*3.5.1 Overview, prophylaxis, and awareness*

Cholera control strategies in Mozambique have been changing over time, perhaps due to governmental priorities, an increasing knowledge, or resources available. Regarding Mozambique, it is important to keep in mind that Mozambique has undergone major political changes, there have been conflicts, including armed, natural calamities such as drought, floods, typhoons, economic crises, and fluctuations. All these phenomena resulted in mobility or affected people's livelihoods, changing the dynamics of access to resources, including potable water, ultimately impacting public health. This ever-changing environment has been determining, at a certain extent, the way the government deals with the epidemics of infectious diseases, including cholera. Chissaque et al. [20] mentioned some key actions of the government's strategy: vaccination, health education, introduction of zinc and salts for oral hydration, improvement of basic sanitation (construction of latrines and access to potable water), and organization of national health weeks. Dengo-Baloi et al. [18] added vigilance among the measures, and Vanormelingen et al. [17] said that the government coordinated a real-time mapping of the epidemic and supported social mobilization with the assistance of the United Nations Children's Fund, World Health Organization, and Médecins Sans Frontières (MSF).

The most relevant actions in the last decade are perhaps related to the Ministry of Health's implementation of vaccination campaigns using Shanchol™ (BivWC, Shantha [48], Ranga Reddy District, Telangana, India) in Nampula City's six most vulnerable neighborhoods, in October 2016 and also the subsequent years [4, 10, 21]. It was in response to the outbreak in 2015, and the strategy was to deliver the vaccine door to door in two rounds [23]. Paulo et al. [22] mentioned another outbreak in November 2017, but it did not seem as severe. The 2016 campaign was strategically set to cover 193,403 individuals and prevent the expansion of cholera to less affected areas [4, 18]. Though the first round only covered 69.5% of the target population, and the second covered 51.2%, Baltazar et al. [23] considered the experience as a success and shared the belief that similar strategies can have more adherence in urban settings when there is no emergency. Considerably low adherence was mostly because many people were not at home during the campaign, and 17.3% of 636 people enquired said that they were unaware of the campaign. The situation was similar in the following 2 years [21]. Thus, it is important to improve or use more effectively the channels to communicate with the residents.

After vaccination, there were adverse effects such as abdominal pain, nausea, and diarrhea, but none seemed severe enough to require any medical assistance [18]. The National Institute of Health organized a vigilance of postimmunization adverse effects in nine healthcare units, and, according to Dengo-Baloi et al. [18], there were eight cases reported after the first round of vaccination, three during the second, and one case during both rounds. Yet, there were certainly more cases because Baltazar et al. [23] reported adverse effects in 47 people of 451 interviewed after receiving vaccination. A possible explanation for the discrepancy between both studies is the fact that PIAE vigilance recorded mostly cases that occurred 24 h after vaccination, and it was based on records from healthcare units, while the other study was based on inquiries directly to randomly chosen individuals from the community from 2 to 9 November 2016 [18, 23].

Among the 428 interviewees of Borges et al. [5] in Metangula, the level of awareness on cholera was very high (98%), and they said that radio (35%) and lectures at the healthcare center (28%) were the main sources of information about the disease. If the population in general is aware of the disease and still Metangula is the town most affected with cholera in Niassa Province, perhaps most inhabitants lack essential knowledge on how to prevent the disease or have very few alternatives as source of water or means to properly treat it. Yet, the investigators claim that most people from Metangula have access to potable water, but they prefer the untreated from the Lake Niassa and proposed further studies to understand their motivation. They also believe that it is necessary to intensify awareness campaigns on how to prevent cholera. However, such campaigns might not be very effective if people mistrust the authorities, as Victorino et al. [6] said. The latter authors interviewed 30 residents throughout three neighborhoods of Nampula City (the same region of the country), and they unanimously claimed that the government was responsible for the outbreak of cholera. Furthermore, the majority (18 people) did not really understand the concept of cholera (bacterial disease transmitted through water), and 12 did not know how to prevent the disease. In this case, it would be more prudent to approach the residents through authorities they might be more prone to trust, such as teachers at schools, traditional leaders and religious entities.

#### *3.5.2 Constraints and limitations*

At a first glance, the main constraints seem related to vaccination, improper treatment and potential misdiagnosis of diarrheic diseases, unclear notion on the impact of risk factors, shortage of resources for interventions, and government mistrust. Some constraints might be related, and for this reason they will not be necessarily presented in the same order as mentioned. This subsection might seem redundant in the sense that it recapitulates some limitations from the previous subsections. However, it seems important to discuss them in more detail, as they are likely to be the starting point for future researchers aiming to study the dynamics of cholera epidemiology and control strategies in Mozambique. Furthermore, some ideas are consolidated, and some relationships are explored more critically in this subsection.

According to Baltazar et al. [23], during the 2016 vaccination campaign in Nampula, more than one third missed the vaccine because they were not at home or did not receive any information prior to the campaign, and in the second round, there were less people available, though dropout rates from the first to the second dose up to 13% is not uncommon due to factors such as migration or other reasons leading people to be absent [49, 50]. Salomão et al. [21] stated that it happened again the following year, and, according to them, the main reasons were lack of time, absence, and lack of information. The overall vaccine wastage rate was 10%, and it seems high if compared with the experience in Bangladesh between February and April 2011, where it was 1.2% [49]. Such wastage might be partially related to reasons to be discussed in the following paragraph.

It seems important to discuss the most likely motivation for the vaccination campaign's suboptimal adherence. Since the strategy was door to door, it seems difficult to suddenly receive someone claiming to be from the government and offering substances to all family members including children. Even if the visitors show credentials, many inhabitants mistrust the government and blame it for the disease [6, 8]. In contrast, Botão et al. [8] interviewed 145 individuals from the target population, and 92% said they were willing to receive the vaccine. It is hard to clarify why they showed interest, but the actions were different, but a possible explanation would be that they just manifested agreement for the convenience of the interview or because

**141**

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

absent during the campaigns.

differential diagnoses when it is possible.

they fear the authorities. Such attitude toward the government is not new or exclusive to Nampula or northern Mozambique. For instance, Pool et al. [33] reported a similar behavior during a campaign for immunization against malaria 10 years before in Manhiça District, southern Mozambique. Similarly, rumors stated that the local clinic was trying to poison the children. In Gurúè City, people believe that cholera is sent as spells by evil individuals [2]. It would be an asset to investigate what religious leaders or traditional healers think of cholera and government interventions, because it is common for people in Mozambique to rely on them in matters of health, in some cases even for immunization. The fact that conventional practitioners are a direct competition for their source of income cannot be underestimated, and if people, including their leaders and traditional healers, regard outbreaks of diarrhea as a spiritual matter, they might not understand the governments' true motivations, and "conspiracy theories" will keep spreading. Botão et al. [8] reported emerging conflicts related to previous cholera interventions between health professionals, community leaders, and health activists, sometimes escalating to episodes of violence. Interventions seem to become more difficult over time as the locals create barriers for the professionals, and both Botão et al. [8] and Salomão et al. [21] believe only the notion that cholera is life-threatening can motivate the population to accept the vaccine. In any case, prior to vaccination, there should be a strong campaign targeting traditional authorities in order to promote their collaboration and influence the adults, and likewise directed to teachers, to influence the children. It would also include, in the strategy, ways to make sure that people are not

Baltazar et al. [23] also stated that 10% of the individuals experienced side effects after vaccination, and it seems a plausible explanation for the decline of 18.3% in adherence between the two rounds. It is possible that such individuals and their families or relatives preferred not to receive the second dose, and it can still be confirmed if the interview records are available. Minor side effects to this vaccine (Shanchol™) should have been expected in some people [48, 51], and it has been observed in Bangladesh [52]. The vaccination campaign in Nampula was certainly carried with informed consent and following the WHO [53] recommendations, but if the side effects in fact led people to withdraw from the second round, it is important to reevaluate the communication with the target population. The Centers for Disease Control and Prevention [54] recommend competent authorities to explain the people to be vaccinated about the "benefits of and risks from vaccines in

language that is culturally sensitive and at an appropriate educational level." Misdiagnoses should also not be underestimated, especially because it has impact on the choice of treatment. Chissaque et al. [20] reported lack of consistent protocols to directly relate a pathogen with a particular diarrheic profile and also the respective risk factors. Outbreak of a disease can be misleading when there are people carrying diseases with similar symptoms. For instance, Chitio et al. [24] detected *Aeromonas spp.* in 10.4% of 289 samples of rectal swabs from individuals with symptoms consistent with cholera during outbreaks of the latter. Sometimes even conventional culture methods can fail to detect *V. cholerae* [55]. Furthermore, Gupta et al. [56] found that clinical conditions of a coinfection cholera-rotavirus and cholera alone can easily be confused. There should be efforts to ensure rigorous

Salência et al. [11] reported the abusive use of antibiotics to treat acute diarrhea in children, including confirmed cases of cholera (2.4%), between May 2014 and December 2017 in major hospitals from all regions of Mozambique. According to the authors, antibiotics were used to treat 94% of the patients, and this represents a violation of the WHO's protocol that recommends the use of these compounds when there is cholera, dysentery, and other "recognizable severe cases" [57].

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

*Healthcare Access - Regional Overviews*

*3.5.2 Constraints and limitations*

subsection.

Among the 428 interviewees of Borges et al. [5] in Metangula, the level of awareness on cholera was very high (98%), and they said that radio (35%) and lectures at the healthcare center (28%) were the main sources of information about the disease. If the population in general is aware of the disease and still Metangula is the town most affected with cholera in Niassa Province, perhaps most inhabitants lack essential knowledge on how to prevent the disease or have very few alternatives as source of water or means to properly treat it. Yet, the investigators claim that most people from Metangula have access to potable water, but they prefer the untreated from the Lake Niassa and proposed further studies to understand their motivation. They also believe that it is necessary to intensify awareness campaigns on how to prevent cholera. However, such campaigns might not be very effective if people mistrust the authorities, as Victorino et al. [6] said. The latter authors interviewed 30 residents throughout three neighborhoods of Nampula City (the same region of the country), and they unanimously claimed that the government was responsible for the outbreak of cholera. Furthermore, the majority (18 people) did not really understand the concept of cholera (bacterial disease transmitted through water), and 12 did not know how to prevent the disease. In this case, it would be more prudent to approach the residents through authorities they might be more prone to

trust, such as teachers at schools, traditional leaders and religious entities.

At a first glance, the main constraints seem related to vaccination, improper treatment and potential misdiagnosis of diarrheic diseases, unclear notion on the impact of risk factors, shortage of resources for interventions, and government mistrust. Some constraints might be related, and for this reason they will not be necessarily presented in the same order as mentioned. This subsection might seem redundant in the sense that it recapitulates some limitations from the previous subsections. However, it seems important to discuss them in more detail, as they are likely to be the starting point for future researchers aiming to study the dynamics of cholera epidemiology and control strategies in Mozambique. Furthermore, some ideas are consolidated, and some relationships are explored more critically in this

According to Baltazar et al. [23], during the 2016 vaccination campaign in Nampula, more than one third missed the vaccine because they were not at home or did not receive any information prior to the campaign, and in the second round, there were less people available, though dropout rates from the first to the second dose up to 13% is not uncommon due to factors such as migration or other reasons leading people to be absent [49, 50]. Salomão et al. [21] stated that it happened again the following year, and, according to them, the main reasons were lack of time, absence, and lack of information. The overall vaccine wastage rate was 10%, and it seems high if compared with the experience in Bangladesh between February and April 2011, where it was 1.2% [49]. Such wastage might be partially related to

It seems important to discuss the most likely motivation for the vaccination campaign's suboptimal adherence. Since the strategy was door to door, it seems difficult to suddenly receive someone claiming to be from the government and offering substances to all family members including children. Even if the visitors show credentials, many inhabitants mistrust the government and blame it for the disease [6, 8]. In contrast, Botão et al. [8] interviewed 145 individuals from the target population, and 92% said they were willing to receive the vaccine. It is hard to clarify why they showed interest, but the actions were different, but a possible explanation would be that they just manifested agreement for the convenience of the interview or because

reasons to be discussed in the following paragraph.

**140**

they fear the authorities. Such attitude toward the government is not new or exclusive to Nampula or northern Mozambique. For instance, Pool et al. [33] reported a similar behavior during a campaign for immunization against malaria 10 years before in Manhiça District, southern Mozambique. Similarly, rumors stated that the local clinic was trying to poison the children. In Gurúè City, people believe that cholera is sent as spells by evil individuals [2]. It would be an asset to investigate what religious leaders or traditional healers think of cholera and government interventions, because it is common for people in Mozambique to rely on them in matters of health, in some cases even for immunization. The fact that conventional practitioners are a direct competition for their source of income cannot be underestimated, and if people, including their leaders and traditional healers, regard outbreaks of diarrhea as a spiritual matter, they might not understand the governments' true motivations, and "conspiracy theories" will keep spreading. Botão et al. [8] reported emerging conflicts related to previous cholera interventions between health professionals, community leaders, and health activists, sometimes escalating to episodes of violence. Interventions seem to become more difficult over time as the locals create barriers for the professionals, and both Botão et al. [8] and Salomão et al. [21] believe only the notion that cholera is life-threatening can motivate the population to accept the vaccine. In any case, prior to vaccination, there should be a strong campaign targeting traditional authorities in order to promote their collaboration and influence the adults, and likewise directed to teachers, to influence the children. It would also include, in the strategy, ways to make sure that people are not absent during the campaigns.

Baltazar et al. [23] also stated that 10% of the individuals experienced side effects after vaccination, and it seems a plausible explanation for the decline of 18.3% in adherence between the two rounds. It is possible that such individuals and their families or relatives preferred not to receive the second dose, and it can still be confirmed if the interview records are available. Minor side effects to this vaccine (Shanchol™) should have been expected in some people [48, 51], and it has been observed in Bangladesh [52]. The vaccination campaign in Nampula was certainly carried with informed consent and following the WHO [53] recommendations, but if the side effects in fact led people to withdraw from the second round, it is important to reevaluate the communication with the target population. The Centers for Disease Control and Prevention [54] recommend competent authorities to explain the people to be vaccinated about the "benefits of and risks from vaccines in language that is culturally sensitive and at an appropriate educational level."

Misdiagnoses should also not be underestimated, especially because it has impact on the choice of treatment. Chissaque et al. [20] reported lack of consistent protocols to directly relate a pathogen with a particular diarrheic profile and also the respective risk factors. Outbreak of a disease can be misleading when there are people carrying diseases with similar symptoms. For instance, Chitio et al. [24] detected *Aeromonas spp.* in 10.4% of 289 samples of rectal swabs from individuals with symptoms consistent with cholera during outbreaks of the latter. Sometimes even conventional culture methods can fail to detect *V. cholerae* [55]. Furthermore, Gupta et al. [56] found that clinical conditions of a coinfection cholera-rotavirus and cholera alone can easily be confused. There should be efforts to ensure rigorous differential diagnoses when it is possible.

Salência et al. [11] reported the abusive use of antibiotics to treat acute diarrhea in children, including confirmed cases of cholera (2.4%), between May 2014 and December 2017 in major hospitals from all regions of Mozambique. According to the authors, antibiotics were used to treat 94% of the patients, and this represents a violation of the WHO's protocol that recommends the use of these compounds when there is cholera, dysentery, and other "recognizable severe cases" [57].

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 quinolone or third-generation cephalosporins [60].
