Prevalence of Sexually Transmitted Infections in Women Attending Antenatal Care in Tete Province; Mozambique

Objective. To determine the prevalence of Chlamydia trachomatis (CT); Neisseria gonorrhoeae (NG) and syphilis in pregnant women. Methods. A cross-sectional study was conducted among women attending antenatal care clinics (ANCs). Blood samples were tested for syphilis using the rapid plasma reagin (RPR) and treponemal haemaggluti- nation (TPHA) tests; CT and NG were diagnosed using a manual polymerase chain reaction assay on first-void urine samples. A socio-demographic questionnaire was completed. Results were compared with previous published data on sexually transmitted infection (STI) prevalence in Mozambique. Results. Blood and urine samples were collected from 1 119 and 835 women; respectively. The prevalence of CT was 4.1; and that of NG 2.5. The RPR test was positive in 5.2of the women; and 7.1had a positive TPHA test. Active syphiliswas found in 4.7. In univariate analysis; CT was associated with having had any level of education (p0.05); reactive RPR and TPHA were associated with illiteracy (p0.05); and TPHA was associated with age 25. Multivariate analysis did not show any significant association. In comparisonwith published data from 1993; a decline was observed for CT (p0.05); NG and syphilis (p0.001). Conclusions. Compared with available data; a decline of STI prevalence was observed in our setting. This might be the result of community-based education programmes focusing on changes to sexual behaviour; as well as the widespread use of the syndromic approach to managing STIs and the expansion of syphilis screening in primary health care settings. However; STI rates are still high; and the problem needs more concrete and sustained efforts for its control

Molecular identification of pathogenicity genes and ERIC types in Vibrio cholerae O1 epidemic strains from Mozambique.

The phenotypic and genotypic profiles of the V. cholerae strains causing the Mozambican 1997-8 epidemic were characterized to provide a reference for comparison with other epidemic strains. A total of 75 strains of V. cholerae O1 isolated in different provinces, were analysed. Strains were characterized by PCR for detecting toxin genes (ctxA, zot and ace), virulence associated genes (tcpA. nanH, hlyA and torR) and ERIC sequences. All V. cholerae strains were serotype O1, Ogawa, biotype El Tor. MIC testing showed a high proportion of strains multi-resistant to drugs (100% to cotrimoxazole and 52% to tetracycline) and susceptibility to ciprofloxacin. The isolates contained two intact copies of the CTX genetic element and all other genes tested. PCR of restricted DNA revealed two ERIC types: the first in provincial isolates, also predominant in other African epidemic strains, and the second in Maputo isolates (the national capital).

An intervention study to reduce adverse pregnancy outcomes as a result of syphilis in Mozambique.

OBJECTIVES: To create and evaluate an alternative screening approach among pregnant women in order to reduce adverse pregnancy outcome as a result of syphilis in Mozambique. METHODS: Four suburban antenatal clinics, two "control" and two "intervention" clinics, were compared regarding syphilis screening and treatment. Pregnant women with positive rapid plasma reagin (RPR) test (n = 929) were enrolled, 453 in the intervention and 476 in the control clinics. In control clinics the normal routine regarding syphilis screening was followed for 383 women remaining for follow up. In intervention clinics nurse midwives were trained to perform the RPR test. RPR seropositive cases were immediately treated on site by the nurse midwives and the partners were invited to come any afternoon for treatment. In the third trimester (around 30 weeks) a new RPR test was performed and all women with positive RPR test results were again treated and the partners were invited to come for treatment. RESULTS: At delivery, the drop out rate was 15.7% in the intervention and 20.1% in the control group. The perinatal mortality was significantly higher in the control group than in the intervention group, 3.4% v 1.3% (p = 0.030). At delivery the intervention group had significantly more negative RPR results--40.9% v 24.2% (p = 0.000). CONCLUSION: More active training of nurse midwives in antenatal care to perform on site RPR tests, to give syphilis treatment, and to notify partners results in improved perinatal outcome and more seronegative parturient women.

A case control study of chorioamniotic infection and histological chorioamnionitis in stillbirth.

In order to elucidate the role and aetiology of chorioamnionitis in stillbirth a case referent study was carried out in 58 pregnant women with late foetal death (cases) and in 58 pregnant women at term with live foetus (referents) matched for age and parity in Maputo Mozambique. Samples from women, stillborns and liveborns, were collected for microbiological and histological assessment. Histological chorioamnionitis was diagnosed in 96% of the cases and in 67% of the referents (OR = 13.5; 95% CI: 2.9-123.9). Escherichia coli was the species most frequently isolated in stillborns; in 14/16 (88%) cases it was isolated from intracardiac fluid. E. coli was associated with chorioamnionitis in 28% of the stillborns as compared to 5% of the referents (OR = 6.9; 95% CI: 1.4-65.4). No group B streptococci were recovered from any placenta or newborn. Vasculitis was present in 12 (21%) cases and in 3 (5%) referents (OR = 4.8; 95%, CI: 1.2-27.7). Histological chorioamnionitis was thus associated with stillbirth. E. coli was common in stillborns. The presence of vasculitis in one fifth of the stillborns indicated that the foetus was alive at the onset of infection.

Syphilis seroprevalence among pregnant women and its role as a risk factor for stillbirth in Maputo, Mozambique.

OBJECTIVE: To elucidate the role of current syphilis as a risk factor for foetal death. METHODS: Sera were obtained from 57 women with third trimester foetal death (cases) and 58 women with foetus alive (controls) matched for age and parity. All sera reactive in qualitative Rapid Plasma Reagin (RPR) analyses were tested with serial twofold dilutions to determine endpoint flocculation titres and tested with the micro-haemagglutination assay for Treponema pallidum (MHA-TP). Placental biopsies were sectioned and stained by haematoxylin-eosin and Warthin-Starry for light microscopy. SETTING: Central Hospital, in Maputo, Mozambique, from January 1990 to June 1991. RESULTS: The MHA-TP was reactive in 42% of cases and in 12% of controls (OR = 5.3; 95% CI: 1.9-15.4). The RPR card test was reactive at the dilution of 1.32 or greater in 28% of cases and in 7% of controls. All these results were confirmed by MHA-TP (OR = 5.3; 95% CI: 1.5-15.4). In 9/28 (32%) MHA-TP seroreactive women (7 cases and 2 controls) placental morphological changes indicated syphilitic infection. CONCLUSION: MHA-TP seroreactivity and high titre RPR were associated with stillbirth. Morphological changes presumptive of syphilis infection were found in 32% placentas histologically studied. Syphilis is a risk factor for foetal death in Maputo, Mozambique.

Genital infections in the aetiology of late fetal death: an incident case-referent study.

Women with prelabour fetal death in the third trimester were recruited in order to study the association between intra-uterine death and maternal genital colonization of bacteria. Fifty-eight women with verified fetal death were compared with a group of 58 women matched for age, parity and gestational length (the first referent group) and with women delivering liveborn neonates (second referent group). Cultures from the vagina, the endocervix, the amniotic fluid, the placenta, the conjunctivae of the newborn and the secretion of gastric aspirate of the newborn were carried out. Blood was taken for haemoglobin, thick film (malaria) and syphilis and HIV serology. Cases were more affected by previous stillbirths than first referents (OR = 11.88). Preterm delivery was significantly more common in cases than in second referents (OR = 57.70). Cases had significantly more often < 3 ANC visits (OR = 2.81). Cases had a lower body mass index than first referents (OR = 2.38). Temperature > or = 37 degrees C was 12 times more frequent in cases than in first referents (OR = 21.20) and four times more frequent than in second referents (OR = 6.60). Average birth weight among stillborns was 1954 g and in liveborns 3223 g (P = 0.001). The corresponding prevalence of LBW was 78% in cases and 0% among second referents (P < 0.001). Histological chorioamnionitis was significantly prevalent in cases than in second referents (OR = 4.97). Syphilis was significantly more common in cases than in first (OR = 7.71) and in second referents (OR = 5.30).(ABSTRACT TRUNCATED AT 250 WORDS)

An incident case-referent study of threatening preterm birth and genital infection.

A total of 53 pregnant Mozambican women identified as having painful uterine contractions in the preterm period were studied and compared to referents, matched for age, parity, and gestational length, without such contractions. Both groups were studied regarding socio-economic and obstetric background factors, current clinical features, and microbiological findings in the lower genital tract. Cases tended to seek antenatal care earlier than referents. Salaried work outside the home was more common among cases (OR = 16.9). It was shown that affected cases had significantly more antenatal card risk factors (OR = 3.4) and that 10 times more cases than referents had elevated body temperature (OR = 16.7). Anaemia was more common among cases than among referents (OR = 3.7) and malaria parasitaemia was over-represented among cases (OR = 12.4). Mid-upper-arm circumference was shorter among cases than among referents (OR = 2.4). Anaerobic bacteria tended to be isolated from endocervix more often among cases than among referents (OR = 2.4). Only one woman in the study was HIV-1-positive. It is concluded that febrile infection is strongly associated with preterm labour and that salaried work outside home, anaemia, and malaria are significant risk factors in the setting studied.

A case-control study on post-caesarean endometritis-myometritis in Mozambique.

Post-caesarean endometritis-myometritis (PCEM) was diagnosed in 49 Mozambican women. They were compared with 47 control women without signs of PCEM after caesarean section. The patients and controls were matched for age, parity and days post partum. Features of the socio-economic background and of past and current obstetric history were registered. Endocervical, intracavitary and blood cultures were carried out. Screening for syphilis seropositivity and HIV-1 and HIV-2 antibodies was performed. Socio-economic and obstetric background factors were similarly distributed in cases and referents, though previous caesarean section was less frequent among cases than among referents (OR 0.12). Moderate high-risk factors in existing antenatal card tended to be more frequent among cases than among referents (OR 3.29). Microbiological findings indicated more anaerobes in the vagina, in the endocervix and in the uterine cavity, though the differences only approached significance. It is concluded that women with PCEM in the setting studied expose few characteristic background features discriminating them from women with uneventful post-caesarean outcome. Further research efforts should be directed towards case-control studies with focus upon surgical factors and on a more comprehensive microbiology and serology approach.

PIP: A case control study included 49 women diagnosed with post-cesarean endometritis-myometritis (PCEM) and 47 controls who had also undergone a cesarean section but had no PCEM. Controls were matched with cases by age, parity, and days postpartum. All cases and controls delivered at Maputo Central Hospital in Mozambique. The study aimed to define potential background PCEM risk factors of socioeconomic and obstetric origin and serological and microbiological correlates. Health workers took blood samples, endocervical swabs, and intracavitary cultures from all cases and controls. They administered intraoperative prophylactic antibiotics to all cases and controls. Cases were more likely to live in a household of at least 6 persons (odds ratio [OR] = 4.44). Other socioeconomic factors studied were not significantly different between the 2 groups. Number of live births, stillbirths, abortions, and previous low birth weight deliveries were similar among both cases and controls. Cases were significantly less likely to have undergone a previous cesarean section than controls (OR = 0.12). Anaerobic bacteria were isolated more often from cases than controls in vaginal, endocervical, and intrauterine cultures (OR = 1.65, 1.95, and 1.77, respectively). Yet, the observed cultures were not significantly different between the 2 groups. Syphilis seropositivity and Chlamydia trachomatis rates were similar in cases and controls. These findings did not reveal any easily recognizable background risk factors for PCEM or any etiologic agent for PCEM. Additional case control studies are needed to focus on surgical factors. They also need to take on a more comprehensive microbiology and serology approach.

Low birth weight and genital infections. An incident case-referent study.

In an attempt to elucidate the potential association between genital infections and low birth weight (LBW) births, 51 women with LBW neonates were identified and compared to 51 women with normal birthweight (NBW) neonates. Both groups were matched according to age and parity. All women were subjected to interviews regarding socioeconomic background and obstetric history. The were examined clinical and tested regarding serum haemoglobin, malaria parasitaemia, syphilis and HIV serology. Cultures were taken from the vagina, endocervix, amniotic fluid and from various sites of newborn, including the conjunctivae and the stomach and from the interior of the placenta. Whilst socioeconomic background factors did not differ among cases and referents, previous neonatal death did. Significant differences were also found in mid-upper-arm circumference (OR 3.08) and body mass index (OR 6.00). The prevalence of alleged risk factors according to the antenatal card was similar among cases and referents. Birthweight < 2,000 g was significantly more often associated with chorioamnionitis than birthweight between 2,000 and 2,499 g (OR 5.46). Bacteriological findings did not show significant differences in cases and referents. Haemoglobin values and prevalence of malaria parasitaemia were similar as was the neonatal mortality. It is concluded that LBW births is difficult to predict by use of alleged risk factors in existing antenatal cards.

Syphilis and HIV infection among prisoners in Maputo, Mozambique.

A cross-sectional study was carried out among 1284 male and 54 female prisoners to assess the prevalence of and risk factors for sexually transmitted diseases (STD) in 4 correctional institutions of Maputo, Mozambique. Among the men, 32% reported a history of prostitute contact and 41% reported a history of STD. Only 9% reported having ever used condoms. Seventy (5.5%) men reported having had sexual intercourse while in prison, in all but one instance this involved sex with another man. There was no reported intravenous drug use. One hundred and four (7.8%) inmates had positive serological tests for syphilis and 8 (0.6%) had antibodies to HIV. Among men, syphilis was associated with a history of genital ulcer [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 1.4, 6.4] and uncircumcised status (OR = 1.5, 95% CI = 1.0, 2.5). This study demonstrates that syphilis is common among inmates in Maputo and that risk behaviours for STD transmission exist within Maputo prisons. There is a need for STD screening and treatment programmes within prisons in Mozambique and the introduction of educational interventions, including condom promotion.

PIP: Syphilis is a major public health problem in Mozambique, with 603 of 14,036 blood donations made at the central hospital in Maputo during 1990 being positive on VDRL testing. There were approximately 2340 prisoners held at Machava, Mutatele, and Hanhane prisons, and Cadeia civil jail between September 1990 and February 1991, the period during which a cross-sectional study was conducted to determine the prevalence of and risk factors for sexually transmitted diseases (STDs) among inmates in the 4 facilities. 1284 male and 54 female inmates voluntarily agreed to participate in the study. The men were of mean age 26.2 years (range, 15-70 years) and had been in jail an average of 5.5 months. 36% of the men reported having been imprisoned on at least one previous occasion. The men and women reported having a mean 1.6 and 1.2 sex partners per week, respectively, before their detention. 32% of men reported having a history of sexual relations with prostitutes; 41% and 17% of men and women, respectively, reported a history of STDs; and 9% of men and no woman reported ever having used condoms. 7.9% of men and 3.7% of women had syphilis. 70 men reported having sexual intercourse in jail, 69 of whom reported such intercourse as being with other men. 0.6% of men and no woman had antibodies to HIV. There was no reported IV drug use among respondents. Among men, syphilis infection was significantly associated with a history of genital ulcers and being uncircumcised. 64% of the men were uncircumcised. STD screening and treatment programs, educational interventions, and condom promotion are needed in Mozambique's prisons.

Syphilis and HIV infection among displaced pregnant women in rural Mozambique.

A cross-sectional study was conducted among displaced pregnant women in Mozambique to determine the prevalence and correlates of HIV infection and syphilis. Between September 1992 and February 1993, 1728 consecutive antenatal attendees of 14 rural clinics in Zambézia were interviewed, examined, and tested for HIV and syphilis antibodies. The seroprevalence of syphilis and HIV were 12.2% and 2.9%, respectively. Reported sexual abuse was frequent (8.4%) but sex for money was uncommon. A positive MHA-TP result was significantly associated with unmarried status, history of past STD, HIV infection, and current genital ulcers, vaginal discharge, or genital warts. Significant correlates of HIV seropositivity included anal intercourse, history of past STD, and syphilis. In summary, displaced pregnant women had a high prevalence of syphilis but a relatively low HIV seroprevalence suggesting recent introduction of HIV infection in this area or slow spread of the epidemic. A syphilis screening and treatment programme is warranted to prevent perinatal transmission and to reduce the incidence of chancres as a cofactor for HIV transmission.

Risk factors in puerperal endometritis-myometritis. An incident case-referent study.

Postpartum endometritis-myometritis (PPEM) was identified in 51 women after vaginal delivery, who were compared with 51 healthy referent parturients, matched for age, parity and days postpartum. Socio-economic background data, past and current obstetric history and clinical data from recent delivery were analyzed. Endocervical and intracavitary cultures and blood cultures were performed and serological analyses of syphilis and HIV antibodies were carried out. No socio-economic factor studied discriminated significantly between cases and referents. Previous stillbirth (OR 9.44) and previous low-birthweight delivery (OR 3.90) occurred significantly more often among cases. In recently past pregnancy preterm delivery (OR 10.07), low birthweight (OR 16.55) and serious neonatal morbidity (OR 14.27) were significantly more common among cases. Cases and referents differed also significantly in body mass index < 22.5 (OR 3.41), left mid-upper-arm circumference < 25 cm (OR 2.66), haemoglobin < 100 g/l (OR 3.12) and high-risk classification in antenatal care (OR 11.95). Bacterial intracavitary cultures tended to be positive and have anaerobes more frequently in cases than in referents. It is concluded that women with PPEM in the setting studied belong to a group at risk also regarding adverse fetal outcome, both in recently past and in previous pregnancies.

Shiguelose em criancas internadas no Hospital Central de Maputo; MocambiqueJose A. Valdivia; Benedita Silva; Migdalia Hung; Elena Folgosa

From April to July 1993; Maputo City suffered an epidemic of dysentery. We analysed stool samples from 142 consecutive children hospitalized with acute bloody diarrhoea in the pediatric infectious diseases ward of Maputo Central Hospital. The samples were analysed for known pathogenic microbial organisms. 74 (52.1) were male and 68 (47.9) female; the mean age was 2.62 years. Shigella dysenteriae type-1 was isolated in 59 (41.5) cases. The probability of isolation of shigella dysenteriae was greater when the evolution time of the illness was equal to or less than five days and the number of daily stools was six or greater at the time of sample collection. For the diagnosis of shigellosis; the presence of macroscopic blood in liquid stools showed a sensitivity of 86.2; a specificity of 82.9; a positive predictive value of 78.1; and a negative predictive value of 89.5. All Shigella spisollated were sensitive to nalidixic acid; cephalothin; kanamycin and gentamicin and resistant to tetracycline; trimethoprim; chloramphenicol; ampicillin; sulfurisoxazole; cotrimoxazole and erythromycin. There was a statistical association (p0.05) between malaria due to plasmodium falciparum and the presence of macroscopic blood in the stools

Colera na Cidade e Provincia de Maputo : resultados laboratoriais das amostras analizadas no periodo de Junho de 1991 a Junho de 1992

Foi efectuado um estudo retrospectivo das amostras recebidas no Laboratorio de Microbiologia da Faculdade de Medicina no periodo compreendido entre Junho de 1991 e Junho de 1992; para confirmacao laboratorial do diagnostico clinico de colera. De um total de 2823 amostras analisadas; provenientes de igual numero de casos; 1399(49;5) proveniente da cidade de Maputoe 1424(50;4) da Provincia de Maputo. Corresponderam a individuos do sexo maculino; 1494(52.9) e ao sexo feminino; 1329 (47.1) resultaram positivas; 952(33.7) amostras das quais; 856(89.9) corresponderam ao serotipo Inaba e 96(10.1) ao Ogawa. Todas as estirpes isoladas foram biotipo El Tor e sensiveis in vitro a Tetraciclina; Doxiciclina; Sulfadiazina e Cloranfenicol. Em ambos os locais de estudo; as amostras positivas foram mais frequentes na estacao quente que na fria (pO.0001); e nos individuos do sexo masculino no grupo eterio de mais de 16 anos (p

High prevalence of sexually transmitted diseases in a rural area in Mozambique.

OBJECTIVE: To assess the extent of the sexually transmitted diseases (STDs) problem in a rural area of Mozambique. METHODS: A cross sectional study among pregnant women and patients presenting with genital complaints. Laboratory confirmation was done for gonorrhoea, chlamydial infection, active syphilis, trichomoniasis and HIV infection. SETTING: A primary health care setting in Vilanculos, Inhambane province, Mozambique. RESULTS: Evidence of one or more of the above STDs was found in 51% of 201 pregnant women, 56% of 85 women and 62% of 77 men with genital complaints. Neisseria gonorrhoea or Chlamydia trachomatis were found in 16% of pregnant women, 23% of female patients and 28% of male patients; genital ulcer disease was present in 6%, 28% and 36%, of respectively pregnant women, female and male patients. The prevalence of active syphilis was about the same in the three groups of study subjects, that is 15%. HIV infection was found in 4% of the male patients; no HIV infection could be detected in the female groups. CONCLUSION: STDs were a major health problem in this rural area in Mozambique. Though HIV infection was still low, the high prevalence of STDs indicates that the potential is there for an explosive spread of the HIV/AIDS epidemic.