**4. Conclusions**

The presentations in the XVI National Health Journeys and the recent articles on cholera offered an invaluable contribution to the current knowledge on the disease in Mozambique, particularly regarding the risk factors, health determinants, and immunization process. Such contributions showed how important the journeys were. The Ministry of Health and related institutions have been active in research and interventions to control cholera in Mozambique. The immunization campaign in 2016 certainly had high impact in reducing the incidence of cholera, as no outbreak has been as wide and severe as 2015's (the ones this year are not considered because their extent is still to be assessed). Yet, governmental effort cannot achieve the desired results if there is no collaboration from the civil society. The etiology, risk factors, and epidemiology of the disease are fairly known, and, although the government lacks resources to provide proper sanitation, access to clean water, or vaccine coverage for all people at risk, it is now a matter of designing a strategy to tackle each the issue, and if the plan is solid, funds can be acquired and well used.

### **5. Recommendations**

The following recommendations are not simply observations based on findings shared during the XVI Health Journeys. They are supplemental observations on their actual recommendations, in a broader context if necessary. It seemed unnecessary to bring to light ideas of improvements if the authors have already done so, this being a mere enhancement if they seem incomplete.

Environmental determinants such as water, sanitation, and hygiene synergistically impact the extent of severity of cholera. Thus, Marrufo et al. [4] strongly recommended their evaluation during outbreak-related emergencies. It is true, but such evaluation should not solely occur during outbreaks. Proper management of the way people use water is crucial to prevent outbreaks in the first place, although factors such as heavy rainfall, warm air temperature, or low river flows cannot be controlled, and they increase the exposition of humans to *V. cholerae* [61, 62]. Ramos et al. [19] and Chissaque et al. [20] agreed, but they proposed a more practical approach through construction of specialized improved latrines, adaptable to high levels of the water table, and improved sanitation. Paulo et al. [22] added that it could be done through multi-sectoral groups involving researchers, community leaders, and engineers. It is eventually necessary to act rather than waste plenty of time analyzing the situation, particularly when it urges to make decisions, but

**143**

a standard.

*An Update on Cholera Studies in Mozambique DOI: http://dx.doi.org/10.5772/intechopen.88431*

Marrufo's opinion seems more prudent, and it should be the first step, and then the government could consider improvements, still after evaluating their viability. Considering the cost Dengo-Baloi et al. [7] explained the necessity to evaluate how much the Ministry of Health spends for an immunization campaign, but it applies to all forms of intervention and also research. The economic component is crucial, and it should also include how and where to obtain and channel the funds and the

Still within the context of health determinants, Borges et al. [5] manifested preoccupations with the people directly using lake water in Niassa, without any treatment, even when they have potable water available. They intended to understand why, and they recommended studies in this direction. They and other authors [6, 22] also think health education campaigns could lead people to understand the risk of such behavior and ultimately take the appropriate measures. The authors are certainly pointing to a constructive direction, but it is a delicate endeavor to convince people to abandon their values and traditions. Niassa Lake, more than a useful water source, is certainly also a source of recreation and economic activities such as fishing or *garimpo*, and the reasons why people use the lake even with water at home might be the same as why urban populations leave their homes to a swimming pool or to the sea for surfing or fishing. Maybe they are moved by the experience, not merely out of necessity. The disbelief in cholera as a bacterial worldwide pandemic in favor of theories of government conspiracy worsens the situation. In this case, particularly if the lake is a source of so many benefits, positive psychology seems to be a more effective direction to consider: showing the benefits of using alternatives (e.g., consuming only treated water) for the same ends rather than repeating how prejudicial the lake water might be. It still means that community education is

best way to manage it in order to prevent unnecessary losses.

necessary because people have to know how to prevent cholera.

the consequences of their possible misdiagnosis?

Chitio and Langa [24] called for a clear definition of cases of *Aeromonas* spp. contaminations during cholera outbreaks to prevent improper treatment. This should not be just for the genus mentioned, but in general physicians should require differential diagnostic for suspected cases of cholera, rather than taking rushed decisions based on arbitrary probability during outbreaks, because it might worsen the problem or create new problems for the patients. If they found that 10% of the cases suspected of cholera were actually related to *Aeromonas* infection, how many might have been related to other causes than *Vibrio* or *Aeromonas*? And which were

After successfully performing the rapid test for cholera, Dengo-Baloi et al. [18] recommended it as an alternative tool, but they believe that the culture method shall remain to confirm the epidemics, to monitor antibiotic sensitivity, and to produce pure isolates for molecular characterization. Considering how critical outbreaks are, the authors provided a very prudent opinion, and, although their results were highly promising, it is perhaps better to keep testing the method and compare the results with others from authors in different settings before it becomes

Immunization is already a well-developed area because there are very wellcrafted guidelines, based on logical, scientific, and empirical sources, and it has been practiced for many years. Still, healthcare professionals have to face contextual issues, and it results in every-evolving strategies. The door-to-door vaccination strategy seems very effective, and Baltazar et al. [23] said it is better to implement as a preventive measure against potential outbreaks. Having said so, they did not put emphasis on the strategy during outbreaks, possibly because it is preferable to manage the disease when it is easier to control. It is perhaps important to consider the Médecins Sans Frontières [63] recommendations for door-to-door strategies, some of which are already fulfilled. First, it is good that people already have

#### *An Update on Cholera Studies in Mozambique DOI: http://dx.doi.org/10.5772/intechopen.88431*

*Healthcare Access - Regional Overviews*

**4. Conclusions**

**5. Recommendations**

quinolone or third-generation cephalosporins [60].

being a mere enhancement if they seem incomplete.

Antibiotic misuse is frequent in developing countries but such level was extreme. For instance, Runesson et al. [58] reported the use of antibiotics in 70% of cases of children with diarrhea, randomly examined in a children's hospital, from which at least 35% did not really need antibiotics. According to Rogawski et al. [59], antibiotics have the potential to modify the gastrointestinal microbiota and increase the risk of a reduced time to a subsequent diarrhea episode. It is also known that antibiotic abuse frequently results in resistance. In 2007, Mandomando et al. [60] reported a high incidence of resistance to chloramphenicol (57.9%), co-trimoxazole (96.6%), and tetracycline (97.3%), and low for quinolone (4.2%). Salência et al. [11] mentioned the use of ampicillin (45%), gentamicin (39%) combined with therapy, and gentamicin (10%). Thus, there should be efforts to discourage physicians to prescribe antibiotics when it is not necessary. When appropriate, they can use

The presentations in the XVI National Health Journeys and the recent articles on cholera offered an invaluable contribution to the current knowledge on the disease in Mozambique, particularly regarding the risk factors, health determinants, and immunization process. Such contributions showed how important the journeys were. The Ministry of Health and related institutions have been active in research and interventions to control cholera in Mozambique. The immunization campaign in 2016 certainly had high impact in reducing the incidence of cholera, as no

outbreak has been as wide and severe as 2015's (the ones this year are not considered because their extent is still to be assessed). Yet, governmental effort cannot achieve the desired results if there is no collaboration from the civil society. The etiology, risk factors, and epidemiology of the disease are fairly known, and, although the government lacks resources to provide proper sanitation, access to clean water, or vaccine coverage for all people at risk, it is now a matter of designing a strategy to tackle each the issue, and if the plan is solid, funds can be acquired and well used.

The following recommendations are not simply observations based on findings shared during the XVI Health Journeys. They are supplemental observations on their actual recommendations, in a broader context if necessary. It seemed unnecessary to bring to light ideas of improvements if the authors have already done so, this

Environmental determinants such as water, sanitation, and hygiene synergistically impact the extent of severity of cholera. Thus, Marrufo et al. [4] strongly recommended their evaluation during outbreak-related emergencies. It is true, but such evaluation should not solely occur during outbreaks. Proper management of the way people use water is crucial to prevent outbreaks in the first place, although factors such as heavy rainfall, warm air temperature, or low river flows cannot be controlled, and they increase the exposition of humans to *V. cholerae* [61, 62]. Ramos et al. [19] and Chissaque et al. [20] agreed, but they proposed a more practical approach through construction of specialized improved latrines, adaptable to high levels of the water table, and improved sanitation. Paulo et al. [22] added that it could be done through multi-sectoral groups involving researchers, community leaders, and engineers. It is eventually necessary to act rather than waste plenty of time analyzing the situation, particularly when it urges to make decisions, but

**142**

Marrufo's opinion seems more prudent, and it should be the first step, and then the government could consider improvements, still after evaluating their viability. Considering the cost Dengo-Baloi et al. [7] explained the necessity to evaluate how much the Ministry of Health spends for an immunization campaign, but it applies to all forms of intervention and also research. The economic component is crucial, and it should also include how and where to obtain and channel the funds and the best way to manage it in order to prevent unnecessary losses.

Still within the context of health determinants, Borges et al. [5] manifested preoccupations with the people directly using lake water in Niassa, without any treatment, even when they have potable water available. They intended to understand why, and they recommended studies in this direction. They and other authors [6, 22] also think health education campaigns could lead people to understand the risk of such behavior and ultimately take the appropriate measures. The authors are certainly pointing to a constructive direction, but it is a delicate endeavor to convince people to abandon their values and traditions. Niassa Lake, more than a useful water source, is certainly also a source of recreation and economic activities such as fishing or *garimpo*, and the reasons why people use the lake even with water at home might be the same as why urban populations leave their homes to a swimming pool or to the sea for surfing or fishing. Maybe they are moved by the experience, not merely out of necessity. The disbelief in cholera as a bacterial worldwide pandemic in favor of theories of government conspiracy worsens the situation. In this case, particularly if the lake is a source of so many benefits, positive psychology seems to be a more effective direction to consider: showing the benefits of using alternatives (e.g., consuming only treated water) for the same ends rather than repeating how prejudicial the lake water might be. It still means that community education is necessary because people have to know how to prevent cholera.

Chitio and Langa [24] called for a clear definition of cases of *Aeromonas* spp. contaminations during cholera outbreaks to prevent improper treatment. This should not be just for the genus mentioned, but in general physicians should require differential diagnostic for suspected cases of cholera, rather than taking rushed decisions based on arbitrary probability during outbreaks, because it might worsen the problem or create new problems for the patients. If they found that 10% of the cases suspected of cholera were actually related to *Aeromonas* infection, how many might have been related to other causes than *Vibrio* or *Aeromonas*? And which were the consequences of their possible misdiagnosis?

After successfully performing the rapid test for cholera, Dengo-Baloi et al. [18] recommended it as an alternative tool, but they believe that the culture method shall remain to confirm the epidemics, to monitor antibiotic sensitivity, and to produce pure isolates for molecular characterization. Considering how critical outbreaks are, the authors provided a very prudent opinion, and, although their results were highly promising, it is perhaps better to keep testing the method and compare the results with others from authors in different settings before it becomes a standard.

Immunization is already a well-developed area because there are very wellcrafted guidelines, based on logical, scientific, and empirical sources, and it has been practiced for many years. Still, healthcare professionals have to face contextual issues, and it results in every-evolving strategies. The door-to-door vaccination strategy seems very effective, and Baltazar et al. [23] said it is better to implement as a preventive measure against potential outbreaks. Having said so, they did not put emphasis on the strategy during outbreaks, possibly because it is preferable to manage the disease when it is easier to control. It is perhaps important to consider the Médecins Sans Frontières [63] recommendations for door-to-door strategies, some of which are already fulfilled. First, it is good that people already have

experience with this approach, and there is some acceptance [23]. Second, it is important to coordinate the process with the authorities at neighborhood levels or small communities, where information is easy to spread, and it is also easy to record the number of residents or households in order to keep track of individuals absent during each round and organize catch-up rounds. Baltazar et al. [23] also suggested short-term effectiveness studies, but these have been done and reported by Dengo-Baloi et al. [7] from the same research team. Perhaps the results had not yet been analyzed when Baltazar et al. [23] had already completed their report. To maximize adherence, Botão et al. [8] suggested sensibilization of the population through identification of credible leaders and other influential individualities to function as mobilizers during the entire campaign.

Salência et al. [11] discussed about the indiscriminate use of antibiotic to children with acute diarrhea as a violation of WHO guidelines, and the authors appealed for the optimization of prescription of antibiotics for diarrhea. The authors are correct, but the issue requires perhaps more attention, considering that WHO guidelines result from the international consensus and, in general, physicians are expected to be aware of the dangers of antibiotic overprescription, and this practice is often most likely an act of negligence. Thus, there should be penalties to discourage such kind of misconduct because it is a sensitive public health matter.

The National Health Institute and partners shall keep organizing the National Health Journeys and similar events because they are very constructive platforms in which researchers, scholars, and health professionals can share information and broaden their scope regarding the reality of cholera and other diseases in Mozambique. Such events should be more frequent and organized all over the country to give opportunities to people residing in other areas than the capital city. It would perhaps be a very good idea to promote conferences about the control of cholera or diarrheic diseases in areas of high incidence and engage local health professionals or potential actors who can really influence the current situation.

The final recommendation is based on the words of Chissaque et al. [10] in their summary: the key to control cholera and other diarrheic diseases is a deep understanding of the local epidemiology. Such comprehension would facilitate predictions and planning on how to prevent outbreaks and manage them if they eventually happen. Mozambique could study carefully experiences from other countries where cholera is endemic, such as India or Bangladesh, and understand how they deal with the matter or at least draw some comparisons and interact with foreign scientists. The contexts are surely different, but the problem is similar, and solutions might arise from unexpected variables.

### **6. Post-conclusive note**

There will be soon more updates on cholera in Mozambique because there were two major outbreaks [40, 64, 65], one still ongoing as this manuscript is under preparation [66]. They are related to the intense tropical cyclones Idai and Kenneth that made landfall in Mozambique's central and northern provinces, respectively [67]. According to Miller and Adebayo [37], Kenneth it is the strongest cyclone recorded in the country, and together the tragedies certainly caused the biggest losses since the flood in 2000 [68]. Briefly, Devi [40] said that up to April 20, the Ministry of Health had declared an outbreak due to Idai, and there had been at least 4979 cases of cholera and 6 deaths. Regarding Kenneth, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) [64] declared that as of 12 May, there were 149 confirmed cases of cholera in Pemba, Metuge, and Mecufi.

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**Author details**

Jacinto Singo1

Edgar Manuel Cambaza1

University, Maputo, Mozambique

\*, Edson Mongo1

1 Department of Biological Sciences, Faculty of Sciences, Eduardo Mondlane

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Edsone Machava1

2 National Health Institute, Maputo, Mozambique

provided the original work is properly cited.

\*Address all correspondence to: accademus@protonmail.com

, Elda Anapakala<sup>2</sup>

, Robina Nhambire1

,

*An Update on Cholera Studies in Mozambique DOI: http://dx.doi.org/10.5772/intechopen.88431*

The authors declare no conflict of interest.

**Conflict of interest**

*An Update on Cholera Studies in Mozambique DOI: http://dx.doi.org/10.5772/intechopen.88431*
