Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique.

INTRODUCTION: Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. METHODS: Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. RESULTS: Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). CONCLUSIONS: Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.

Evaluation of radiological capacity and usage in paediatric TB diagnosis: A mixed-method protocol of a comparative study in Mozambique, South Africa and Spain.

INTRODUCTION: Tuberculosis remains one of the top ten causes of mortality globally. Children accounted for 12% of all TB cases and 18% of all TB deaths in 2022. Paediatric TB is difficult to diagnose with conventional laboratory tests, and chest radiographs remain crucial. However, in low-and middle-income countries with high TB burden, the capacity for radiological diagnosis of paediatric TB is rarely documented and data on the associated radiation exposure limited. METHODS: A multicentre, mixed-methods study is proposed in three countries, Mozambique, South Africa and Spain. At the national level, official registry databases will be utilised to retrospectively compile an inventory of licensed imaging resources (mainly X-ray and Computed Tomography (CT) scan equipment) for the year 2021. At the selected health facility level, three descriptive cross-sectional standardised surveys will be conducted to assess radiology capacity, radiological imaging diagnostic use for paediatric TB diagnosis, and radiation protection optimization: a site survey, a clinician-targeted survey, and a radiology staff-targeted survey, respectively. At the patient level, potential dose optimisation will be assessed for children under 16 years of age who were diagnosed and treated for TB in selected sites in each country. For this component, a retrospective analysis of dosimetry will be performed on TB and radiology data routinely collected at the respective sites. National inventory data will be presented as the number of units per million people by modality, region and country. Descriptive analyses will be conducted on survey data, including the demographic, clinical and programmatic characteristics of children treated for TB who had imaging examinations (chest X-ray (CXR) and/or CT scan). Dose exposure analysis will be performed by children's age, gender and disease spectrum. DISCUSSION: As far as we know, this is the first multicentre and multi-national study to compare radiological capacity, radiation protection optimization and practices between high and low TB burden settings in the context of childhood TB management. The planned comparative analyses will inform policy-makers of existing radiological capacity and deficiencies, allowing better resource prioritisation. It will inform clinicians and radiologists on best practices and means to optimise the use of radiological technology in paediatric TB management.

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

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

Dung beetle fauna from Mount Mabu, Mozambique. Part 3: A new species of Proagoderus van Lansberge, 1883 with an annotated checklist of the Proagoderus dives (Harold, 1877) species-group (Coleoptera: Scarabaeidae: Scarabaeinae).

A new species of dung beetle, Proagoderus mabuensis Daniel, Josso, Nganhane & Strmpher, new species from Mount Mabu, northern Mozambique, is described, diagnosed, and illustrated. We provide a morphological comparison between the new species and a similar species from Mount Namuli, Mozambique, Proagoderus camiadei Josso, 2014. Both species belong to the Proagoderus dives (Harold, 1877) species-group. Furthermore, we provide an updated checklist of all known members of the dives species-group.

An evaluation of LLIN physical integrity and population attitudes towards net use, care and handling during the Magude project in southern Mozambique.

BACKGROUND: The Magude Project assessed the feasibility of eliminating malaria in Magude district, a low transmission setting in southern Mozambique, using a package of interventions, including long-lasting insecticidal nets (LLINs). As the efficacy of LLINs depends in part on their physical integrity, this metric was quantified for Olyset® Nets post mass-distribution, in addition to net use, care and handling practices and other risk factors associated with net physical integrity. METHODS: Nets were collected during a cross-sectional net evaluation, nine months after the Magude project commenced, which was 2 years after the nets were distributed by the National Malaria Control Programme (NMCP). The physical integrity of the nets was assessed by counting and sizing the holes at different positions on each net. A structured questionnaire was administered to assess how the selected net was used and treated (care, wash and repair). Net bio-efficacy was assessed following the standard World Health Organization (WHO) cone bioassay procedures. RESULTS: Out of the 170 Olyset® Nets included in the analysis, 63.5% had been used the night before. The main reason for not using a net was the notion that there were no mosquitoes present. The average number of people using each net was 1.79. Two thirds of the nets had only been washed once or twice since distribution. Most nets (80.9%) were holed and 18% were torn, but none of the risk factors were significantly associated with net integrity, except for presence of mice in the household. Less than half of the participants noticed holes in holed nets, and of those only 38.6% attempted to repair those. None of the six nets that were tested for bio-efficacy passed the WHO threshold of 80% mosquito mortality. CONCLUSION: Overall the majority of Olyset® Nets were in serviceable condition two years post-distribution, but their insecticidal effect may have been lost. This study-together with previous evidence on suboptimal access to and use of LLINs in Magude district-highlights that LLINs as an intervention could have been optimized during the Magude project to achieve maximum intervention impact.

Evaluation of a peer-support, 'mentor mother' program in Gaza, Mozambique; a qualitative study.

BACKGROUND: Retention in prevention of mother-to-child transmission of HIV programs is critical to reduce vertical transmission. To addresses challenges with retention, Mozambique launched a peer-support program in 2018, in which HIV-positive mothers provide adherence support as mentor mothers (MMs) for HIV-positive pregnant and lactating women and HIV-exposed and infected children. METHODS: A descriptive qualitative evaluation was conducted across nine facilities in Gaza Province to assess the acceptability and barriers to implementation of the mentor mother program (MMP) among those receiving services and providing services. In-depth interviews and focus group discussions were conducted with MMs, MM supervisors, health care workers (HCWs), HIV-positive mothers enrolled in the MMP, HIV-positive mothers who declined MMP enrollment, and key informants involved in the implementation of the program. Thematic analysis identified emerging recurrent themes and patterns across the participants' responses. Data were collected between November-December 2020. RESULTS: There were initial challenges with acceptability of the MMP, especially regarding confidentiality concerns and MM roles. Sharing additional information about MMs and making small changes during the beginning of the MMP resulted in generally high acceptance of the MMP. HIV-positive mothers reported that counseling from MMs improved their understanding of the importance of anti-retroviral treatment (ART) and how to take and administer ART. HIV-positive mothers reported having reduced guilt and shame about their HIV-status, feeling less alone, and having more control over their health. MMs shared that their work made them feel valued and decreased their self-stigmatization. However, MMs also reported feeling that they had inadequate resources to perform optimal job functions; they listed inadequate transportation, insufficient stipends, and false addresses of clients among their constraints. Overall, HCWs felt that their workload was significantly reduced with MM support and wanted more MMs in the community and health facility. CONCLUSIONS: This study found that the MMP was considered a substantive and highly valued support to HIV-positive mothers, resulting in increased ART literacy among patients, improved self-reported well-being and sense of community and reduced feelings of isolation. Recommendations include strengthening MM training, increasing financial and materiel resources, additional information provided to newly enrolled mothers and support for the male partners.

Human resources challenges in the management of diabetes and hypertension in Mozambique.

BACKGROUND: The major burden of non-communicable diseases (NCDs) globally occurs in low-and middle-income countries, where this trend is expected to increase dramatically over the coming years. The resultant change in demand for health care will imply significant adaptation in how NCD services are provided. This study aimed to explore self-reported training and competencies of healthcare providers, and the barriers they face in NCD services provision. METHODS: A qualitative design was used to conduct this study. Data was collected through semi-structured interviews with government officials within the Mozambican Ministry of Health, district health authorities, health facility managers, and health providers at urban and rural health facilities of Maputo, in Mozambique. The data was then analyzed under three domains: provider´s capacity building, health system structuring, and policy. RESULTS: A total of 24 interviews of the 26 planed with managers and healthcare providers at national, district, and health facility levels were completed. The domains analyzed enabled the identification and description of three themes. First, the majority of health training courses in Mozambique are oriented towards infectious diseases. Therefore, healthcare workers perceive that they need to consolidate and broaden their NCD-related knowledge or else have access to NCD-related in-service training to improve their capacity to manage patients with NCDs. Second, poor availability of diagnostic equipment, tools, supplies, and related medicines were identified as barriers to appropriate NCD care and management. Finally, insufficient NCD financing reflects the low level of prioritization felt by managers and healthcare providers. CONCLUSION: There is a gap in human, financial, and material resources to respond to the country's health needs, which is more significant for NCDs as they currently compete against major infectious disease programming, which is better funded by external partners. Healthcare workers at the primary health care level of Mozambique's health system are inadequately skilled to provide NCD care and they lack the diagnostic equipment and tools to adequately provide such care. Any increase in global and national responses to the NCD challenge must include investments in human resources and appropriate equipment.

Tobacco policy (in)coherence in Mozambique: an examination of national and subnational stakeholder perspectives.

Mozambique ranks fifth on the list of tobacco producing countries in Africa, while also being a Party to the WHO Framework Convention on Tobacco Control (FCTC). Tobacco farming is regarded by some governments as a strategic economic commodity for export and remains deeply entrenched within Mozambique's political and economic landscape. This study uses a qualitative description methodology to identify tensions, conflicts and alignment or misalignment in policy on tobacco across government sectors and levels in Mozambique. We conducted semi-structured qualitative interviews with 33 key informants from sectors across national and subnational levels including health, agriculture, economic and commercial sectors, as well as non-state actors from civil society organizations, the tobacco industry, farmers unions and associations and individual farmers. Incoherence was present across sectoral mandates, perspectives on industry's presence in the country and regions and between FCTC provisions and informant perceptions of tobacco production as a development strategy. Despite tobacco being viewed as an important economic commodity by many informants, there was also widespread dissatisfaction with tobacco from both farmers and some government officials. There were indications of an openness to shifting to a policy that emphasizes alternatives to tobacco growing. The findings also illustrate where points of convergence exist across sectors and where opportunities for aligning tobacco policy with the provisions of the FCTC can occur.

Realist evaluation of maternity waiting home intervention models in Inhambane, Mozambique: protocol for a comparative embedded case study, the Mozambique-Canada Maternal Health Project.

INTRODUCTION: This is a study protocol that tests and refines realist theories regarding the uptake and scale-up of the linked maternity waiting home (hereafter MWH) and facility birth intervention in the Mozambican context. The theories were developed through a realist review of MWH-facility birth literature from low-income and middle-income countries. The aim of the proposed study is to contribute to a contextually refined understanding of the causal chains underlying MWH-facility birth adoption by pregnant women and their families, communities, the health system and donors. METHODS AND ANALYSIS: The overarching methodology is mixed-methods realist evaluation. The study will adopt a comparative embedded case study design comparing three new masonry MWHs built by the Mozambique-Canada Maternal Health Project in Inhambane province with three older MWHs selected based on variation in the built environment. Baseline data on participating MWH-facility birth interventions will be collected through observations, reviews of routine data and analysis of statistics and reports from provincial and district health authorities and the Mozambique-Canada Maternal Health project. Realist interviews will be conducted with MWH users and non-users, companions of MWH users and non-users, partners of MWH users and non-users, and stakeholders within the health system and the non-governmental organisation sector. Realist focus groups will be used to collect data from community-level implementers. The analysis will be retroductive and use the context-mechanism-outcome configuration heuristic tool to represent generative causation. We will analyse data from intervention and comparator MWHs independently and compare the resulting refined programme theories. Data analysis will be done in NVivo 12. ETHICS AND DISSEMINATION: Ethics approval for the project has been obtained from the Mozambique National Bioethics Committee (CNBS-Comité Nacional de Bioética para a Saúde) and the University of Saskatchewan Bioethical Research Ethics Board. The evaluation will adhere to the International Ethical Guidelines for Biomedical Research Involving Human Subjects and the African adaptation of evaluation ethics and principles. Evaluation results will be disseminated to stakeholders' practice audiences through peer-reviewed publications, plain-language briefs, theory validation/feedback meetings and conference presentations.

Associations between Shared Sanitation, Stunting and Diarrhoea in Low-Income, High Density Urban Neighbourhoods of Maputo, Mozambique - a Cross-Sectional Study.

INTRODUCTION: Shared sanitation facilities are used by over 500 million people around the world. Most research evidence indicates that shared sanitation conveys higher risk than household sanitation for many adverse health outcomes. However, studies often fail to account for variation between different types of shared facilities. As informal housing development outpaces sanitation infrastructure, it is imperative to understand which components of shared facilities may mitigate the health risks of shared sanitation use. METHODS: This cross-sectional study determines whether sanitation improvement or compound hygiene were associated with stunting or diarrhoeal prevalence in children under five living in Maputo, Mozambique who rely on shared sanitation facilities. The study uses logistic and linear multivariable regression analysis to search for associations and control for potential confounding factors. RESULTS: 346 children (43.9%) in the study population were stunted. Each unit increase in sanitation score was associated with an approximate decrease of 22% in the odds of stunting (OR: 0.78, CI: 0.66, 0.92), and an increase in height of 0.23 height-for-age z-scores (CI: 0.10, 0.36). There was no evidence that the compound hygiene score was associated with height as measured by stunting (OR: 1.05, CI: 0.87, 1.26) or z-score (-0.06, CI: -0.21, 0.09). Neither sanitation nor compound hygiene score were associated with diarrhoea in the population. CONCLUSIONS: Use of an improved shared latrine is associated with decreased odds of stunting. There is no evidence of an association between latrine improvement and diarrhoea. Further investigation is necessary to isolate attributes of shared sanitation facilities that may reduce health risks.

Genomic malaria surveillance of antenatal care users detects reduced transmission following elimination interventions in Mozambique.

Routine sampling of pregnant women at first antenatal care (ANC) visits could make Plasmodium falciparum genomic surveillance more cost-efficient and convenient in sub-Saharan Africa. We compare the genetic structure of parasite populations sampled from 289 first ANC users and 93 children from the community in Mozambique between 2015 and 2019. Samples are amplicon sequenced targeting 165 microhaplotypes and 15 drug resistance genes. Metrics of genetic diversity and relatedness, as well as the prevalence of drug resistance markers, are consistent between the two populations. In an area targeted for elimination, intra-host genetic diversity declines in both populations (p = 0.002-0.007), while for the ANC population, population genetic diversity is also lower (p = 0.0004), and genetic relatedness between infections is higher (p = 0.002) than control areas, indicating a recent reduction in the parasite population size. These results highlight the added value of genomic surveillance at ANC clinics to inform about changes in transmission beyond epidemiological data.

Direitos reprodutivos das mulheres submetidas à cesárea em Moçambique: uma revisão integrativa / Drets reproductius de les dones sotmeses a cesària a Moçambic: una revisió integradora / Derechos reproductivos de las mujeres sometidas a cesárea en Mozambique: una revisión integradora / Reproductive rights of women undergoing cesarean section in Mozambique: an integrative review

O presente artigo está voltado às questões referentes aos direitos reprodutivos e ao parto cesárea das mulheres em Moçambique. O objetivo foi analisar as ações/estratégias governamentais e não governamentais que visem a efetivação dos direitos reprodutivos das mulheres submetidas ao parto cesárea em Moçambique, discutindo sobre as fragilidades que configuram a violação desses direitos. Para tanto, foi realizada uma revisão integrativa da literatura nas bases de dados Elsevier, GALE, PubMed, Web of Science e DOAJ a partir da combinação dos descritores cesarean section OR reproductive rights AND Mozambique. Depois de aplicadas as estratégias de inclusão e exclusão, resultaram 13 artigos elegíveis para elaboração do presente estudo. Os resultados apontam para a falta de aplicabilidade das ações governamentais que, apesar de existirem, ainda são ineficazes para que as mulheres de Moçambique tenham seus direitos reprodutivos garantidos e assistidos.(AU)

Aquest article es centra en qüestions relacionades amb els drets reproductius i el part per cesària de les dones a Moçambic. L'objectiu era analitzar les accions/estratègies tant governamentalscom no governamentals que busquen l'efectivitat dels drets reproductius de les dones sotmeses a cesària a Moçambic, discutint les debilitats que constitueixen la violació d'aquests drets. Per fer-ho, es va realitzar una revisió integradora de la literatura a les bases de dades Elsevier, GALE, PubMed, Web of Science i DOAJ a partir de la combinació dels descriptors cesarean section OR reproductive rights AND Mozambique. Després d'aplicar les estratègies d'inclusió i exclusió, es van obtenir 13 articles elegibles per a l'elaboració del present estudi. Els resultats assenyalen la manca d'aplicabilitat de les accions governamentals que, malgrat existir, encara són ineficaços per garantir i atendre els drets reproductius de les dones a Moçambic.(AU)

El presente artículo se centra en cuestiones relacionadas con los derechos reproductivos y el parto por cesárea de las mujeres en Mozambique. El objetivo fue analizar las acciones/estrategias gubernamentales y no gubernamentales que buscan la efectividad de los derechos reproductivos de las mujeres sometidas a cesárea en Mozambique, discutiendo las debilidades que constituyen la violación de estos derechos. Para ello, se realizó una revisión integradora de la literatura en las bases de datos Elsevier, GALE, PubMed, Web of Science y DOAJ a partir de la combinación de los descriptores cesarean section OR reproductive rights AND Mozambique. Después de aplicar las estrategias de inclusión y exclusión, se obtuvieron 13 artículos elegibles para la elaboración del presente estudio. Los resultados señalan la falta de aplicabilidad de las acciones gubernamentales que, a pesar de existir, aún son ineficaces para garantizary atender los derechos reproductivos de las mujeres en Mozambique.(AU)

This article addresses issues related to reproductive rights and cesarean delivery for women in Mozambique. The objective was to analyze governmental and non-governmental actions / strategies aimed at the realization of the reproductive rights of women submitted to cesarean delivery in Mozambique, discussing the weaknesses that constitute the violation of these rights. To this end, an integrative literature review was carried out in the Elsevier, GALE, PubMed, Web of Science and DOAJ databases based on the combination of the descriptors cesarean section OR reproductive rights AND Mozambique. After applying the inclusion and exclusion strategies, 14 articles were eligible for the preparation of this study. The results point to the lack of applicability of government actions that, although they exist, are still ineffective for women in Mozambique to have their reproductive rights fully guaranteed and assisted.(AU)

Prevalence and correlates of hazardous alcohol drinking and drug use among female sex workers and men who have sex with men in Mozambique.

BACKGROUND: Hazardous drinking and drug consumption are associated with an increased risk of HIV due to the complex interplay of factors influencing decision-making capability, stigma and social marginalization. In this study, we explore the patterns of hazardous alcohol and drug use and correlates of risk factors among female sex workers (FSW) and men who as sex with men (MSM) in Mozambique. METHODS: We conducted a secondary data analysis of bio-behavioral surveys (BBS) among FSW and MSM using a respondent-driven sampling methodology conducted in five main urban areas of Mozambique from 2019 to 20. The survey included a standardized questionnaire, where hazardous drinking was assessed (using AUDIT-C scores ≥ 4 for men, ≥ 3 for women) and drug use in the last year (FSW). Chi-squared test was used to analyze the association between socio-demographic and behavioral variables, and multivariate logistic regression measured the impact of the associated factors. RESULTS: The prevalence of hazardous alcohol drinking was 47.1% (95% CI:44.8-49.5) for FSW and 46.5 (95% CI: 44.0-49.0) for MSM. Current drug use was reported in 13.3% of FSW. FSW engaging in hazardous alcohol drinking reported more sexual partners in the last month than those no reporting hazardous alcohol use (55.3% vs. 47,1%, p < 0.001), higher rates of self-reported STIs in the last year (62,5% vs. 48,2%, p < 0.001), physical (53.5% vs. 46.7%, p < 0.0001) and sexual violence (54.7% vs. 44.2%, p < 0.001), and HIV prevalence (55.2% vs. 44.2 p < 0.001). Among MSM with hazardous alcohol drinking, there was a higher prevalence of self-reported STIs (52.8% vs. 45.4%, p < 0.001), experiences of sexual violence (18.0% vs. 8.3%, p < 0.001), and HIV prevalence (53.0% vs. 46.3%, p < 0.001). In addition, FSW who reported illicit drug use were more likely to self-reported HIV own risk (14.2% vs. 9.7%), early start sexual activity (15.4% vs. 5.3%), self-reported STIs (17.9% vs. 10.2%), and experiences of both physical (17.4% vs. 7.0%) and sexual violence (18.6% vs. 8.9%). CONCLUSION: There is an immediate need for the introduction and integration of comprehensive substance use harm mitigation and mental health interventions into HIV prevention programs, particularly those targeting key populations in Mozambique.

Genome-wide diversity, population structure and signatures of inbreeding in the African buffalo in Mozambique.

The African buffalo, Syncerus caffer, is a key species in African ecosystems. Like other large herbivores, it plays a fundamental role in its habitat acting as an ecosystem engineer. Over the last few centuries, African buffalo populations have declined because of range contraction and demographic decline caused by direct or indirect human activities. In Mozambique, historically home to large buffalo herds, the combined effect of colonialism and subsequent civil wars has created a critical situation that urgently needs to be addressed. In this study, we focused on the analysis of genetic diversity of Syncerus caffer caffer populations from six areas of Mozambique. Using genome-wide SNPs obtained from ddRAD sequencing, we examined the population structure across the country, estimated gene flow between areas under conservation management, including national reserves, and assessed the inbreeding coefficients. Our results indicate that all studied populations of Syncerus caffer caffer are genetically depauperate, with a high level of inbreeding. Moreover, buffaloes in Mozambique present a significant population differentiation between southern and central areas. We found an unexpected genotype in the Gorongosa National Park, where buffaloes experienced a dramatic population size reduction, that shares a common ancestry with southern populations of Catuane and Namaacha. This could suggest the past occurrence of a connection between southern and central Mozambique and that the observed population structuring could reflect recent events of anthropogenic origin. All the populations analysed showed high levels of homozygosity, likely due to extensive inbreeding over the last few decades, which could have increased the frequency of recessive deleterious alleles. Improving the resilience of Syncerus caffer caffer in Mozambique is essential for preserving the ecosystem integrity. The most viable approach appears to be facilitating translocations and re-establishing connectivity between isolated herds. However, our results also highlight the importance of assessing intraspecific genetic diversity when considering interventions aimed at enhancing population viability such as selecting suitable source populations.

A stool based qPCR for the diagnosis of TB in children and people living with HIV in Uganda, Eswatini and Mozambique (Stool4TB): a protocol for a multicenter diagnostic evaluation.

BACKGROUND: Tuberculosis (TB) is a major cause of mortality worldwide. Children and people living with HIV (PLHIV) have an increased risk of mortality, particularly in the absence of rapid diagnosis. The main challenges of diagnosing TB in these populations are due to the unspecific and paucibacillary disease presentation and the difficulty of obtaining respiratory samples. Thus, novel diagnostic strategies, based on non-respiratory specimens could improve clinical decision making and TB outcomes in high burden TB settings. We propose a multi-country, prospective diagnostic evaluation study with a nested longitudinal cohort evaluation to assess the performance of a new stool-based qPCR, developed by researchers at Baylor College of Medicine (Houston, Texas, USA) for TB bacteriological confirmation with promising results in pilot studies. METHODS: The study will take place in high TB/HIV burden countries (Mozambique, Eswatini and Uganda) where we will enroll, over a period of 30 months, 650 PLHIV (> 15) and 1295 children under 8 years of age (irrespective of HIV status) presenting pressumptive TB. At baseline, all participants will provide clinical history, complete a physical assessment, and undergo thoracic chest X-ray imaging. To obtain bacteriological confirmation, participants will provide respiratory samples (1 for adults, 2 in children) and 1 stool sample for Xpert Ultra MTB/RIF (Cepheid, Sunnyvale, CA, USA). Mycobacterium tuberculosis (M.tb) liquid culture will only be performed in respiratory samples and lateral flow lipoarabinomannan (LF-LAM) in urine following WHO recommendations. Participants will complete 2 months follow-up if they are not diagnosed with TB, and 6 months if they are. For analytical purposes, the participants in the pediatric cohort will be classified into "confirmed tuberculosis", "unconfirmed tuberculosis" and "unlikely tuberculosis". Participants of the adult cohort will be classified as "bacteriologically confirmed TB", "clinically diagnosed TB" or "not TB". We will assess accuracy of the novel qPCR test compared to bacteriological confirmation and Tb diagnosis irrespective of laboratory results. Longitudinal qPCR results will be analyzed to assess its use as treatment response monitoring. DISCUSSION: The proposed stool-based qPCR is an innovation because both the strategy of using a non-sputum based sample and a technique specially designed to detect M.tb DNA in stool. PROTOCOL REGISTRATION DETAILS: ClinicalTrials.gov Identifier: NCT05047315.

H7N6 highly pathogenic avian influenza in Mozambique, 2023.

On 13 October 2023, the National Directorate for Livestock Development in Mozambique was notified of a suspected outbreak of avian influenza in commercial layers. Samples were screened by real-time and conventional RT-PCR and were positive for both H7 and N6. Full genome sequences were obtained for three representative samples. Sequence analysis of the H7 cleavage site confirmed that the viruses were highly pathogenic (i.e. 333- PEPPKGPRFRR/GLF-346). In addition, the H7 and N6 sequences were highly similar (from 99.4-99.5% and 99.6-99.7% for the HA gene and the NA gene, respectively) to the sequences of a H7N6 virus identified in the Republic of South Africa in May 2023 indicating a similar origin of the viruses. The identification of H7N6 HPAIV in Mozambique has important implications for disease management and food security in the region.

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

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

Estimating the impact of alternative programmatic cotrimoxazole strategies on mortality among children born to mothers with HIV: A modelling study.

BACKGROUND: World Health Organization (WHO) guidelines recommend cotrimoxazole prophylaxis for children who are HIV-exposed until infection is excluded and vertical transmission risk has ended. While cotrimoxazole has benefits for children with HIV, there is no mortality benefit for children who are HIV-exposed but uninfected, prompting a review of global guidelines. Here, we model the potential impact of alternative cotrimoxazole strategies on mortality in children who are HIV-exposed. METHODS AND FINDINGS: Using a deterministic compartmental model, we estimated mortality in children who are HIV-exposed from 6 weeks to 2 years of age in 4 high-burden countries: Côte d'Ivoire, Mozambique, Uganda, and Zimbabwe. Vertical transmission rates, testing rates, and antiretroviral therapy (ART) uptake were derived from UNAIDS data, trial evidence, and meta-analyses. We explored 6 programmatic strategies: maintaining current recommendations; shorter cotrimoxazole provision for 3, 6, 9, or 12 months; and starting cotrimoxazole only for children diagnosed with HIV. Modelled alternatives to the current strategy increased mortality to varying degrees; countries with high vertical transmission had the greatest mortality. Compared to current recommendations, starting cotrimoxazole only after a positive HIV test had the greatest predicted increase in mortality: Mozambique (961 excess annual deaths; excess mortality 339 per 100,000 HIV-exposed children; risk ratio (RR) 1.06), Uganda (491; 221; RR 1.04), Zimbabwe (352; 260; RR 1.05), and Côte d'Ivoire (125; 322; RR 1.06). Similar effects were observed for 3-, 6-, 9-, and 12-month strategies. Increased mortality persisted but was attenuated when modelling lower cotrimoxazole uptake, smaller mortality benefits, higher testing coverage, and lower vertical transmission rates. The study is limited by uncertain estimates of cotrimoxazole coverage in programmatic settings; an inability to model increases in mortality arising from antimicrobial resistance due to limited surveillance data in sub-Saharan Africa; and lack of a formal health economic analysis. CONCLUSIONS: Changing current guidelines from universal cotrimoxazole provision for children who are HIV-exposed increased predicted mortality across the 4 modelled high-burden countries, depending on test-to-treat cascade coverage and vertical transmission rates. These findings can help inform policymaker deliberations on cotrimoxazole strategies, recognising that the risks and benefits differ across settings.

Malaria elimination and the need for intensive inter-country cooperation. a critical evaluation of regional technical co-operation in Southern Africa.

BACKGROUND: Malaria elimination requires closely co-ordinated action between neighbouring countries. In Southern Africa several countries have reduced malaria to low levels, but the goal of elimination has eluded them thus far. The Southern Africa Development Community (SADC) Malaria Elimination Eight (E8) initiative was established in 2009 between Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe to coordinate malaria interventions aiming to eliminate malaria by 2030. Cross-border coordination is important in malaria elimination settings as it strengthens surveillance, joint planning and implementation, knowledge exchange and optimal use of resources. This paper describes how this collaboration is realized in practice, its achievements and challenges, and its significance for malaria elimination prospects. METHODS: The ministers of health of the E8 countries oversee an intergovernmental technical committee supported by specialist working groups consisting of technical personnel from member countries and partner institutions. These technical working groups are responsible for malaria elimination initiatives in key focus areas such as surveillance, vector control, diagnosis, case management, behaviour change and applied research. The technical working groups have initiated and guided several collaborative projects which lay essential groundwork for malaria elimination. RESULTS: The E8 collaboration has yielded achievements in the following key areas. (1) Establishment and evaluation of malaria border health posts to improve malaria services in border areas and reduce malaria among resident and, mobile and migrant populations. (2) The development of a regional malaria microscopy slide bank providing materials for diagnostic training and proficiency testing. (3) A facility for regional external competency assessment and training of malaria microscopy trainers in collaboration with the World Health Organization. (4) Entomology fellowships that improved capacity in entomological surveillance; an indoor residual spraying (IRS) training of trainers' scheme to enhance the quality of this core intervention in the region. (5) Capacity development for regional malaria parasite genomic surveillance. (6) A mechanism for early detection of malaria outbreak through near real time reporting and a quarterly bulletins of malaria incidence in border districts. CONCLUSIONS: The E8 technical working groups system embodies inter-country collaboration of malaria control and elimination activities. It facilitates sustained interaction between countries through a regional approach. The groundwork for elimination has been laid, but the challenge will be to maintain funding for collaboration at this level whilst reducing reliance on international donors and to build capacities necessary to prepare for malaria elimination.

Women's voices and meanings of empowerment for reproductive decisions: a qualitative study in Mozambique.

BACKGROUND: Women in Mozambique are often disempowered when it comes to making decisions concerning their lives, including their bodies and reproductive options. This study aimed to explore the views of women in Mozambique about key elements of empowerment for reproductive decisions and the meanings they attach to these elements. METHODS: Qualitative in-depth interviews were undertaken with 64 women of reproductive age (18-49 years) in two provinces in Mozambique. Participants were recruited through convenience sampling. Data collection took place between February and March 2020 in Maputo city and Province, and during August 2020 in Nampula Province. A thematic analysis was performed. RESULTS: Women described crucial elements of how power is exerted for reproductive choices. These choices include the ability to plan the number and timing of pregnancies and the ability either to negotiate with sexual partners by voicing choice and influencing decisions, or to exercise their right to make decisions independently. They considered that women with empowerment had characteristics such as independence, active participation and being free. These characteristics are recognized key enablers for the process of women's empowerment. CONCLUSIONS: This study's findings contribute to an expanded conceptualization and operationalization of women's sexual and reproductive empowerment by unveiling key elements that need to be considered in future research and approaches to women's empowerment. Furthermore, it gave women the central role and voice in the research of empowerment's conceptualization and measurement where women's views and meanings are seldom considered.

Women who are empowered seem to make better health decisions for themselves. Nevertheless, women's views about and understanding of empowerment are seldom considered in the study of empowerment and its definitions. In this study we explore how women in Mozambique view, understand and experience empowerment, i.e., gaining power and control in the household, and specifically around decision-making processes concerning their reproductive lives. A total of 64 adult women were interviewed in rural and urban areas within two provinces of Mozambique. Through the data analysis, we identified key characteristics of the empowerment process that Mozambican women perceived to be of relevance in their context. Women who have power were perceived as financially and socially independent, free to choose their own pathway, and be active participants in the household decision-making process. In reproductive decisions, women show power through the ability to negotiate with their partner, or by making sole decisions and by planning the number of pregnancies and the size of the family. The elements identified provide important information for improving the definition and the measurement of empowerment in Mozambique, as well as for the support of women in their pathways to empowerment within this context.