Emerging Zoonotic Diseases among Pastoral Communities of Caia and Búzi Districts, Sofala, Mozambique: Evidence of Antibodies against Brucella, Leptospira, Rickettsia, and Crimean-Congo Hemorrhagic Fever Virus.

BACKGROUND: Emerging zoonotic diseases are an increasing threat to public health. There is little data on the seroprevalence of zoonotic diseases among pastoralists in the country. We aim to carry out a cross-sectional study on the prevalence of major zoonotic diseases among pastoral communities in the Caia and Búzi districts. METHODS: Between January and December 2018, a questionnaire was used to solicit socio-demographic data from consenting pastoralists with the collection of blood samples in the Caia and Búzi districts of the Sofala province. All samples were tested using ELISA commercial reagents for the detection of IgM antibodies against Brucella and Leptospira. Likewise, IgM and IgG antibodies against Rickettsia and CCHFV were determined using ELISA kits. RESULTS: A total of 218 samples were tested, of which 43.5% (95/218) were from the district of Caia and 56.4% (123/218) from the Búzi district. Results from both districts showed that the seroprevalence of IgM antibodies against Brucella and Leptospira was 2.7% (6/218) and 30.3% (67/218), respectively. Positivity rates for IgM and IgG anti-Rickettsia and CCHFV were 8.7% (19/218), 2.7% (6/218), 4.1% (9/218), and 0.9% (2/218), respectively. CONCLUSIONS: Results from our study showed evidence of antibodies due to exposure to Brucella, Leptospira, Rickettsia, and CCHFV with antibodies against Leptospira and Rickettsia being the most prevalent. Hence, laboratory diagnosis of zoonotic diseases is essential in the early detection of outbreaks, the identification of silent transmission, and the etiology of non-febrile illness in a pastoral community. There is a need to develop public health interventions that will reduce the risk of transmission.

Multi-Cause Calibration of Verbal Autopsy-Based Cause-Specific Mortality Estimates of Children and Neonates in Mozambique.

The Countrywide Mortality Surveillance for Action platform is collecting verbal autopsy (VA) records from a nationally representative sample in Mozambique. These records are used to estimate the national and subnational cause-specific mortality fractions (CSMFs) for children (1-59 months) and neonates (1-28 days). Cross-tabulation of VA-based cause-of-death (COD) determination against that from the minimally invasive tissue sampling (MITS) from the Child Health and Mortality Prevention project revealed important misclassification errors for all the VA algorithms, which if not accounted for will lead to bias in the estimates of CSMF from VA. A recently proposed Bayesian VA-calibration method is used that accounts for this misclassification bias and produces calibrated estimates of CSMF. Both the VA-COD and the MITS-COD can be multi-cause (i.e., suggest more than one probable COD for some of the records). To fully use this probabilistic COD data, we use the multi-cause VA calibration. Two different computer-coded VA algorithms are considered-InSilicoVA and EAVA-and the final CSMF estimates are obtained using an ensemble calibration that uses data from both the algorithms. The calibrated estimates consistently offer a better fit to the data and reveal important changes in the CSMF for both children and neonates in Mozambique after accounting for VA misclassification bias.

Correcting for Verbal Autopsy Misclassification Bias in Cause-Specific Mortality Estimates.

Verbal autopsies (VAs) are extensively used to determine cause of death (COD) in many low- and middle-income countries. However, COD determination from VA can be inaccurate. Computer coded verbal autopsy (CCVA) algorithms used for this task are imperfect and misclassify COD for a large proportion of deaths. If not accounted for, this misclassification leads to biased estimates of cause-specific mortality fractions (CSMFs), a critical piece in health-policy making. Recent work has demonstrated that the knowledge of the CCVA misclassification rates can be used to calibrate raw VA-based CSMF estimates to account for the misclassification bias. In this manuscript, we review the current practices and issues with raw COD predictions from CCVA algorithms and provide a complete primer on how to use the VA calibration approach with the calibratedVA software to correct for verbal autopsy misclassification bias in cause-specific mortality estimates. We use calibratedVA to obtain CSMFs for child (1-59 months) and neonatal deaths using VA data from the Countrywide Mortality Surveillance for Action project in Mozambique.

Cyclone Idai as a Trigger for Pellagra Outbreak in Nhamatanda, Mozambique: A Case-Control Study.

In mid-June 2019, 3 months after cyclone Idai landfall in Mozambique, health authorities of Nhamatanda district reported an outbreak of Pellagra. Applying a mixed-method protocol, we carried out an investigation to characterize cases of pellagra, identify the associated factors for the outbreak using a case-control study, and explore the perceived impact on food security (availability, access, and usage) before and after Idai. We collected data from 121 cases and 121 controls and conducted in-depth interviews with 69 heads of households. The cases were more likely to be female (P < 0.01) and less educated (P < 0.01) than controls. Insufficient consumption of chicken and peanut before cyclone Idai arrival were statistically associated with pellagra (P < 0.05). From interviewed households' heads, 51% were experiencing food shortages even before the cyclone hit. Cyclone Idai served as a trigger to reduce niacin consumption below the threshold that protected Nhamatanda population from pellagra and caused a ≈2,300 case (707.9/100,000 inhabitants) outbreak.

High level of HIV false positives using EIA-based algorithm in survey: Importance of confirmatory testing.

The Mozambique Indicators of Immunization, Malaria and HIV/AIDS (IMASIDA) survey was conducted in 2015 and used a two Enzyme Immunoassay (EIA) (Vironostika HIV-1/2 and Murex HIV-1/2) based algorithm to determine the HIV status of the consented participants. The Mozambique Ministry of Health, with support from the US Centers for Disease Control and Prevention (US CDC), added Bio-Rad Geenius™ HIV-1/2 Supplemental Assay to the IMASIDA HIV testing algorithm to confirm all specimens that were found to be reactive on one or both EIAs. In total 11690 specimens were collected to estimate the proportion of HIV positive samples. Results indicate that the proportion of HIV positive samples based on the concordant positive results of two EIA assays was 21.5% (2518/11690). The addition of the Geenius assay to the IMASIDA HIV testing algorithm demonstrated that 792 (31.5%) of 2518 specimens were false-positive and reduced the proportion of HIV positive samples to 14.7% (1722/11690), demonstrating the importance of including a highly specific HIV test to confirm HIV diagnosis. HIV surveys exclusively based on EIA testing algorithm may result in misleading high prevalence results. Our results demonstrate that more specific confirmatory testing should be added to the EIA-based algorithms to ensure accurate HIV diagnosis and correct HIV prevalence estimate in cross-sectional surveys.

A survey of RNA viruses in mosquitoes from Mozambique reveals novel genetic lineages of flaviviruses and phenuiviruses, as well as frequent flavivirus-like viral DNA forms in Mansonia

Background: Mosquito-borne diseases involving arboviruses represent expanding threats to sub-Saharan Africa imposing as considerable burden to human and veterinary public health. In Mozambique over one hundred species of potential arbovirus mosquito vectors have been identi-fied, although their precise role in maintaining such viruses in circulation in the country remains to be elucidated. The aim of this study was to screen for the presence of flaviviruses, alphaviruses and bunyaviruses in mosquitoes from different regions of Mozambique. Results: Our survey analyzed 14,519 mosquitoes, and the results obtained revealed genetically distinct insectspecific flaviviruses, detected in multiple species of mosquitoes from different genera. In addition, smaller flaviviruslike NS5 sequences, frequently detected in Mansonia seemed to correspond to defective viral sequences, present as viral DNA forms. Furthermore, three lineages of putative members of the Phenuiviridae family were also detected, two of which apparently corresponding to novel viral genetic lineages. Conclusion: This study reports for the first-time novel insect-specific flaviviruses and novel phenuiviruses, as well as frequent flavivirus-like viral DNA forms in several widely known vector species. This unique work represents recent investigation of virus screening conducted in mosquitoes from Mozambique and an important contribution to inform the establishment of a vector control program for arbovirus in the country and in the region.

Care-seeking behaviour and treatment practices for malaria in children under 5 years in Mozambique: a secondary analysis of 2011 DHS and 2015 IMASIDA datasets.

BACKGROUND: In Mozambique, the prevalence of malaria in children under 5 years of age is among the highest in the world, but limited data exist on determinants of care-seeking behaviour for malaria. This study aimed at determining the trends and factors associated with care-seeking behaviour for fever among children under 5 years of age and to assess the treatment practices for malaria. METHODS: Secondary data analysis of two cross-sectional studies. Descriptive statistics were used to summarize socio-economic and demographic characteristics of participants, using data from the 2011 Demographic and Health Survey and 2015 Indicators of Immunization, Malaria and HIV/AIDS Survey. Complex sampling logistic regression model was used to identify factors associated with care-seeking behaviour, with estimated adjusted odds ratio and respective 95% confidence intervals, only for 2015 IMASIDA data. RESULTS: A total of 10,452 and 5168 children under 5 years of age were enrolled in the 2011 DHS and 2015 IMASIDA, respectively. Care-seeking for fever in public and private sectors remained stable during this period (62.6%; 835/1432 in 2011 and 63.7%; 974/1529 in 2015). The main place where care was sought in both surveys was public hospitals (86.2%; 773/897 in 2011 and 86.7%; 844/974 in 2015). Prescription of anti-malarial drugs increased from 42.9% (385/897) in 2011 to 53.8% (524/974) in 2015. Artemether-lumefantrine was the most used anti-malarial drug for febrile children in both surveys and its use increased from 59.0% (219/373) in 2011 to 89.3% (457/512) in 2015. Data from 2015 elucidated that care-seeking was more common in children whose mothers had a secondary level of education (AOR = 2.27 [95% CI 1.15-4.49]) and among those in poorer quintile (AOR = 1.46 [95% CI 0.83-1.90]). Mothers with higher education level (AOR = 0.16 [95% CI 0.34-0.78]) were less likely to seek out care. People from Manica (AOR = 2.49 [1.03-6.01]), Sofala ([AOR = 2.91 [1.03-8.24]), Inhambane (AOR = 3.95 [1.25-12.45]), Gaza (AOR = 3.25 [1.22-8.65]) and Maputo Province (AOR = 2.65 [1.10-6.41]) were more likely to seek care than people from Maputo City. CONCLUSION: Data from this study showed that care-seeking in Mozambique remained suboptimal. Interventions to raise the awareness for early care-seeking during episodes of fever should be urgently reinforced and intensified.

Retrospective investigation of antibodies against chikungunya virus (CHIKV) in serum from febrile patients in Mozambique, 2009-2015: Implications for its prevention and control

Introduction: Longitudinal data and trends about chikungunya virus (CHIKV) are critical for its control, however in Mozambique very few studies were conducted over 5 decades, between 1957 and 2013. In this study, we retrospectively investigated the occurrence, geographical distribution and trend of anti-CHIKV antibodies between 2009 and 2015 in Mozambique using serum samples from febrile patients. Methods: A total of 895 serum samples collected from febrile patients for measles and rubella surveillance between 2009 and 2015 in 127 districts of Mozambique were retrospectively tested for IgM and IgG antibodies against CHIKV using a commercially available ELISA. Results: The median age of patients was 2 years (IQR: 1-5 years) and 44.2% (395/895) of them were female. We found that 54 (6.0%) of samples were positive for anti-IgM chikungunya, and 160 (17.9%) were positive for anti-CHIKV IgG. Antibodies against CHIKV (IgM and IgG) were identified in serum throughout 2009 to 2015. While frequency of IgG antibodies was significantly higher in 2015 as compared to other years, frequency of IgM antibodies was homogeneous between 2009 and 2015. Antibodies against CHIKV were reported in all provinces and in 84 (66.1%) of the districts studied. Frequency of IgM and IgG antibodies was not significantly similar between age groups. Conclusion: This is the largest and longest serological screening of antibodies against CHIKV in febrile patients in Mozambique and findings from this study suggest that Mozambicans from all over the country have been silently exposed to CHIKV for several years.

Hepatocellular Carcinoma: Clinical-pathological features and HIV infection in Mozambican patients

Mozambique had been ranked among the countries with the highest global incidence of HCC with chronic hepatitis B infection and high exposure to aflatoxin-B1 (AFB1) being major risk factors. Indeed, HCC remains one of the most frequent cancer in Maputo. On the other hand, Mozambique has a high prevalence of infection with Human Immunodeficiency virus (HIV). Our study aims to describe the epidemiology, clinicopathological and serological features of patients with HCC in Maputo Central Hospital and its relationship with HIV. A series of 206 patients, diagnosed with HCC via fine needle aspiration, were consecutively included in the study. Patient data was collected using a questionnaire and all patients were tested for HBV, HCV, HIVMedian age was 49 years old and the M: F sex ratio was 2.4. A total of 114 (56.2%) of the patients were HBsAg positive. Hepatitis C antibodies were present in 8.9% of cases, and coinfection with HBV and HCV (HBsAg/anti-HCV) was observed in 4 (2.0%) cases. The remainder, 36.3%, were neither hepatitis B- nor C-related. HIV was detected in 34 cases (18.0%) cases. HIVHBV or HIV-HCV co-infections were observed in 22 (68.8%) and 2 (6.2%) cases. Overall, positivity for HIV was associated with younger age, and especially in patients with HBsAg+/antiHCV+. Our data emphasize the need for a reinforcement of secondary prevention measures in Mozambique. Serological screening for HBV in people born before universal antihepatitis B immunization (2001), effective screening, and specific management in HIV(+) patients are urgently needed.

Knowledge, attitudes and practices regarding antibiotic use in Maputo City, Mozambique

Background Irrational use of antibiotics is a major driver of antimicrobial resistance (AMR) worldwide. Sub-Saharan Africa, where the risk of spread of AMR is highest, lacks data on the knowledge, attitudes and practices regarding antibiotic prescription and use. This is the first study in Mozambique toaddress this gap. Methods Across-sectional study was conducted in 2016 in 1091 adults (age �18 years) living in five districts in peri-urban areas of Maputo City. Three stage cluster sampling was used to select the households. A semi-structured questionnaire was used to collect information on the knowledge, attitudes and practices regarding antibiotics and their use and socio-demographic data. Results Of the 1091participants, 20.9% (228/1091) had used non-prescribed antibiotics. Most of the non-prescribed antibiotics were purchased in pharmacies (199/228; 87.3%). The proportion of use of non-prescribed antibiotics was higher in those who purchased from informal markets (82.6%; 14/17) and home stores (66.7%; 12/18), compared to pharmacies (24.6%; 199/810) (p = 0.000). Variables significantly associated with use of non-prescribed antibiotics were male gender (p =0.004), living in the Central A (p<0.001), Aeroporto B (p<0.001) or 25 deJunho(p<0.001) neighborhoods, purchase of antibiotics in informal markets (p<0.002) or obtaining from home stores (p = 0.026), not completing the course (p<0.001) andhaving poor knowledge on the use ofantibiotics (p<0.001). Main reasons for use of non-prescribed antibiotics were a perception that there was no need to attend a health facility (26.8%), followed by someone else's advice (7.7%), symptoms similar to a previous episode (6.2%) and poor quality of care in health facilities (6.7%). PLOSONE|https://doi.org/10.1371/journal.pone.0221452 August 22, 2019 1/ 15Knowledge, attitudes and practices regarding antibiotic use in Maputo, Mozambique Conclusions Ourstudy shows for the first time that knowledge regarding antibiotics is poor in Maputo City. Purchase of non-prescribed antibiotics is a common practice and most are sold in pharmacies, indicating deficient inspection. Interventions to reinforce adherence by pharmacies to current legislation for dispensing antibiotics, combined with community education are urgently needed.

Self-reported non-receipt of HIV test results: A silent barrier to HIV epidemic control in Mozambique

Introduction: People living with HIV (PLHIV) and who are aware of their HIV status can access and benefit from antiretroviral therapy (ART) with subsequent individual and public health benefits; however, many PLHIV are unaware of their HIV status. We assessed the magnitude and determinants of self-reported non-receipt of HIV test results in adults aged 15-59 years old in Mozambique. Methods: We performed a secondary analysis of data from the 2015 Mozambique Immunization indicators, Malaria and HIV/AIDS (IMASIDA 2015). Eligible adults (15-59 years) from each selected household were interviewed and data on sociodemographic characteristics, HIV knowledge, attitudes and behaviors, and HIV testing history were collected. Multivariable logistic regression assessed factors associated with self-reported non-receipt of HIV test results. Population representative estimates were calculated. Results: 13,028 (90.8%) of 14,343 eligible participants were interviewed. A total of 6,654 (51.1%) respondents had previously been tested for HIV and were included in the analysis. Of these, 308 (4.6%; 95% CI: 3.70-5.77) self-reported not having received HIV test results. In the multivariable analysis, previous sexually transmitted infection (aOR: 2.76; 95% CI: 1.44-5.31), HIV stigmatizing attitudes (aOR: 1.96; 95% CI: 1.14-3.37), and lack of decision-making power towards health care seeking (aOR: 2.51; 95% CI: 1.39-4.52) were associated with non-receipt of HIV test results. Whereas, secondary or higher education (aOR: 0.25; 95% CI: 0.12-0.54), higher HIV knowledge (aOR: 0.47; 95% CI: 0.26-0.86), and age between 30-34 and 35-39 years old (aOR 0.47; 95% CI: 0.28-0.80; and aOR: 0.49; 95% CI: 0.27-0.90, respectively), were associated with receipt of HIV test results. Conclusions: In this nationally representative survey, self-reported non-receipt of HIV test results was high and of public health relevance. These findings suggest adaptation of HIV counseling and testing programs emphasizing individualized approaches that target the youngest, least educated and the poorest individuals, especially those living in rural areas.

Client experiences with antenatal care waiting times in southern Mozambique

Background: Antenatal care (ANC) provides a range of critical health services during pregnancy that can improve maternal and neonatal health outcomes. In Mozambique, only half of women receive four or more ANC visits, which are provided for free at public health centers by maternal and child health (MCH) nurses. Waiting time has been shown to contribute to negative client experiences, which may be a driver of low maternity care utilization. A recent pilot study of a program to schedule ANC visits demonstrated that scheduling care reduces waiting time and results in higher rates of complete ANC. This study aims to explore client experiences with waiting time for ANC in standard practice and care and after the introduction of appointment scheduling. Methods: This study uses a series of qualitative interviews to unpack client experiences with ANC waiting time with and without scheduled care, in order to better understand the impact of waiting time on client experiences. Thirtyeight interviews were collected in May to June 2017 at three pilot study clinics in southern Mozambique, with a focus on two paired intervention and comparison facilities sharing similar facility characteristics. Data were analyzed using inductive thematic analysis methods using NVivo software. Results: Clients described strong motivations to seek ANC, pointing to the need to address convenience of care, and highlighted direct and indirect costs of seeking care that were exacerbated by long waiting times. Direct costs include time and transport costs of going to the clinic, while indirect costs include being unable to fulfill household and work obligations. Other barriers to complete ANC utilization of four or more visits include transport costs, negative provider experiences, and delayed ANC initiation, which limit the potential number of clinic contacts. Conclusions: Findings demonstrate that the scheduling intervention improves the client experience of seeking care by allowing women to both seek ANC and fulfill other productive obligations. Innovation in healthcare delivery should consider adapting models that minimize waiting times.

Correction: HBV infection in untreated HIV-infected adults in Maputo, Mozambique.

[This corrects the article DOI: 10.1371/journal.pone.0181836.].

Seroepidemiology of Rubella in Mozambique, 2006-2014: Implications for Rubella Immunization in Settings With High Fertility Rates

Background: Rubella and congenital rubella syndrome are highly underreported and neglected in most sub-Saharan countries and vaccination has not yet been incorporated into their national immunization schedules. In this study, we investigated the frequency of immunoglobulin M antibodies against rubella and examined correlations with fertility rates during the period from 2006 to 2014 in Mozambique. Methods: We conducted a retrospective analysis of data collected through the routine case-based surveillance system for measles in Mozambique. Results: A total of 7312 serum samples from suspected cases of measles were tested between 2006 and 2014. The median age was 4 years (interquartile range: 1-8 years). Of these, 1331 (18.2%) were positive for immunoglobulin M anti-rubella. The highest frequency of rubella was observed within the 5-9-year-old age group (32.6%). The frequency in the age groups <1 years old, 1-4, 10-14, 15-19, 20-29 and ≥30 were 4.5%, 13.1%, 28.7%,18.7%, 5.2% and 5.1%, respectively. Conclusion: Our data show that rubella is frequent among women of childbearing age in Mozambique. Considering that early pregnancy is common in Mozambique, this suggests that, in settings such as ours, the introduction of routine rubella vaccination in children should be accompanied by repeated vaccination campaigns targeting older children and adolescents.

Prescription practices for malaria in Mozambique: poor adherence to the national protocols for malaria treatment in 22 public health facilities

Background: Current World Health Organization and national protocols recommend the 'test and treat' strategy for the management of uncomplicated malaria, to reduce over prescription of artemisinin-based combination treatment (ACT). Therefore, adherence to these protocols varies in different sub-Saharan African countries and no information is available for Mozambique. This study was conducted with the aim to evaluate the prescription practices of ACT in Mozambique. Methods: Retrospective audit of medical records corresponding to the period between July and December 2011 was conducted in 22 health units across 11 provinces in Mozambique. Two health units were selected per province according to availability of laboratory data (performing microscopy and rapid diagnostics testing-RDT or RDT only) and geographic setting (rural versus urban). At each facility, demographic data, laboratory results (blood smear or RDT), and prescription of ACT were all collected from the existing records. Results: Between July and December 2011, a total of 61,730 cases were tested for malaria, of which 42.7 % (26,369/61,730) were positive. A total of 35.361 patients were malaria negative, and ACT was prescribed to 72.0 % (25.448/35.361) of them. Prescription of ACT to malaria negative patients was higher in the central region of the country as compared to the northern and southern (81.1 % in the central region versus 72.4 and 63.7 % in the northern and southern, respectively, p = 0.000) and in urban settings (88.7 % in rural versus 58.0 % in urban settings, p = 0.000). Stock out of RDT was observed in six (27.3 %) of the health facilities. When no RDT was available, patients were empirically treated with ACT. Conclusion: Findings from this study demonstrate that health care worker's adherence to the new guidelines for malaria treatment is poor in Mozambique and prescription of ACT to malaria negative patients remains very high. Enhanced training and supervision activities, community education and external quality assurance might lead to significant improvements in the clinician's adherence to the new guideline for malaria treatment in Mozambique. Keywords: Malaria management, Over-treatment of malaria vs under-diagnosis of test-based malaria, Overtreatment of malaria