Orvalho Augusto - Academia.edu (original) (raw)

Papers by Orvalho Augusto

PLOS Medicine, Jul 19, 2022

Background Surveillance systems are important in detecting changes in disease patterns and can ac... more Background Surveillance systems are important in detecting changes in disease patterns and can act as early warning systems for emerging disease outbreaks. We hypothesized that analysis of data from existing global influenza surveillance networks early in the COVID-19 pandemic could identify outliers in influenza-negative influenza-like illness (ILI). We used data-driven methods to detect outliers in ILI that preceded the first reported peaks of COVID-19. Methods and findings We used data from the World Health Organization's Global Influenza Surveillance and Response System to evaluate time series outliers in influenza-negative ILI. Using automated autoregressive integrated moving average (ARIMA) time series outlier detection models and baseline influenza-negative ILI training data from 2015-2019, we analyzed 8,792 country-weeks across 28 countries to identify the first week in 2020 with a positive outlier in influenza-negative ILI. We present the difference in weeks between identified outliers and the first reported COVID-19 peaks in these 28 countries with high levels of data completeness for influenza surveillance data and the highest number of reported COVID-19 cases globally in 2020. To account for missing data, we also performed a sensitivity analysis using linear interpolation for missing observations of influenza-negative ILI. In 16 of the 28 countries (57%) included in this study, we identified positive outliers in cases of influenzanegative ILI that predated the first reported COVID-19 peak in each country; the average lag between the first positive ILI outlier and the reported COVID-19 peak was 13.3 weeks PLOS MEDICINE

Introduction: There is a lack of sufficient evidence on the safety of use of artemisinin-based co... more Introduction: There is a lack of sufficient evidence on the safety of use of artemisinin-based combination therapies (ACT) among pregnant women, especially during early pregnancy. We determined the association between exposure to ACT during the first trimester of pregnancy and occurrence of low birth weight (LBW), and small for gestational age (SGA) among the offspring of pregnant women. Methods: We performed a secondary analysis of data from a prospective cohort study of pregnant women recruited at three health and demographic surveillance system (HDSS) sites in the sub-Saharan African countries of Mozambique, Burkina Faso and Kenya. Data from the HDSS allowed earlier pregnancy identification and linkage and tracking of pregnancy outcomes to determine birth weight and gestational age at delivery. Exposure to any antimalarials was ascertained through a combination of data collected from clinic registers, prescription records and self-reported usage by the women. Results: There was no difference in the pooled prevalence of LBW among children born to pregnant women who were exposed to quinine, ACT and had no exposure to antimalarials, 21.0%, 11.3% and 10.2%, respectively. Children whose mothers had exposure to ACTs during the first trimester had 21% lower occurrence of LBW when compared to children born to mothers exposed to ACTs in second or third trimester, this difference was not statistical significant (95%CI:-7-49%). Conclusion: ACT exposure during the first trimester was not associated with an increased risk of LBW. Our findings support the use of ACT for treatment of malaria during the first trimester of pregnancy. This work would not have been possible without the support and dedication from many. Firstly, I thank all ASAP study participants, clinicians and other study staff. Many thanks to Stephanie Kovacs, Greg Calip, Stephanie Dellicour and Brandon Guthrie for the immense guidance you offered me. Thank you Kenneth Sherr, James Pfeiffer, Julie Cliff and the great Health Alliance International for your support and making my way to Seattle possible. I am grateful to the Kunde's family (Bob and Gwen) who without reservation accepted me in their home, kept me alive and supported me in every step. I am indebted to the magnificent 2014 MPH cohort for the continuous infusion of good mood, thank you for that. I also thank Anne Njoroge, Gloria Ikilezi and Christopher Kemp for helping out on desperation. Finally, I thank my thesis committee members, Stephen Gloyd and my committee chair Andy Stergachis along with my longtime mentor, Esperanca Sevene. Kanimambo! Dedication To my parents (Augusto and Isabel) who sacrificed a lot and dedicate their life for my education and wellbeing. To my brothers (Olinda, Ivo, Paulo and Augusto Jr) who understood and taught me what is love and sharing. To my Country, Mozambique, that has been promoting health and education for everyone even under the most adverse circumstances.

The Lancet Regional Health - Western Pacific, Apr 1, 2021

Background The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health ... more Background The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over four years of routine health information system data. Methods We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in healthcare utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) – an area-level measure of socioeconomic status – were conducted to assess potential heterogeneity in effects. Findings In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of healthcare utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline in February ranged from 63% (95% CI 61–65%; p<0•0001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70–72%; p<0•0001) in all-cause visits at primary care clinics to 33% (95% CI 24–42%; p<0•0001) in inpatient volume and 10% (95% CI 3–17%; p = 0•0076) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% versus 48%; p<0•0079). The reductions in both health facility visits and inpatient volume were greater in hospitals than in primary health care facilities (p<0•0001) and greater in developed regions than in underdeveloped regions (p<0•0001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators except outpatient and inpatient volume in regions with low HDI and inpatient volume in private hospitals had not achieved their pre-SARS-COV-2 forecasted levels. In total, we estimated cumulative losses of 1020.5 (95% CI 951.2- 1089.4; P<0.0001) million or 23.9% (95% CI 22.5–25.2%; P<0.0001) health facility visits, and 28.9 (95% CI 26.1–31.6; P<0.0001) million or 21.6% (95% CI 19.7–23.4%; P<0.0001) inpatients as of June 2020. Interpretation Inpatient and outpatient health services utilization in China declined significantly after the SARS-CoV-2 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020. Funding The National Natural Science Foundation of China (No. 72042014).

International Journal of Environmental Research and Public Health, Jan 31, 2023

Social Science Research Network, 2020

Background: The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health... more Background: The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over 5 years of routine health information system data. Methods: We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in healthcare utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) – an area-level measure of socioeconomic status – were conducted to assess potential heterogeneity in effects. Findings: In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of healthcare utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline ranged from 63% (95% CI 61-65%; p<0.001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70-72%; p<0.001) in all-cause visits at primary care clinics to 33% (95% CI 24-42%; p<0.001) in inpatient volume at hospitals in regions with low HDI and 10% (95% CI 3-17%; p<0.01) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% vs. 48%; p<0.01). The reductions in both health facility visits and outpatient volume were greater in hospitals than in primary health care facilities (p<0.001) and greater in developed regions than in underdeveloped regions (p<0.001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators had not achieved their pre-SARS-COV-2 levels. In total, we estimated cumulative losses of 1020.5 (95% CI 952.7- 1088.6; P<0.001) million health facility visits and 28.9 (95% CI 26.1-31.6; P<0.001) million inpatients as of June 2020. Interpretation: Inpatient and outpatient health services utilization in China declined significantly after the COVIID-19 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020. Funding: The National Natural Science Foundation of China (No. 72042014). Conflict of Interest: We declare no competing interests.

BMC Health Services Research, Nov 28, 2022

Research Square (Research Square), Oct 17, 2019

Circulation

Introduction: Endomyocardial fibrosis (EMF) is a myocardiopathy that results from restriction of ... more Introduction: Endomyocardial fibrosis (EMF) is a myocardiopathy that results from restriction of the ventricular filling caused by the presence of fibrous tissue in the endocardium. It is estimated that this disease affects approximately 12 millions of people worldwide and most of these people are in the Sub-Saharan Africa. Until today there is no consensus regarding the best therapeutic approach in these patients, but there are reports of encouraging results in patients treated surgically. Objective: To describe the results of surgical treatment of patients with EMF and the factors that influence it. Methodology: 86 patients with EMF were operated at Instituto do Coração (Heart Institute) in Mozambique, between 2002 and 2017. Results: Most of the patients were male (61.6%) with ages between 3 and 39 years (mean, 12 years). Forty-three per cent (43%) of the patients were coming from the province of Inhambane and 81.4% of them had biventricular disease. Sixty-two per cent (62%) of th...

PLOS Global Public Health

Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-... more Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-term follow-up for a large cohort. We estimated HIV incidence among women who recently delivered in southern Mozambique by leveraging data available in routine health cards. A cross-sectional household HIV-testing survey was conducted from October 2017 to April 2018 among mothers of children born in the previous four years in the Manhiça Health Demographic Surveillance System area. Randomly-selected mother-child pairs were invited to participate and asked to present documentation of their last HIV test result. HIV-testing was offered to mothers with no prior HIV-testing history, or with negative HIV results obtained over three months ago. HIV incidence was estimated as the number of mothers newly diagnosed with HIV per total person-years, among mothers with a prior documented HIV-negative test. Among 5000 mother-child pairs randomly selected, 3069 were interviewed, and 2221 reported a pr...

BMJ Open

Background and objectiveThe Ministry of Health of Lesotho and Partners In Health piloted the Leso... more Background and objectiveThe Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement.Methods and analysisThe WHO Data Quality Assurance framework’s core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho’s health system, following a purposive sampling approach. Interviews were anal...

Journal of the International AIDS Society

IntroductionIn 2018, Mozambique's Ministry of Health launched a guideline for a nationwide im... more IntroductionIn 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.MethodsTwenty 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 fa...

BMJ Open

ObjectivesThis study aimed to assess the national-level and subnational-level effects of the COVI... more ObjectivesThis study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana.DesignInterrupted time-series.Setting and participantsThis study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020.Outcome measuresAs the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures.ResultsIn April 2020, as an immediate effect of the COVID-19 pandemic, the number of...

The Lancet

Background Malaria in the first trimester of pregnancy is associated with adverse pregnancy outco... more Background Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisininbased combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisininbased treatment (ABT) versus non-ABTs in the first trimester of pregnancy. Methods For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. Findings We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5•7%) of 736 ABT-exposed pregnancies compared with 96 (8•9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0•71, 95% CI 0•49-1•03). Similar results were seen for the individual components of miscarriage (aHR=0•74, 0•47-1•17), stillbirth (aHR=0•71, 0•32-1•57), and major congenital anomalies (aHR=0•60, 0•13-2•87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4•8%] of 524 vs 84 [9•2%] of 915; aHR 0•58, 0•36-0•92). Interpretation We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted.

BMC Public Health

Background Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of dia... more Background Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of diabetes in the next 25 years. The latest Mozambican population-based STEPS survey (STEPS 2005) estimated a 2.9% prevalence of diabetes in the adult population aged 25-64 years. We aimed to assess the change in prevalence, awareness, and management of diabetes in the national STEPS survey from 2014/2015 compared to 2005. Methods We conducted an observational, quantitative, cross-sectional study following the WHO STEPS surveillance methodology in urban and rural settings, targeting the adult population of Mozambique in 2015. We collected sociodemographic data, anthropometric, and 12 hour fasting glucose blood samples in a sample of 1321 adults. The analysis consisted of descriptive measures of the prevalence of impaired fasting glucose (IFG), diabetes and related risk factors by age group, sex, and urban/rural residence and compared the findings to those of the 2005 survey results. Results T...

PLOS ONE

Background Hepatitis B virus (HBV) infection can be prevented by vaccination. Exposure to blood o... more Background Hepatitis B virus (HBV) infection can be prevented by vaccination. Exposure to blood or body fluids poses a high risk of transmission of HBV in health care workers (HCWs). This study aimed to determine the prevalence of markers of exposure, susceptibility, and protection to HBV infection in HCWs in Beira, Mozambique. Methods A cross-sectional study was conducted between June and August 2020 in Beira City, Mozambique, in HCWs based on self-administered questionnaires and blood samples. Plasma samples were tested for HBV surface antigen (HBsAg), antibodies to HBV core antigen (anti-HBc), antibodies to HBsAg (anti-HBs) and HBV viral load (HBV DNA). Results Most of the 315 HCWs in the study were nurses (125; 39.7%). Of the HCWs, 5.1% (16; 95% Confidence Interval (CI): 2.9 to 8.1%) were infected by HBV (HBsAg and/or HBV DNA positive). Occult HBV infection (OBI) (HBV DNA positive and HBsAg negative) was found in 0.3% (1; 95% CI: 0.0 to 1.8%) of participants; 27.9% (88; 95% CI: ...

Transcultural Psychiatry

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can... more Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach’s alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that “brain hot” and “heart fall down” were the most difficult idioms of distress to endorse while “things playing on the mind” was the easiest. All LDS-11 elements were associated with elevated function impairment, with “things playing on the mind,” “wor...

Microbial Genomics

Genomic studies of the Mycobacterium tuberculosis complex (MTBC) might shed light on the dynamics... more Genomic studies of the Mycobacterium tuberculosis complex (MTBC) might shed light on the dynamics of its transmission, especially in high-burden settings, where recent outbreaks are embedded in the complex natural history of the disease. To this end, we conducted a 1 year prospective surveillance-based study in Mozambique. We applied whole-genome sequencing (WGS) to 295 positive cultures. We fully characterized MTBC isolates by phylogenetics and dating evaluation, and carried out a molecular epidemiology analysis to investigate further associations with pre-defined transmission risk factors. The majority of strains (49.5%, 136/275) belonged to lineage (L) 4; 57.8 % of them (159/275) were in genomic transmission clusters (cut-off 5 SNPs), and a strikingly high proportion (45.5%) shared an identical genotype (0 SNP pairwise distance). We found two ‘likely endemic’ clades, comprising 67 strains, belonging to L1.2, which dated back to the late 19th century and were associated with recen...

PLOS ONE

Background Although blood transfusion is an intervention that saves lives, it poses significant r... more Background Although blood transfusion is an intervention that saves lives, it poses significant risks to the blood receivers, including the transmission of bloodborne pathogens. We aimed at determining the prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), and Hepatitis C virus (HCV) in candidates approved for blood donation, and in samples considered to be negative in reference blood banks in Mozambique. Methods A cross-sectional study was performed between November 2014 and October 2015 in Maputo and Beira cities. Demographic information was obtained from all consenting blood donors using a structured questionnaire. Plasma samples were screened for HIVAb/Ag combinations, HBsAg and Anti-HCV. Blood donors considered to be negative by serological testing were re-tested in pools of six plasma samples using nucleic acid testing (NAT). Results Most blood donors were male 2,320 (83.4%) with an age range of 18 to 34 years. The overall seroprevalence of HIV, HBV and...

PLOS Medicine, Jul 19, 2022

Background Surveillance systems are important in detecting changes in disease patterns and can ac... more Background Surveillance systems are important in detecting changes in disease patterns and can act as early warning systems for emerging disease outbreaks. We hypothesized that analysis of data from existing global influenza surveillance networks early in the COVID-19 pandemic could identify outliers in influenza-negative influenza-like illness (ILI). We used data-driven methods to detect outliers in ILI that preceded the first reported peaks of COVID-19. Methods and findings We used data from the World Health Organization's Global Influenza Surveillance and Response System to evaluate time series outliers in influenza-negative ILI. Using automated autoregressive integrated moving average (ARIMA) time series outlier detection models and baseline influenza-negative ILI training data from 2015-2019, we analyzed 8,792 country-weeks across 28 countries to identify the first week in 2020 with a positive outlier in influenza-negative ILI. We present the difference in weeks between identified outliers and the first reported COVID-19 peaks in these 28 countries with high levels of data completeness for influenza surveillance data and the highest number of reported COVID-19 cases globally in 2020. To account for missing data, we also performed a sensitivity analysis using linear interpolation for missing observations of influenza-negative ILI. In 16 of the 28 countries (57%) included in this study, we identified positive outliers in cases of influenzanegative ILI that predated the first reported COVID-19 peak in each country; the average lag between the first positive ILI outlier and the reported COVID-19 peak was 13.3 weeks PLOS MEDICINE

Introduction: There is a lack of sufficient evidence on the safety of use of artemisinin-based co... more Introduction: There is a lack of sufficient evidence on the safety of use of artemisinin-based combination therapies (ACT) among pregnant women, especially during early pregnancy. We determined the association between exposure to ACT during the first trimester of pregnancy and occurrence of low birth weight (LBW), and small for gestational age (SGA) among the offspring of pregnant women. Methods: We performed a secondary analysis of data from a prospective cohort study of pregnant women recruited at three health and demographic surveillance system (HDSS) sites in the sub-Saharan African countries of Mozambique, Burkina Faso and Kenya. Data from the HDSS allowed earlier pregnancy identification and linkage and tracking of pregnancy outcomes to determine birth weight and gestational age at delivery. Exposure to any antimalarials was ascertained through a combination of data collected from clinic registers, prescription records and self-reported usage by the women. Results: There was no difference in the pooled prevalence of LBW among children born to pregnant women who were exposed to quinine, ACT and had no exposure to antimalarials, 21.0%, 11.3% and 10.2%, respectively. Children whose mothers had exposure to ACTs during the first trimester had 21% lower occurrence of LBW when compared to children born to mothers exposed to ACTs in second or third trimester, this difference was not statistical significant (95%CI:-7-49%). Conclusion: ACT exposure during the first trimester was not associated with an increased risk of LBW. Our findings support the use of ACT for treatment of malaria during the first trimester of pregnancy. This work would not have been possible without the support and dedication from many. Firstly, I thank all ASAP study participants, clinicians and other study staff. Many thanks to Stephanie Kovacs, Greg Calip, Stephanie Dellicour and Brandon Guthrie for the immense guidance you offered me. Thank you Kenneth Sherr, James Pfeiffer, Julie Cliff and the great Health Alliance International for your support and making my way to Seattle possible. I am grateful to the Kunde's family (Bob and Gwen) who without reservation accepted me in their home, kept me alive and supported me in every step. I am indebted to the magnificent 2014 MPH cohort for the continuous infusion of good mood, thank you for that. I also thank Anne Njoroge, Gloria Ikilezi and Christopher Kemp for helping out on desperation. Finally, I thank my thesis committee members, Stephen Gloyd and my committee chair Andy Stergachis along with my longtime mentor, Esperanca Sevene. Kanimambo! Dedication To my parents (Augusto and Isabel) who sacrificed a lot and dedicate their life for my education and wellbeing. To my brothers (Olinda, Ivo, Paulo and Augusto Jr) who understood and taught me what is love and sharing. To my Country, Mozambique, that has been promoting health and education for everyone even under the most adverse circumstances.

The Lancet Regional Health - Western Pacific, Apr 1, 2021

Background The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health ... more Background The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over four years of routine health information system data. Methods We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in healthcare utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) – an area-level measure of socioeconomic status – were conducted to assess potential heterogeneity in effects. Findings In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of healthcare utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline in February ranged from 63% (95% CI 61–65%; p<0•0001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70–72%; p<0•0001) in all-cause visits at primary care clinics to 33% (95% CI 24–42%; p<0•0001) in inpatient volume and 10% (95% CI 3–17%; p = 0•0076) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% versus 48%; p<0•0079). The reductions in both health facility visits and inpatient volume were greater in hospitals than in primary health care facilities (p<0•0001) and greater in developed regions than in underdeveloped regions (p<0•0001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators except outpatient and inpatient volume in regions with low HDI and inpatient volume in private hospitals had not achieved their pre-SARS-COV-2 forecasted levels. In total, we estimated cumulative losses of 1020.5 (95% CI 951.2- 1089.4; P<0.0001) million or 23.9% (95% CI 22.5–25.2%; P<0.0001) health facility visits, and 28.9 (95% CI 26.1–31.6; P<0.0001) million or 21.6% (95% CI 19.7–23.4%; P<0.0001) inpatients as of June 2020. Interpretation Inpatient and outpatient health services utilization in China declined significantly after the SARS-CoV-2 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020. Funding The National Natural Science Foundation of China (No. 72042014).

International Journal of Environmental Research and Public Health, Jan 31, 2023

Social Science Research Network, 2020

Background: The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health... more Background: The aim of this study is to quantify the effects of the SARS-CoV-2 pandemic on health services utilization in China using over 5 years of routine health information system data. Methods: We conducted a retrospective observational cohort study of health services utilization from health facilities at all levels in all provinces of mainland China. We analyzed monthly all-cause health facility visits and inpatient volume in health facilities before and during the SARS-CoV-2 outbreak using nationwide routine health information system data from January 2016 to June 2020. We used interrupted time series analyses and segmented negative binomial regression to examine changes in healthcare utilization attributable to the pandemic. Stratified analyses by facility type and by provincial Human Development Index (HDI) – an area-level measure of socioeconomic status – were conducted to assess potential heterogeneity in effects. Findings: In the months before the SARS-CoV-2 outbreak, a positive secular trend in patterns of healthcare utilization was observed. After the SARS-CoV-2 outbreak, we noted statistically significant decreases in all indicators, with all indicators achieving their nadir in February 2020. The magnitude of decline ranged from 63% (95% CI 61-65%; p<0.001) in all-cause visits at hospitals in regions with high HDI and 71% (95% CI 70-72%; p<0.001) in all-cause visits at primary care clinics to 33% (95% CI 24-42%; p<0.001) in inpatient volume at hospitals in regions with low HDI and 10% (95% CI 3-17%; p<0.01) in all-cause visits at township health centers (THC) in regions with low HDI. The reduction in health facility visits was greater than that in the number of outpatients discharged (51% vs. 48%; p<0.01). The reductions in both health facility visits and outpatient volume were greater in hospitals than in primary health care facilities (p<0.001) and greater in developed regions than in underdeveloped regions (p<0.001). Following the nadir of health services utilization in February 2020, all indicators showed statistically significant increases. However, even by June 2020, nearly all indicators had not achieved their pre-SARS-COV-2 levels. In total, we estimated cumulative losses of 1020.5 (95% CI 952.7- 1088.6; P<0.001) million health facility visits and 28.9 (95% CI 26.1-31.6; P<0.001) million inpatients as of June 2020. Interpretation: Inpatient and outpatient health services utilization in China declined significantly after the COVIID-19 outbreak, likely due to changes in patient and provider behaviors, suspension of health facilities or their non-emergency services, massive mobility restrictions, and the potential reduction in the risk of non-SARS-COV-2 diseases. All indicators rebounded beginning in March but most had not recovered to their pre-SARS-COV-2 levels as of June 2020. Funding: The National Natural Science Foundation of China (No. 72042014). Conflict of Interest: We declare no competing interests.

BMC Health Services Research, Nov 28, 2022

Research Square (Research Square), Oct 17, 2019

Circulation

Introduction: Endomyocardial fibrosis (EMF) is a myocardiopathy that results from restriction of ... more Introduction: Endomyocardial fibrosis (EMF) is a myocardiopathy that results from restriction of the ventricular filling caused by the presence of fibrous tissue in the endocardium. It is estimated that this disease affects approximately 12 millions of people worldwide and most of these people are in the Sub-Saharan Africa. Until today there is no consensus regarding the best therapeutic approach in these patients, but there are reports of encouraging results in patients treated surgically. Objective: To describe the results of surgical treatment of patients with EMF and the factors that influence it. Methodology: 86 patients with EMF were operated at Instituto do Coração (Heart Institute) in Mozambique, between 2002 and 2017. Results: Most of the patients were male (61.6%) with ages between 3 and 39 years (mean, 12 years). Forty-three per cent (43%) of the patients were coming from the province of Inhambane and 81.4% of them had biventricular disease. Sixty-two per cent (62%) of th...

PLOS Global Public Health

Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-... more Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-term follow-up for a large cohort. We estimated HIV incidence among women who recently delivered in southern Mozambique by leveraging data available in routine health cards. A cross-sectional household HIV-testing survey was conducted from October 2017 to April 2018 among mothers of children born in the previous four years in the Manhiça Health Demographic Surveillance System area. Randomly-selected mother-child pairs were invited to participate and asked to present documentation of their last HIV test result. HIV-testing was offered to mothers with no prior HIV-testing history, or with negative HIV results obtained over three months ago. HIV incidence was estimated as the number of mothers newly diagnosed with HIV per total person-years, among mothers with a prior documented HIV-negative test. Among 5000 mother-child pairs randomly selected, 3069 were interviewed, and 2221 reported a pr...

BMJ Open

Background and objectiveThe Ministry of Health of Lesotho and Partners In Health piloted the Leso... more Background and objectiveThe Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement.Methods and analysisThe WHO Data Quality Assurance framework’s core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho’s health system, following a purposive sampling approach. Interviews were anal...

Journal of the International AIDS Society

IntroductionIn 2018, Mozambique's Ministry of Health launched a guideline for a nationwide im... more IntroductionIn 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.MethodsTwenty 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 fa...

BMJ Open

ObjectivesThis study aimed to assess the national-level and subnational-level effects of the COVI... more ObjectivesThis study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana.DesignInterrupted time-series.Setting and participantsThis study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020.Outcome measuresAs the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures.ResultsIn April 2020, as an immediate effect of the COVID-19 pandemic, the number of...

The Lancet

Background Malaria in the first trimester of pregnancy is associated with adverse pregnancy outco... more Background Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisininbased combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisininbased treatment (ABT) versus non-ABTs in the first trimester of pregnancy. Methods For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. Findings We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5•7%) of 736 ABT-exposed pregnancies compared with 96 (8•9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0•71, 95% CI 0•49-1•03). Similar results were seen for the individual components of miscarriage (aHR=0•74, 0•47-1•17), stillbirth (aHR=0•71, 0•32-1•57), and major congenital anomalies (aHR=0•60, 0•13-2•87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4•8%] of 524 vs 84 [9•2%] of 915; aHR 0•58, 0•36-0•92). Interpretation We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted.

BMC Public Health

Background Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of dia... more Background Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of diabetes in the next 25 years. The latest Mozambican population-based STEPS survey (STEPS 2005) estimated a 2.9% prevalence of diabetes in the adult population aged 25-64 years. We aimed to assess the change in prevalence, awareness, and management of diabetes in the national STEPS survey from 2014/2015 compared to 2005. Methods We conducted an observational, quantitative, cross-sectional study following the WHO STEPS surveillance methodology in urban and rural settings, targeting the adult population of Mozambique in 2015. We collected sociodemographic data, anthropometric, and 12 hour fasting glucose blood samples in a sample of 1321 adults. The analysis consisted of descriptive measures of the prevalence of impaired fasting glucose (IFG), diabetes and related risk factors by age group, sex, and urban/rural residence and compared the findings to those of the 2005 survey results. Results T...

PLOS ONE

Background Hepatitis B virus (HBV) infection can be prevented by vaccination. Exposure to blood o... more Background Hepatitis B virus (HBV) infection can be prevented by vaccination. Exposure to blood or body fluids poses a high risk of transmission of HBV in health care workers (HCWs). This study aimed to determine the prevalence of markers of exposure, susceptibility, and protection to HBV infection in HCWs in Beira, Mozambique. Methods A cross-sectional study was conducted between June and August 2020 in Beira City, Mozambique, in HCWs based on self-administered questionnaires and blood samples. Plasma samples were tested for HBV surface antigen (HBsAg), antibodies to HBV core antigen (anti-HBc), antibodies to HBsAg (anti-HBs) and HBV viral load (HBV DNA). Results Most of the 315 HCWs in the study were nurses (125; 39.7%). Of the HCWs, 5.1% (16; 95% Confidence Interval (CI): 2.9 to 8.1%) were infected by HBV (HBsAg and/or HBV DNA positive). Occult HBV infection (OBI) (HBV DNA positive and HBsAg negative) was found in 0.3% (1; 95% CI: 0.0 to 1.8%) of participants; 27.9% (88; 95% CI: ...

Transcultural Psychiatry

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can... more Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach’s alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that “brain hot” and “heart fall down” were the most difficult idioms of distress to endorse while “things playing on the mind” was the easiest. All LDS-11 elements were associated with elevated function impairment, with “things playing on the mind,” “wor...

Microbial Genomics

Genomic studies of the Mycobacterium tuberculosis complex (MTBC) might shed light on the dynamics... more Genomic studies of the Mycobacterium tuberculosis complex (MTBC) might shed light on the dynamics of its transmission, especially in high-burden settings, where recent outbreaks are embedded in the complex natural history of the disease. To this end, we conducted a 1 year prospective surveillance-based study in Mozambique. We applied whole-genome sequencing (WGS) to 295 positive cultures. We fully characterized MTBC isolates by phylogenetics and dating evaluation, and carried out a molecular epidemiology analysis to investigate further associations with pre-defined transmission risk factors. The majority of strains (49.5%, 136/275) belonged to lineage (L) 4; 57.8 % of them (159/275) were in genomic transmission clusters (cut-off 5 SNPs), and a strikingly high proportion (45.5%) shared an identical genotype (0 SNP pairwise distance). We found two ‘likely endemic’ clades, comprising 67 strains, belonging to L1.2, which dated back to the late 19th century and were associated with recen...

PLOS ONE

Background Although blood transfusion is an intervention that saves lives, it poses significant r... more Background Although blood transfusion is an intervention that saves lives, it poses significant risks to the blood receivers, including the transmission of bloodborne pathogens. We aimed at determining the prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), and Hepatitis C virus (HCV) in candidates approved for blood donation, and in samples considered to be negative in reference blood banks in Mozambique. Methods A cross-sectional study was performed between November 2014 and October 2015 in Maputo and Beira cities. Demographic information was obtained from all consenting blood donors using a structured questionnaire. Plasma samples were screened for HIVAb/Ag combinations, HBsAg and Anti-HCV. Blood donors considered to be negative by serological testing were re-tested in pools of six plasma samples using nucleic acid testing (NAT). Results Most blood donors were male 2,320 (83.4%) with an age range of 18 to 34 years. The overall seroprevalence of HIV, HBV and...