96 research outputs found
Weak surveillance and policy attention to cancer in global health: the example of Mozambique
Cancer is an emerging public health problem in sub-Saharan
Africa due to population growth, ageing and westernisation of
lifestyles. The increasing burden of cancer calls for urgent
policy attention to develop cancer prevention and control
programmes. Cancer surveillance is an essential prerequisite.
Only one in five low-income and middle-income countries have the
necessary data to drive policy and reduce the cancer burden. In
this piece, we use data from Mozambique over a 50-year period to
illustrate cancer epidemiological trends in low-income and
middle-income countries to hypothesise potential circumstances
and factors that could explain changes in cancer burden and to
discuss surveillance weaknesses and potential improvements. Like
many low-income and middle-income countries, Mozambique faces
the dual challenge of a still high morbidity and mortality due
to infectious diseases in rural areas and increased incidence of
cancers associated with westernisation of lifestyles in urban
areas, as well as a rise of cancers related to the HIV epidemic.
An increase in cancer burden and changes in the cancer profile
should be expected in coming years. The Mozambican healthcare
and health-information systems, like in many other low-income
and middle-income countries, are not prepared to face this
epidemiological transition, which deserves increasing policy
attention
Trends in Cancer Incidence in Maputo, Mozambique, 1991-2008
BACKGROUND: Very limited information is available regarding the
incidence of cancer in sub-Saharan Africa. We analyzed changes
in cancer patterns from 1991 to 2008 in Maputo (Mozambique).
METHODS: We calculated the rates of incidence of different
cancer sites by sex in the 5-year age-group of the population of
Maputo city as well as age-standardized rates (ASRs) and average
annual percentage changes (AAPC). RESULTS: Over the 18-year
study period a total of 12,674 cases of cancer (56.9% females)
were registered with an overall increase in the risk of cancer
in both sexes. In males, the most common cancers were those of
the prostate, Kaposi sarcoma (KS) and the liver. Prostate cancer
showed the most dramatic increase over the whole study period
(AAPC +11.3%; 95% CI: 9.7-13.0), with an ASR of 61.7 per 105 in
2003-2008. In females, the most frequent cancers were of the
uterine cervix, the breast and KS, with the former increasing
along the whole study period (AAPC + 4.7%; 95% CI: 3.4-6) with
an ASR of 62.0 per 105 in 2003-2008 as well as breast cancer
(AAPC +6.5%; 95%CI: 4.3-8.7). CONCLUSIONS: Overall, the risk of
cancer rose in both sexes during the study period, particularly
among cancers associated with westernization of lifestyles
(prostate, breast), combined with increasingly rising incidences
or limited changes in cancers associated with infection and
poverty (uterine cervix, liver). Moreover, the burden of
AIDS-associated cancers has shown a marked increase
Incidence Of Endemic Burkitt Lymphoma In Three Regions Of Mozambique
Data on the burden and incidence of endemic Burkitt lymphoma (eBL) across Mozambique are scarce. We retrospectively retrieved information on eBL cases from reports of the three main hospitals of Mozambique: Maputo Central Hospital (MCH), Beira Central Hospital (BCH), and Nampula Central Hospital (NCH) between 2004 and 2014. For 2015, we prospectively collected information of new eBL cases attending these hospitals. A total of 512 eBL cases were reported between 2004 and 2015: 153 eBL cases were reported in MCH, 195 in BCH, and 164 in NCH. Mean age of cases was 6.9 years (standard deviation = 2.8); 63% (319/504) of cases were males. For 2015, the estimated incidence rate of eBL was 2.0, 1.7, and 3.9 per 10(6) person-year at risk in MCH, BCH, and NCH, respectively. Incidence was higher in NCH (northern Mozambique), where intensity of malaria transmission is higher. Data presented show that eBL is a common pediatric malignancy in Mozambique, as observed in neighboring countries
Pathological Methods Applied to the Investigation of Causes of Death in Developing Countries: Minimally Invasive Autopsy Approach
BACKGROUND AND AIMS: Complete diagnostic autopsies (CDA) remain the gold standard in the determination of cause of death (CoD). However, performing CDAs in developing countries is challenging due to limited facilities and human resources, and poor acceptability. We aimed to develop and test a simplified minimally invasive autopsy (MIA) procedure involving organ-directed sampling with microbiology and pathology analyses implementable by trained technicians in low- income settings. METHODS: A standardized scheme for the MIA has been developed and tested in a series of 30 autopsies performed at the Maputo Central Hospital, Mozambique. The procedure involves the collection of 20 mL of blood and cerebrospinal fluid (CSF) and puncture of liver, lungs, heart, spleen, kidneys, bone marrow and brain in all cases plus uterus in women of childbearing age, using biopsy needles. RESULTS: The sampling success ranged from 67% for the kidney to 100% for blood, CSF, lung, liver and brain. The amount of tissue obtained in the procedure varied from less than 10 mm2 for the lung, spleen and kidney, to over 35 mm2 for the liver and brain. A CoD was identified in the histological and/or the microbiological analysis in 83% of the MIAs. CONCLUSIONS: A simplified MIA technique allows obtaining adequate material from body fluids and major organs leading to accurate diagnoses. This procedure could improve the determination of CoD in developing countrie
Carriage prevalence of Salmonella enterica serotype Typhi in gallbladders of adult autopsy cases from Mozambique
INTRODUCTION: Typhoid fever is an important public health
problem in many low-income countries where asymptomatic carriers
play an important role in its dissemination. The bacterium
causing typhoid fever can live in the gallstones of asymptomatic
persons after the infection. These carriers are reservoirs of S.
Typhi, are highly contagious, and spread the disease through the
secretion of bacteria in feces and urine. The aim of this study
was to determine the carrier rate in an area of Mozambique.
METHODOLOGY: The presence of S. Typhi was analyzed in
gallbladder samples obtained from 99 adult corpses (in-hospital
deaths) from Mozambique by gold-standard culture and polymerase
chain reaction (PCR). RESULTS: Only one sample was positive with
the culture. However, nine additional samples were positive by
PCR and confirmed by DNA sequencing. Thus, the prevalence of S.
Typhi was 10.1% (10/99). CONCLUSIONS: We report a high
prevalence of S. Typhi in gallbladders among adult autopsy cases
from Mozambique
The role of Xpert MTB/RIF in diagnosing pulmonary tuberculosis in post-mortem tissues
The extent to which the Xpert MTB/RIF (Gene Xpert) contributes
to tuberculosis (TB) diagnosis in samples other than sputum and
cerebrospinal fluid remains uncertain. We aimed to assess the
role of Xpert MTB/RIF for detecting M. tuberculosis in
post-mortem tissues. We conducted a study among 30 complete
diagnostic autopsies (CDA) performed at the Maputo Central
Hospital (Mozambique). Lung tissues were screened for TB in all
cases. In addition other tissues were tested when compatible
lesions were identified in the histological exam. We used
in-house real time PCR and LAMP assays to confirm the presence
of M. tuberculosis DNA. The diagnosis of tuberculosis at death
was established based on microbiological and histopathological
results. Eight out of 30 cases (26.7%) were diagnosed of
tuberculosis. Xpert had a sensitivity to detect TB in lung
tissue of 87.5% (95% CI 47.3-99.7) and a specificity of 95.7%
(95% CI: 78.1-99.9). In-house DNA amplification methods and
Xpert showed 93.6% concordance for lung tissue and 100%
concordance for brain and liver tissues. The final cause of
death was attributable to tuberculosis in four cases. Xpert
MTB/RIF may represent a valuable, easy-to perform technique for
post-mortem TB diagnosis
Limitations to current methods to estimate cause of death: a validation study of a verbal autopsy model
Background: Accurate information on causes of death (CoD) is essential to estimate burden of disease, track global progress, prioritize cost-effective interventions, and inform policies to reduce mortality. In low-income settings, where a significant proportion of deaths take place at home or in poorly-resourced peripheral health facilities, data on CoD often relies on verbal autopsies (VAs). Validations of VAs have been performed against clinical diagnosis, but never before against an acceptable gold standard: the complete diagnostic autopsy (CDA). Methods: We have validated a computer-coded verbal autopsy method -the InterVA- using individual and population metrics to determine CoD against the CDA, in 316 deceased patients of different age groups who died in a tertiary-level hospital in Maputo, Mozambique between 2013 and 2015. Results: We found a low agreement of the model across all age groups at the individual (kappa statistic ranging from -0.030 to 0.232, lowest in stillbirths and highest in adults) and population levels (chance-corrected cause-specific mortality fraction accuracy ranging from -1.00 to 0.62, lowest in stillbirths, highest in children). The sensitivity in identifying infectious diseases was low (0% for tuberculosis, diarrhea, and disseminated infections, 32% for HIV-related infections, 33% for malaria and 36% for pneumonia). Of maternal deaths, 26 were assigned to eclampsia but only four patients actually died of eclampsia. Conclusions: These findings do not lead to building confidence in current estimates of CoD. They also call to the need to implement autopsy methods where they may be feasible, and to improve the quality and performance of current VA techniques
Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies
Background: Although an increasing number of pregnant women in resource-limited areas deliver in health-care facilities, maternal mortality remains high in these settings. Inadequate diagnosis and management of common life-threatening conditions is an important determinant of maternal mortality. We analysed the clinicopathological discrepancies in a series of maternal deaths from Mozambique and assessed changes over 10 years in the diagnostic process. We aimed to provide data on clinical diagnostic accuracy to be used for improving quality of care and reducing maternal mortality. Methods: We did a retrospective analysis of clinicopathological discrepancies in 91 maternal deaths occurring from Nov 1, 2013, to March 31, 2015 (17 month-long period), at a tertiary-level hospital in Mozambique, using complete diagnostic autopsies as the gold standard to ascertain cause of death. We estimated the performance of the clinical diagnosis and classified clinicopathological discrepancies as major and minor errors. We compared the findings of this analysis with those of a similar study done in the same setting 10 years earlier. Findings: We identified a clinicopathological discrepancy in 35 (38%) of 91 women. All diagnostic errors observed were classified as major discrepancies. The sensitivity of the clinical diagnosis for puerperal infections was 17% and the positive predictive value was 50%. The sensitivity for non-obstetric infections was 48%. The sensitivity for eclampsia was 100% but the positive predictive value was 33%. Over the 10-year period, the performance of clinical diagnosis did not improve, and worsened for some diagnoses, such as puerperal infection. Interpretation: Decreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care
'Pomegranate' Spleen in Disseminated Tuberculosis
A 33-year-old HIV-infected female patient who had died at Maputo Central Hospital, Maputo, Mozambique, after less than 24 hours of hospitalization, underwent a full postmortem examination to ascertain the cause of death. Antemortem chest radiography showed hyperinflated lungs, with scattered bilateral lesions compatible with a diagnosis of miliary tuberculosis (TB), which was (after postmortem examination) determined to be the final cause of death. The spleen was firm at touch, with multiple yellowish nodules randomly distributed throughout the surface of the spleen capsule. Gross examination of the spleen sections showed that the nodules and plaques massively infiltrated the spleen parenchyma, which showed a characteristic pomegranate aspect (Figures 1A and 1B). The histological sections confirmed the presence of caseous granulomas (Figure 1C). The presence of Mycobacterium tuberculosis bacilli in the spleen samples was confirmed by a specific in-house real-time polymerase chain reaction (1) and by Xpert MTB/RIF assay. The main differential diagnosis of this rarely reported macroscopic finding would be splenic neoplasms, infarcts, abscesses, and granulomas of varying etiology; and, in endemic areas, melioidosis (2). Although scarce data exist in the literature, the frequency of the underlying disease causing this macroscopic finding varies significantly depending on the geographical area. Infectious diseases account for a significant proportion of these lesions in developing countries (3), whereas in Western countries the predominant causes are neoplasms, mainly malignant lymphomas or metastatic carcinomas (4). Knowledge of the macroscopic aspect of splenic TB, which at cross-section resembles the inside of a pomegranate, could guide pathologists to rule in disseminated TB diagnosis on the basis of gross pathology, especially in high-burden TB/HIV countries
Unmasking the hidden tuberculosis mortality burden in a large postmortem study in Maputo Central Hospital, Mozambique
Sensitive tools are
needed to accurately establish the diagnosis of tuberculosis
(TB) at death, especially in low-income countries. The objective
of this study was to evaluate the burden of TB in a series of
patients who died in a tertiary referral hospital in sub-Saharan
Africa using an in-house real time PCR (TB-PCR) and the Xpert
MTB/RIF Ultra (Xpert Ultra) assay.Complete diagnostic autopsies
were performed in a series of 223 deaths (56.5% being
HIV-positive), including 54 children, 57 maternal deaths and 112
other adults occurring at the Maputo Central Hospital,
Mozambique. TB-PCR was performed in all lung, cerebrospinal
fluid and central nervous system samples in HIV-positive
patients. All samples positive for TB-PCR or showing
histological findings suggestive of TB were analysed with the
Xpert Ultra assay.TB was identified as the cause of death in 31
patients: 3/54 (6%) children, 5/57 (9%) maternal deaths and
23/112 (21%) other adults. The sensitivity of the main clinical
diagnosis to detect TB as the cause of death was 19.4% (95% CI:
7.5-37.5) and the specificity was 97.4% (94.0-99.1) compared to
autopsy findings. Concomitant TB (TB disease in a patient dying
of other causes) was found in 31 additional cases. Xpert Ultra
helped to identify 15 cases of concomitant TB. In 18 patients, "
- " DNA was identified by TB-PCR and Xpert Ultra in the absence
of histological TB lesions. Overall, 62 cases (27.8%) had TB
disease at death and 80 (35.9%) had TB findings.The use of
highly sensitive, easy to perform molecular tests in complete
diagnostic autopsies may contribute to identifying TB cases at
death that would have otherwise been missed. Routine use of
these tools in certain diagnostic algorithms for hospitalised
patients needs to be considered. Clinical diagnosis showed poor
sensitivity for the diagnosis of TB at death
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