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

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

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

Norovirus Genetic Diversity in Children under Five Years Old with Acute Diarrhea in Mozambique (2014–2015)

Funding Information: This study was supported by the European Initiative for Research in Neglected Tropical Diseases (EFINTD), World Health Organization (WHO), The Global Alliance for Vaccines and Immunizations—Health System Strengthening (GAVI—HSS), Fundo Nacional de Investigação (FNI) and the National Research Foundation, South Africa (M.B.T., Grant specific reference number (UID 85799). Any opinion, finding, conclusion or recommendation expressed in this material is that of the author(s), and the NRF does not accept any liability in this regard. Publisher Copyright: © 2022 by the authors.Norovirus (NoV) is the second most important cause of viral diarrheal disease in children worldwide after rotavirus and is estimated to be responsible for 17% of acute diarrhea in low-income countries. This study aimed to identify and report NoV genotypes in Mozambican children under the age of five years with acute diarrhea. Between May 2014 and December 2015, stool specimens were collected within the Mozambique Diarrhea National Surveillance (ViNaDia) and tested for NoV genogroups I (GI) and II (GII) using conventional reverse transcriptase-polymerase chain reaction (RT-PCR). Partial capsid and RNA-dependent RNA polymerase (RdRp) nucleotide sequences were aligned using the Muscle tool, and phylogenetic analyses were performed using MEGA X. A total of 204 stool specimens were tested for NoV. The detection rate of NoV was 14.2% (29/204). The presence of NoV was confirmed, by real-time RT-PCR (RT-qPCR), in 24/29 (82.8%) specimens, and NoV GII predominated (70.8%; 17/24). NoV GII.4 Sydney 2012[P31] was the predominant genotype/P-type combination detected (30.4%; 7/23). This is the first study which highlights the high genetic diversity of NoV in Mozambican children and the need to establish a continuous NoV surveillance system.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

Effectiveness of Monovalent Rotavirus Vaccine in Mozambique, a Country with a High Burden of Chronic Malnutrition

Funding Information: Funding: This research was funded by GAVI through the Centers for Disease Control and Prevention (CDC), Atlanta and World Health Organization, Regional Office for Africa (WHO/AFRO). African Research in Neglected Tropical Diseases (EFINTD, grant number 89539); Deutsche Forschungsge-meinschaft (DFG; grant number JO369/5-1); Fundo Nacional de Investigação (FNI); United States Agency for International Development (USAID; grant number AID-656-F-16-00002); the Calouste Gulbenkian Foundation from where A.C., F.M., and J.S. have a PhD fellowship. Publisher Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland.Mozambique introduced monovalent rotavirus vaccine (Rotarix® ) in September 2015. We evaluated the effectiveness of Rotarix® under conditions of routine use in Mozambican children hospitalized with acute gastroenteritis (AGE). A test negative case-control analysis was performed on data collected during 2017–2019 from children <5 years old, admitted with AGE in seven sentinel hospital sites in Mozambique. Adjusted VE was calculated for ≥1 dose of vaccine vs. zero doses using unconditional logistic regression, where VE = (1 − aOR) × 100%. VE estimates were stratified by age group, AGE severity, malnutrition, and genotype. Among 689 children eligible for analysis, 23.7% were rotavirus positive (cases) and 76.3% were negative (controls). The adjusted VE of ≥1 dose in children aged 6–11 months was 52.0% (95% CI, −11, 79), and −24.0% (95% CI, −459, 62) among children aged 12–23 months. Estimated VE was lower in stunted than non-stunted children (14% (95% CI, −138, 66) vs. 59% (95% CI, −125, 91)). Rotavirus vaccination appeared moderately effective against rotavirus gastroenteritis hospitalization in young Mozambican children. VE point estimates were lower in older and stunted children, although confidence intervals were wide and overlapped across strata. These findings provide additional evidence for other high-mortality countries considering rotavirus vaccine introduction.publishersversionpublishe

Readiness of Mozambique Health Facilities to Address Undernutrition and Diarrhea in Children under Five: Indicators from 2018 and 2021 Survey Data

The World Health Organization&rsquo;s systems framework shows that service delivery is key to addressing pressing health needs. Inadequate healthcare and the lack of healthcare services are factors associated with undernutrition and diarrhea in children under five, two health conditions with high morbi-mortality rates in Mozambique. The aim of the analysis was to determine the readiness score of nutrition and diarrhea services for children under five and the influence of malaria and HIV (Human Immunodeficiency Virus) service readiness on the readiness of these two services. A total of 1644 public health facilities in Mozambique were included from the 2018 Service Availability and Readiness Assessment. Additionally, a cross-sectional study was conducted to determine the availability and readiness scores of nutrition services in 2021 in five referral health facilities. The availability of nutrition and diarrhea services for children is low in Mozambique, with both scoring below 75%. Major unavailability was observed for human resources, guidelines, and training dimensions. Diarrhea (median (IQ): 72.2% (66.7 to 83.3)) and nutrition service readiness (median (IQ): 57.1% (52.4 to 57.1)) scores were significantly different (p &lt; 0.001), while it is desirable for both services to be comprehensively ready. Nutrition services are positively associated with diarrhea service readiness and both services are associated with malaria and HIV service readiness (p &lt; 0.05). None of the health facilities had all tracer items available and none of the facilities were considered ready (100%). There is a persisting need to invest comprehensively in readiness dimensions, within and across child health services

Quality of routine data for monitoring nutrition and diarrhoea indicators of children under 5 in Mozambique: an ecological study over a 5-year period

Background Undernutrition and diarrhoea have a high burden in children under 5 in low/middle-income countries. Having data-driven quality health services for these two diseases is key in order to address the high burden of diseases; therefore, health systems must provide data to monitor, manage, plan and decide on policies at all levels of health services.Objective We aimed to assess the quality of nutrition and diarrhoea routine data on children under 5 in Mozambique.Design A longitudinal ecological study was implemented. Secondary data were used to assess the quality of moderate acute malnutrition (MAM), deworming and rotavirus vaccine indicators based on the data’s completeness, presence of outliers and consistency, and seasonality analysis in the form of time series analysis was performed.Setting We used monthly district-level count data from 2017 to 2021, from all health facilities, from the Mozambican health information system (Sistema de Informação de Saúde para Monitoria e Avaliação, or District Health Information System version 2).Results The rotavirus vaccine indicators presented better completeness when compared with other indicators under analysis. Extreme outliers were observed for deworming and rotavirus vaccines, with a higher number of outliers in the Zambezia and Nampula Provinces. Better consistency over time was observed when analysing the period before the COVID-19 pandemic, for all of the indicators and across provinces. Indicators of MAM and MAM-recovered showed more consistency issues over time in both periods of 2017–2019 and 2018–2021. In terms of seasonality analysis, for the MAM and MAM-recovered indicators, lower variation was observed, and heterogeneous patterns were seen across provinces for the rotavirus vaccine, which had the most pronounced negative seasonality components in Maputo City.Conclusion Major deficits regarding the analysed quality indicators were observed for Cabo Delgado, Nampula, Zambezia, Tete, Manica, and Maputo City and Province

Performance Evaluation of the STANDARDTM Q COVID-19 and PanbioTM COVID-19 Antigen Tests in Detecting SARS-CoV-2 during High Transmission Period in Mozambique

(1) Background: Laboratory-based molecular assays are the gold standard to detect SARS-CoV-2. In resource-limited settings, the implementation of these assays has been hampered by operational challenges and long turnaround times. Rapid antigen detection tests are an attractive alternative. Our aim is to evaluate the clinical performance of two SARS-CoV-2 rapid antigen tests during a high transmission period. (2) Methods: A total of 1277 patients seeking SARS-CoV-2 diagnosis were enrolled at four health facilities. Nasopharyngeal swabs for rapid antigen and real time PCR testing were collected for each patient. Sensitivity, specificity, positive and negative predictive values, misclassification rate, and agreement were determined. (3) Results: The overall sensitivity of Panbio COVID-19 was 41.3% (95% CI: 34.6&ndash;48.4%) and the specificity was 98.2% (95% CI: 96.2&ndash;99.3%). The Standard Q had an overall sensitivity and specificity of 45.0% (95% CI: 39.9&ndash;50.2%) and 97.6% (95% CI: 95.3&ndash;99.0%), respectively. The positive predictive value of a positive test was 93.3% and 95.4% for the Panbio and Standard Q Ag-RDTs, respectively. A higher sensitivity of 43.2% and 49.4% was observed in symptomatic cases for the Panbio and Standard Q Ag-RDTs, respectively. (4) Conclusions: Despite the overall low sensitivity, the two evaluated rapid tests are useful to improve the diagnosis of symptomatic SARS-CoV-2 infections during high transmission periods

Testing for SARS-CoV-2 in resource-limited settings: A cost analysis study of diagnostic tests using different Ag-RDTs and RT-PCR technologies in Mozambique.

Early diagnosis of SARS-CoV-2 is fundamental to reduce the risk of community transmission and mortality, as well as public sector expenditures. Three years after the onset of the SARS-CoV-2 pandemic, there are still gaps on what is known regarding costs and cost drivers for the major diagnostic testing strategies in low- middle-income countries (LMICs). This study aimed to estimate the cost of SARS-CoV-2 diagnosis of symptomatic suspected patients by reverse transcription polymerase chain reaction (RT-PCR) and antigen rapid diagnostic tests (Ag-RDT) in Mozambique. We conducted a retrospective cost analysis from the provider's perspective using a bottom-up, micro-costing approach, and compared the direct costs of two nasopharyngeal Ag-RDTs (Panbio and Standard Q) against the costs of three nasal Ag-RDTs (Panbio, COVIOS and LumiraDx), and RT-PCR. The study was undertaken from November 2020 to December 2021 in the country's capital city Maputo, in four healthcare facilities at primary, secondary and tertiary levels of care, and at one reference laboratory. All the resources necessary for RT-PCR and Ag-RDT tests were identified, quantified, valued, and the unit costs per test and per facility were estimated. Our findings show that the mean unit cost of SARS-CoV-2 diagnosis by nasopharyngeal Ag-RDTs was MZN 728.00 (USD 11.90, at 2020 exchange rates) for Panbio and MZN 728.00 (USD 11.90) for Standard Q. For diagnosis by nasal Ag-RDTs, Panbio was MZN 547.00 (USD 8.90), COVIOS was MZN 768.00 (USD 12.50), and LumiraDx was MZN 798.00 (USD 13.00). Medical supplies expenditures represented the main driver of the final cost (>50%), followed by personnel and overhead costs (mean 15% for each). The mean unit cost regardless of the type of Ag-RDT was MZN 714.00 (USD 11.60). Diagnosis by RT-PCR cost MZN 2,414 (USD 39.00) per test. Our sensitivity analysis suggests that focussing on reducing medical supplies costs would be the most cost-saving strategy for governments in LMICs, particularly as international prices decrease. The cost of SARS-CoV-2 diagnosis using Ag-RDTs was three times lower than RT-PCR testing. Governments in LMICs can include cost-efficient Ag-RDTs in their screening strategies, or RT-PCR if international costs of such supplies decrease further in the future. Additional analyses are recommended as the costs of testing can be influenced by the sample referral system