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

Congenital cytomegalovirus, parvovirus and enterovirus infection in Mozambican newborns at birth: A cross-sectional survey

BACKGROUND: Congenital cytomegalovirus (cCMV) infection is the most prevalent congenital infection acquired worldwide, with higher incidence in developing countries and among HIV-exposed children. Less is known regarding vertical transmission of parvovirus B19 (B19V) and enterovirus (EV). We aimed to assess the prevalence of CMV, B19V and EV vertical transmission and compare results of screening of congenital CMV obtained from two different specimens in a semirural Mozambican maternity. METHODS: A cross sectional study was conducted among pregnant mothers attending Manhica District Hospital upon delivery. Information on maternal risk factors was ascertained. Dried umbilical cord (DUC) samples were collected in filter paper for CMV, B19V and EV detection by real-time polymerase chain reaction (RT-PCR), and nasopharyngeal aspirates (NPA) to test for CMV by RT-PCR. Maternal blood samples and placental biopsy samples were also obtained to investigate CMV maternal serology, HIV status and immunopathology. RESULTS: From September 2014 to January 2015, 118 mothers/newborn pairs were recruited. Prevalence of maternal HIV infection was 31.4% (37/118). CMV RT-PCR was positive in 3/115 (2.6%) of DUC samples and in 3/96 (6.3%) of NPA samples obtained from neonates. The concordance of the RT-PCR assay through DUC with their correspondent NPA sample was moderate (Kappa = 0.42 and p<0.001. No differences on cCMV prevalence were found among HIV-exposed and unexposed. All (100%) mothers were seropositive for CMV IgG. RT-PCR of EV and B19V in DUC were both negative in all screened cases. No histological specific findings were found in placental tissues. No risk factors associated to vertical transmission of these viral infections were found. CONCLUSIONS: This study indicates the significant occurrence of vertical transmission of CMV in southern Mozambique. Larger studies are needed to evaluate the true burden, clinical relevance and consequences of congenital infections with such pathogens in resource-constrained settings

Development of a post-mortem procedure to reduce the uncertainty regarding causes of death in developing countries

A major failure of our global society in the 21st century is that many people in developing countries are not only born and live without any official record of their existence a flagrant deprivation of an essential human right but also die without having been seen by medically qualified personnel. The resultant uncertainty about the real burden of specific causes of death is being increasingly recognised by international health and funding agencies as a crucial limitation in the prioritisation of effective public health programmes and assessment of their effect

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

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