**3.5 Control strategies**

*Healthcare Access - Regional Overviews*

susceptible to cholera.

It is general knowledge that cholera is spread through water and improper sanitation is a major risk factor for transmission. Thus, the disease deeply related to poverty in several ways including obviously the lack of resources for prevention or treatment and limitations in education or information. It is intuitive that the most susceptible are people living in highly crowded suburban areas when people have little access to clean water, or in rural settings, when people directly consume water from lakes or rivers without any treatment. People living around Lake Niassa use it for domestic purposes [5]. This is the reality in several areas of Mozambique. This must be understood on top of any specificity of the studies explained or discussed in this subsection. It must be implicit that all the studies' target populations were

The research team of Baltazar et al. [23] belongs to the National Institute of Health, and they conducted most studies related to the vaccination campaign in Nampula City, 2016. In the particular study cited, they focused on inhabitants over 1 year old living in the city's six most susceptible neighborhoods, mentioned in Section 5.4.1 (Geographical distribution). People from surrounding areas are also at risk [4] because of mobility and interaction with residents of the endemic neighbor-

Children are the most susceptible to diarrheic diseases in general [11, 20] perhaps because of their immunity still under development, their unawareness of the bacterial load in the untreated water, and their behavior. In reality, they have always been the priority and focus of the vaccination campaigns [10, 45]. Among 1910 children hospitalized with acute diarrhea from May 2014 to December 2017, Salência et al. [11] found that <1-year-olds were the most affected and 19 infants (2.4%) had *V. cholerae*. The majority (58%) were male, but it seems that the proportion male/female always gravitates around 1:1 [1, 11, 22]. Mesa et al. [1] analyzed 128 processes of patients with acute diarrhea in Mocuba District Hospital, admitted during June and July 2015 in the local hospital. According to the authors, all patients presented symptoms consistent with cholera, but, despite their convictions, there was no confirmation, and they based their conclusions on clinical data (aqueous stool, vomit, and fever). In any case, all were below 16 years old in which 41% were below 5 years and 4% of the cases ended in decease. Differently, Paulo et al. [22] found 68% of individuals over 15 years old among 135 cases of cholera in the Center for Treatment of Diarrheic Diseases in Nacarôa District, recorded from 12 to 28 November 2017. The difference is likely due to a fact mentioned by the authors that none treated the water before consuming and the majority (64%) used well water. One has to imagine that the entire household uses the same water source and all the members have nearly the same level of exposition if it is contaminated, independently of the age and behavior of each individual. The age or sex differences might be a reflection of the actual sociodemographic profile of the

There is little novelty on diagnosis in Mozambique since the beginning of the decade. It is perhaps worth mentioning that during the 2016 massive vaccination campaign in Nampula, Dengo-Baloi et al. [18] performed a rapid test to verify if it could be an alternative to the culture-based standard, as the latter takes 48 to 72 hours and the rapid test would take approximately 6 hours. They used an alkaline peptone water (APW) enrichment method, but they did not specify the origin of the kit. It was likely Crystal VC RDT (Span Divergent, Mumbai, India), previously used by George et al. [46] in Bangladesh and Ontweka et al. [47] in South Sudan. According to the latter, it is also considerably inexpensive. Dengo-Baloi et al. [18]

hoods or exchange of food or drinks coming from such zones.

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community.

**3.4 Diagnosis**
