a before-and-after study and scale-up process in Mozambique

BACKGROUND: The universal coverage bed nets campaign is a proven health intervention promoting increased access, ownership, and use of bed nets to reduce malaria burden. This article describes the intervention and implementation strategies that Mozambique carried out recently in order to improve access and increase demand for long-lasting insecticidal nets (LLINs). METHODS: A before-and-after study with a control group was used during Stage I of the implementation process. The following strategies were tested in Stage I: (1) use of coupons during household registration; (2) use of stickers to identify the registered households; (3) new LLIN ascription formula (one LLIN for every two people). In Stage II, the following additional strategies were implemented: (4) mapping and micro-planning; (5) training; and (6) supervision. Odds ratio (OR) and 95% confidence interval (CI) were used to compare and establish differences between intervened and control districts in Stage I. Main outcomes were: percentage of LLINs distributed, percentage of target households benefited. RESULTS: In Stage I, 87.8% (302,648) of planned LLINs were distributed in the intervention districts compared to 77.1% (219,613) in the control districts [OR: 2.14 (95% CI 2.11-2.16)]. Stage I results also showed that 80.6% (110,453) of households received at least one LLIN in the intervention districts compared to 72.8% (87,636) in the control districts [OR: 1.56 (95% CI 1.53-1.59)]. In Stage II, 98.4% (3,536,839) of the allocated LLINs were delivered, covering 98.6% (1,353,827) of the registered households. CONCLUSIONS: Stage I results achieved better LLINs and household coverage in districts with the newly implemented strategies. The results of stage II were also encouraging. Additional strategies adaptation is required for a wide-country LLIN campaignpublishersversionpublishe

Impact of mass distribution of insecticide-treated nets in Mozambique, 2012 to 2025: Estimates of child lives saved using the Lives Saved Tool

Malaria was the leading cause of post-neonatal deaths in Mozambique in 2017. The use of insecticide treated nets (ITNs) is recognized as one of the most effective ways to reduce malaria mortality in children. No previous analyses have estimated changes in mortality attributable to the scale-up of ITNs, accounting for provincial differences in mortality rates and coverage of health interventions. Based upon annual provincial ownership coverage of ITNs, the Lives Saved Tool (LiST), a multi-cause mathematical model, estimated under-5 lives saved attributable to increased household ITN coverage in 10 provinces of Mozambique between 2012 and 2018, and projected lives saved from 2019 to 2025 if 2018 coverage levels are sustained. An estimated 14,040 under-5 child deaths were averted between 2012 and 2018. If 2018 coverage levels are maintained until 2025, an additional 33,277 child deaths could be avoided. If coverage reaches at least 85% in all ten provinces by 2022, then a projected 36,063 child lives can be saved. From 2012 to 2018, the estimated number of lives saved was highest in Zambezia and Tete provinces. Increases in ITN coverage can save a substantial number of child lives in Mozambique. Without continued investment, thousands of avoidable child deaths will occur

Effectiveness of a new long-lasting insecticidal nets delivery model in two rural districts of Mozambique: a before-after study

BACKGROUND: In 2015, Mozambique piloted a new model of long-lasting insecticidal nets (LLINs) delivery in a campaign. The new delivery model was used in two rural districts were, and two others were considered as control, maintaining the old delivery model. The aim of this study is to compare the coverage of ownership and use of LLINs in intervention and control districts in Mozambique. METHODS: A before-after design with control group was carried out 6 months after LLINs distribution. Using systematic probabilistic sampling, 1547 households were surveyed by means of a questionnaire. To find associations between the district categories (intervention and control) and the main outcomes of the study (LLIN ownership, use, and universal coverage achievement), odds ratio (OR) and respective confidence intervals were calculated. RESULTS: Of the 760 households surveyed in the intervention districts, 98.8% had at least one LLIN; of the 787 households surveyed in the control districts, 89.6% had at least one LLIN [OR: 9.7, 95% (CI 4.84-19.46)]. Around 95 and 87% of households owning at least one LLIN reported having slept under the LLIN the previous night in the intervention and control districts, respectively [OR: 3.2; 95% (CI 2.12-4.69)]. Seventy-one percent of the households surveyed achieved universal coverage in the intervention districts against 59.6% in the control districts [OR: 1.6; 95% (CI 1.33-2.03)]. CONCLUSIONS: The universal coverage campaign piloted with the new delivery model has increased LLINs ownership, use, and progression for reaching universal coverage targets in the community.publishersversionpublishe

Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique

BACKGROUND: To improve retention in antiretroviral therapy (ART), lessons learned from chronic disease care were applied to HIV care, providing more responsibilities to patients in the care of their chronic disease. In Tete - Mozambique, patients stable on ART participate in the ART provision and peer support through Community ART Groups (CAG). This article analyses the evolution of the CAG-model during its implementation process. METHODS: A mixed method approach was used, triangulating qualitative and quantitative findings. The qualitative data were collected through semi-structured focus groups discussions and in-depth interviews. An inductive qualitative content analysis was applied to condense and categorise the data in broader themes. Health outcomes, patients’ and groups’ characteristics were calculated using routine collected data. We applied an ‘input – process – output’ pathway to compare the initial planned activities with the current findings. RESULTS: Input wise, the counsellors were considered key to form and monitor the groups. In the process, the main modifications found were the progressive adaptations of the daily CAG functioning and the eligibility criteria according to the patients’ needs. Beside the anticipated outputs, i.e. cost and time saving benefits and improved treatment outcomes, the model offered a mutual adherence support and protective environment to the members. The active patient involvement in several health activities in the clinics and the community resulted in a better HIV awareness, decreased stigma, improved health seeking behaviour and better quality of care. CONCLUSIONS: Over the past four years, the modifications in the CAG-model contributed to a patient empowerment and better treatment outcomes. One of the main outstanding questions is how this model will evolve in the future. Close monitoring is essential to ensure quality of care and to maintain the core objective of the CAG-model ‘facilitating access to ART care’ in a cost and time saving manner

a supplementary tool for improving bed nets universal coverage campaign in Mozambique

BACKGROUND: WhatsApp (WA) is the most recent and attractive applicative among Smartphone users. The use of WA in healthcare environment has been shown of multiple benefices. Mozambique team involved in 2017 bed nets universal coverage campaign (UCC) implemented a distant mentoring strategy using WA. This study aims to perform a descriptive analysis of the use of WA as a supplementary tool for mentoring provincial and district health teams during bed nets universal coverage campaign in Mozambique. METHODS: Using WA, a qualitative study was carried out between March and July 2017. Seven WA groups were created. One group for central-level team, and six groups corresponding to each implementation province. The WA content was analyzed, grouped into separate themes, and subject to information triangulation among researchers and group participants. Saturation guided the quantity and quality of information. RESULTS: A total of 511 members were included in all WA groups. Of these, 96% were provincial WA groups. A total of 24,897 messages (text and images) were exchanged in all WA groups. The main communication form was text (22,660-91%), followed by images (2237-9%). Five themes emerged from content analyses: 1) administrative/financial, 2) logistic, 3) planning and implementation, 4) monitoring and evaluation, and 5) best practice. CONCLUSIONS: The use of WA during universal coverage bed nets campaign implementation in Mozambique fostered central-level coordination, providing implementation support to district and provincial teams, and promoting wider and timely information sharing among group members.publishersversionpublishe

Sustaining control : lessons from the Lubombo spatial development initiative in southern Africa

BACKGROUND : The Lubombo Spatial Development Initiative (LSDI) was a tri-country project between South Africa, Swaziland and Mozambique with the aim of accelerating socio-economic development in the region. The malaria component of the project was introduced to decrease the transmission of malaria in the region. This goal was met but with termination of this project resulted in an upsurge of malaria cases in the sub-region mainly as a result of migration from high transmission areas to low transmission ones. The movement of people across borders in southern Africa remains a challenge in sustaining malaria control and elimination. METHODS : Malaria case data for Swaziland and South Africa were obtained from their respective national Malaria Information Systems. Data for Mozambique was obtained from the Mozambican Ministry of Health. Data obtained during the course of the LSDI project was compared to the case data post the termination of the LSDI. RESULTS : The 12-year period of the LSDI showed a substantial decrease in disease burden amongst the three countries involved when compared to the baseline year of 2000. The decrease in malaria cases was 99 % in South Africa and 98 % in Swaziland. Malaria prevalence in Mozambique decreased by 85 % over the same period. However, after the LSDI ended, between 2012 and 2014, there was an upward trend in case data that was counter to the goal of elimination. CONCLUSION : South Africa and Swaziland benefitted from the LSDI and were able to sustain malaria control and progress to the stage of elimination. Mozambique could not sustain the gains made during the LSDI and case numbers increased. Technical and financial resources are key challenges for malaria control and elimination interventions.Data used in this study are available from the Ministries of Health in South Africa, Swaziland and Mozambique.No direct funding was received for this study however the original LSDI study was made possible by funds received from the Global Fund to fight AIDS, TB and Malariahttp://www.malariajournal.comam2016School of Health Systems and Public Health (SHSPH

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.publishersversionpublishe

Spatio-temporal modelling of weekly malaria incidence in children under 5 for early epidemic detection in Mozambique

Malaria is a major cause of morbidity and mortality in Mozambique. We present a malaria early warning system (MEWS) for Mozambique informed by seven years of weekly case reports of malaria in children under 5 years of age from 142 districts. A spatio-temporal model was developed based on explanatory climatic variables to map exceedance probabilities, defined as the predictive probability that the relative risk of malaria incidence in a given district for a particular week will exceed a predefined threshold. Unlike most spatially discrete models, our approach accounts for the geographical extent of each district in the derivation of the spatial covariance structure to allow for changes in administrative boundaries over time. The MEWS can thus be used to predict areas that may experience increases in malaria transmission beyond expected levels, early enough so that prevention and response measures can be implemented prior to the onset of outbreaks. The framework we present is also applicable to other climate-sensitive diseases

Cost and cost-effectiveness of indoor residual spraying with pirimiphos-methyl in a high malaria transmission district of Mozambique with high access to standard insecticide-treated nets

Background: As malaria cases increase in some of the highest burden countries, more strategic deployment of new and proven interventions must be evaluated to meet global malaria reduction goals. Methods: The cost and cost-effectiveness of indoor residual spraying (IRS) with pirimiphos-methyl (Actellic®300 CS) were assessed in a high transmission district (Mopeia) with high access to pyrethroid insecticide-treated nets (ITNs), compared to ITNs alone. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. A decision analysis approach was followed to conduct deterministic and probabilistic sensitivity analyses in a theoretical cohort of 10,000 children under five years of age (U5) and 10,000 individuals of all ages, separately. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. Results: The average IRS cost per person protected was US$8.26 and 51$400 (95% CI 399–402) per DALY averted. In the all-age cohort, the ICER was higher: US$1,860 (95$7.06) and IRS was highly cost-effective in children U5 (ICER = US$312) and cost-effective in individuals of all ages (ICER = US$1,431), compared to ITNs alone. Conclusion: This study provides robust evidence that IRS with pirimiphos-methyl can be cost-effective in high transmission regions with high pyrethroid ITN coverage where the major vector is susceptible to pirimiphos-methyl but resistant to pyrethroids. The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. Trial registration: ClinicalTrials.gov identifier NCT02910934 (Registered 22 September 2016). https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=

In-Vivo Efficacy of Chloroquine to Clear Asymptomatic Infections in Mozambican Adults: A Randomized, Placebo-controlled Trial with Implications for Elimination Strategies

Recent reports regarding the re-emergence of parasite sensitivity to chloroquine call for a new consideration of this drug as an interesting complementary tool in malaria elimination efforts, given its good safety profile and long half-life. A randomized (2:1), single-blind, placebo-controlled trial was conducted in Manhica, Mozambique, to assess the in-vivo efficacy of chloroquine to clear plasmodium falciparum (Pf) asymptomatic infections. Primary study endpoint was the rate of adequate and parasitological response (ACPR) to therapy on day 28 (PCR-corrected). Day 0 isolates were analyzed to assess the presence of the PfCRT-76T CQ resistance marker. A total of 52 and 27 male adults were included in the CQ and Placebo group respectively. PCR-corrected ACPR was significantly higher in the CQ arm 89.4% (95%CI 80-98%) compared to the placebo (p < 0.001). CQ cleared 49/50 infections within the first 72 h while placebo cleared 12/26 (LRT p < 0.001). The PfCRT-76T mutation was present only in one out of 108 (0.9%) samples at baseline, well below the 84% prevalence found in 1999 in the same area. This study presents preliminary evidence of a return of chloroquine sensitivity in Mozambican Pf isolates, and calls for its further evaluation in community-based malaria elimination efforts, in combination with other effective anti-malarials. TRIAL REGISTRATION: www.clinicalTrials.gov NCT02698748