Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study.

INTRODUCTION: As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The 'COVid and hIV' (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic's impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines. METHODS AND ANALYSIS: A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures. ETHICS AND DISSEMINATION: Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums. TRIAL REGISTRATION NUMBER: NCT05022407.

Early effects of COVID-19 on maternal and child health service disruption in Mozambique.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Introduction: After the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths. Methods: Using data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST). Results: All maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers. Conclusion: Findings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country.

Tracking SARS-CoV-2 introductions in Mozambique using pandemic-scale phylogenies: a retrospective observational study.

BACKGROUND: From the start of the SARS-CoV-2 outbreak, global sequencing efforts have generated an unprecedented amount of genomic data. Nonetheless, unequal sampling between high-income and low-income countries hinders the implementation of genomic surveillance systems at the global and local level. Filling the knowledge gaps of genomic information and understanding pandemic dynamics in low-income countries is essential for public health decision making and to prepare for future pandemics. In this context, we aimed to discover the timing and origin of SARS-CoV-2 variant introductions in Mozambique, taking advantage of pandemic-scale phylogenies. METHODS: We did a retrospective, observational study in southern Mozambique. Patients from Manhiça presenting with respiratory symptoms were recruited, and those enrolled in clinical trials were excluded. Data were included from three sources: (1) a prospective hospital-based surveillance study (MozCOVID), recruiting patients living in Manhiça, attending the Manhiça district hospital, and fulfilling the criteria of suspected COVID-19 case according to WHO; (2) symptomatic and asymptomatic individuals with SARS-CoV-2 infection recruited by the National Surveillance system; and (3) sequences from SARS-CoV-2-infected Mozambican cases deposited on the Global Initiative on Sharing Avian Influenza Data database. Positive samples amenable for sequencing were analysed. We used Ultrafast Sample placement on Existing tRees to understand the dynamics of beta and delta waves, using available genomic data. This tool can reconstruct a phylogeny with millions of sequences by efficient sample placement in a tree. We reconstructed a phylogeny (~7·6 million sequences) adding new and publicly available beta and delta sequences. FINDINGS: A total of 5793 patients were recruited between Nov 1, 2020, and Aug 31, 2021. During this time, 133 328 COVID-19 cases were reported in Mozambique. 280 good quality new SARS-CoV-2 sequences were obtained after the inclusion criteria were applied and an additional 652 beta (B.1.351) and delta (B.1.617.2) public sequences were included from Mozambique. We evaluated 373 beta and 559 delta sequences. We identified 187 beta introductions (including 295 sequences), divided in 42 transmission groups and 145 unique introductions, mostly from South Africa, between August, 2020 and July, 2021. For delta, we identified 220 introductions (including 494 sequences), with 49 transmission groups and 171 unique introductions, mostly from the UK, India, and South Africa, between April and November, 2021. INTERPRETATION: The timing and origin of introductions suggests that movement restrictions effectively avoided introductions from non-African countries, but not from surrounding countries. Our results raise questions about the imbalance between the consequences of restrictions and health benefits. This new understanding of pandemic dynamics in Mozambique can be used to inform public health interventions to control the spread of new variants. FUNDING: European and Developing Countries Clinical Trials, European Research Council, Bill & Melinda Gates Foundation, and Agència de Gestió d'Ajuts Universitaris i de Recerca.

From External to Local: Opportunities and Lessons Learned from Transitioning COMSA-Mozambique.

Donor transitions, where externally funded programs transfer to country ownership and management, are increasingly common. The Countrywide Mortality Surveillance for Action - Mozambique (COMSA) project established a nationwide surveillance system capturing vital events at the community level with funding from the Bill and Melinda Gates Foundation. COMSA was implemented in partnership between Johns Hopkins University (a U.S.-based academic institution) and the Instituto Nacional de Saúde (National Institute for Health) and Instituto Nacional de Estatística (National Institute for Statistics), two Mozambican public institutions. Midway through the project, the Gates Foundation directed COMSA's partners to develop and implement a transition plan that ensured COMSA's activities could be institutionalized after Gates Foundation funding ended. Here we describe the process and activities that COMSA underwent for transition planning, including stakeholder engagement and advocacy, securing financial commitments, documenting operational activities, capacity building, and supporting strategic planning. Facilitators included a project model that already embedded significant implementation and management responsibility with local agencies, high-level commitment to COMSA's activities from local stakeholders, establishing dedicated personnel and budget to manage transition, and fortuitous timing for financing. Challenges included needing to engage multiple government agencies to ensure buy-in, navigating tensions around future roles and responsibilities, reviewing and adjusting existing implementation structures, and the reality that this transition involved shifting financing from one development partner to another. Transition implementation was also constrained by the COVID-19 pandemic because key stakeholders were engaged in response efforts. COMSA's experience highlights lessons and threats for future programs facing donor transition in uncertain environments.

Determinants of COVID-19 vaccine acceptance in Mozambique: The role of institutional trust.

BACKGROUND: Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust. METHODS: The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N = 3809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance. RESULTS: One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status. CONCLUSIONS: Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic.

Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study.

INTRODUCTION: In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. METHODS: Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. RESULTS: The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. CONCLUSIONS: This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.

Sociodemographic characteristics of professional categories most affected by COVID-19 in Mozambique from March to July 2020.

Introduction: the risk of a worker becoming ill due to coronavirus disease 2019 (COVID-19) is related to occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to the need to restore work activities in Mozambique, the study was conducted with the aim of identifying the occupational categories most affected by COVID-19 in the former in the period from March to July 2020. Methods: this is a cross-sectional descriptive study, in which data from professions of confirmed cases of COVID-19 from 22 March to 29 July 2020 in Mozambique were analyzed. The professionals' data were reported daily by the National Institute of Health (NIH) and merged into a single database and exported to Excel, the latter categorized according to standard operating procedure (SOP) and descriptive statistics performed for its analysis. Results: in the period under analysis, 1,127 professionals were diagnosed with COVID-19, divided into 11 categories. Nampula province had the highest frequency of cases with 25.00% (277). The highest frequency of cases was registered in the domestic professional category, which had 16.77% (189/1,127) with the female sex being more frequent, 79.37% (150/189); and defense and security had 14.20% (160/1,127) of cases and male gender with 91.25% (146/160); Health workers had 13.04% (147/1,127), and the maximum number of COVID-19 cases was recorded in June with 58.50% (86/147). Conclusion: the professional categories most affected by COVID-19 in the period under review correspond to those groups that carry out activities requiring a physical presence at the workplace and from this; it is recommended that professionals reinforce preventive measures.

Linked transmission chains of imported SARS-CoV-2 variant B.1.351 across mainland France, January 2021.

Two cases of confirmed SARS-CoV-2 infection with the B.1.351 variant were reported in France in mid-January, 2020. These cases attended a gathering in Mozambique in mid-December 2020. Investigations led to the identification of five imported cases responsible for 14 transmission chains and a total 36 cases. Epidemiological characteristics seemed comparable to those described before the emergence of the South African variant B.1.351. The lack of tertiary transmission outside of the personal sphere suggests that distancing and barrier measures were effective.

Enhancing retention in care in HIV-infected adolescents during COVID-19 in Mozambique: results from the DREAM program.

INTRODUCTION: Around 1,7 million adolescents aged 10-19 years worldwide are infected with HIV, 84% of them living in Sub-Saharan Africa. Mozambique is one of the countries with the highest prevalence of HIV in the world. According to UNAIDS, HIV services for adolescents should be tailored and specifically designed for them. METHODS: We aimed to evaluate a package of activities to enhance the retention of HIV-infected adolescent in Mozambique. We retrospectively reviewed routine data from 7 health centers involved in 26 months, from March 2020 to May 2022. A package of tailored interventions was implemented in all the sites. We reviewed activity data from the included centers. RESULTS: The median number of patients per center was 343 (IQR: 289-466) at the beginning of the period and 395 (IQR: 322-453) at the end. The median overall retention in care and rate of lost to follow-up at the beginning and the end of the period were respectively: 94.2% (IQR 91.9-97.3%) to 99.0% (IQR 96.8-99.5%), 1.5% (IQR 1-3.2%) to 0% (IQR 0.0-0.3%). The total number of deaths increased reaching a plateau after September 2021. All the indicators improved after the beginning of the intervention, also during COVID-19 pandemic. CONCLUSIONS: Our data support the idea that enhancing retention in care for HIV positive adolescents need tailored interventions, based on deep rooting in the specific social context. Tailored intervention can resist external shock such as COVID-19.

Bombali Ebolavirus in Mops condylurus Bats (Molossidae), Mozambique.

We detected Bombali ebolavirus RNA in 3 free-tailed bats (Mops condylurus, Molossidae) in Mozambique. Sequencing of the large protein gene revealed 98% identity with viruses previously detected in Sierra Leone, Kenya, and Guinea. Our findings further support the suspected role of Mops condylurus bats in maintaining Bombali ebolavirus.

Malaria, HIV and Malnutrition among Internally Displaced People in Mozambique During COVID-19 Pandemic: Results from a Community-Based Intervention.

Background: The spread of COVID-19 poses an unprecedented challenge to care delivery in post-disaster and conflict situations. In Mozambique, the 2019 cyclone Idai and the violence by Non-State-Armed-Groups devastated the province of Sofala and Cabo Delgado respectively and led to the displacement of thousands of people living in poor and overcrowded conditions. The pandemic has further aggravated the situation. Doctors with Africa CUAMM (University college for aspiring missionary doctors) implemented surveillance activities in these regions between October 2020 and September 2021. The aim of this study is to give an overview of the prevalence of malaria, malnutrition, COVID-19 related symptoms and access to HIV testing. Methods: Data were collected in targeted internally displaced people (IDP) sites in Sofala and Cabo Delgado province between 31st January and 25th September 2021. The tool used enabled to assess COVID-19 symptoms, risk of HIV infection, malaria cases and malnutrition in children under five. Results: The project reached 93 503 people. During the study period, 13.6% people reported at least one symptom suggestive of COVID-19 infection. Malaria Rapid Diagnostic Tests (RDT) were administered to 86% of the recruited people (n = ?), with a positive diagnosis in the 4.5% of them (n = ?). Among the recruited Internally Displaced Persons (IDP), 23.1% were considered eligible for HIV screening, but only 1.4% were referred for testing. Acute malnutrition was found in 6.3% of children screened and, among these, a higher prevalence of concurrent COVID-19 symptoms was reported. Discussion: Our study highlights the importance of mass clinical screening for COVID-19 infection in this target population to enact prevention behavior, although this may not be enough, due to the pivotal role played by asymptomatic transmissions. Considering the overlap of the symptoms of COVID-19 and malaria, a combined diagnostic algorithm is urgently needed to avoid underdiagnosing malaria. Moreover, the high prevalence of respiratory symptoms in malnourished children confirmed the known correlation between malnutrition and respiratory infection. Finally, access to HIV screening needs to be implemented, given the high prevalence of people with HIV risk factors to avoid diagnostic delay. Conclusions: Population-specific needs make necessary to develop new screening methods that respond to the specific characteristics of the target population.

Effects of the COVID-19 pandemic on maternal and perinatal health service utilisation and outcomes in Mozambique: an interrupted time series analysis.

OBJECTIVES: To measure the effects of the COVID-19 pandemic on maternal and perinatal health services and outcomes in Mozambique. DESIGN: This is an observational study analysing routine service delivery data using interrupted time series analysis. We used 43 months of district-level panel data with April 2020 as the point of interruption, adjusting for seasonality and population growth to analyse service utilisation outcomes. SETTING: The 222 public health facilities in Nampula Province, Mozambique, from January 2018 to July 2021. OUTCOME MEASURES: The change in the number of antenatal care (ANC) visits and facility deliveries, and the change in the rate of adverse birth outcomes at pandemic onset and over time compared with expected levels and trends, respectively. RESULTS: There were no significant disruptions to ANC at pandemic onset. Following this, there was a significant monthly increase of 29.8 (18.2-41.4) first ANC visits and 11.3 (5.5-17.2) ANC visits within the first trimester per district above prepandemic trends. There was no significant change in the number of fourth ANC visits completed. At the onset of COVID-19, districts experienced a significant decrease of 71.1 (-110.5 to -31.7) facility deliveries, but the rate then increased significantly above prepandemic trends. There was no significant increase in any adverse birth outcomes during the pandemic. Conversely, districts observed a significant monthly decrease of 5.3 uterine rupture cases (-9.9 to -0.6) and 19.2 stillbirths (-33.83 to -4.58) per 100 000 facility deliveries below prepandemic trends. There was a significant drop of 23.5 cases of neonatal sepsis/100 000 facility deliveries per district at pandemic onset. CONCLUSION: Despite pandemic interference, Nampula Province saw no disruptions to ANC, only temporary disruptions to facility deliveries and no increases in adverse birth outcomes. ANC visits surprisingly increased, and the rates of uterine rupture, stillbirth and neonatal sepsis decreased, suggesting that Nampula Province may offer insights about health system resilience.

Prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Antibodies in the Mozambican Population: A Cross-Sectional Serologic Study in 3 Cities, July-August 2020.

BACKGROUND: The extent of population exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was uncertain in many African countries during the onset of the pandemic. METHODS: We conducted a cross-sectional study and randomly selected and surveyed general population and occupational groups from 6 July to 24 August 2020, in 3 cities in Mozambique. Anti-SARS-CoV-2-specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies were measured using a point-of-care rapid test. The prevalence was weighted for population (by age, sex, and city) and adjusted for test sensitivity and specificity. RESULTS: A total of 21 183 participants, including 11 143 from the general population and 10 040 from occupational groups, were included across all 3 cities. General population seropositivity (IgM or IgG) prevalence was 3.0% (95% confidence interval [CI], 1.0%-6.6%) in Pemba, 2.1% (95% CI, 1.2%-3.3%) in Maputo City, and 0.9% (95% CI, .1%-1.9%) in Quelimane. The prevalence in occupational groups ranged from 2.8% (95% CI, 1.3%-5.2%) to 5.9% (95% CI, 4.3%-8.0%) in Pemba, 0.3% (95% CI, .0%-2.2%) to 4.0% (95% CI, 2.6%-5.7%) in Maputo City, and 0.0% (95% CI, .0%-.7%) to 6.6% (95% CI, 3.8%-10.5%) in Quelimane, and showed variations between the groups tested. CONCLUSIONS: In the first representative COVID-19 serosurveys in Mozambique, in mid-2020, weighted and assay-adjusted seroprevalence in 3 provincial capitals of anti-SARS-CoV-2 ranged from 0.9% to 3.0%, whereas adjusted prevalence in occupational groups ranged from 0.0% to 6.6% with variation between groups. Exposure to SARS-CoV-2 was extensive during the first pandemic wave, and transmission may have been more intense among occupational groups. These data have been of utmost importance to inform public health intervention to control and respond to the pandemic in Mozambique.

The impact of COVID-19 on self-reported burnout and health and mental health services in Nampula, Mozambique.

Background: The purpose of this study was to examine the impact of the COVID-19 pandemic on self-reported burnout of health workers, quality of care, and perceptions of COVID-19-related stigma in Mozambique. Method: We conducted a cross-sectional quantitative assessment of 170 frontline health workers in Nampula District, Mozambique, including 149 (87.6%) primary care providers and 21 (12.4%) mental health specialists. Results: Of the 170 frontline workers, only 10.1% of frontline workers were experiencing more professional burnout, whereas 33.3% felt it had lessened. The perceived impact on quality of care also varied, without any significant differences by sex, education level, or mental health training background. Compared to the beginning of the COVID-19 pandemic in March 2020, 42.3 and 38.1% providers felt that their ability to provide mental health and general health care, respectively, had worsened, compared to 57.7 and 61.9% who believed that either there was no change, or that the work had become easier. Likewise, 26.8% of providers felt that their ability to meet patients' needs had gotten more difficult, whereas 43.4% reported no change and 29.8% reported that it was easier. Twenty-two percent of providers reported an overall increase in caseloads since before the pandemic whereas the majority (67.9%) reported a decrease. Providers believed that 57.1% of people in general were afraid of people with COVID-19, 27.5% were afraid of a person recovered from COVID-19, and 39.9% were afraid of a person with family members with COVID-19. The perceived stigma about healthcare professionals was also low; only 27.4% believed that people in general were afraid of healthcare providers who deliver care to people with COVID-19. Conclusion: In contrast with other global studies, many healthcare workers in our sample reported a reduction in burnout, which may be associated with the lower overall caseloads seen during this period. Similarly, the quality of care was minimally impacted. More research is needed to determine whether the experience in Mozambique is unique, or similarly observed in other low-resource settings.

Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study.

BACKGROUND: Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique. METHODS: Prospective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women-up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance). RESULTS: We included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups. CONCLUSION: The prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of  COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

Investigation and contact tracing of the first cases of COVID-19 in Mozambique, 2020.

Introduction: contact tracing is an important strategy to interrupt the spread of infectious disease and prevent new cases. After the confirmation of the first positive case of COVID-19 in Mozambique on March 22, 2020, case investigation and contact tracing were immediately initiated, which included clinical and laboratory monitoring of cases and contacts throughout the quarantine period. We aim to describe the methodology and impact of early investigation and contact tracing. Methods: in the context of implementation of the national COVID-19 preparedness and response plan, guidelines and forms for contact tracing were adapted from the existing World Health Organization (WHO) and The Centers for Disease Control and Prevention (CDC) guidelines. The case definition used was "patient with travel or residency history in a country reporting local transmission of COVID-19 during the 14 days prior to the onset of symptoms". The cases interviews were face to face and contacts were followed up daily by phone calls for 14 consecutive days: using a structured questionnaire. Data were entered in an electronic Excel database. We collected samples for diagnosis of those who developed symptoms and provided quarantine follow up. Results: a total of 8 cases were confirmed, of which 6 (75%) were male. The average age of the cases was 51, median 44 (range: 31 to 80) years old. The majority of cases presented common symptoms of COVID-19, including headaches (50%), cough (37.5%), and fever (25%). Our case series included the country´s index case, two close positive contacts, and 5 additional cases that were not epidemiologically linked to the others and identified by the COVID-19 national surveillance system. All of them were identified in Maputo City from March 22 to March 28. Cases had a total of 123 contacts and all of them were tracked; 79 were contacts of the first case. From all the contacts in follow up, two had laboratory confirmed COVID-19. All cases and contacts were quarantined and none of them developed severe symptoms or required hospitalization. Conclusion: timely case identification and systematic contact tracing can be effective in breaking the chain of COVID-19 transmission when there is strong collaboration between epidemiological, laboratory surveillance and case management.

COVID-19-related healthcare impacts: an uncontrolled, segmented time-series analysis of tuberculosis diagnosis services in Mozambique, 2017-2020.

INTRODUCTION: Currently, COVID-19 dominates the public health agenda and poses a permanent threat, leading to health systems' exhaustion and unprecedented service disruption. Primary healthcare services, including tuberculosis services, are at increased risk of facing severe disruptions, particularly in low-income and middle-income countries. Indeed, corroborating model-based forecasts, there is increasing evidence of the COVID-19 pandemic's negative impact on tuberculosis case detection. METHODS: Applying a segmented time-series analysis, we assessed the effects of COVID-19-related measures on tuberculosis diagnosis service across districts in Mozambique. Ministry health information system data were used from the first quarter of 2017 to the end of 2020. The model, performed under the Bayesian premises, was estimated as a negative binomial with random effects for districts and provinces. RESULTS: A total of 154 districts were followed for 16 consecutive quarters. Together, these districts reported 96 182 cases of all forms of tuberculosis in 2020. At baseline (first quarter of 2017), Mozambique had an estimated incidence rate of 283 (95% CI 200 to 406) tuberculosis cases per 100 000 people and this increased at a 5% annual rate through the end of 2019. We estimated that 17 147 new tuberculosis cases were potentially missed 9 months after COVID-19 onset, resulting in a 15.1% (95% CI 5.9 to 24.0) relative loss in 2020. The greatest impact was observed in the southern region at 40.0% (95% CI 30.1 to 49.0) and among men at 15% (95% CI 4.0 to 25.0). The incidence of pulmonary tuberculosis increased at an average rate of 6.6% annually; however, an abrupt drop (15%) was also observed immediately after COVID-19 onset in March 2020. CONCLUSION: The most significant impact of the state of emergency was observed between April and June 2020, the quarter after COVID-19 onset. Encouragingly, by the end of 2020, clear signs of health system recovery were visible despite the initial shock.

The epidemiology of severe malaria at Manhiça District Hospital, Mozambique: a retrospective analysis of 20 years of malaria admissions surveillance data.

BACKGROUND: Most malaria burden estimates rely on modelling infection prevalence to case incidence data, with insufficient attention having been paid to the changing clinical presentation of severe disease and its relationship with changing transmission intensity. We present 20 years of longitudinal surveillance data to contribute to the understanding of the relationship between malaria transmission and the burden and clinical presentation of severe malaria and to inform policy. METHODS: This retrospective analysis of clinical surveillance hospital data included all children younger than 15 years admitted with malaria to Manhiça District Hospital (MDH), Mozambique, from July 1, 1997, to June 30, 2017. Case fatality ratios (CFRs) were calculated as the number of patients who died having a specific diagnosis or syndrome divided by the total number of patients with known outcome admitted with that diagnosis or syndrome. FINDINGS: Over the study period, 32 138 children were admitted to MDH with a malaria diagnosis. Malaria accounted for a large proportion of admissions, ranging from 4083 (76·9%) of 5307 admissions in 2000-01 to 706 (27·5%) of 2568 admissions in 2010-11. Since 2000-02, the absolute and relative number of malaria admissions and deaths presented a decreasing trend. The age pattern of patients with malaria shifted to older ages with a median age of 1·7 years (IQR 0·9-3·0) in 1997-2006 and 2·6 years (IQR 1·3-4·4) in 2006-17, although most malaria deaths (60-88% in 2009-17) still occurred in children younger than 5 years. The clinical presentation of severe malaria changed, with an increase in cerebral malaria and a decrease in severe anaemia and respiratory distress, leading to similar yearly cases for the three syndromes. CFRs for severe malaria fluctuated between 1·1% (2 of 186 in 2014-15) and 7·2% (11 of 152 in 2010-11), varying by severe malaria syndrome (3·3% [70 of 2105] for severe anaemia, 5·1% [191 of 3777] for respiratory distress, and 14·8% [72 of 487] for cerebral malaria). Overall malaria CFRs (1·8% [543 of 30 163]) did not vary by age group. INTERPRETATION: Despite the unprecedented scale up of malaria control tools, malaria still represented around 30-40% of paediatric hospital admissions in 2006-17. The age shift towards older children was not accompanied by an increase in severe malaria or deaths; however, control programmes should consider adapting their high-risk target groups to include older children. Malaria remains a leading cause of disease and health-care system use and the massive unfinished malaria control agenda warrants intensified efforts. FUNDING: Spanish Agency for International Cooperation and Development.