Levels and trends of demographic indices in southern rural Mozambique: evidence from demographic surveillance in Manhica district

Background: In Mozambique most of demographic data are obtained using census or sample survey including indirect estimations. A method of collecting longitudinal demographic data was introduced in southern Mozambique since 1996 (DSS -Demographic Surveillance System in Manhiça district, Maputo province), but the extent to which it yields demographic measures that are typical of southern rural Mozambique has not been evaluated yet. Methods: Data from the DSS were used to estimate the levels and trends of fertility, mortality and migration in Manhiça, between 1998 and 2005. The estimates from Manhiça were compared with estimates from Maputo province using the 1997 National census and 1997 Demographic and Health Survey (DHS). The DHS data were used to estimate levels and trends of adult mortality using the siblings' histories and the orphanhood methods. Results: The populations in Manhiça and in Maputo province are young (44% <15 years in Manhiça and 42% in Maputo); with reduced adult males when compared to females (all ages sex ratio of 78.7 in Manhiça and 89 in Maputo). Fertility in Manhiça is at a similar level as in Maputo province and has remained around 5 children per woman, during the eight years of surveillance in Manhiça. Although the infant mortality rate (IMR) in Mozambique has decreased during the last two decades (from 148 deaths per 1000 live births in 1980 to 101 in 2003), it has remained stable around 80 in Manhiça during the surveillance period. Adult mortality has increased both in Manhiça (probability of dying from ages 15 to 60 increased from 0.4 in 1998 to 0.6 in 2005 in Manhiça, from 0.3 in 1992 to 0.4 in 1997 in Maputo province and from 0.1 in 1980 to 0.6 in 2000 in Mozambique). Consequently, the life expectancy decreased from 53 to 46 in Manhiça and from 42 years in 1997 to 38 in 2004 in Mozambique. Migration is high in Manhiça but tends to stabilise after the movements of resettlement that followed the end of the civil war in 1992. Conclusion: The population under demographic surveillance in Manhiça district presents characteristics that are typical of southern rural Mozambique, with predominance of young people and reduction of adult males. Labour migration and excess adult male mortality are the major factors for the reduction of adult males. Mortality is high and only infant mortality has started to stabilise while adult mortality has increased, and as consequence, life expectancy has decreased. The Manhiça DSS is an adequate tool to report demographic measures for southern rural Mozambique

Levels and trends of demographic indices in southern rural Mozambique: evidence from demographic surveillance in Manhiça district

BACKGROUND: In Mozambique most of demographic data are obtained using census or sample survey including indirect estimations. A method of collecting longitudinal demographic data was introduced in southern Mozambique since 1996 (DSS -Demographic Surveillance System in Manhiça district, Maputo province), but the extent to which it yields demographic measures that are typical of southern rural Mozambique has not been evaluated yet. METHODS: Data from the DSS were used to estimate the levels and trends of fertility, mortality and migration in Manhiça, between 1998 and 2005. The estimates from Manhiça were compared with estimates from Maputo province using the 1997 National census and 1997 Demographic and Health Survey (DHS). The DHS data were used to estimate levels and trends of adult mortality using the siblings' histories and the orphanhood methods. RESULTS: The populations in Manhiça and in Maputo province are young (44% <15 years in Manhiça and 42% in Maputo); with reduced adult males when compared to females (all ages sex ratio of 78.7 in Manhiça and 89 in Maputo). Fertility in Manhiça is at a similar level as in Maputo province and has remained around 5 children per woman, during the eight years of surveillance in Manhiça. Although the infant mortality rate (IMR) in Mozambique has decreased during the last two decades (from 148 deaths per 1000 live births in 1980 to 101 in 2003), it has remained stable around 80 in Manhiça during the surveillance period. Adult mortality has increased both in Manhiça (probability of dying from ages 15 to 60 increased from 0.4 in 1998 to 0.6 in 2005 in Manhiça, from 0.3 in 1992 to 0.4 in 1997 in Maputo province and from 0.1 in 1980 to 0.6 in 2000 in Mozambique). Consequently, the life expectancy decreased from 53 to 46 in Manhiça and from 42 years in 1997 to 38 in 2004 in Mozambique. Migration is high in Manhiça but tends to stabilise after the movements of resettlement that followed the end of the civil war in 1992. CONCLUSION: The population under demographic surveillance in Manhiça district presents characteristics that are typical of southern rural Mozambique, with predominance of young people and reduction of adult males. Labour migration and excess adult male mortality are the major factors for the reduction of adult males. Mortality is high and only infant mortality has started to stabilise while adult mortality has increased, and as consequence, life expectancy has decreased. The Manhiça DSS is an adequate tool to report demographic measures for southern rural Mozambique

Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention

INTRODUCTION: Context-specific improvements in the continuum of HIV care are needed in order to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. METHODS: Adults newly diagnosed with HIV from voluntary counseling and testing (VCT), provider-initiated (PICT) and home-based HIV testing (HBT) services were prospectively enrolled between 2014- 2015 at the Manhica District. Patients were passively followed-up through chart examination .Tracing was performed at 12-months to ascertain causes of loss to follow-up. Fine and Grey competing risk analysis was performed to determine factors associated with the each step of the cascade. RESULTS: Overall linkage to care as defined by having a CD4 count at 3 months, was 43.7% (95CI% 40.8-46.6) and 25.2% of all participants initiated ART. Factors associated with increased linkage in multivariable analysis included testing at VCT, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month , and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI 70.2-80.5) to 84.2% (95% CI 79.2-88.5). CONCLUSIONS: HBT reached a socio-demographically distinct population from that of clinic based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss-to-follow-up can significantly change indicators of retention in care

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study.

"Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhi\xC3\xA7a District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P\xE2\x80\x8A<\xE2\x80\x8A.001] and 0.93 (95% CI: 0.87-1.00; P\xE2\x80\x8A=\xE2\x80\x8A.045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

Invasive bacterial disease trends and characterization of group B streptococcal isolates among young infants in southern Mozambique, 2001-2015

BACKGROUND: Maternal group B streptococcal (GBS) vaccines under development hold promise to prevent GBS disease in young infants. Sub-Saharan Africa has the highest estimated disease burden, although data on incidence and circulating strains are limited. We described invasive bacterial disease (IBD) trends among infants <90 days in rural Mozambique during 2001-2015, with a focus on GBS epidemiology and strain characteristics. METHODS: Community-level birth and mortality data were obtained from Manhica's demographic surveillance system. IBD cases were captured through ongoing surveillance at Manhica district hospital. Stored GBS isolates from cases underwent serotyping by multiplex PCR, antimicrobial susceptibility testing, and whole genome sequencing. RESULTS: There were 437 IBD cases, including 57 GBS cases. Significant declines in overall IBD, neonatal mortality, and stillbirth rates were observed (P<0.0001), but not for GBS (P = 0.17). In 2015, GBS was the leading cause of young infant IBD (2.7 per 1,000 live births). Among 35 GBS isolates available for testing, 31 (88.6%) were highly related serotype III isolates within multilocus sequence types (STs) 17 (68.6%) or 109 (20.0%). All seven ST109 isolates (21.9%) had elevated minimum inhibitory concentration (MIC) to penicillin (>/=0.12 mug/mL) associated with penicillin-binding protein (PBP) 2x substitution G398A. Epidemiologic and molecular data suggest this is a well-established clone. CONCLUSION: A notable young infant GBS disease burden persisted despite improvements in overall maternal and neonatal health. We report an established strain with pbp2x point mutation, a first-step mutation associated with reduced penicillin susceptibility within a well-known virulent lineage in rural Mozambique. Our findings further underscores the need for non-antibiotic GBS prevention strategies

Demographic and health community-based surveys to inform a malaria elimination project in Magude district, southern Mozambique

--- - Label: OBJECTIVES NlmCategory: OBJECTIVE content: A Demographic and Health Platform was established in Magude in 2015, prior to the deployment of a project aiming to evaluate the feasibility of malaria elimination in southern Mozambique, named the Magude project. This platform aimed to inform the design, implementation and evaluation of the Magude project, through the identification of households and population; and the collection of demographic, health and malaria information. - Label: SETTING NlmCategory: METHODS content: Magude is a rural district of southern Mozambique which borders South Africa. It has nine peripheral health facilities and one referral health centre with an inpatient ward. - Label: INTERVENTION NlmCategory: METHODS content: "A baseline census enumerated and geolocated all the households, and their resident and non-resident members, collecting demographic and socio-economic information, and data on the coverage and usage of malaria control tools. Inpatient and outpatient data during the 5\xE2\x80\x89years (2010 to 2014) before the survey were obtained from the district health authorities. The demographic platform was updated in 2016." - Label: RESULTS NlmCategory: RESULTS content: "The baseline census conducted in 2015 reported 48\xE2\x80\x89448 (92.1%) residents and 4133 (7.9%) non-residents, and 10\xE2\x80\x89965 households. Magude's population is predominantly young, half of the population has no formal education and the main economic activities are agriculture and fishing. Houses are mainly built with traditional non-durable materials and have poor sanitation facilities. Between 2010 and 2014, malaria was the most common cause of all-age inpatient discharges (representing 20% to 40% of all discharges), followed by HIV (12% to 22%) and anaemia (12% to 15%). In early 2015, all-age bed-net usage was between 21.8% and 27.1%\xE2\x80\x89and the reported coverage of indoor residual spraying varied across the district between 30.7% and 79%." - Label: CONCLUSION NlmCategory: CONCLUSIONS content: This study revealed that Magude has limited socio-economic conditions, poor access to healthcare services and low coverage of malaria vector control interventions. Thus, Magude represented an area where it is most pressing to demonstrate the feasibility of malaria elimination. - Label: TRIAL REGISTRATION NUMBER NlmCategory: BACKGROUND content: NCT02914145; Pre-results

Setting the scene and generating evidence for malaria elimination in Southern Mozambique

Mozambique has historically been one of the countries with the highest malaria burden in the world. Starting in the 1960s, malaria control efforts were intensified in the southern region of the country, especially in Maputo city and Maputo province, to aid regional initiatives aimed to eliminate malaria in South Africa and eSwatini. Despite significant reductions in malaria prevalence, elimination was never achieved. Following the World Health Organization's renewed vision of a malaria-free-world, and considering the achievements from the past, the Mozambican National Malaria Control Programme (NMCP) embarked on the development and implementation of a strategic plan to accelerate from malaria control to malaria elimination in southern Mozambique. An initial partnership, supported by the Bill and Melinda Gates Foundation and the La Caixa Foundation, led to the creation of the Mozambican Alliance Towards the Elimination of Malaria (MALTEM) and the Malaria Technical and Advisory Committee (MTAC) to promote national ownership and partner coordination to work towards the goal of malaria elimination in local and cross-border initiatives. Surveillance systems to generate epidemiological and entomological intelligence to inform the malaria control strategies were strengthened, and an impact and feasibility assessment of various interventions aimed to interrupt malaria transmission were conducted in Magude district (Maputo Province) through the "Magude Project". The primary aim of this project was to generate evidence to inform malaria elimination strategies for southern Mozambique. The goal of malaria elimination in areas of low transmission intensity is now included in the national malaria strategic plan for 2017-22 and the NMCP and its partners have started to work towards this goal while evidence continues to be generated to move the national elimination agenda forward

Escherichia coli ST131 clones harbouring AggR and AAF/V fimbriae causing bacteremia in Mozambican children: Emergence of new variant of fimH27subclone

Multidrug-resistant Escherichia coli ST131 fimH30 responsible for extra-intestinal pathogenic (ExPEC) infections is globally distributed. However, the occurrence of a subclone fimH27 of ST131 harboring both ExPEC and enteroaggregative E. coli (EAEC) related genes and belonging to commonly reported O25:H4 and other serotypes causing bacteremia in African children remain unknown. We characterized 325 E. coli isolates causing bacteremia in Mozambican children between 2001 and 2014 by conventional multiplex polymerase chain reaction and whole genome sequencing. Incidence rate of EAEC bacteremia was calculated among cases from the demographic surveillance study area. Approximately 17.5% (57/325) of isolates were EAEC, yielding an incidence rate of 45.3 episodes/105 children-years-at-risk among infants; and 44 of isolates were sequenced. 72.7% (32/44) of sequenced strains contained simultaneously genes associated with ExPEC (iutA, fyuA and traT); 88.6% (39/44) harbored the aggregative adherence fimbriae type V variant (AAF/V). Sequence type ST-131 accounted for 84.1% (37/44), predominantly belonging to serotype O25:H4 (59% of the 37); 95.6% (35/44) harbored fimH27. Approximately 15% (6/41) of the children died, and five of the six yielded ST131 strains (83.3%) mostly (60%; 3/5) due to serotypes other than O25:H4. We report the emergence of a new subclone of ST-131 E. coli strains belonging to O25:H4 and other serotypes harboring both ExPEC and EAEC virulence genes, including agg5A, associated with poor outcome in bacteremic Mozambican children, suggesting the need for prompt recognition for appropriate management

Malaria in rural Mozambique. Part I: Children attending the outpatient clinic

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A 10 year study of the cause of death in children under 15 years in Manhiça, Mozambique

<p>Abstract</p> <p>Background</p> <p>Approximately 46 million of the estimated 60 million deaths that occur in the world each year take place in developing countries. Further, this mortality is highest in Sub-Saharan Africa, although causes of mortality in this region are not well documented. The objective of this study is to describe the most frequent causes of mortality in children under 15 years of age in the demographic surveillance area of the Manhiça Health Research Centre, between 1997 and 2006, using the verbal autopsy tool.</p> <p>Methods</p> <p>Verbal autopsy interviews for causes of death in children began in 1997. Each questionnaire was reviewed independently by three physicians with experience in tropical paediatrics, who assigned the cause of death according to the International Classification of Diseases (ICD-10). Each medical doctor attributed a minimum of one and a maximum of 2 causes. A final diagnosis is reached when at least two physicians agreed on the cause of death.</p> <p>Results</p> <p>From January 1997 to December 2006, 568499 person-year at risk (pyrs) and 10037 deaths were recorded in the Manhiça DSS. 3730 deaths with 246658 pyrs were recorded for children under 15 years of age. Verbal autopsy interviews were conducted on 3002 (80.4%) of these deaths. 73.6% of deaths were attributed to communicable diseases, non-communicable diseases accounted for 9.5% of the defined causes of death, and injuries for 3.9% of causes of deaths. Malaria was the single largest cause, accounting for 21.8% of cases. Pneumonia with 9.8% was the second leading cause of death, followed by HIV/AIDS (8.3%) and diarrhoeal diseases with 8%.</p> <p>Conclusion</p> <p>The results of this study stand out the big challenges that lie ahead in the fight against infectious diseases in the study area. The pattern of childhood mortality in Manhiça area is typical of developing countries where malaria, pneumonia and HIV/AIDS are important causes of death.</p