a narrative review of literature, accomplishments, and perspectives

Funding Information: We would like to thank the Calouste Gulbenkian Foundation and the Flandres Government (Building Institutional Capacity at the Mozambique INS – BICMINS) from where M. Cassocera has a PhD scholarship; Fundo Nacional de Investigação-Moçambique and German Research Foundation (DFG) from where A. Chissaque has scholarship. Sousa Ribe and Orvalho Augusto for the inputs and clarifications regarding the Expanded Program on Immunization. Publisher Copyright: © 2020 Fundacao Oswaldo Cruz. All rights reserved.In Mozambique, the Expanded Program on Immunization (EPI) was implemented in 1979 with the objective of reducing child mortality and morbidity through the provision of immunization services. This study aims to describe the characteristics of the EPI and review the available information related to immunization service in Mozambique, its accomplishments and perspectives. A narrative review of the literature was carried out and the electronic databases accessed were VHL, Google Scholar, and PubMed between 1979 and 2019, using descriptors related to the theme. A total of 28 articles and other relevant sources have been consulted for the review. The national immunization coverage in Mozambique between 1997 (47%) and 2015 (66%) improved 19 percentual points; also immunization coverage of children under 12 months has increased from 44.3% (1997) to 57% (2015). The 2015 survey showed that out of the 11 provinces, only the southern and Cabo Delgado province could reach the 80% recommended goal at the provincial level. Zambézia, Nampula, and Tete provinces have been reporting low coverage over the years and Cabo Delgado presents coverage oscillation. The BCG, DPT3, Polio 3, and measles have reached 80% of coverage goal from 1997 to 2015. Our analysis have shown important improvements in national immunization, characterized by an overall increase in the national and provincial coverage and a decrease in the number of children that did not receive any vaccine. Despite these improvements, some provinces have lower coverages than expected and it is necessary to understand the determinants of dropout in children to retain them and provide timely and full immunization.publishersversionpublishe

A cross-sectional study in four provinces of Mozambique: Diarrheagenic Escherichia coli in Mozambique

Funding Information: The National Surveillance of Diarrhea was supported by a Senior Fellowship awarded to Nilsa de Deus by the European Foundations Initiative for African Research into Neglected Tropical Diseases (EFINTD, grant number 98539), the World Health Organization, a Master Fellowship funded by the Italian Agency for Development Cooperation (AICS) project AID10524, Deutsche Forschungsgemeinschaft (DFG, grant number JO369/5–1)—where Adilson Fernando Loforte Bauhofer and Assucênio Chissaque are fellows, GAVI (Global Alliance for Vaccines and Immunization) through Health System Strengthening (HSS), and Fundo Nacional de Investigação (FNI). The protocol was approved by the National Bioethics Committee for Health of Mozambique (IRB00002657, reference number: 348/CNBS/13), and each caregiver gave written informed consent to authorize their child's participation. The authors want to thank the parents or guardians who consented to their children's enrollment in the surveillance program. The authors acknowledge Dr. Octávio Jossai, the National Reference Laboratory of Microbiology team, all the focal points, and the provincial field teams who helped to conduct this study. Funding Information: The National Surveillance of Diarrhea was supported by a Senior Fellowship awarded to Nilsa de Deus by the European Foundations Initiative for African Research into Neglected Tropical Diseases (EFINTD, grant number 98539), the World Health Organization, a Master Fellowship funded by the Italian Agency for Development Cooperation (AICS) project AID10524, Deutsche Forschungsgemeinschaft (DFG, grant number JO369/5–1)—where Adilson Fernando Loforte Bauhofer and Assucênio Chissaque are fellows, GAVI (Global Alliance for Vaccines and Immunization) through Health System Strengthening (HSS), and Fundo Nacional de Investigação (FNI). Publisher Copyright: © 2022Objectives: Analyze the frequency of diarrheagenic Escherichia coli (DEC) pathotypes and their antimicrobial resistance profiles among children aged <15 years with diarrhea in four Mozambican provinces. Methods: A cross-sectional hospital-based surveillance program of diarrhea was implemented in Maputo, Sofala, Zambézia, and Nampula. A single stool sample was collected from each child from May 2014 to May 2017. Culture methods and biochemical characterization were performed to detect E. coli strains. DEC pathotypes were determined by conventional polymerase chain reaction targeting specific virulence genes. Antimicrobial susceptibility was assessed by the Kirby–Bauer method. Results: From 723 specimens analyzed by culture, 262 were positive for E. coli. A total of 208 samples were tested by polymerase chain reaction for DEC identification, of which 101 (48.6%) were positive for a DEC pathotype. The predominant pathotypes were enteroaggregative (66.3%, 67/101), enteropathogenic (15.8%, 16/101), enterotoxigenic (13.9%, 14/101), and enteroinvasive E. coli (4.0%, 4/101). No Shiga toxin–producing E. coli was identified. Regardless of the province, the most frequent pathotype was enteroaggregative E. coli. Isolated DEC presented high frequency of resistance to ampicillin (97.8%), tetracycline (68.3%), chloramphenicol (28.4%), nalidixic acid (19.5%), and gentamicin (14.4%). Conclusion: Children with diarrhea in Mozambique had DEC and higher resistance to ampicillin and tetracycline.publishersversionpublishe

emergence of genotypes G3P[4] and G3P[8]

Group A rotavirus (RVA) remains the most important etiological agent associated with severe acute diarrhea in children. Rotarix® monovalent vaccine was introduced into Mozambique’s Expanded Program on Immunization in September 2015. In the present study, we report the diversity and prevalence of rotavirus genotypes, pre-(2012–2015) and post-vaccine (2016–2019) introduction in Mozambique, among diarrheic children less than five years of age. Genotyping data were analyzed for five sentinel sites for the periods indicated. The primary sentinel site, Mavalane General Hospital (HGM), was analyzed for the period 2012–2019, and for all five sites (country-wide analyses), 2015–2019. During the pre-vaccine period, G9P[8] was the most predominant genotype for both HGM (28.5%) and the country-wide analysis (46.0%). However, in the post-vaccine period, G9P[8] was significantly reduced. Instead, G3P[8] was the most common genotype at HGM, while G1P[8] predominated country-wide. Genotypes G9P[4] and G9P[6] were detected for the first time, and the emergence of G3P[8] and G3P[4] genotypes were observed during the post-vaccine period. The distribution and prevalence of rotavirus genotypes were distinct in pre-and post-vaccination periods, while uncommon genotypes were also detected in the post-vaccine period. These observations support the need for continued country-wide surveillance to monitor changes in strain diversity, due to possible vaccine pressure, and consequently, the effect on vaccine effectiveness.publishersversionpublishe

A Hospital Based Cross-Sectional Study, 2015–2019

792. The Global Alliance for Vaccine and Immunization through the Health System Strengthening (HSS) project. The Flandres Government, BICMINS project. The Calouste Gulbenkian Foundation from where J?lia Sambo, Marta Cassocera and Assuc?nio Chissaque have a PhD fellowship. Acknowledgments: We would like to thank the parents or guardians who consented for their children to be enrolled in the surveillance and all ViNaDia team for their dedication and effort with recruitment, data collection and shipment of specimens to the central laboratory in Maputo: Miguel Bambo, Carlos Guilamba, Celina Nhamuave, M?rcia Nhaca, Judite Sal?ncia, Herm?nio Cossa, F?lix Gundane, Aun?sia Marurele, Angelina Pereira, Mulaja Kabeya ?tienne, Celso Gabriel, Titos Maulate, Julieta Ernesto, Siasa Mendes, H?rcio Simbine, Susete de Carvalho, Marcos Joaquim, Elvira Sarguene, Fernando Vilanculos, Felicidade Martins, Dulce Gra?a, Edma Samuel, Vivaldo Pedro, L?cia Matabel, Aida Junta, Gilda Maria Safrina, Nat?rcia Abreu, Vanessa da Silva, Nazareth Mabutana, Delcio Muteto, Benilde Munlela and Carolina Conjo. A special thank you also to Timothy Kellogg for all the guidance during the initial data analysis process. Publisher Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland.Diarrhoea is associated with undernutrition and this association is related to increased morbidity and mortality in children under-five. In this analysis we aimed to assess the frequency and associated factors of undernutrition in children under-five with diarrhoea. A hospital-based cross-sectional study was conducted from January 2015 to December 2019 through a surveillance system in five sentinel hospitals in Mozambique. Sociodemographic and clinical information was collected, including anthropometry. A total of 963 children were analysed. The overall undernutrition frequency was 54.1% (95% CI: 50.9–57.2), with 32.5% (95% CI: 29.6–35.5) stunting, 26.6% (95% CI: 23.9–29.6) wasting and 24.7% (95% CI: 22.1–27.5) underweight. Children from Nampula province had 4.7 (p = 0.016) higher odds for stunting compared with children from Maputo and Zambézia. Children whose mother was illiterate had higher odds of being underweight 5.4 (p < 0.001). Children born under 2500 g of weight had 2.85 (p = 0.001), 2.97 (p < 0.001) and 2.19 (p = 0.013) higher odds for being underweighted, wasted and stunted, respectively. The HIV positive status of the children was associated with higher odds of being underweight 2.88 (p = 0.005), wasted 2.24 (p = 0.025), and stunted 2.89 (p = 0.004). The province, caregiver education level, child’s birthweight and HIV status were factors associated with undernutrition in children with diarrhoea. These findings emphasise the need for additional caregiver’s education on the child’s nutrition and associated infectious diseases. More studies are needed to better understand the social context in which a child with diarrhoea and undernutrition is inserted.publishersversionpublishe

Risk factors, genotypes distribution by vaccination status and age of children in Nampula Province, Northern Mozambique (2015-2019)

Publisher Copyright: © 2021 Chissaque et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Mozambique introduced the monovalent rotavirus vaccine (Rotarix®, GSK Biologicals, Rixensart, Belgium) in September 2015. Previous analysis, showed that Nampula province continues reporting a high frequency of Rotavirus A (RVA) infection and the emergence of G9P[6], G9P[4] and G3P[4] genotypes. This analysis aimed to determine the RVA frequency; risk factors; genotype distribution by vaccination status and age between pre- and post-vaccine periods in children under-five years old with diarrhea in Nampula. A cross-sectional, hospital-based surveillance study was conducted in the Hospital Central de Nampula in Mozambique. Socio-demographic and clinical data were collected to assess factors related to RVA infection in both periods. Stool specimens were screened to detect RVA by ELISA, and positive samples were genotyped. Between 2015 (pre-vaccine period) and 2016-2019 (post-vaccine period), 614 stool specimens were collected and tested for RVA in which 34.9% (67/192) were positive in pre-vaccine period and 21.8% (92/422) in post-vaccine (p = 0.001). In the post-vaccine period, age, year, and contact with different animal species (chicken, duck, or multiple animals) were associated with RVA infection. RVA infection was higher in children partially vaccinated (40.7%, 11/27) followed by the fully vaccinated (29.3%, 56/191) and the unvaccinated (15.3%, 21/137) (p = 0.002). G1P[8] and G9P[4] were common in vaccinated children less than 12 months. The present analysis showed that RVA infection reduced slightly in the post-vaccine period, with a high proportion of infection and genotype diversity in children, under 12 months of age, vaccinated. Further research on factors associated with RVA infection on vaccinated compared to unvaccinated children and vaccination optimization should be done.publishersversionpublishe

Immunogenicity of Reduced-Dose Monovalent Type 2 Oral Poliovirus Vaccine in Mocuba, Mozambique

Funding Information: This work was supported by Rotary International, through a grant from the World Health Organization (grant 2019/889177-2). Publisher Copyright: © The Author(s) 2020.Background. The monovalent type 2 oral poliovirus vaccine (mOPV2) stockpile is low. One potential strategy to stretch the existing mOPV2 supply is to administer a reduced dose: 1 drop instead of 2. Methods. We conducted a randomized, controlled, open-label, noninferiority trial (10% margin) to compared immunogenicity after administration of 1 versus 2 drops of mOPV2. We enrolled 9–22-month-old infants from Mocuba district of Mozambique. Poliovirus neutralizing antibodies were measured in serum samples collected before and 1 month after mOPV2 administration. Immune response was defined as seroconversion from seronegative (<1:8) at baseline to seropositive (≥1:8) after vaccination or boosting titers by ≥4-fold for those with titers between 1:8 and 1:362 at baseline. The trial was registered at anzctr.org.au (no. ACTRN12619000184178p). Results. We enrolled 378 children, and 262 (69%) completed per-protocol requirements. The immune response of mOPV2 was 53.6% (95% confidence interval, 44.9%–62.1%) and 60.6% (52.2%–68.4%) in 1-drop and 2-drop recipients, respectively. The noninferiority margin of the 10% was not reached (difference, 7.0%; 95% confidence interval, −5.0% to 19.0%). Conclusion. A small loss of immunogenicity of reduced mOPV2 was observed. Although the noninferiority target was not achieved, the Strategic Advisory Group of Experts on Immunization recommended the 1-drop strategy as a dose-sparing measure if mOPV2 supplies deteriorate further.publishersversionpublishe

Enterovirus detection in stool samples from Mozambican children with acute gastroenteritis

Funding Information: Diocreciano Bero, Ph.D. was supported by Brazilian National Council for Scientific and Technological Development and the Academy of Sciences for the Developing World (CNPq/TWAS, grant number 190,897/2015–5). The ViNaDia was sponsored by Gavi, the Vaccine Alliance through Centers for Disease Control and Prevention (CDC) , Atlanta and World Health Organization, Regional Office for Africa (WHO/AFRO), Deutsche Forschungsgemeinschaft (DFG, grant number JO369/5–1). Nilsa de Deus was fellowship of the European Foundation Initiative into African Research in Neglected Tropical Diseases (EFINTD, grant number 89,539). Publisher Copyright: © 2022Enteroviruses (EV) are predominantly enteric viruses, present in all parts of the world causing disease in humans with a broad spectrum of clinical presentations. The purpose of this study was to identify non-polio enteroviruses (NPEV) in stool samples collected from children with acute gastroenteritis (AGE) symptoms of unknown etiology in four provinces (Maputo, Nampula, Sofala and Zambézia) of Mozambique. From June 2014 to March 2018, 327 stool samples were collected from children hospitalized with AGE in health care units. NPEVs were detected in 52 samples (52/327; 15.9%) and were more frequent in children under 5 years of age. The age group from 12 to 23 months was the most affected and showed more severity of disease. We also identified 26 different EV-types with the following detection pattern EV-B>EV-C>EV-A. The major EV-types were EV-A119 (9/52; 17.3%) and EV-C99 (8/52; 15.4%), accounting for 32.7% of the total. In addition to EV-A119, other uncommon EV-types were also identified, such as EV-B75, EV-B97 and EV-C113. The current study shows a high heterogeneity of EV types circulating in children with AGE in Mozambique as well as the identification of rarely described enteroviruses.publishersversionpublishe

Trends and Determinants of Full Immunisation among Children Aged 12&ndash;23 Months: Analysis of Pooled Data from Mozambican Household Surveys between 1997 and 2015

The 1974 Expanded Program on Immunisation has saved millions of children worldwide by promoting full immunisation coverage (FIC). However, forty years later, many sub-Saharan African countries remain well below its target of 90% FIC. This study analysed the level, trends and determinants of FIC in 4322 Mozambican children aged 12&ndash;23 months from pooled data from four national surveys between 1997 and 2015. Descriptive statistics and multivariable logistic regression models were performed to analyse the factors associated with full immunisation coverage. Overall, the coverage of fully immunised children increased from 47.9% in 1997 to 66.5% in 2015, corresponding to a 1.8% yearly increase. The needed FIC growth rate post-2015 was 4.3 times higher. Increased maternal education and a higher household wealth index were associated with higher odds of FIS. Furthermore, attending antenatal care (ANC) visits, institutional delivery and living in southern provinces were also associated with increased odds of FIS. Between 1997 and 2015, FIC among 12&ndash;23-month-old children made modest annual gains but remained well below international targets. Factors related to access to healthcare, educational level, socioeconomic status and geographical location were associated with improved FIC. Targeted interventions to expand these factors will improve immunisation coverage among Mozambican children

Rotavirus A strains obtained from children with acute gastroenteritis in Mozambique, 2012‑2013 : G and P genotypes and phylogenetic analysis of VP7 and partial VP4 genes

In Mozambique rotavirus (RV) was shown to be the greatest cause of acute diarrhoea in infants from 0 to 11 months, and in 2015, national rotavirus vaccination was introduced. As with other developing countries, there is very limited active strain characterisation. Rotavirus positive clinical specimens, collected between 2012 and 2013, have now provided information on the genotypes circulating in southern Mozambique prior to vaccine introduction. Genotypes G2 (32.4%), G12 (28.0%), P[4] (41.4%) and P[6] (22.9%) (n = 157) strains were commonly detected with G2P[4] (42.3%) RVs being predominant, specifically during 2013. Phylogenetic evaluation of the VP7 and VP8* encoding genes showed, for the majority of the Mozambican strains, that they clustered with other African strains based on genotype. RVA/Human-wt/MOZ/0153/2013/G2P[4], RVA/Human-wt/MOZ/0308/2012/G2P[4] and RVA/Humanwt/ MOZ/0288/2012/G12P[8] formed separate clusters from the other Mozambican strains with similar genotypes, suggesting possible reassortment. Amino acid substitutions in selected epitope regions also supported phylogenetic clustering. As expected, the VP7 and VP8* genes from the Mozambican strains differed from both the RotaTeq ® (SC2-9) G2P[5] and Rotarix ® (A41CB052A) G1P[8] genes. This study provides information on the genetic diversity of rotavirus strains prior to vaccine introduction and generates baseline data for future monitoring of any changes in rotavirus strains in response to vaccine pressure.Senior Fellowship to ND by European Foundation Initiative for African Research into Neglected Tropical Diseases (EFINTD, Grant no: 89539) and Mozambique/South Africa Research Cooperative Programme (Grant no: 86822) to HGO; UFS Postdoctoral Fellowship to AS, Poliomyelitis Research Foundation of South Africa bursary (13/67) to LM and Calouste Gulbenkian Foundation for EDJ scholarship.http://link.springer.com/journal/705am2018Medical Virolog

Whole Genome Characterization and Evolutionary Analysis of G1P[8] Rotavirus A Strains during the Pre- and Post-Vaccine Periods in Mozambique (2012–2017)

Mozambique introduced the Rotarix&reg; vaccine (GSK Biologicals, Rixensart, Belgium) into the National Immunization Program in September 2015. Although G1P[8] was one of the most prevalent genotypes between 2012 and 2017 in Mozambique, no complete genomes had been sequenced to date. Here we report whole genome sequence analysis for 36 G1P[8] strains using an Illumina MiSeq platform. All strains exhibited a Wa-like genetic backbone (G1-P[8]-I1-R1-C1-M1-A1-N1-T1-E1-H1). Phylogenetic analysis showed that most of the Mozambican strains clustered closely together in a conserved clade for the entire genome. No distinct clustering for pre- and post-vaccine strains were observed. These findings may suggest no selective pressure by the introduction of the Rotarix&reg; vaccine in 2015. Two strains (HJM1646 and HGM0544) showed varied clustering for the entire genome, suggesting reassortment, whereas a further strain obtained from a rural area (MAN0033) clustered separately for all gene segments. Bayesian analysis for the VP7 and VP4 encoding gene segments supported the phylogenetic analysis and indicated a possible introduction from India around 2011.7 and 2013.0 for the main Mozambican clade. Continued monitoring of rotavirus strains in the post-vaccine period is required to fully understand the impact of vaccine introduction on the diversity and evolution of rotavirus strains