Malaria, HIV and Malnutrition among Internally Displaced People in Mozambique During COVID-19 Pandemic: Results from a Community-Based Intervention

ABSTRACT Background: The spread of COVID-19 poses an unprecedented challenge to care delivery in post-disaster and conflict situations. In Mozambique, the 2019 cyclone Idai and the violence by Non-State-Armed-Groups devastated the province of Sofala and Cabo Delgado respectively and led to the displacement of thousands of people living in poor and overcrowded conditions. The pandemic has further aggravated the situation. Doctors with Africa CUAMM (University college for aspiring missionary doctors) implemented surveillance activities in these regions between October 2020 and September 2021. The aim of this study is to give an overview of the prevalence of malaria, malnutrition, COVID-19 related symptoms and access to HIV testing. Methods: Data were collected in targeted internally displaced people (IDP) sites in Sofala and Cabo Delgado province between 31st January and 25th September 2021. The tool used enabled to assess COVID-19 symptoms, risk of HIV infection, malaria cases and malnutrition in children under five. Results: The project reached 93 503 people. During the study period, 13.6% people reported at least one symptom suggestive of COVID-19 infection. Malaria Rapid Diagnostic Tests (RDT) were administered to 86% of the recruited people (n = ?), with a positive INTRODUCTION Internally displaced people (IDP) are among the most vulnerable populations since they struggle to access essential health, water, and sanitation services including clean water [1]. In March 2019, Sofala province was hit by the cyclone Idai, resulting in the displacement of thousands of people [2], while the violence carried out by Non-State Armed Groups in Cabo Delgado province led to the displacement of hundreds of thousands of people. Apart from the insufficient access to proper sanitation and vaccination, internally displaced people (IDP) live in situations of overcrowding, are more vulnerable to HIV infection [3], and routinely face surges in malaria and malnutrition [4, 5]. In times of pandemics, HIV, malnutrition and malaria control in vulnerable populations is further threatened by supply-chain interruptions, health resources overload and decision-making adaptation [6]. In this scenario, the advent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), brought significant disruption. In March 2020, the first cases of the COVID-19 pandemic were reported in Mozambique. Pandemics usually have a major impact on vulnerable communities and, although COVID-19 is well-known in Mozambique, myths about avoidance and cures must be dispelled. As happened in other sub-Saharan countries, the infection rate rose in two peaks, occurring from January to April 2021 and July to September 2021 [7]. The spectrum of clinical manifestations of COVID-19 ranges from pauci- or asymptomatic infections to severe respiratory failure and death [8]. The most common clinical symptoms of COVID-19 include loss of smell, loss of taste, cough, runny nose, fatigue, fever, and chest pain and, in some patients, SARS- CoV2 acute infection resolves in a wide spectrum of long-term signs and symptoms known as “long COVID”. Even though symptom-screening alone is considered unreliable in COVID-19 identification and surveillance [9], symptomatic individuals are significantly more likely to test positive [10]. From October 2020 to September 2021, Doctors with Africa CUAMM (University college for aspiring missionary doctors) implemented a community-based surveillance intervention with support from the United Nations Population Fund (UNFPA) in Mozambique. The initiative was funded by Norway as part of a project that aimed to contribute to Mozambique’s efforts in preparing and responding to the COVID-19 pandemic, with a focus on mitigating its consequences on the lives of women and girls affected by cyclone Idai and Kenneth in Sofala and armed conflicts in Cabo Delgado. CUAMM’s interventions targeted internally displaced people (IDPs) accommodated in 12 resettlement sites established since 2019. In those areas, the project piloted the community surveillance strategy developed by the Mozambican Ministry of Health. The aim of this study is to report test-positivity rate and prevalence of malaria, malnutrition, COVID-19-related symptoms and access to HIV Di Gennaro et al. 2 Annals of Global Health DOI: 10.5334/aogh.3969 diagnosis in the 4.5% of them (n = ?). Among the recruited Internally Displaced Persons (IDP), 23.1% were considered eligible for HIV screening, but only 1.4% were referred for testing. Acute malnutrition was found in 6.3% of children screened and, among these, a higher prevalence of concurrent COVID-19 symptoms was reported. Discussion: Our study highlights the importance of mass clinical screening for COVID-19 infection in this target population to enact prevention behavior, although this may not be enough, due to the pivotal role played by asymptomatic transmissions. Considering the overlap of the symptoms of COVID-19 and malaria, a combined diagnostic algorithm is urgently needed to avoid underdiagnosing malaria. Moreover, the high prevalence of respiratory symptoms in malnourished children confirmed the known correlation between malnutrition and respiratory infection. Finally, access to HIV screening needs to be implemented, given the high prevalence of people with HIV risk factors to avoid diagnostic delay. Conclusions: Population-specific needs make necessary to develop new screening methods that respond to the specific characteristics of the target population.