in seven provinces of Mozambique to genotype antimalarial resistance markers and interrogate parasite population structure using genome-wide microhaplotyes. Here we show that the only resistance-associated markers observed at frequencies above 5% were pfmdr1-184F (59%), pfdhfr-51I/59 R/108 N (99%) and pfdhps-437G/540E (89%). The frequency of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine resistance increased from 80% in 2015 to 89% in 2018 (p < 0.001), with a lower expected heterozygosity and higher relatedness of microhaplotypes surrounding pfdhps mutants than wild-type parasites suggestive of recent selection. pfdhfr/pfdhps quintuple mutants also increased from 72% in the north to 95% in the south (2018; p < 0.001). This resistance gradient was accompanied by a concentration of mutations at pfdhps-436 (17%) in the north, a south-to-north increase in the genetic complexity of P. falciparum infections (p = 0.001) and a microhaplotype signature of regional differentiation. The parasite population structure identified here offers insights to guide antimalarial interventions and epidemiological surveys.

Tracking SARS-CoV-2 introductions in Mozambique using pandemic-scale phylogenies: a retrospective observational study

From the start of the SARS-CoV-2 outbreak, global sequencing efforts have generated an unprecedented amount of genomic data. Nonetheless, unequal sampling between high-income and low-income countries hinders the implementation of genomic surveillance systems at the global and local level. Filling the knowledge gaps of genomic information and understanding pandemic dynamics in low-income countries is essential for public health decision making and to prepare for future pandemics. In this context, we aimed to discover the timing and origin of SARS-CoV-2 variant introductions in Mozambique, taking advantage of pandemic-scale phylogenies. Methods: We did a retrospective, observational study in southern Mozambique. Patients from Manhiça presenting with respiratory symptoms were recruited, and those enrolled in clinical trials were excluded. Data were included from three sources: (1) a prospective hospital-based surveillance study (MozCOVID), recruiting patients living in Manhiça, attending the Manhiça district hospital, and fulfilling the criteria of suspected COVID-19 case according to WHO; (2) symptomatic and asymptomatic individuals with SARS-CoV-2 infection recruited by the National Surveillance system; and (3) sequences from SARS-CoV-2-infected Mozambican cases deposited on the Global Initiative on Sharing Avian Influenza Data database. Positive samples amenable for sequencing were analysed. We used Ultrafast Sample placement on Existing tRees to understand the dynamics of beta and delta waves, using available genomic data. This tool can reconstruct a phylogeny with millions of sequences by efficient sample placement in a tree. We reconstructed a phylogeny (~7·6 million sequences) adding new and publicly available beta and delta sequences. Findings: A total of 5793 patients were recruited between Nov 1, 2020, and Aug 31, 2021. During this time, 133 328 COVID-19 cases were reported in Mozambique. 280 good quality new SARS-CoV-2 sequences were obtained after the inclusion criteria were applied and an additional 652 beta (B.1.351) and delta (B.1.617.2) public sequences were included from Mozambique. We evaluated 373 beta and 559 delta sequences. We identified 187 beta introductions (including 295 sequences), divided in 42 transmission groups and 145 unique introductions, mostly from South Africa, between August, 2020 and July, 2021. For delta, we identified 220 introductions (including 494 sequences), with 49 transmission groups and 171 unique introductions, mostly from the UK, India, and South Africa, between April and November, 2021. Interpretation: The timing and origin of introductions suggests that movement restrictions effectively avoided introductions from non-African countries, but not from surrounding countries. Our results raise questions about the imbalance between the consequences of restrictions and health benefits. This new understanding of pandemic dynamics in Mozambique can be used to inform public health interventions to control the spread of new variants. Funding: European and Developing Countries Clinical Trials, European Research Council, Bill & Melinda Gates Foundation, and Agència de Gestió d'Ajuts Universitaris i de Recerca.

Tracking SARS-CoV-2 introductions in Mozambique using pandemic-scale phylogenies: a retrospective observational study.

BACKGROUND: From the start of the SARS-CoV-2 outbreak, global sequencing efforts have generated an unprecedented amount of genomic data. Nonetheless, unequal sampling between high-income and low-income countries hinders the implementation of genomic surveillance systems at the global and local level. Filling the knowledge gaps of genomic information and understanding pandemic dynamics in low-income countries is essential for public health decision making and to prepare for future pandemics. In this context, we aimed to discover the timing and origin of SARS-CoV-2 variant introductions in Mozambique, taking advantage of pandemic-scale phylogenies. METHODS: We did a retrospective, observational study in southern Mozambique. Patients from Manhiça presenting with respiratory symptoms were recruited, and those enrolled in clinical trials were excluded. Data were included from three sources: (1) a prospective hospital-based surveillance study (MozCOVID), recruiting patients living in Manhiça, attending the Manhiça district hospital, and fulfilling the criteria of suspected COVID-19 case according to WHO; (2) symptomatic and asymptomatic individuals with SARS-CoV-2 infection recruited by the National Surveillance system; and (3) sequences from SARS-CoV-2-infected Mozambican cases deposited on the Global Initiative on Sharing Avian Influenza Data database. Positive samples amenable for sequencing were analysed. We used Ultrafast Sample placement on Existing tRees to understand the dynamics of beta and delta waves, using available genomic data. This tool can reconstruct a phylogeny with millions of sequences by efficient sample placement in a tree. We reconstructed a phylogeny (~7·6 million sequences) adding new and publicly available beta and delta sequences. FINDINGS: A total of 5793 patients were recruited between Nov 1, 2020, and Aug 31, 2021. During this time, 133 328 COVID-19 cases were reported in Mozambique. 280 good quality new SARS-CoV-2 sequences were obtained after the inclusion criteria were applied and an additional 652 beta (B.1.351) and delta (B.1.617.2) public sequences were included from Mozambique. We evaluated 373 beta and 559 delta sequences. We identified 187 beta introductions (including 295 sequences), divided in 42 transmission groups and 145 unique introductions, mostly from South Africa, between August, 2020 and July, 2021. For delta, we identified 220 introductions (including 494 sequences), with 49 transmission groups and 171 unique introductions, mostly from the UK, India, and South Africa, between April and November, 2021. INTERPRETATION: The timing and origin of introductions suggests that movement restrictions effectively avoided introductions from non-African countries, but not from surrounding countries. Our results raise questions about the imbalance between the consequences of restrictions and health benefits. This new understanding of pandemic dynamics in Mozambique can be used to inform public health interventions to control the spread of new variants. FUNDING: European and Developing Countries Clinical Trials, European Research Council, Bill & Melinda Gates Foundation, and Agència de Gestió d'Ajuts Universitaris i de Recerca.

Anti-malarial resistance in Mozambique: Absence of Plasmodium falciparum Kelch 13 (K13) propeller domain polymorphisms associated with resistance to artemisinins.

BACKGROUND: Malaria remains one of the most serious public health problems in sub-Saharan Africa and Mozambique is the world's fourth largest contributor, with 4.7% of disease cases and 3.6% of total deaths due to malaria. Its control relies on the fight against the vector and treatment of confirmed cases with anti-malarial drugs. Molecular surveillance is an important tool for monitoring the spread of anti-malarial drug resistance. METHODS: A cross-sectional study recruited 450 participants with malaria infection detected by Rapid Diagnostic Tests, from three different study sites (Niassa, Manica and Maputo) between April and August 2021. Correspondent blood samples were collected on filter paper (Whatman® FTA® cards), parasite DNA extracted and pfk13 gene sequenced using Sanger method. SIFT software (Sorting Intolerant From Tolerant) was used, predict whether an amino acid substitution affects protein function. RESULTS: No pfkelch13-mediated artemisinin resistance gene mutation was detected in this study settings. However, non-synonymous mutations were detected at prevalence of 10.2%, 6% and 5% in Niassa, Manica and Maputo, respectively. Most (56.3%) of the reported non-synonymous mutations were due to substitution at the first base of the codon, 25% at the second base and 18.8% at the third base. Additionally, 50% of non-synonymous mutations showed a SIFTscore bellow cut off value of 0.05, therefore, they were predicted to be deleterious. CONCLUSION: These results do not show an emergence of artemisinin resistance cases in Mozambique. However, the increased number of novel non-synonymous mutations highlights the relevance of increasing the number of studies focused on the molecular surveillance of artemisinin resistance markers, for its early detection.

Feasibility, Acceptability, and Protective Efficacy of Seasonal Malaria Chemoprevention Implementation in Nampula Province, Mozambique: Protocol for a Hybrid Effectiveness-Implementation Study.

BACKGROUND: Seasonal malaria chemoprevention (SMC) is a highly effective community-based intervention to prevent malaria infections in areas where the malaria burden is high and transmission occurs mainly during the rainy season. In Africa, so far, SMC has been implemented in the Sahel region. Mozambique contributes 4% of the global malaria cases, and malaria is responsible for one-quarter of all deaths in the country. Based on recommendations in the Malaria Strategic Plan, the Malaria Consortium, in partnership with the National Malaria Control Programme in Mozambique, initiated a phased SMC implementation study in the northern province of Nampula. The first phase of this 2-year implementation study was conducted in 2020-2021 and focused on the feasibility and acceptability of SMC. The second phase will focus on demonstrating impact. This paper describes phase 2 of the implementation study. OBJECTIVE: Specific objectives include the following: (1) to determine the effectiveness of SMC in terms of its reduction in incidence of malaria infection among children aged 3 to 59 months; (2) to determine the chemoprevention efficacy of sulfadoxine-pyrimethamine plus amodiaquine (SP+AQ) when used for SMC in Nampula Province, Mozambique, and the extent to which efficacy is impacted by drug resistance and drug concentrations; (3) to investigate the presence and change in SP+AQ- and piperaquine-resistance markers over time as a result of SMC implementation; and (4) to understand the impact of the SMC implementation model, determining the process and acceptability outcomes for the intervention. METHODS: This type 2, hybrid, effectiveness-implementation study uses a convergent mixed methods approach. SMC will be implemented in four monthly cycles between December 2021 and March 2022 in four districts of Nampula Province. Phase 2 will include four components: (1) a cluster randomized controlled trial to establish confirmed malaria cases, (2) a prospective cohort to determine the chemoprevention efficacy of the antimalarials used for SMC and whether drug concentrations or resistance influence the duration of protection, (3) a resistance marker study in children aged 3 to 59 months to describe changes in resistance marker prevalence over time, and (4) a process evaluation to determine feasibility and acceptability of SMC. RESULTS: Data collection began in mid-January 2022, and data analysis is expected to be completed by October 2022. CONCLUSIONS: This is the first effectiveness trial of SMC implemented in Mozambique. The findings from this trial will be crucial to policy change and program expansion to other suitable geographies outside of the Sahel. The chemoprevention efficacy cohort study is a unique opportunity to better understand SMC drug efficacy in this new SMC environment. TRIAL REGISTRATION: ClinicalTrials.gov NCT05186363; https://clinicaltrials.gov/ct2/show/NCT05186363. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36403.

Prospective surveillance study to detect antimalarial drug resistance, gene deletions of diagnostic relevance and genetic diversity of Plasmodium falciparum in Mozambique: protocol.

INTRODUCTION: Genomic data constitute a valuable adjunct to routine surveillance that can guide programmatic decisions to reduce the burden of infectious diseases. However, genomic capacities remain low in Africa. This study aims to operationalise a functional malaria molecular surveillance system in Mozambique for guiding malaria control and elimination. METHODS AND ANALYSES: This prospective surveillance study seeks to generate Plasmodium falciparum genetic data to (1) monitor molecular markers of drug resistance and deletions in rapid diagnostic test targets; (2) characterise transmission sources in low transmission settings and (3) quantify transmission levels and the effectiveness of antimalarial interventions. The study will take place across 19 districts in nine provinces (Maputo city, Maputo, Gaza, Inhambane, Niassa, Manica, Nampula, Zambézia and Sofala) which span a range of transmission strata, geographies and malaria intervention types. Dried blood spot samples and rapid diagnostic tests will be collected across the study districts in 2022 and 2023 through a combination of dense (all malaria clinical cases) and targeted (a selection of malaria clinical cases) sampling. Pregnant women attending their first antenatal care visit will also be included to assess their value for molecular surveillance. We will use a multiplex amplicon-based next-generation sequencing approach targeting informative single nucleotide polymorphisms, gene deletions and microhaplotypes. Genetic data will be incorporated into epidemiological and transmission models to identify the most informative relationship between genetic features, sources of malaria transmission and programmatic effectiveness of new malaria interventions. Strategic genomic information will be ultimately integrated into the national malaria information and surveillance system to improve the use of the genetic information for programmatic decision-making. ETHICS AND DISSEMINATION: The protocol was reviewed and approved by the institutional (CISM) and national ethics committees of Mozambique (Comité Nacional de Bioética para Saúde) and Spain (Hospital Clinic of Barcelona). Project results will be presented to all stakeholders and published in open-access journals. TRIAL REGISTRATION NUMBER: NCT05306067.

In vivo efficacy and safety of artemether-lumefantrine and amodiaquine-artesunate for uncomplicated Plasmodium falciparum malaria in Mozambique, 2018.

BACKGROUND: Artemisinin-based combination therapy (ACT) has been the recommended first-line treatment for uncomplicated malaria in Mozambique since 2006, with artemether-lumefantrine (AL) and amodiaquine-artesunate (AS-AQ) as the first choice. To assess efficacy of currently used ACT, an in vivo therapeutic efficacy study was conducted. METHODS: The study was conducted in four sentinel sites: Montepuez, Moatize, Mopeia and Massinga. Patients between 6 and 59 months old with uncomplicated Plasmodium falciparum malaria (2000-200,000 parasites/µl) were enrolled between February and September of 2018, assigned to either an AL or AS-AQ treatment arm, and monitored for 28 days. A Bayesian algorithm was applied to differentiate recrudescence from new infection using genotyping data of seven neutral microsatellites. Uncorrected and PCR-corrected efficacy results at day 28 were calculated. RESULTS: Totals of 368 and 273 patients were enrolled in the AL and AS-AQ arms, respectively. Of these, 9.5% (35/368) and 5.1% (14/273) were lost to follow-up in the AL and AS-AQ arms, respectively. There were 48 and 3 recurrent malaria infections (late clinical and late parasitological failures) in the AL and AS-AQ arms, respectively. The day 28 uncorrected efficacy was 85.6% (95% confidence interval (CI) 81.3-89.2%) for AL and 98.8% (95% CI 96.7-99.8%) for AS-AQ, whereas day 28 PCR-corrected efficacy was 97.9% (95% CI 95.6-99.2%) for AL and 99.6% (95% CI 97.9-100%) for AS-AQ. Molecular testing confirmed that 87.4% (42/48) and 33.3% (1/3) of participants with a recurrent malaria infection in the AL and AS-AQ arms were new infections; an expected finding in a high malaria transmission area. Adverse events were documented in less than 2% of participants for both drugs. CONCLUSION: Both AL and AS-AQ have therapeutic efficacies well above the 90% WHO recommended threshold and remain well-tolerated in Mozambique. Routine monitoring of therapeutic efficacy should continue to ensure the treatments remain efficacious. Trial registration Clinicaltrials.gov: NCT04370977.

Molecular surveillance for polymorphisms associated with artemisinin-based combination therapy resistance in Plasmodium falciparum isolates collected in Mozambique, 2018.

BACKGROUND: Due to the threat of emerging anti-malarial resistance, the World Health Organization recommends incorporating surveillance for molecular markers of anti-malarial resistance into routine therapeutic efficacy studies (TESs). In 2018, a TES of artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) was conducted in Mozambique, and the prevalence of polymorphisms in the pfk13, pfcrt, and pfmdr1 genes associated with drug resistance was investigated. METHODS: Children aged 6-59 months were enrolled in four study sites. Blood was collected and dried on filter paper from participants who developed fever within 28 days of initial malaria treatment. All samples were first screened for Plasmodium falciparum using a multiplex real-time PCR assay, and polymorphisms in the pfk13, pfcrt, and pfmdr1 genes were investigated by Sanger sequencing. RESULTS: No pfk13 mutations, associated with artemisinin partial resistance, were observed. The only pfcrt haplotype observed was the wild type CVMNK (codons 72-76), associated with chloroquine sensitivity. Polymorphisms in pfmdr1 were only observed at codon 184, with the mutant 184F in 43/109 (39.4%) of the samples, wild type Y184 in 42/109 (38.5%), and mixed 184F/Y in 24/109 (22.0%). All samples possessed N86 and D1246 at these two codons. CONCLUSION: In 2018, no markers of artemisinin resistance were documented. Molecular surveillance should continue to monitor the prevalence of these markers to inform decisions on malaria treatment in Mozambique.

In vivo efficacy and safety of artemether-lumefantrine and amodiaquine-artesunate for uncomplicated Plasmodium falciparum malaria in Mozambique, 2018

Artemisinin-based combination therapy (ACT) has been the recommended first-line treatment for uncomplicated malaria in Mozambique since 2006, with artemether-lumefantrine (AL) and amodiaquine-artesunate (AS-AQ) as the first choice. To assess efficacy of currently used ACT, an in vivo therapeutic efficacy study was conducted. Methods: The study was conducted in four sentinel sites: Montepuez, Moatize, Mopeia and Massinga. Patients between 6 and 59 months old with uncomplicated Plasmodium falciparum malaria (2000-200,000 parasites/µl) were enrolled between February and September of 2018, assigned to either an AL or AS-AQ treatment arm, and monitored for 28 days. A Bayesian algorithm was applied to differentiate recrudescence from new infection using genotyping data of seven neutral microsatellites. Uncorrected and PCR-corrected efficacy results at day 28 were calculated. Results: Totals of 368 and 273 patients were enrolled in the AL and AS-AQ arms, respectively. Of these, 9.5% (35/368) and 5.1% (14/273) were lost to follow-up in the AL and AS-AQ arms, respectively. There were 48 and 3 recurrent malaria infections (late clinical and late parasitological failures) in the AL and AS-AQ arms, respectively. The day 28 uncorrected efficacy was 85.6% (95% confidence interval (CI) 81.3-89.2%) for AL and 98.8% (95% CI 96.7-99.8%) for AS-AQ, whereas day 28 PCR-corrected efficacy was 97.9% (95% CI 95.6-99.2%) for AL and 99.6% (95% CI 97.9-100%) for AS-AQ. Molecular testing confirmed that 87.4% (42/48) and 33.3% (1/3) of participants with a recurrent malaria infection in the AL and AS-AQ arms were new infections; an expected finding in a high malaria transmission area. Adverse events were documented in less than 2% of participants for both drugs. Conclusion: Both AL and AS-AQ have therapeutic efficacies well above the 90% WHO recommended threshold and remain well-tolerated in Mozambique. Routine monitoring of therapeutic efficacy should continue to ensure the treatments remain efficacious. Trial registration Clinicaltrials.gov

Assessment of the Feasibility, Acceptability, and Impact of Implementing Seasonal Malaria Chemoprevention in Nampula Province, Mozambique: Protocol for a Hybrid Effectiveness-Implementation Study.

BACKGROUND: Malaria is a significant cause of morbidity and mortality in children aged under 5 years in Mozambique. The World Health Organization recommends seasonal malaria chemoprevention (SMC), the administration of four monthly courses of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ), to children aged 3-59 months during rainy season. However, as resistance to SP is widespread in East and Southern Africa, SMC has so far only been implemented across the Sahel in West Africa. OBJECTIVE: This protocol describes the first phase of a pilot project that aims to assess the protective effect of SP and AQ when used for SMC and investigate the levels of molecular markers of resistance of Plasmodium falciparum to antimalarial medicines in the study districts. In addition, it is important to understand whether SMC is a feasible and acceptable intervention in the context of Nampula Province, Mozambique. METHODS: This study will adopt a hybrid effectiveness-implementation design to conduct a mixed methods evaluation with six objectives: a molecular marker study, a nonrandomized controlled trial, an analysis of reported malaria morbidity indicators, a documentation exercise of the contextual SMC adaptation, an acceptability and feasibility assessment, and a coverage and quality assessment. RESULTS: Ethical approval for this study was granted by the Mozambican Ministry of Health National Bioethics Committee on September 15, 2020. Data collection began in October 2020, and data analysis is expected to be completed by August 2021. CONCLUSIONS: This research will make a unique contribution to our understanding of whether the combination of SP and AQ, when used for SMC, can confer a protective effect against malaria in children aged 3-59 months in a region where malaria transmission is seasonal and SP resistance is expected to be high. If the project is successful, subsequent phases are expected to provide a more comprehensive assessment of the effectiveness and sustainability of SMCs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27855.

Assessment of the Feasibility, Acceptability, and Impact of Implementing Seasonal Malaria Chemoprevention in Nampula Province, Mozambique: Protocol for a Hybrid Effectiveness-Implementation Study

Background Malaria is a significant cause of morbidity and mortality in children aged under 5 years in Mozambique. The World Health Organization recommends seasonal malaria chemoprevention (SMC), the administration of four monthly courses of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ), to children aged 3-59 months during rainy season. However, as resistance to SP is widespread in East and Southern Africa, SMC has so far only been implemented across the Sahel in West Africa. Objective This protocol describes the first phase of a pilot project that aims to assess the protective effect of SP and AQ when used for SMC and investigate the levels of molecular markers of resistance of Plasmodium falciparum to antimalarial medicines in the study districts. In addition, it is important to understand whether SMC is a feasible and acceptable intervention in the context of Nampula Province, Mozambique. Methods This study will adopt a hybrid effectiveness-implementation design to conduct a mixed methods evaluation with six objectives: a molecular marker study, a nonrandomized controlled trial, an analysis of reported malaria morbidity indicators, a documentation exercise of the contextual SMC adaptation, an acceptability and feasibility assessment, and a coverage and quality assessment. Results Ethical approval for this study was granted by the Mozambican Ministry of Health National Bioethics Committee on September 15, 2020. Data collection began in October 2020, and data analysis is expected to be completed by August 2021. Conclusions This research will make a unique contribution to our understanding of whether the combination of SP and AQ, when used for SMC, can confer a protective effect against malaria in children aged 3-59 months in a region where malaria transmission is seasonal and SP resistance is expected to be high. If the project is successful, subsequent phases are expected to provide a more comprehensive assessment of the effectiveness and sustainability of SMCs.

Utilization of a local 'Malaria Post' indicates that carers from a village in Mozambique respond appropriately to malaria attacks

As malaria elimination becomes a possibility the focus of interventions changes from vector control to disease control. It is important that treatment occurs early during an infection in order for it to be efficacious, especially at the population level. The time between the onset of symptoms and treatment seeking is, therefore, crucial. Following a census and an oral autopsy survey of the inhabitants of Furvela, a village in southern Mozambique, a malaria post (MP) where malaria was diagnosed and treated was established in 2001. The time between the onset of symptoms and attendance at the MP was determined and compared to the severity of disease. A cross-sectional survey was also conducted, in 2007, to determine prevalence amongst 235 children aged between 6 months and 15 years of age. Malaria was hyperendemic in the village and was responsible for most deaths reported from the two years prior to the start of the project. In the prevalence survey 74% of two-to-four-year-old children had malaria parasites. The likelihood of being parasite positive was significantly higher in children living in houses with roofs made of traditional materials compared to those living in houses with tin roofs. At the start of the project only 12% of residents owned or used a mosquito net, most of which were not treated with insecticide. However, even before any formal intervention, malaria declined in the village between 2001 and 2007, but there was a rebound in later years. Nevertheless, the relative proportion of patients who had to be referred to the hospital declined significantly in the latter years of the project, and the incidence of both Plasmodium ovale and P. malariae also decreased significantly. Overall 16698 patients, the majority of which were under one year of age, attended the MP between 2001 and 2010. The proportion of patients with a positive slide for P. falciparum remained relatively constant throughout the study (mean 0.66 std. dev. 0.3) Most of the patients came from the village of Furvela, or its environs, but some came from the nearby town, ostensibly because of the good treatment they received. Infection rates increased up to the first three years of life to a peak incidence of 92% at 31 months. Children with fever had higher parasite densities than those without fever. Mothers generally bought their children to the MP on the second day of symptoms but on the first day if they had fever. Older patients, with lower density infections, delayed in coming for treatment. These patients may harbour sub-microscopic gametocytes which would help maintain transmission in the village. Mothers acted appropriately in their treatment seeking behaviour. The establishment of village-based MPs are an effective way of providing adequate diagnosis and treatment in villages such as Furvela.

Utilization of a local 'Malaria Post' indicates that carers from a village in Mozambique respond appropriately to malaria attacks.

As malaria elimination becomes a possibility the focus of interventions changes from vector control to disease control. It is important that treatment occurs early during an infection in order for it to be efficacious, especially at the population level. The time between the onset of symptoms and treatment seeking is, therefore, crucial. Following a census and an oral autopsy survey of the inhabitants of Furvela, a village in southern Mozambique, a malaria post (MP) where malaria was diagnosed and treated was established in 2001. The time between the onset of symptoms and attendance at the MP was determined and compared to the severity of disease. A cross-sectional survey was also conducted, in 2007, to determine prevalence amongst 235 children aged between 6 months and 15 years of age. Malaria was hyperendemic in the village and was responsible for most deaths reported from the two years prior to the start of the project. In the prevalence survey 74% of two-to-four-year-old children had malaria parasites. The likelihood of being parasite positive was significantly higher in children living in houses with roofs made of traditional materials compared to those living in houses with tin roofs. At the start of the project only 12% of residents owned or used a mosquito net, most of which were not treated with insecticide. However, even before any formal intervention, malaria declined in the village between 2001 and 2007, but there was a rebound in later years. Nevertheless, the relative proportion of patients who had to be referred to the hospital declined significantly in the latter years of the project, and the incidence of both Plasmodium ovale and P. malariae also decreased significantly. Overall 16698 patients, the majority of which were under one year of age, attended the MP between 2001 and 2010. The proportion of patients with a positive slide for P. falciparum remained relatively constant throughout the study (mean 0.66 std. dev. 0.3) Most of the patients came from the village of Furvela, or its environs, but some came from the nearby town, ostensibly because of the good treatment they received. Infection rates increased up to the first three years of life to a peak incidence of 92% at 31 months. Children with fever had higher parasite densities than those without fever. Mothers generally bought their children to the MP on the second day of symptoms but on the first day if they had fever. Older patients, with lower density infections, delayed in coming for treatment. These patients may harbour sub-microscopic gametocytes which would help maintain transmission in the village. Mothers acted appropriately in their treatment seeking behaviour. The establishment of village-based MPs are an effective way of providing adequate diagnosis and treatment in villages such as Furvela.

Adherence to COVID-19 Preventive Measures in Mozambique: Two Consecutive Online Surveys.

We assessed adherence to government recommendations implemented shortly after the introduction of COVID-19 in Mozambique in March 2020, through two online cross-sectional surveys in April and June 2020. We quantified adherence to preventive measures by a composite score comprising of five measures: physical distancing, face mask use, hand hygiene, cough hygiene, and avoidance of touching the face. 3770 and 1115 persons participated in the first and second round respectively. Wearing face masks, regular handwashing and cough hygiene all reached compliance rates of over 90% while physical distancing and avoiding to touch the face reached a compliance rate of 80-90%. A multivariable model investigating factors associated with adherence found that being older, more educated, and belonging to the healthcare sector increased the odds for higher adherence. Private workers and retired people, respondents receiving COVID-19 information through social media, and those who reported flu-like symptoms were less likely to adhere. 6% of respondents reported flu-like symptoms which aligned with the WHO clinical definition of COVID-19, suggesting low level community transmission. In conclusion, most respondents in this online survey in Mozambique complied well with strategies to prevent COVID-19. Whether the good preventive behaviour explains the low grade COVID-19 transmission requires further study.

Adherence to COVID-19 Preventive Measures in Mozambique: Two Consecutive Online Surveys

We assessed adherence to government recommendations implemented shortly after the introduction of COVID-19 in Mozambique in March 2020, through two online cross-sectional surveys in April and June 2020. We quantified adherence to preventive measures by a composite score comprising of five measures: physical distancing, face mask use, hand hygiene, cough hygiene, and avoidance of touching the face. 3770 and 1115 persons participated in the first and second round respectively. Wearing face masks, regular handwashing and cough hygiene all reached compliance rates of over 90% while physical distancing and avoiding to touch the face reached a compliance rate of 80-90%. A multivariable model investigating factors associated with adherence found that being older, more educated, and belonging to the healthcare sector increased the odds for higher adherence. Private workers and retired people, respondents receiving COVID-19 information through social media, and those who reported flu-like symptoms were less likely to adhere. 6% of respondents reported flu-like symptoms which aligned with the WHO clinical definition of COVID-19, suggesting low level community transmission. In conclusion, most respondents in this online survey in Mozambique complied well with strategies to prevent COVID-19. Whether the good preventive behaviour explains the low grade COVID-19 transmission requires further study.

In vivo efficacy and safety of artemetherlumefantrine and amodiaquine­artesunate for uncomplicated Plasmodium falciparum malaria in Mozambique, 2018

Background: Artemisinin-based combination therapy (ACT) has been the recommended first-line treatment for uncomplicated malaria in Mozambique since 2006, with artemether­lumefantrine (AL) and amodiaquine­artesunate (AS­AQ) as the first choice. To assess efficacy of currently used ACT, an in vivo therapeutic efficacy study was conducted. Methods: The study was conducted in four sentinel sites: Montepuez, Moatize, Mopeia and Massinga. Patients between 6 and 59 months old with uncomplicated Plasmodium falciparum malaria (2000­200,000 parasites/µl) were enrolled between February and September of 2018, assigned to either an AL or AS­AQ treatment arm, and monitored for 28 days. A Bayesian algorithm was applied to differentiate recrudescence from new infection using genotyping data of seven neutral microsatellites. Uncorrected and PCR-corrected efficacy results at day 28 were calculated. Results: Totals of 368 and 273 patients were enrolled in the AL and AS­AQ arms, respectively. Of these, 9.5% (35/368) and 5.1% (14/273) were lost to follow-up in the AL and AS­AQ arms, respectively. There were 48 and 3 recurrent malaria infections (late clinical and late parasitological failures) in the AL and AS­AQ arms, respectively. The day 28 uncorrected efficacy was 85.6% (95% confidence interval (CI) 81.3­89.2%) for AL and 98.8% (95% CI 96.7­99.8%) for AS­AQ, whereas day 28 PCR-corrected efficacy was 97.9% (95% CI 95.6­99.2%) for AL and 99.6% (95% CI 97.9­100%) for AS­AQ. Molecular testing confirmed that 87.4% (42/48) and 33.3% (1/3) of participants with a recurrent malaria infection in the AL and AS­AQ arms were new infections; an expected finding in a high malaria transmission area. Adverse events were documented in less than 2% of participants for both drugs. Conclusion: Both AL and AS­AQ have therapeutic efficacies well above the 90% WHO recommended threshold and remain well-tolerated in Mozambique. Routine monitoring of therapeutic efficacy should continue to ensure the treatments remain efficacious.

Percepções sobre a divulgação da imagem institucional do Instituto Nacional de Saúde, 2015-2017 / Perceptions on the dissemination of the institutional image of the National Institute of Health, 2015-2017

Introdução: Imagem institucional ou corporativa é a imagem mental que um indivíduo ou grupo de pessoas têm, que acompanha a menção do nome da instituição. Essa imagem é continuamente modificada de acordo com as circunstâncias da instituição, cobertura da mídia, desempenho, pronunciamentos, entre outros elementos. Objectivo: Descrever a percepção dos profissionais do Instituto Nacional de Saúde (INS) e do público externo em relação a divulgação da imagem institucional do Instituto Nacional de Saúde. Metods: Trata-se de uma pesquisa qualitativa exploratória na qual foi avaliada a percepção dos participantes de estudo (funcionários do INS e público externo) em relação a temática em estudo. A recolha de dados foi por meio do roteiro de entrevista semi-estruturada, realizadas entre os meses de Julho a Agosto de 2016, num universo de 22 participantes. Os resultados do presente estudo, foram analisados pela técnica de análise de conteúdo. Resultados: A maior parte dos participantes mencionou que existe um conhecimento incipiente por parte dos funcionários do INS sobre a importância da divulgação da imagem institucional, além disso os meios de comunicação que o INS tem usado para se comunicar com o público externo, não tem sido potencialmente explorado, existindo ainda muita produção técnica e científica que não é divulgada. Conclusão: Concluímos que o INS precisa apostar mais na divulgação da sua imagem e nas principais áreas de intervenção de modo a garantir maior visibilidade, particularmente a nível externo. Para o efeito, deverá elaborar uma estratégia específica de comunicação e apostar mais no marketing digital.

marketing digital. 1.641 / 5.000 Resultados de tradução Resultado da tradução Introduction: Institutional or corporate image is the mental image that an individual or group of people have, which accompanies the mention of the name of the institution. This image is continually modified according to the institution's circumstances, media coverage, performance, pronouncements, among other elements. Objective: To describe the perception of professionals at the National Institute of Health (INS) and the external public regarding the dissemination of the institutional image of the National Institute of Health. Methods: This is an exploratory qualitative research in which the perception of the study participants (employees of the INS and external public) in relation to the theme under study was evaluated. Data collection was through a semi-structured interview script, carried out between the months of July and August 2016, in a universe of 22 participants. The results of this study were analyzed using the content analysis technique. Results: Most of the participants mentioned that there is an incipient knowledge on the part of INS employees about the importance of publicizing the institutional image, in addition, the means of communication that INS has used to communicate with the external public, has not been potentially explored, there is still a lot of technical and scientific production that is not divulged. Conclusion: We conclude that the INS needs to invest more in publicizing its image and in the main areas of intervention in order to guarantee greater visibility, particularly externally. For this purpose, you should develop a specific communication strategy and focus more on digital marketing.

Access to and use of preventive intermittent treatment for Malaria during pregnancy: A qualitative study in the Chókwè district, Southern Mozambique.

BACKGROUND: Malaria remains a significant health problem in Mozambique, particularly in the case of pregnant women and children less than five years old. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPT-SP) is recommended for preventing malaria in pregnancy (MiP). Despite the widespread use and cost-effectiveness of IPTp-SP, coverage remains low. In this study, we explored factors limiting access to and use of IPTp-SP in a rural part of Mozambique. METHODS AND FINDINGS: We performed a qualitative study using semi-structured interviews to collect data from 46 pregnant women and four health workers in Chókwè, a rural area of southern Mozambique. Data were transcribed, translated where appropriate, manually coded, and the content analyzed according to key themes. The women interviewed were not aware of the risks of MiP or the benefits of its prevention. Delays in accessing antenatal care, irregular attendance of visits, and insufficient time for proper antenatal care counselling by health workers were driving factors for inadequate IPTp delivery. CONCLUSIONS: Pregnant women face substantial barriers in terms of optimal IPTp-SP uptake. Health system barriers and poor awareness of the risks and consequences of MiP and of the measures available for its prevention were identified as the main factors influencing access to and use of IPTp-SP. Implementation of MiP prevention strategies must be improved through intensive community health education and increased access to other sources of information. Better communication between health workers and ANC clients and better knowledge of national ANC and IPTp policies are important.

Fórum de pós-graduação: experiência e lições aprendidas / Post-graduate forum: fxperiences and lessons learned

O presente artigo apresenta os objectivos, a metodologia, e uma visão geral da experiência e das lições aprendidas nos dois fóruns de pós-graduação realizados no Instituto Nacional de Saúde (INS) em Março de 2016 e (mês) de 2017.. A iniciativa de implementar fóruns de pós-graduação surge por um lado, como uma ferramenta para melhoria de qualidade das formações e por outro, como oportunidade de intercâmbio entre os estudantes que frequentam os cursos de pós-graduação coordenados pelo INS e os técnicos do INS que se encontram em programas de pós-graduação. Espera-se que os fóruns de pós-graduação no INS estimulem o desenvolvimento de actividades académicas e contribuam para o enriquecimento dos programas institucionais de pós-graduação.

is report describes the objective, methodology, the experience and Lessons learned in the -rst and second post-graduation forums, performed at the National Institute of Health of Mozambique (Instituto Nacional de Saúde, INS); in March 2016 and 2017, respectively. e introduction of post-graduation forums, arises, on the one hand, as a tool for improving quality of training, on the other, as an opportunity to promote discussions in a collaborative way between students attending the post-graduate courses coordinated by INS and INS technicians in post-graduate programs in other national and international institutions. e post-graduate forums at INS will also stimulate the development of academic activities and contribute to the improvement INS post-graduation programs.

Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Chókwè district, southern Mozambique.

BACKGROUND: Malaria in pregnancy leads to serious adverse effects on the mother and the child and accounts for 75,000-200,000 infant deaths every year. Currently, the World Health Organization recommends intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) at each scheduled antenatal care (ANC) visit. This study aimed to assess IPTp-SP coverage in mothers delivering in health facilities and at the community. In addition, factors associated with low IPTp-SP uptake and malaria adverse outcomes in pregnancy were investigated. METHODS: A community and a health facility-based surveys were conducted in mothers delivering in Chókwè district, southern Mozambique. Social-demographic data, malaria prevention practices and obstetric history were recorded through self-report and antenatal records. For women delivering at health facilities, a clinical examination of mother and child was performed, and malaria infection at delivery was determined by rapid diagnostic test, microscopy, quantitative PCR and placental histology. RESULTS: Of 1141 participants, 46.6, 30.2, 13.5 and 9.6% reported taking ≥ 3, two, one and none SP doses, respectively. Low IPTp uptake (< 3 doses) was associated with non-institutional deliveries (AOR = 2.9, P < 0.001), first ANC visit after week 28 (AOR = 5.4, P < 0.001), low awareness of IPTp-SP (AOR = 1.6, P < 0.002) and having no or only primary education (AOR = 1.3, P = 0.041). The overall prevalence of maternal malaria (peripheral and/or placental) was 16.8% and was higher among women from rural areas compared to those from urban areas (AOR = 1.9, P < 0.001). Younger age (< 20 years; AOR = 1.6, P = 0.042) and living in rural areas (AOR = 1.9, P < 0.001) were predictors of maternal malaria at delivery. Being primigravidae (AOR = 2.2, P = 0.023) and preterm delivery (AOR = 2.6, P < 0.001) predicted low birth weight while younger age was also associated with premature delivery (AOR = 1.4, P = 0.031). CONCLUSION: The coverage for two and ≥ 3 doses of IPTp-SP is moderately higher than estimates from routine health facility records in Gaza province in 2015. However, this is still far below the national target of 80% for ≥ 3 doses. Ongoing campaigns aiming to increase the use of malaria prevention strategies during pregnancy should particularly target rural populations, increasing IPTp-SP knowledge, stimulate early visits to ANC, improve access to health services and the quality of the service provided.