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Relaunch of the official community health worker programme in Mozambique: is there a sustainable basis for iCCM policy?

Chilundo B , Cliff J , Mariano A , (2015), Health Policy Plan, 30(Suppl 2), ii54–ii64

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BACKGROUND: In Mozambique, integrated community case management (iCCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme, mainstreaming it into government policy and service delivery. Since its inception in 1978, the CHW programme has functioned unevenly, was suspended in 1989, but relaunched in 2010. To assess the long-term success of iCCM in Mozambique, this article addresses whether the current CHW programme exhibits characteristics that facilitate or impede its sustainability. METHODOLOGY: We undertook a qualitative case study based on document review (n = 54) and key informant interviews (n = 21) with respondents from the Ministry of Health (MOH), multilateral and bilateral agencies and non-governmental organizations (NGOs) in Maputo in 2012. Interviews were mostly undertaken in Portuguese and all were coded using NVivo. A sustainability framework guided thematic analysis according to nine domains: strategic planning, organizational capacity, programme adaptation, programme monitoring and evaluation, communications, funding stability, political support, partnerships and public health impact. RESULTS: Government commitment was high, with the MOH leading a consultative process in Maputo and facilitating successful technical coordination. The MOH made strategic decisions to pay CHWs, authorize their prescribing abilities, foster guidance development, support operational planning and incorporate previously excluded old CHWs. Nonetheless, policy negotiations excluded certain key actors and uncertainty remains about CHW integration into the civil service and their long-term retention. In addition, reliance on NGOs and donor funding has led to geographic distortions in scaling up, alongside challenges in harmonization. Finally, dependence on external funding, when both external and government funding are declining, may hamper sustainability. CONCLUSIONS: Our analysis represents a nuanced assessment of the various domains that influence CHW programme sustainability, highlighting strategic areas such as CHW payment and programme financing. These organizational and contextual determinants of sustainability are central to CHW programme strengthening and iCCM policy support.

Long-Term Safety and Efficacy of the RTS,S/AS02A Malaria Vaccine in Mozambican Children

J , Aide P Aponte J J Renom M Leach A Mandomando I Lievens M Bassat Q Lafuente S Macete E Veke J (2009), J Infect Dis, 200(3), 329-336

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Abstract Background We previously reported that the RTS,S/AS02A vaccine had an acceptable safety profile, was immunogenic, and demonstrated efficacy against Plasmodium falciparum malaria disease for 21 months. Methods We conducted a randomized, controlled, phase 2b trial of RTS,S/AS02A in 2022 Mozambican children aged 1–4 years. We now report safety results for all randomized subjects and vaccine efficacy (VE) findings for children in the Manhiça area over the 45-month surveillance period. Results During the surveillance period, the VE(2.5–45) (VE over months 2.5–45 of surveillance) against a first or only episode of clinical malaria disease was 30.5% (95% confidence interval [CI], 18.9%–40.4%; P <.001 ), and the VE(2.5–45) against all episodes was 25.6% (95% CI, 11.9%–37.1%; P <.001). When the same period was considered, the VE(2.5–45) for subjects protected against severe malaria was 38.3% (95% CI, 3.4%–61.3%; P = .045). At study month 45, the prevalence of P. falciparum was 34% lower in the RTS,S/AS02A group than in the control group (66 [12.2%] of 541 patients vs 101 [18.5%] of 547 patients) (P = .004). Conclusion These results show evidence that RTS,S/AS02A maintained protection during the 45-month surveillance period, and they highlight the feasibility of developing an effective vaccine against malaria. In combination with other malaria-control measures, such a vaccine could greatly contribute to reducing the intolerable global burden of this disease. Trial registration identifiers NCT00197041 and NCT00323622.

Is the Role of Physicians Really Evolving Due to Non-physician Clinicians Predominance in Staff Makeup in Sub-Saharan African Health Systems?

Sidat M , (2016), Int J Health Policy Manag , 5(12), 725–727

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Health workforce shortages in Sub-Saharan Africa are widely recognized, particularly of physicians, leading the training and deployment of Non-physician clinicians (NPCs). The paper by Eyal et al provides interesting and legitimate viewpoints on evolving role of physicians in context of decisive increase of NPCss in Sub-Saharan Africa. Certainly, in short or mid-term, NPCs will continue to be a proxy solution and a valuable alternative to overcome physicians shortages in sub-Saharan Africa. Indeed, NPCs have an important role at primary healthcare (PHC) level. Physicians at PHC level can certainly have all different roles that were suggested by Eyal et al, including those not directly related to healthcare provision. However, at secondary and higher levels of healthcare, physicians would assume other roles that are mainly related to patient clinical care. Thus, attempting to generalize the role of physicians without taking into account the context where they will work would be not entirely appropriate. It is true that often physicians start the professional carriers at PHC level and progress to other levels of healthcare particularly after clinical post-graduation training. Nevertheless, the training programs offered by medical institutions in sub-Saharan Africa need to be periodically reviewed and take into account professional and occupational roles physicians would take in context of evolving health systems in sub-Saharan Africa.

Analysis of trauma admission data at an urban hospital in Maputo, Mozambique

Taibo C , Sidat M , Folgosa E , Moon D T Joaquim A O Machado R C Merchant A McQueen K (2016), Int J Emerg Med, 9(6), 1-7

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Background Trauma is a major public health concern. Worldwide, injuries resulted in 4.8 million deaths in 2013, an increase of 11 % since 1990. The majority of deaths from trauma in low-and middle-income countries occur in a pre-hospital setting. Morbidity from trauma contributes significantly to disability in these countries. Mozambique has experienced a rise in injury-related morbidity and mortality. Efforts are underway to prioritize surgical and anesthesiology care in the post-2015 Global Surgery agenda that will build on momentum of the Millennium Development Goals. Injury surveillance remains vital to defining priorities and implementing policy changes. Methods We performed a cross-sectional study between June and September, 2010 at the Hospital Central de Maputo (HCM). Data were collected on all patients admitted to the HCM emergency surgical services with a diagnosis of trauma. We describe patient characteristics and mechanism of traumatic injury by calculating simple proportions (for dichotomous or categorical variables) or medians with interquartile ranges (IQR) for continuous variables. Multivariable logistic regression analysis was used to estimate the mechanisms of trauma most associated with alcohol consumption. Results A total of 517 patients were approached for inclusion in this study. Of these, 441 (91.5 %) participants were followed from admission until discharge. Three hundred twenty-four participants (73.5 %) were male. The most common age group was 20–29 years old. The three principal mechanisms of injury were road traffic injury, fighting, and falls, accounting for 74 % of injuries recorded. Traumatic injury involving alcohol consumption was nine times more likely to occur at a recreation/sporting event (OR 9.0, 95 % CI 3.01–27.13, p ≤ 0.0001). Conclusions As Mozambique prepares to respond to the post-2015 international development agenda, urgent action is required to scale-up its national injury surveillance networks. Injury prevention efforts in Mozambique should focus attention on improving road safety regulations and their implementation, as well as on interventions targeting violence reduction and the reduction of alcohol consumption at sporting events. Keywords Trauma Injury Sub-Saharan Africa Mozambique

System and market failures: the unavailability of magnesium sulphate for the treatment of eclampsia and pre-eclampsia in Mozambique and Zimbabwe

, Mariano A , Cliff J , Lewin S Woelk G Oxman D Matinhure S Fernandes B Daniels K (2005), BMJ, 331(7519), 765–769

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Low cost and effective drugs, such as magnesium sulphate, need to be included in initiatives to improve access to essential medicines in Africa

Swine, human or avian influenza viruses differentially activates porcine dendritic cells cytokine profile

(2013), Vet Immunol Immunopathol, 154(1-2), 25-35

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Swine influenza virus (SwIV) is considered a zoonosis and the fact that swine may act as an intermediate reservoir for avian influenza virus, potentially infectious for humans, high- lights its relevance and the need to understand the interaction of different influenza viruses with the porcine immune system. Thus, in vitro porcine bone marrow-derived dendritic cell (poBMDCs) were infected with a circulating SwIV A/Swine/Spain/SF32071/2007(H3N2), 2009 human pandemic influenza virus A/Catalonia/63/2009(H1N1), low pathogenic avian influenza virus (LPAIV) A/Anas plathyrhynchos/Spain/1877/2009(aH7N2) or high pathogenic avian influenza virus (HPAIV) A/Chicken/Italy/5093/1999(aH7N1). Swine influenza virus H3N2 infection induced an increase of SLA-I and CD80/86 at 16 and 24 h post infection (hpi), whereas the other viruses did not. All viruses induced gene expression of NF-􏰀B, TGF-ˇ, IFN-ˇ and IL-10 at the mRNA level in swine poBMDCs to different extents and in a time-dependent manner. All viruses induced the secretion of IL-12 mostly at 24 hpi whereas IL-18 was detected at all tested times. Only swH3N2 induced IFN-􏰂 in a time- dependent manner. Swine H3N2, aH7N2 and aH7N1 induced secretion of TNF-􏰂 also in a time-dependent manner. Inhibition of NF-􏰃B resulted in a decrease of IFN-􏰂 and IL-12 secretion by swH3N2-infected poBMDC at 24 hpi, suggesting a role of this transcription fac- tor in the synthesis of these cytokines. Altogether, these data might help in understanding the relationship between influenza viruses and porcine dendritic cells in the innate immune response in swine controlled through soluble mediators and transcription factors.

Review: Influenza virus in pigs

(2013), Mol Immunol., 55(3-4), 200-11

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Research ethics review at University Eduardo Mondlane (UEM)/Maputo Central Hospital, Mozambique (2013-2016): a descriptive analysis of the start-up of a new research ethics committ

J , TD. M E H J S L F A M M M C M V M (2018), BMC Med Ethics., (),

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BACKGROUND: Mozambique has seen remarkable growth in biomedical research over the last decade. To meet a growing need, the National Committee for Bioethics in Health of Mozambique (CNBS) encouraged the development of ethical review processes at institutions that regularly conduct medical and social science research. In 2012, the Faculty of Medicine (FM) of University Eduardo Mondlane (UEM) and the Maputo Central Hospital (MCH) established a joint Institutional Committee on Bioethics for Health (CIBS FM & MCH). This study examines the experience of the first 4 years of the CIBS FM & MCH. METHODS: This study provides a descriptive, retrospective analysis of research protocols submitted to and approved by the CIBS FM & MCH between March 1, 2013 and December 31, 2016, together with an analysis of the Committee's respective reviews and actions. RESULTS: A total of 356 protocols were submitted for review during the period under analysis, with 309 protocols approved. Sixty-four percent were submitted by students, faculty, and researchers from UEM, mainly related to Master's degree research (42%). Descriptive cross-sectional studies were the most frequently reviewed research (61%). The majority were prospective (71%) and used quantitative methodologies (51%). The Departments of Internal Medicine at MCH and Community Health at the FM submitted the most protocols from their respective institutions, with 38 and 53% respectively. The CIBS's average time to final approval for all protocols was 56 days, rising to 161 for the 40 protocols that required subsequent national-level review by the CNBS. CONCLUSIONS: Our results show that over its first 4 years, the CIBS FM & MCH has been successful in managing a constant demand for protocol review and that several broad quality improvement initiatives, such as investigator mentoring and an electronic protocol submission platform have improved efficiency in the review process and the overall quality of the protocols submitted. Beyond Maputo, long-term investments in training and ethical capacity building for CIBS across the country continue to be needed, as Mozambique develops greater capacity for research and makes progress toward improving the health of all its citizens. KEYWORDS: Ethics; Low-and middle-income country; Mozambique; Research ethics committee; Research ethics review

What does the COVID-19 pandemic mean for HIV, tuberculosis, and malaria control?

Amimo F , (2020), Trop Med Health, 48(1), 1-4

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Despite its current relatively low global share of cases and deaths in Africa compared to other regions, coronavirus disease 2019 (COVID-19) has the potential to trigger other larger crises in the region. This is due to the vulnerability of health and economic systems, coupled with the high burden of human immunodeficiency virus (HIV), tuberculosis (TB), and malaria. Here we examine the potential implications of COVID-19 on the control of these major epidemic diseases in Africa. We use current evidence on disease burden of HIV, TB, and malaria, and epidemic dynamics of COVID-19 in Africa, retrieved from the literature. Our analysis shows that the current measures to control COVID-19 neglect important and complex context-specific epidemiological, social, and economic realities in Africa. There is a similarity of clinical features of TB and malaria, with those used to track COVID-19 cases. This coupled with institutional mistrust and misinformation might result in many patients with clinical features similar to

An RNA-seq Based Machine Learning Approach Identifies Latent Tuberculosis Patients With an Active Tuberculosis Profile

(2020), Frontier Immunology, 11(), 1470.

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A better understanding of the response against Tuberculosis (TB) infection is required to accurately identify the individuals with an active or a latent TB infection (LTBI) and also those LTBI patients at higher risk of developing active TB. In this work, we have used the information obtained from studying the gene expression profile of active TB patients and their infected –LTBI- or uninfected –NoTBI- contacts, recruited in Spain and Mozambique, to build a class-prediction model that identifies individuals with a TB infection profile. Following this approach, we have identified several genes and metabolic pathways that provide important information of the immune mechanisms triggered against TB infection. As a novelty of our work, a combination of this class-prediction model and the direct measurement of different immunological parameters, was used to identify a subset of LTBI contacts (called TB-like) whose transcriptional and immunological profiles are suggestive of infection with a higher probability of developing active TB. Validation of this novel approach to identifying LTBI individuals with the highest risk of active TB disease merits further longitudinal studies on larger cohorts in TB endemic areas.

Serum proteomics of active tuberculosis patients and contacts reveals unique processes activated during Mycobacterium tuberculosis infection

(2020), Nature Scientific Reports, 10 􏰄 􏰅 􏰅 􏰆 􏰇 􏰈 􏰉 􏰇 􏰊 􏰋 􏰅 􏰌 􏰍 􏰉 􏰌 􏰍 􏰎 􏰏 􏰅 􏰃 􏰐 􏰌 􏰑 􏰒 􏰏 􏰓 􏰍 􏰔 􏰍 􏰓 􏰕 􏰍 􏰖 􏰑 􏰎 (), 3844 􏰁 􏰂

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􏰙􏰚􏰛􏰜􏰊􏰝􏰚􏰞􏰇􏰃􏰈􏰃 􏰠􏰙􏰡􏰢 􏰈􏰃 􏰁􏰀􏰜 􏰣􏰇􏰃􏰁 􏰞􏰜􏰁􏰀􏰤􏰞 􏰈􏰥􏰦􏰜􏰝􏰁􏰈􏰇􏰥 􏰤􏰣􏰇􏰥􏰋 􏰈􏰥􏰦􏰜􏰝􏰁􏰈􏰇􏰚􏰃 􏰆􏰈􏰃􏰜􏰤􏰃􏰜􏰃􏰉 􏰙􏰀􏰜 􏰃􏰂􏰜􏰝􏰈􏰧􏰝 􏰤􏰈􏰣 􏰇􏰦 􏰁􏰀􏰈􏰃 study was to establish panels of serum protein biomarkers representative of active TB patients and their household contacts who were either infected (LTBI) or uninfected (EMI-TB Discovery Cohort, 􏰨􏰇􏰥􏰁􏰜􏰩􏰜􏰆􏰊􏰤 􏰪􏰜􏰋􏰈􏰇􏰥􏰘 􏰫􏰂􏰤􏰈􏰥􏰢􏰉 􏰬 􏰙􏰭􏰙 􏰠􏰙􏰤􏰣􏰆􏰜􏰣 􏰣􏰤􏰃􏰃 􏰁􏰤􏰋􏰃􏰢 􏰌􏰍􏰂􏰞􏰜􏰮􏰓􏰛􏰤􏰃􏰜􏰆 􏰯􏰚􏰤􏰥􏰁􏰈􏰁􏰤􏰁􏰈􏰩􏰜 􏰂􏰊􏰇􏰁􏰜􏰇􏰣􏰈􏰝􏰃 􏰃􏰁􏰚􏰆􏰰 􏰱􏰤􏰃 􏰂􏰜􏰊􏰦􏰇􏰊􏰣􏰜􏰆 􏰈􏰥 􏰯􏰚􏰈􏰥􏰁􏰚􏰂􏰞􏰈􏰝􏰤􏰁􏰜 􏰝􏰇􏰥􏰁􏰤􏰈􏰥􏰈􏰥􏰋 􏰤 􏰁􏰇􏰁􏰤􏰞 􏰇􏰦 􏰌􏰑 􏰈􏰥􏰆􏰈􏰩􏰈􏰆􏰚􏰤􏰞 􏰃􏰜􏰊􏰚􏰣 􏰃􏰤􏰣􏰂􏰞􏰜􏰃 􏰂􏰜􏰊 􏰋􏰊􏰇􏰚􏰂􏰉 􏰨􏰜􏰂􏰁􏰈􏰆􏰜􏰃 were analyzed in an LC-Orbitrap Elite platform, and raw data were processed using Proteome 􏰲􏰈􏰃􏰝􏰇􏰩􏰜􏰊􏰜􏰊 􏰔􏰉􏰌􏰉 􏰬 􏰁􏰇􏰁􏰤􏰞 􏰇􏰦 􏰐􏰌􏰏 􏰂􏰊􏰇􏰁􏰜􏰈􏰥􏰃 􏰱􏰜􏰊􏰜 􏰯􏰚􏰤􏰥􏰁􏰈􏰧􏰜􏰆􏰉 􏰙􏰀􏰜 􏰃􏰂􏰜􏰝􏰈􏰧􏰝 􏰂􏰊􏰇􏰁􏰜􏰈􏰥 􏰃􏰈􏰋􏰥􏰤􏰁􏰚􏰊􏰜 􏰇􏰦 􏰤􏰝􏰁􏰈􏰩􏰜 TB patients was characterized by an accumulation of proteins related to complement activation, 􏰈􏰥􏰳􏰤􏰣􏰣􏰤􏰁􏰈􏰇􏰥 􏰤􏰥􏰆 􏰣􏰇􏰆􏰚􏰞􏰤􏰁􏰈􏰇􏰥 􏰇􏰦 􏰈􏰣􏰣􏰚􏰥􏰜 􏰊􏰜􏰃􏰂􏰇􏰥􏰃􏰜 􏰤􏰥􏰆 􏰤􏰞􏰃􏰇 􏰛􏰰 􏰤 􏰆􏰜􏰝􏰊􏰜􏰤􏰃􏰜 􏰇􏰦 􏰤 􏰃􏰣􏰤􏰞􏰞 􏰃􏰚􏰛􏰃􏰜􏰁 􏰇􏰦 􏰂􏰊􏰇􏰁􏰜􏰈􏰥􏰃􏰘 including apolipoprotein A and serotransferrin, indicating the importance of lipid transport and iron 􏰤􏰃􏰃􏰈􏰣􏰈􏰞􏰤􏰁􏰈􏰇􏰥 􏰈􏰥 􏰁􏰀􏰜 􏰂􏰊􏰇􏰋􏰊􏰜􏰃􏰃􏰈􏰇􏰥 􏰇􏰦 􏰁􏰀􏰜 􏰆􏰈􏰃􏰜􏰤􏰃􏰜􏰉 􏰙􏰀􏰈􏰃 􏰃􏰈􏰋􏰥􏰤􏰁􏰚􏰊􏰜 􏰱􏰤􏰃 􏰩􏰜􏰊􏰈􏰧􏰜􏰆 􏰛􏰰 􏰁􏰀􏰜 􏰁􏰤􏰊􏰋􏰜􏰁􏰜􏰆 􏰣􏰜􏰤􏰃􏰚􏰊􏰜􏰣􏰜􏰥􏰁 􏰇􏰦 􏰃􏰜􏰞􏰜􏰝􏰁􏰜􏰆 􏰝􏰤􏰥􏰆􏰈􏰆􏰤􏰁􏰜􏰃 􏰈􏰥 􏰤 􏰃􏰜􏰝􏰇􏰥􏰆 􏰝􏰇􏰀􏰇􏰊􏰁 􏰠􏰴􏰭􏰵􏰓􏰙􏰡 􏰶􏰜􏰊􏰈􏰧􏰝􏰤􏰁􏰈􏰇􏰥 􏰷􏰇􏰀􏰇􏰊􏰁􏰘 􏰭􏰤􏰂􏰚􏰁􏰇 􏰪􏰜􏰋􏰈􏰇􏰥􏰘 􏰭􏰇􏰸􏰤􏰣􏰛􏰈􏰯􏰚􏰜􏰢 􏰛􏰰 􏰴􏰹􏰵􏰫􏰬 􏰤􏰥􏰆 􏰥􏰜􏰂􏰀􏰜􏰞􏰇􏰣􏰜􏰁􏰊􏰰 􏰁􏰜􏰝􏰀􏰥􏰈􏰯􏰚􏰜􏰃􏰉 􏰙􏰀􏰜􏰃􏰜 􏰧􏰥􏰆􏰈􏰥􏰋􏰃 􏰱􏰈􏰞􏰞 􏰤􏰈􏰆 􏰇􏰚􏰊 􏰚􏰥􏰆􏰜􏰊􏰃􏰁􏰤􏰥􏰆􏰈􏰥􏰋 􏰇􏰦 􏰁􏰀􏰜 􏰝􏰇􏰣􏰂􏰞􏰜􏰮 metabolic processes associated with TB progression from LTBI to active disease.

Respiratory syncytial and influenza viruses in children under 2 years old with severe acute respiratory infection (SARI) in Maputo, 2015

(2017), Plos One, 12(11),

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Introduction Although respiratory syncytial virus (RSV) and influenza virus (influenza) infections are one of the leading causes of Severe Acute Respiratory Infections (SARI) and death in young children worldwide, little is known about the burden of these pathogens in Mozambique. Material and methods From January 2015 to January 2016, nasopharyngeal swabs from 450 children, aged 2 years, who had been admitted to the Pediatric Department of the Maputo Central Hospital (HCM) in Mozambique, suffering with SARI were enrolled and tested for influenza and RSV using a real-time PCR assay. Results Influenza and RSV were detected in 2.4% (11/450) and 26.7% (113/424) of the participants. Children with influenza were slightly older than those infected with RSV (10 months in influ- enza-infected children compared to 3 months in RSV-infected children); male children were predominant in both groups (63.6% versus 54.9% in children with influenza and RSV, respectively). There was a trend towards a higher frequency of influenza (72.7%) and RSV (93.8%) cases in the dry season. Bronchopneumonia, bronchitis and respiratory distress were the most common diagnoses at admission. Antibiotics were administered to 27,3% and 15,9% of the children with influenza and RSV, respectively. Two children, of whom, one was positive for RSV (aged 6 months) and another was positive for Influenza (aged 3 months) died; both were children of HIV seropositive mothers and had bronchopneumonia. Conclusions Our data demonstrated that RSV, and less frequently influenza, occurs in children with SARI in urban/sub-urban settings from southern Mozambique. The occurrence of deaths in small children suspected of being HIV-infected, suggests that particular attention should be given to this vulnerable population. Our data also provide evidence of antibiotics prescription in children with respiratory viral infection, which represents an important public health prob- lem and calls for urgent interventions.

Clinical and epidemiological characterization of influenza virus infections in children with severe acute respiratory infection in Maputo, Mozambique: Results from the implementati

(2018), Plos One, 13(3), e0194138. 10.1371/journal.pone.0194138

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In Sub-Saharan Africa, where burden, impact, and incidence of acute respiratory infections (ARI) are the highest in the world, conversely, the epidemiology of influenza-associated severe acute respiratory infections (SARI) is incompletely known. The aim of this study was to describe the clinical and epidemiological features of influenza-associated SARI in hospi- talized children in Maputo city, Mozambique. Nasopharyngeal and oropharyngeal swabs were collected from children aged 0–14 years old who met the case definition for SARI in two hospitals in Maputo city after their parents or legal representative consented to partici- pate. A structured questionnaire was used to collect clinical and demographic data. Typing and subtyping of influenza were performed by real-time PCR. From January 2014 to December 2016, a total of 2,007 eligible children were recruited, of whom 1,997 (99.5%) were screened for influenza by real-time PCR. The median age of participants was 16.9 months (IQR: 7.0–38.9 months) and 53.9% (1076/1991) were male. A total of 77 were posi- tive for influenza, yielding a frequency of 3.9% (77/1,991), with the highest frequency being reported in the age group 1–5 years old. Cases of influenza peaked twice each year, during which, its frequency reached up to 60%-80%. Among all influenza confirmed cases, 33.7% (26/77), 35.1% (27/77) and 28.6% (22/77) were typed as influenza A/H3N2, A/H1N1pdm09, and B, respectively. This represents the first report of influenza in urban/sub urban setting in Mozambique and the first evidence of distribution of strains of influenza in the country. Our data showed that frequency of influenza was lower than reported in a rural setting in Mozam- bique and the frequency of seasonal (A/H1N1pdm09) and (A/H3N2) subtypes were similar in children with SARI.

Antigenic and genetic characterization of influenza viruses isolated in Mozambique during the 2015 season

(2018), Plos One, 13(7), e0201248. https://doi. org/10.1371/journal.pone.0201248

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Background Due to the high rate of antigenic variation of influenza virus, seasonal characterization of the virus is crucial to assess and monitor the emergence of new pathogenic variants and hence formulate effective control measures. However, no study has yet been conducted in Mozambique to assess genetic, antigenic and antiviral susceptibility profile of influenza virus. Methods A subset of samples (n = 20) from influenza positive children detected in two hospitals in Maputo city during 2015 season as part of the implementation of influenza surveillance sys- tem, were selected. The following assays were performed on these samples: antigenic char- acterization by hemagglutination inhibition assay, genetic characterization by Sanger sequencing of hemagglutinin (HA) and neuraminidase (NA) and susceptibility to oseltamivir and zanamivir (NA inhibitors) by enzymatic assay. Results The A(H1N1)pdm09 subtype viruses remained closely related antigenically and genetically to the 2016 vaccine virus A/California/7/2009 and other widely distributed viruses belonging to genetic group 6B. The majority of influenza A(H3N2) viruses studied were antigenically similar to the 2016–2017 vaccine virus, A/Hong Kong/4801/2014, and their HA and NA gene sequences fell into genetic subclade 3C.2a being closely related to viruses circulating in southern Africa. The influenza B viruses were antigenically similar to the 2016 season vac- cine virus and HA sequences of all three fell into the B/Yamagata-lineage, clade 3, but con- tained NA genes of the B/Victoria-lineage. All tested viruses were sensitive to oseltamivir and zanamivir. Conclusion Overall, all Mozambican influenza A and B viruses were most closely related to Southern African viruses and all were sensitive to oseltamivir and zanamivir. These findings suggest the existence of an ecological niche of influenza viruses within the region and hence highlighting the need for joint epidemiologic and virologic surveillance to monitor the evolu- tion of influenza viruses.

Etiology of influenza-like-illness in Mozambique: The first 9 Months of influenza virus surveillance

(2014), 16th ICID Abstracts / International Journal of Infectious Diseases, (), 275

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Covid 19 Morbidity and Case Fatality Rate: An Analysis of Possible Confounding Factors

(2020), Journal of Infectious Diseases & Case Reports, 1(4), 1-17

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Introduction: When the first report appeared of a protective effect of universal BCG vaccination on COVID- 19 morbidity and case fatality rates, as well as referring to previous papers on the nonspecific protective effects of BCG, our interest was raised, because Mozambique was in an unusual position in relation to BCG vaccination. Based on our knowledge of the history of global public health, we constructed a table with the number of cases of COVID-19 per 100,000 inhabitants and the case fatality rate of the countries that had carried out universal BCG vaccination for a long period (India, Japan and the ex-USSR countries), compared to countries without a universal BCG vaccination programme. We found that countries that had carried out universal BCG vaccination for a long period had much lower case/population ratios and case fatality rates than those without a universal BCG vaccination programme. This exercise was repeated three times, during the month of April, with consistent results. These results made us take the decision to undertake a study of possible confounding factors Mozambique became independent in June 1975, and immediately after carried out a mass vaccination campaign with the six antigens of the recently created EPI. Smallpox vaccine was added, in order to consolidate smallpox eradication. WHO, at that time, was against vaccination campaigns, but an exceptional agreement was obtained. The campaign took place from the north to the south of the country, from February 1976 to January 1978. Every province started a routine EPI programme as soon as the campaign finished. In the campaign, all children 15 years old or younger received BCG vaccine. The coverage rate in the campaign was 97%, with 99% in the capital city of Maputo. Subsequently, the coverage rate of BCG vaccination at birth in the EPI has been always remarkably high in urban areas. In rural areas, coverage has been irregular, but has been at least 80% in the past 25 years. Therefore, most of the urban population aged 58 or less has received BCG, and so has an important part of the rural population. Such a high coverage of BCG is exceedingly rare in the world. We have analysed the factors that may influence the development of COVID-19 epidemics and concluded that, apart from the virulence of the virus (that we do not have enough data to study), other factors are important, namely, the immune state of the population, the demographic profile and socioeconomic characteristics of the population, ecological and meteorological factors and, finally, the prevention measures taken and the degree of their implementation. Taking into consideration that most countries, with more or less firmness, have followed the WHO recommendations, on measures for prevention and control of COVID- 19, we decided not to analyse these measures. Our study therefore emphasised the other factors. Methods: Our analysis focused on 82 countries, with more than 10 million inhabitants, which together correspond to 72.2% of the world population, distributed in three groups: northern hemisphere (above latitude 23o N), intertropical zone (between 23o latitude N and 23o latitude S) and southern hemisphere (below 23o latitude S). We have studied the relationship of BCG vaccination policies on the number of cases per 100.000 inhabitants and the case fatality rate, in the first 60 days and the first 90 days of the COVID-19 epidemics, in each country. We are performing bilateral and multilateral statistical analysis of variables related to climate (temperature, humidity and ultra-violet radiation), HIV prevalence and ART coverage, malaria (incidence and case fatality rate), tobacco and Vitamin D. Results: The results are being analysed and will be published later. Conclusions and Preliminary Recommendations: There is evidence of the non-specific protective effects of BCG, as well as negative statistical correlations on the malaria / COVID-19 ratio. However, there are still no conclusive proofs. There is scientific evidence on the beneficial effects of solar radiation (ultraviolet radiation) mediated by Vitamin D, which calms the cytokine storm caused by COVID-19. The population is recommended to regularly expose themselves to the sun, using the slogan: “Take the sun staying at home”. We also recommend the systematic administration of Vitamin D to all symptomatic cases of COVID-19 and that doctors be instructed on the appropriate doses of Vitamin D. Declaration of No Conflict Of Interest: The authors have declared that they have not received any financing to perform this research and that they have no competing financial interests or personal relationships that could represent conflict of interest.

Air pollution and other risk factors might buffer COVID-19 severity in Mozambique

(2020), The Journal of Infection in developing countries, 14(9), 994-1000

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Mozambique is located on the East Coast of Africa and was one of the last countries affected by COVID-19. The first case was reported on 22 March 2020 and since then the cases have increased gradually as they have in other countries worldwide. Environmental and population characteristics have been analyzed worldwide to understand their possible association with COVID-19. This article seeks to highlight the evolution and the possible contribution of risk factors for COVID-19 severity according to the available data in Mozambique. The available data highlight that COVID-19 severity can be magnified mainly by hypertension, obesity, cancer, asthma, HIV/SIDA and malnutrition conditions, and buffered by age (youthful population). Due to COVID-19 epidemic evolution, particularly in Cabo Delgado, there is the need to increase laboratory diagnosis capacity and monitor compliance of preventive measures. Particular attention should be given to Cabo Delgado, including its isolation from other provinces, to overcome local transmission and the spread of SARS-CoV-2.

The first pain and palliative care unit in mozambique: howit all began?

(2020), Hospice & Palliative Medicine International Journal, 4(3), 61-63

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Access to health care is a major challenge in low- and middle-income countries. Dispite its limitation in Africa, countries such as Uganda, South Africa and Kenya top the list with the largest number of specialist hospices. Although there are Palliative Care (PC) Policies in Mozambique since 2012 which are approved by the Ministry of Healththat provide for the integration of this care at all levels. However, there was no integration into the National Health System, until 2017. One of the necessary measures for the development of PCin a country is the integration of PC into the structure and financing of the National Health System. The process of implementing PC in Mozambique begun in 2009 with the creation of the Mozambican Palliative Care ́sAssociation, PC Policies,the Curriculum Design and PCReference Manual in 2012, and the Mozambican Pain Study Association in 2013.In response to the progressive increase in HIV/AIDSpatients,and particularly those with cancerwith palliative needs and suffering. In the main hospital of the country, in the Pain Unit, Palliative Care Service was oppened in September 2019 resulting in the Pain and Palliative Care Unit. It hasmultidisciplinary specialized professionals team, the first in Portuguese-speaking African countries. However, the similarity to many other countries with few resources, access and availability of opioids was a harsh reality. Conclusion: Mozambique was the first Portuguese-speaking African Country to create a Pain and Palliative Care Unit with a specialized team. However, access and availability of opioid drugs is one of the major challenges.

Palliative care in Mozambique: Physicians’ knowledge, attitudes and practices

(2020), Plos One, 15(8),

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Background Palliative care is an essential part of medical practice but it remains limited, inaccessible, or even absent in low and middle income countries. Objectives To evaluate the general knowledge, attitudes, and practices of Mozambican physicians on palliative care. Methods A cross–sectional observational study was conducted between August 2018 and January 2019 in the 3 main hospitals of Mozambique, in addition to the only hospital with a stand- alone palliative care service. Data was collected from a self-administered survey directed to physicians in services with oncology patients. Results Two hundred and seven out of 306 physicians surveyed answered the questionnaire. The median physician age was 38 years. Fifty-five percent were males, and 49.8% residents. The most common medical specialty was surgery with 26.1%. Eighty percent of physicians answered that palliative care should be provided to patients when no curative treatments are available; 87% believed that early integration of palliative care can improve patients’ quality of life; 73% regularly inform patients of a cancer diagnosis; 60% prefer to inform the diagnosis and prognosis to the family/caregivers. Fifty percent knew what a “do-not-resusci- tate” order is, and 51% knew what palliative sedation is. Only 25% of the participants answered correctly all questions on palliative care general knowledge, and only 24% of the participants knew all answers about euthanasia. Conclusions Mozambican physicians in the main hospitals of Mozambique have cursory knowledge about palliative care. Paternalism and the family-centered model are the most prevalent. More interventions and training of professionals are needed to improve palliative care knowl- edge and practice in the country.

Breast cancer subtypes: implications for the treatment and survival of patients in Africa—a prospective cohort study from Mozambique

(2020), ESMO Open Cancer Horizons, 5(), e000829.

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Background Data regarding breast cancer epidemiology, treatment and survival in Africa are scarce. We aimed to assess the distribution of breast cancer subtypes in Mozambique and its impact on patients’ treatment and survival. The concordance of biomarker assessment between cytological and histological samples was also evaluated. Methods Prospective cohort study including 210 patients diagnosed between January 2015 and August 2017, followed to November 2019. Clinicopathological characteristics, treatment, 3-year overall survival (OS) and disease-free survival (DFS) were compared across classic tumour subtypes (oestrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, HER2-positive and triple-negative breast cancer (TNBC)) and surrogate intrinsic subtypes (St. Gallen classification). Concordance was measured using Cohen’s κ statistics. Results A total of 51% of patients had ER-positive/ HER2-negative tumours, 24% HER2-positive and 25% TNBC. Concordance between cytological and histological samples regarding ER and HER2 status was substantial (κ=0.762 and κ=0.603, respectively). There were no significant differences across subtypes regarding clinical characteristics and treatment, except for HIV positivity and high histological grade (more prevalent among TNBC) or endocrine therapy (higher use among ER-positive/HER2-negative and HER2-positive patients). Three-year OS was 52.5% (95% CI, 44.3% to 60.0%), being higher in ER-positive/HER2-negative (61.1%) compared with HER2-positive (53.2%) and TNBC (31.9%) patients. Adjusted HRs were 1.96 (95% CI, 1.13 to 3.39) among HER2-positive and 3.10 (95% CI, 1.81 to 5.31) among TNBC versus ER-positive/HER2-negative patients. Three-year DFS was 46.6% (95% CI, 38.0% to 54.8%), being lower among TNBC versus ER-positive/ HER2-negative patients (HR 2.91; 95% CI, 1.64 to 5.16). Results were similar between surrogate intrinsic subtypes. Conclusion There was a high proportion of HER2-positive and TNBC among Mozambican patients and their survival was poor compared with ER-positive/HER2-negative patients, partly due to the limited treatment options. A systematic assessment of ER, PR and HER2 status is feasible and may help tailoring and optimise the treatment of patients with breast cancer in low-resource settings, potentially leading to survival gains in this underserved population.

Trends in comparative efficacy and safety of malaria control interventions for maternal and child health outcomes in Africa

Amimo F , (2019), BMJ Open, 9(2), e024313

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Abstract Introduction Unprecedented global efforts to prevent malaria morbidity and mortality in sub-Saharan Africa have saved hundreds of thousands of lives across the continent in the last two decades. This study aims to determine how the comparative efficacy and safety of available malaria control interventions intended to improve maternal and child health outcomes have changed over time considering the varied epidemiological contexts on the continent. Methods We will review all randomised controlled trials that investigated malaria control interventions in pregnant women in sub-Saharan Africa and were published between January 1980 and December 2018. We will subsequently use network meta-regression to estimate temporal trends in the relative and absolute efficacy and safety of Intermittent Preventive Treatments, Intermittent Screening and Treatments, Insecticide-treated bed nets, and their combinations, and predict their ranking according to their relative and absolute efficacy and safety over time. Our outcomes will include 12 maternal and 7 child mortality and morbidity outcomes, known to be associated with either malaria infection or control. We will use intention-to-treat analysis to derive our estimates and meta-regression to estimate temporal trends and the effect modification by HIV infection, malaria endemicity and Plasmodium falciparum resistance to sulfadoxine–pyrimethamine, while adjusting for multiple potential confounders via propensity score calibration. PROSPERO registration number CRD42018095138.

Impact of Per Capita Income on the Effectiveness of School‑Based Health Education Programs to Promote Cervical Cancer Screening Uptake in Southern Mozambique

Amimo F , (2018), J Global Infect Dis, 10(3), 152-8

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In the face of rising mortality rates from cervical cancer (CC) among women of reproductive age, a nationwide screening program based on visual inspection with acetic acid was introduced in Mozambique in 2009. The objective of the study is to examine the impact of per capita income on the effectiveness of school-based health education programs to promote the utilization of CC screening services. We conducted a cross-sectional study in 2013 involving 105 women randomly selected from households of different economic backgrounds. Marginal effect estimates derived from a logit model were used to explore the patterns in the effectiveness of school-based health education to promote CC screening uptake according to household per capita income, based on purchasing power parity. We found a CC screening uptake of 16.1% (95% confidence interval [CI], 9.7%-24.6%) even though 64.6% (95% CI, 54.2%-74.1%) of women had heard of it. There are important economic differentials in the effectiveness of school-based health education to influence women's decision to receive CC screening. Among women with primary school or less, the probability of accessing CC screening services increases with increasing income (P < 0.05). However, income significantly reduces the effect that school-based health education has on the probability of screening uptake among those women with more than 7 years of educational attainment (P = 0.02). These results show that CC screening programs in resource-constrained settings need approaches tailored to different segments of women with respect to education and income to achieve equitable improvement in the levels of screening uptake.

Implementing a sustainable health insurance system in Cambodia: a study protocol for developing and validating an efficient household income-level assessment model for equitable

, Nakamura H (2020), International Journal for Equity in Health, 19(1), 17

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Background As elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia. Since 2016, the National Social Security Fund (NSSF) has implemented a social health insurance scheme with a contributory approach for formal sector workers. However, informal sector workers and dependents of formal sector workers are still not covered by this insurance because it is difficult to set an optimal amount of contribution for such individuals as their income levels are inestimable. The present study aims to develop and validate an efficient household income-level assessment model for Cambodia. We aim to help the country implement a financially sustainable social health insurance system in which the insured can pay contributions according to their ability. Methods This study will use nationally representative data collected by the Cambodia Socio-Economic Survey (CSES), covering the period from 2009 to 2019, and involving a total of 50,016 households. We will employ elastic net regression analysis, with per capita disposable income based on purchasing power parity as the dependent variable, and individual and community-level socioeconomic and demographic characteristics as independent variables. These analyses aim to create efficient income-level assessment models for health insurance contribution estimation. To fully capture socioeconomic heterogeneity, sub-group analyses will be conducted to develop separate income-level assessment models for urban and rural areas, as well as for each province. Discussion This research will help Cambodia implement a sustainable social health insurance system by collecting optimal amount of contributions from each socioeconomic group of the society. Incorporation of this approach into existing NSSF schemes will enhance the country’s current efforts to prevent impoverishing health expenditure and to achieve UHC.

Developing and Validating Regression Models for Predicting Household Consumption to Introduce an Equitable and Sustainable Health Insurance System in Cambodia

, Nakamura H (2020), Research Square, (),

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Background Financial protection is a key health system objective and an essential dimension of universal health coverage. However, it is a challenge for low- and middle-income countries, where the general tax revenue is limited, and a majority of the population is engaged in the informal economy. This study developed and validated regression models for Cambodia to predict household consumption, which allows the country to collect insurance contributions according to one’s ability to pay. This strategy would maximize the contribution revenue, optimize the government subsidy, and simultaneously ensure equity in healthcare access. Methods This study used nationally representative survey data collected annually between 2010 and 2017, involving 38472 households. We developed four alternative prediction models for annual household consumption: ordinary least squares (OLS) method with manually selected predictors, OLS method with stepwise backward variable selection, mixed-effects linear regression, and elastic net regression, which resulted in an adaptive least absolute shrinkage and selection operator (LASSO) regression. Household-level socioeconomic characteristics were also included as the predictors. Subsequently, we performed out-of-sample cross-validation for each model. Finally, we evaluated the prediction performance of the models using mean absolute error, root mean squared error, and mean absolute percentage error (MAPE). Results Overall, we found a linearly positive relationship between observed and predicted household consumptions in all four models. While the prediction performance of the four alternative models did not substantially differ, Stepwise Linear Model showed the best performance with the lowest values in all three statistical measurements, including MAPE of 1.376%. The use of regularization and the mixed effects in the regression was not particularly effective in this environment. The household consumption was better predicted for those with lower consumption, and the predictive performance declined as the consumption level increased. Although the richer household consumptions were likely to be overestimated, the trend was less noticeable in Adaptive LASSO Model. Conclusions This study suggests the possibility of predicting household consumption at a reasonable level with the existing survey data. Such a prediction would enable the country to raise the secured health insurance revenue equitably. The prediction model should be tested in real settings and continuously improved.

The potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria control in Africa: a systematic review of modelling studies and population surveys

Amimo F , (2020), Research Square, (),

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Background We reviewed current evidence on the impact of COVID-19 on HIV, tuberculosis, and malaria across Africa. Methods We searched medical databases up to 15 September 2020 for epidemiological studies that investigated the impact of COVID-19 on HIV, tuberculosis, and malaria in terms of morbidity, mortality, or healthcare accessibility, covering African countries. We consulted global health and government sources for population surveys providing relevant primary data. We employed meta-study to assess evidence. This study is registered with PROSPERO, number CRD42020209265. Results Of the 128 records screened, 14 epidemiological studies were included in the analysis. We identified 5 population surveys. The largest effect of COVID-19 related disruption of HIV, TB, and malaria services is projected to result from interruption of ART, decline in TB case detection, and interruption of insecticide treated bed nets distribution campaigns, respectively. However, most modelling studies substantially underestimated the potential implications of COVID-19 on HIV, TB, and malaria in Africa and focused on the disruption of healthcare resulting from reduction in the capacity of healthcare provider. Reduced capacity of patients to use health services and adhere to treatment may also contribute to poor outcomes even when health systems capabilities are restored or unaffected. Moreover, these models do not account for any potential interaction of HIV, TB, and malaria with COVID-19, although empirical evidence shows that coinfection between HIV and TB with COVID-19 is significantly associated with increased mortality risk in Africa. Conclusions Current evidence is largely speculative. Innovative COVID-19 resilient solutions calibrated to local vulnerabilities are vital to ensure continuity of care and prevent the emergence of further potentially larger crises.

Plasmodium falciparum resistance to sulfadoxine-pyrimethamine in Africa: a systematic analysis of national trends

Amimo F , (2020), BMJ Global Health, 5(11), e003217

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Introduction The rising burden of drug resistance is a major challenge to the global fight against malaria. We estimated national Plasmodium falciparum resistance to sulfadoxine-pyrimethamine (SP) across Africa, from 2000 to 2020. Methods We assembled molecular, clinical and endemicity data covering malaria-endemic African countries up to December 2018. Subsequently, we reconstructed georeferenced patient data, using pfdhps540E and pfdhps581G to measure mid-level and high-level SP resistance. Gaussian process regression was applied to model spatiotemporal standardised prevalence. Results In eastern Africa, mid-level SP resistance increased by 64.0% (95% uncertainty interval, 30.7%–69.8%) in Tanzania, 55.4% (31.3%–65.2%) in Sudan, 45.7% (16.8%–54.3%) in Mozambique, 29.7% (10.0%–45.2%) in Kenya and 8.7% (1.4%–36.8%) in Malawi from 2000 to 2010. This was followed by a steady decline of 76.0% (39.6%–92.6%) in Sudan, 65.7% (25.5%–85.6%) in Kenya and 17.4% (2.6%–37.5%) in Tanzania from 2010 to 2020. In central Africa, the levels increased by 28.9% (7.2%–62.5%) in Equatorial Guinea and 85.3% (54.0%–95.9%) in the Congo from 2000 to 2020, while in the other countries remained largely unchanged. In western Africa, the levels have remained low from 2000 to 2020, except for Nigeria, with a reduction of 14.4% (0.7%–67.5%) and Mali, with an increase of 7.0% (0.8%–25.6%). High-level SP resistance increased by 5.5% (1.0%–20.0%) in Malawi, 4.7% (0.5%–25.4%) in Kenya and 2.0% (0.1%–39.2%) in Tanzania, from 2000 to 2020. Conclusion Under the WHO protocols, SP is no longer effective for intermittent preventive treatment in pregnancy and infancy in most of eastern Africa and parts of central Africa. Strengthening health systems capacity to monitor drug resistance at subnational levels across the endemicity spectrum is critical to achieve the global target to end the epidemic.

Public health risks of humanitarian crises in Mozambique

Amimo F , (2021), J Glob Health, 11(), 03054

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Manmade disasters are compounded by fragile institutions and high propensity to natural disasters due to geographical exposure to extreme climatic conditions and hazards such as cyclones, storms, and flash floods. Without an effective and integrated global health security infrastructure to protect vulnerable populations in conflict and disasters settings, the world might be at a greater risk of future resurgence of pandemics, resulting from emerging and re-emerging pathogens, as well as emergence and spread of drug-resistant pathogens.

A review of prospective pathways and impacts of COVID-19 on the accessibility, safety, quality, and affordability of essential medicines and vaccines for universal health coverage

Amimo F , (2021), Global Health, 17(), 42

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Background The ongoing pandemic of coronavirus disease 2019 (COVID-19) has the potential to reverse progress towards global targets. This study examines the risks that the COVID-19 pandemic poses to equitable access to essential medicines and vaccines (EMV) for universal health coverage in Africa. Methods We searched medical databases and grey literature up to 2 October 2020 for studies reporting data on prospective pathways and innovative strategies relevant for the assessment and management of the emerging risks in accessibility, safety, quality, and affordability of EMV in the context of the COVID-19 pandemic. We used the resulting pool of evidence to support our analysis and to draw policy recommendations to mitigate the emerging risks and improve preparedness for future crises. Results Of the 310 records screened, 134 were included in the analysis. We found that the disruption of the international system affects more immediately the capability of low- and middle-income countries to acquire the basket of EMV. The COVID-19 pandemic may facilitate dishonesty and fraud, increasing the propensity of patients to take substandard and falsified drugs. Strategic regional cooperation in the form of joint tenders and contract awarding, joint price negotiation and supplier selection, as well as joint market research, monitoring, and evaluation could improve the supply, affordability, quality, and safety of EMV. Sustainable health financing along with international technology transfer and substantial investment in research and development are needed to minimize the vulnerability of African countries arising from their dependence on imported EMV. To ensure equitable access, community-based strategies such as mobile clinics as well as fees exemptions for vulnerable and under-served segments of society might need to be considered. Strategies such as task delegation and telephone triage could help reduce physician workload. This coupled with payments of risk allowance to frontline healthcare workers and health-literate healthcare organization might improve the appropriate use of EMV. Conclusions Innovative and sustainable strategies informed by comparative risk assessment are increasingly needed to ensure that local economic, social, demographic, and epidemiological risks and potentials are accounted for in the national COVID-19 responses.