Análise das políticas de controlo da tuberculose e do perfil epidemiológico da infecção em Moçambique (2009-2017)

A epidemia da tuberculose em Moçambique tem sido influenciada consideravelmente por factores como as condições económicas, incluindo a pobreza e o desemprego, as condições ambientais, incluindo bairros urbanos superlotados, a epidemia de VIH, as condições sociais, incluindo as migrações por trabalho, e as infraestruturas de saúde deficientes, bem como pela ocorrência de novas infecções por tuberculose, que têm aumentado de forma dramática nos últimos 10 a15 anos. A análise das políticas do Programa Nacional de Controlo da Tuberculose é de extrema importância, pois permite avaliar as suas operações e resultados, tornando-as mais efectivas na consecução da cobertura universal dos cuidados de saúde. Estas políticas, adoptadas na área da tuberculose influenciam o perfil epidemiológico da doença, pelo que a análise desse perfil é fundamental para avaliar o desempenho do programa ao longo dos tempos. Por outro lado, a análise do perfil epidemiológico da tuberculose permite, também, ajustar os objectivos e as respectivas intervenções do programa, contribuindo, desta forma, para a melhoria da resposta e dos indicadores de saúde. A maioria dos estudos realizados em Moçambique sobre as políticas de saúde e, mais especificamente, sobre aquelas relacionadas com a tuberculose, analisam as políticas e o perfil dos indicadores do programa de forma independente, desconhecendo-se, até ao presente momento, estudos que adoptem uma abordagem integrada destas duas vertentes – políticas e perfil da infecção. A presente investigação teve como objetivo geral compreender as políticas de controlo de tuberculose e a forma como estas se reflectiram no perfil epidemiológico da doença entre 2009 e 2017. Realizaram-se dois estudos: um qualitativo e outro quantitativo. No primeiro estudo, qualitativo, analisaram-se as políticas do Programa Nacional de Controlo da Tuberculose em Moçambique. Para tal utilizou-se a análise documental para identificar as políticas relevantes e a análise de conteúdo para discernir sobre as mesmas. No segundo estudo, quantitativo, o perfil epidemiológico da tuberculose entre 2009 e 2017 foi analisado utilizando um desenho ecológico descritivo, recorrendo a dados secundários de notificação e de avaliação dos casos, colhidos nos programas provinciais de controlo da tuberculose de Nampula, Sofala e Maputo. Para caracterizar clínica e epidemiológicamente a tuberculose, foram calculados indicadores anuais e a variação percentual ao longo dos anos. De seguida, relacionaram-se as políticas, nomeadamente os seus principais marcos, com o perfil epidemiológico da doença, relacionando-os qualitativamente com os resultados dos indicadores. Assim, ao analisar as políticas de tuberculose no período de 2009 a 2017 identificaram-se duas dimensões fundamentais: expansão dos serviços de saúde e controlo da doença. Na dimensão de expansão dos serviços de saúde, foi possível diferenciar duas subcategorias (acesso a serviços de saúde e melhoria da qualidade dos serviços de saúde) e na dimensão de controlo da doença, foi possível diferenciar três subcategorias (prevenção; diagnóstico e tratamento da tuberculose) que refletem, entre outras, estratégias adoptadas para cumprir total ou parcialmente o objectivo da política: controlar ou prevenir a doença. Em relação à componente de controlo de doença identificada nas políticas da tuberculose, verificou-se, por exemplo, um enfoque na área da comunicação e informação em saúde com a realização, entre outras, de palestras, habitualmente comunitárias, sobre a tuberculose, que se afiguraram efectivas o que pode ser verificado com o aumento do rastreio da doença, designadamente em pessoas que desejavam conhecer o seu estado em relação a tuberculose. Em relação ao perfil epidemiológico da doença, durante o período em análise (2009-2017), foram notificados 87 696 novos casos de tuberculose com baciloscopia positiva (BK+) nas três províncias do país, correspondendo a uma incidência de 346 por cem mil habitantes, sendo que 2,56% (2 243) novos casos tinham ocorrido em menores de 15 anos de idade. Esta incidência dos casos notificados nas três províncias, é relativamente baixa quando comparada por exemplo com a incidência nacional em 2018, que foi de 551 por cem mil habitantes (1). Resultados de notificação, demostraram que a província de Nampula, apresentou maior variação percentual de casos novos notificados em pacientes menores de 15 anos de idade, enquanto que a província de Maputo, apresentou menor variação percentual, em pacientes maiores de 15 anos, ao longo dos oito anos em análise. A província de Maputo, apresentou uma diminuição de casos de tuberculose extra-pulmonar em 35% entre 2009 e 2017 e foi a província que mais casos novos de tuberculose extra-pulmonar notificou, comparativamente a Nampula e Sofala. Em geral houve uma tendência crescente de casos de tuberculose multidroga resistente e a maioria dos casos diagnosticados era proveniente da província de Maputo, seguida de Sofala. Em relação à proporção de cura as províncias de Sofala e Maputo, demostraram uma diminuição na variação percentual deste indicador, com 10,7% e 14,9% respectivamente, entre 2009-2016. No entanto, nas três províncias a variação percentual da proporção de óbitos, revelou uma redução de 3,3%, 2,1% e 1,9% para Maputo, Sofala e Nampula respectivamente e houve um aumento na proporção de abandonos para Maputo e Sofala (2,0% e 1,9% respectivamente) em relação a província de Nampula que teve uma redução em 1,1%. A relação das políticas do programa com o perfil epidemiológico da doença, permitiu visualizar que em 2016, a taxa de notificação de casos novos com baciloscopia positiva foi crescente para as três províncias, como resultado da adopção do GeneXpert, como teste de eleição para o diagnóstico da tuberculose. Por outro lado, em 2013 verificou-se uma redução na proporção de abandonos, facto que pode ser atribuído a aprovação de plano de garantia de acesso universal ao tratamento anti-retroviral em pacientes co-infectados TB/VIH na paragem única naquele ano. A pesquisa concluíu que as intervenções para o controlo da tuberculose estão a surtir efeitos satisfatórios, porém, salienta-se que as políticas por si só não funcionam, é preciso uma implementação efectiva das mesmas, em função do contexto em que foram formuladas.The tuberculosis epidemic in Mozambique has been considerably influenced by factors such as economic conditions, including poverty and unemployment, environmental conditions, including overcrowded urban neighborhoods, the HIV epidemic, social conditions, including migrations by work, and poor health infrastructure; as well as the occurrence of new tuberculosis infections that have increased dramatically in the last 10 to 15 years. The analysis of the policies of the National Tuberculosis Control Program is extremely important, as it allows to evaluate its operations and results, making them more effective in achieving universal health care coverage. These policies adopted in the area of tuberculosis influence the epidemiological profile of the disease, so the analysis of this profile is essential to assess the performance of the program over time. On the other hand, the analysis of the epidemiological profile of tuberculosis also allows to adjust the objectives and respective interventions of the program, thus contributing to the improvement of the response and health indicators. Most of the studies carried out in Mozambique on health policies and, more specifically, on those related to tuberculosis, analyze the policies and the profile of the program indicators independently, and at the moment, studies that adopt an integrated analyze of these two policy approaches and infection profile are unknown. This research aimed to understand the tuberculosis control policies and the way they were reflected in the epidemiological profile of the disease between 2009 and 2017. Two studies were carried out: one qualitative and other quantitative. In the qualitative study, the policies of the National Tuberculosis Control Program in Mozambique were analyzed. To this end, document analysis was used to identify relevant policies and content analysis to discern them. In the seconda, quantitative study, the epidemiological profile of tuberculosis between 2009 and 2017 was analyzed using a descriptive ecological design, using secondary data for notification and case assessment, collected in the provincial tuberculosis control programs of Nampula, Sofala and Maputo. In order to clinically and epidemiologically characterize tuberculosis, annual indicators and percentage change over the years were calculated. Then, the policies, namely their main milestones, were related to the epidemiological profile of the disease, qualitatively relating them to the results of the indicators.Thus, when analyzing tuberculosis policies in the period from 2009 to 2017, two fundamental dimensions were identified: expansion of health services and disease control. In the dimension of expansion of health services, it was possible to differentiate two subcategories (access to health services and improvement in the quality of health services) and in the dimension of disease control, it was possible to differentiate three subcategories (prevention; diagnosis and treatment of tuberculosis) that reflect, among others, strategies adopted to fully or partially fulfill the policy objective: control or prevent the disease. Regarding the disease control component identified in tuberculosis policies, there was, for example, a focus in the area of communication and information in health with the holding, among others, of lectures, usually community, on tuberculosis, which they appeared effective, which can be verified with the increase in the screening of the disease, namely in people who wished to know their status in relation to tuberculosis. Regarding the epidemiological profile of the disease, during the period under analysis (2009-2017), 87 696 new cases of tuberculosis with positive sputum smear microscopy (BK +) were reported in the three provinces of the country, corresponding to an incidence of 346 per hundred thousand inhabitants, with 2.56% (2,243) new cases occurring in children under 15 years of age. This incidence of cases reported in the three provinces is relatively low when compared, for example, to the national incidence in 2018, which was 551 per hundred thousand inhabitants. Notification results showed that Nampula province showed a greater percentage variation in new cases reported in patients under 15 years of age, while the Maputo province showed a lower percentage variation in patients over 15 years of age, during the eight years under review. Maputo province showed a 35% decrease in extra-pulmonary tuberculosis cases between 2009 and 2017 and was the province that reported more new cases of extra-pulmonary tuberculosis, compared to Nampula and Sofala. In general, there was an increasing trend in resistant multidrug tuberculosis cases and the majority of diagnosed cases came from the province of Maputo, followed by Sofala. Regarding the proportion of cure, Sofala and Maputo provinces showed a decrease in the percentage variation of this indicator, with 10.7% and 14.9% respectively, between 2009-2016. However, in the three provinces the percentage change in the proportion of deaths, showed a reduction of 3.3%, 2.1% and 1.9% for Maputo, Sofala and Nampula respectively and there was an increase in the proportion of dropouts for Maputo and Sofala (2.0% and 1.9 % respectively) in relation to the province of Nampula, which decreased by 1.1%. The relationship between the program's policies and the epidemiological profile of the disease, allowed us to see that in 2016, the rate of notification of new cases with positive sputum smear microscopy was increasing for the three provinces, as a result of the adoption of GeneXpert, as the test of choice for diagnosis tuberculosis. On the other hand, in 2013 there was a reduction in the proportion of dropouts, a fact that can be attributed to the approval of a plan to guarantee universal access to antiretroviral treatment in co-infected TB / HIV patients in the single stop that year. The research concluded that interventions for tuberculosis control are having satisfactory effects, however, it is emphasized that policies alone do not work, effective implementation is necessary, depending on the context in which they were formulated

Mycobacterium tuberculosis resistance to antituberculosis drugs in Mozambique,

OBJECTIVE: To determine the drug resistance profile of Mycobacterium tuberculosis in Mozambique. METHODS: We analyzed secondary data from the National Tuberculosis Referral Laboratory, in the city of Maputo, Mozambique, and from the Beira Regional Tuberculosis Referral Laboratory, in the city of Beira, Mozambique. The data were based on culture-positive samples submitted to first-line drug susceptibility testing (DST) between January and December of 2011. We attempted to determine whether the frequency of DST positivity was associated with patient type or provenance. RESULTS: During the study period, 641 strains were isolated in culture and submitted to DST. We found that 374 (58.3%) were resistant to at least one antituberculosis drug and 280 (43.7%) were resistant to multiple antituberculosis drugs. Of the 280 multidrug-resistant tuberculosis cases, 184 (65.7%) were in previously treated patients, most of whom were from southern Mozambique. Two (0.71%) of the cases of multidrug-resistant tuberculosis were confirmed to be cases of extensively drug-resistant tuberculosis. Multidrug-resistant tuberculosis was most common in males, particularly those in the 21-40 year age bracket. CONCLUSIONS: M. tuberculosis resistance to antituberculosis drugs is high in Mozambique, especially in previously treated patients. The frequency of M. tuberculosis strains that were resistant to isoniazid, rifampin, and streptomycin in combination was found to be high, particularly in samples from previously treated patients

Understanding the bricks to build better surgical oncology unit at Maputo Central Hospital: prevalent surgical cancers and residents knowledge

Introduction: cancer is a growing concern in Mozambique. However, the country has limited facilities and few oncologists. Surgical oncologists are an unmet need. The aim of this study was to assess residents' knowledge in prevalent cancer domains and to identify and characterize prevalent cancers treated by surgery at Maputo Central Hospital, the largest hospital in Mozambique. The expectations were that the findings shall inform the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital. Methods: to identify and characterize prevalent cancers, we performed a retrospective analysis of individual cancer patient registries of Maputo Central Hospital (MCH), Mozambique. Information was recorded into data collection sheets and analyzed with SPSS® 21. To assess MCH residents oncologic knowledge, we invited Twenty-six junior residents (49% of all residents) of different specialties to take a 30 item multiple choice written test used elsewhere in previous studies. The test focused on the domains of Basis of oncology, Radiotherapy, Pathology, Chemotherapy, Pain management, Surgical oncology and Clinical Pathway. The test was administered anonymously and without prior notice. We analyzed the overall test and topic performance of residents. Results: the study covered a period of 3 years and 203 patients. The most prevalent malignant tumors treated by general and thoracic surgery in MCH cancer registry were esophageal (7%), female breast (6.5%) and colorectal cancer (2.8%). Globally these malignancies were diagnosed at an advanced stage of the disease and required a multimodal treatment. The mean percent correct score of residents was 37.3%. The dimension with the highest percent correct score were clinical management (46%) and surgical oncology (28%) showed the lowest correct score. Conclusion: in Maputo, Mozambique esophageal, breast and colorectal cancer were the most prevalent malignancies treated, with surgery, by thoracic or general surgery in MCH. The test scores suggest that, among residents, the knowledge in oncology needs to be improved, rendering support to the need of a surgical oncology training tailored to suit the local needs. Specific training should take into account local cancer prevalence, resources, their quality and the support of surgical oncology services with volume and experience

Understanding the bricks to build better surgical oncology unit at Maputo Central Hospital: prevalent surgical cancers and residents knowledge

Cancer is a growing concern in Mozambique. However, the country has limited facilities and few oncologists. Surgical oncologists are an unmet need. The aim of this study was to assess residents' knowledge in prevalent cancer domains and to identify and characterize prevalent cancers treated by surgery at Maputo Central Hospital, the largest hospital in Mozambique. The expectations were that the findings shall inform the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity

Background The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries.Methods The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria.Results A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)).Conclusion Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83–7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97–2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14–1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25–1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population. Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay. Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity. Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes

Liver injury in hospitalized patients with COVID-19: An International observational cohort study

Background: Using a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes.MethodsWe included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission: Normal; Stage I) Liver injury: any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury: any component & GE;3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI).ResultsOf 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]), and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45). Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]).ConclusionsLiver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes