Ana Cristina de Faria Neves Mussagi

Background: Mozambique introduced the 10-valent pneumococcal conjugate vaccine (PCV10) in 2013 using a three-dose primary series with no booster dose (3p+0) and later switched to the PCV13 using a schedule of two primary doses with one booster (2p+1). We aimed to describe the burden and serotype distribution of pneumococcal meningitis in children under 5 years of age in Mozambique over an eleven-year period starting with the year of PCV10 introduction, and assess the impact of the PCV vaccine and schedule changes. Methods: We analysed meningitis surveillance data in Mozambique from March 2013 through to December 2023. Cerebrospinal fluid (CSF) samples were collected from eligible children in three referral hospitals (Maputo Central Hospital [south], Beira Central Hospital [central], and Nampula Central Hospital [north]). Culture and polymerase chain reaction assay (qPCR) were performed on each sample. S. pneumoniae-positive samples were subsequently serotyped using multiplex assay. We estimated annual incidence rates for pneumococcal meningitis in children under 5 years old following the PCVs’ introduction (2013–2023). The impact of the product switch and schedule change from PCV10/3p+0 to PCV13/2p+1 on the burden and serotype distribution of pneumococcal meningitis was assessed. Results: Of the 4075 CSF samples tested, 7.4% (301/4075) were positive for S. pneumoniae, 2.5% (103/4075) for H. influenzae, and 1.0% (42/4075) for N. meningitidis. Pneumococcal meningitis incidence in children under five reduced from 44.7 cases per 100,000 in 2013 to 4.6 cases per 100,000 in 2023, an 89.7% reduction. In the PCV13/2p+1 period (2020–2023), pneumococcal meningitis incidence was 51.2% lower than the PCV10/3p+0 period (2013–2017) (IRR 0.49, 95% CI 0.4–0.6; p < 0.001). PCV10-serotype pneumococcal meningitis incidence among children under five decreased by 65.6% in the PCV13/2p+1 period (IRR 0.34, 95% CI 0.2–0.6; p < 0.001). We detected zero cases of pneumococcal meningitis due to the PCV13-serotype in 2020–2023, whereas non-PCV10/13-serotypes increased by 76% (IRR 1.76, 95% CI 1.2–2.6; p = 0.004). The case–fatality proportion decreased by 71.9% (95% CI 62.9–84.8%) in the PCV13/2p+1 period. Conclusions: Since the introduction of PCVs in Mozambique, the burden of pneumococcal meningitis and deaths in children under 5 years of age has substantially decreased, as well as the prevalence of PCV13-serotypes. Higher valency PCVs are needed due to the increased prevalence of non-PCV10/13-serotypes. Funding: Gavi, The Vaccine Alliance, reference number: MOZ-HSS-2-INS; WHO Reference: 2014405143-0, creation DFC to support HIB & Surveillance System.

Background In Mozambique, the introduction of a 13-valent pneumococcal conjugate vaccine (PCV13) using a two plus one schedule began in September 2019. However, the replacement of serotypes with non-PCV types remains a concern worldwide following widespread vaccination. We aim to describe the epidemiology of non-PCV13 types among children under 5 years of age with pneumococcal meningitis four years after PCV13 introduction in Mozambique. Methods Between January 2020 and December 2023, a total of 2,014 cerebrospinal fluid (CSF) samples were collected from eligible children as part of the meningitis surveillance system in Mozambique, 103 (5.1%) of which tested positive for S. pneumoniae after triplex qPCR. Among these, 86 (83.5%) samples met the quality criteria for serotyping and were subsequently analysed using sequential quadriplex qPCR. Results Among children under 2 years of age, 84.8% of the S. pneumoniae- positive samples belonged to non-PCV13 serotypes, with serotype 15B/C (31.0%) being the most prevalent, followed by 12F/12A/12B/44/46 (12.1%), 38B (10.6%), and 8 (7.6%). Serotypes 15B/C, 12F/12A/12B/44/46, 38, 8, and 1 were predominant in the northern region of the country (Nampula), whereas serotypes 15B/C and 12F/12A/12B/44/46 were most common in the central region (Sofala). The serotypes coverage of the PCV13, PCV15 and PCV20 vaccine formulations were 20.0%, 26.3% and 75.8%, respectively. Conclusion PCV13 vaccines save many lives in Mozambique. However, they do not seem to be adequate in addresing some of the highly prevailing non-PCV13 serotypes (15B/C and 12F/12A/12B/44/46). Therefore, we suggest that the country's National Immunization Technical Advisory Group (NITAG) review new data and advice on switching to extended valency vaccines such as PCV20.

Disseminated or military tuberculosis (TB) is defined as the presence of at least two non-contiguous sites of Mycobacterium tuberculosis, occurring as a result of progressive primary infection, reactivation and spread of a latent focus or due to iatrogenic origin. Disseminated TB represents a life-threatening condition, especially in at-risk children and when diagnosis and treatment are delayed. We report on a case of a 3-year old boy who presented with long-lasting unrecognised disseminated TB that was successfully managed in a low-resource setting.

Disseminated or military tuberculosis (TB) is defined as the presence of at least two non-contiguous sites of Mycobacterium tuberculosis, occurring as a result of progressive primary infection, reactivation and spread of a latent focus or due to iatrogenic origin. Disseminated TB represents a life-threatening condition, especially in at-risk children and when the diagnosis and treatment are delayed. We report on a case of a 3-year old boy who presented with long-lasting unrecognised disseminated TB that was successfully managed in a low-resource setting.