Supplement article - Outbreak Investigation | Volume 5 (1): 5. 23 Feb 2022 | 10.11604/JIEPH.supp.2022.5.1.1181

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

Fabião Mausse, Beatriz Nhamtumbo, Dionísia Balate, Judite Monteiro Braga, Cidia Francisco, Cynthia Semá Baltazar, Érika Valeska Rossetto

Corresponding author: Fabião Maússe, Field Epidemiology and Laboratory Training Program, National Institute of Health, P.O. Box 264, Maputo, Mozambique

Received: 08 Mar 2021 - Accepted: 16 Dec 2021 - Published: 23 Feb 2022

Domain: Epidemiology

Keywords: Measles, Epidemiological surveillance, Outbreaks, Vaccination coverage, Mozambique

This articles is published as part of the supplement Preparedness and response to COVID-19 in Africa (Volume 2), commissioned by AFRICAN FIELD EPIDEMIOLOGY NETWORK (AFENET).

©Fabião Mausse et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Fabião Mausse et al. Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19. Journal of Interventional Epidemiology and Public Health. 2022;5(1):5. [doi: 10.11604/JIEPH.supp.2022.5.1.1181]

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Outbreak Investigation

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

Fabião Mausse1,&, Beatriz Nhamtumbo1, Dionísia Balate1, Judite Monteiro Braga2, Cidia Francisco3, Cynthia Semá Baltazar2, Érika Valeska Rossetto4


1Field Epidemiology and Laboratory Training Program, National Institute of Health, Maputo, Mozambique, 2National Institute of Health, Maputo, Mozambique, 3Eduardo Mondlane University, Maputo, Mozambique, 4MassGenics, assigned to Centers for Disease Control and Prevention, Maputo, Mozambique



&Corresponding author
Fabião Maússe, Field Epidemiology and Laboratory Training Program, National Institute of Health, P.O. Box 264, Maputo, Mozambique.




Introduction: Measles is a disease for which case identification requires notification and requires immediate epidemiological investigation. While the COVID-19 emergency was underway, 417 suspected cases of measles were reported between April and May 2020 in five provinces of Mozambique. This study aimed to investigate the increase in measles cases.


Methods: The study was conducted in the five provinces of Mozambique that reported an increase in measles cases based on the previous year. Surveillance data were based on cases were collected from January to May 2020, while vaccination and surveillance data were collected from the period January-June 2019 and January-June 2020. We used the measure of association to calculate odds ratios (OR) at 95% confidence intervals (95% CI) and used a significance level of 0.05.


Results: A total of 417 suspected cases were reported, of which 20.1% (84) were confirmed for measles. The provinces with the highest number confirmed case counts were Zambézia with 21 cases (25.0%). Of the 84 confirmed measles cases, 58% (49) were female. Nearly all (97.61%; 82/84) of the confirmed cases had known vaccination histories: of whom 64.6% (53/82) were unvaccinated. Vaccinated individuals had a lower chance (OR=0.60) of getting measles disease compared to unvaccinated individuals (95% CI: 0.36- 0.99).


Conclusion: All the five provinces mentioned above, had districts with an increased measles case count. Measles vaccination coverage decreased after the declaration of a state of emergency on 31 March 2020, highlighting the need for greater efforts to control and prevent the spread of measles.



Introduction    Down

Measles is disease that mandates notification and requires immediate epidemiological investigation. The disease has a 90% secondary attack rate among immunocompromised individuals and unvaccinated populations [1,2]. It is caused by a paramyxovirus family virus and is usually passed through direct contact and through the air [3]. Should be modified as “Within ten days after the onset of measles, symptoms such as a viral rash or rash, and can develop into complications such as blindness, encephalitis, or severe respiratory infections such as pneumonia can set in [4].


About 40 million cases of measles occur worldwide each year, with the epidemic accounting for 10 per cent of deaths in children under five, more than half of which occur in Africa [5]. Between 2018 and early 2019, Africa reported 134,494 measles cases and 2,013 deaths [1].


Mozambique reported more than 53,251 cases of measles between 2003 and 2010, and in 2005 the Ministry of Health (MISAU) adopted the elimination of measles strategies through vaccination campaigns in children under 15 years of age [6,7]. Starting in 2006, a reduction of new measles cases was observed. In 2007, MISAU started case-based surveillance, with investigation of all suspected cases of measles and subsequent laboratory confirmation. Currently, measles surveillance is also used to monitor rubella cases in the country [8].


The surveillance process consists of checking the books of entry into the health facilities and laboratory confirmation. Surveillance is carried out by checking the registers of children who have been admitted to the health facilities and who have presented symptoms suggestive of measles, such as a rash and fever, accompanied by signs and symptoms such as cough, coryza and conjunctivitis and subsequent laboratory tests are carried out where samples (blood and urine) are collected from suspected cases of measles.


Measles elimination through vaccination requires at least 95% coverage, which is achieved by implementing a national booster vaccination campaign with coverage of at least 95% and implementing periodic national campaigns at a frequency dependent on the accumulation of unvaccinated people, laboratory-confirmed measles cases [2].


In Mozambique the first case of COVID-19 was registered on March 22nd 2020, and on April 1st the State of Emergency was declared, limiting the movement of people in order to prevent and limit the transmission of COVID-19 [9]. In the context of surveillance for COVID-19, there is a need to strengthen the country's surveillance system for other diseases as people are less likely to frequent health facilities during this period.


Despite the COVID-19 state of emergency, Mozambique strived to continue measles surveillance activities. Such activities include active search of suspected measles cases in communities and in registry books, dissemination of case definitions and checklists for community surveillance, and monitoring of disease trends. The study aimed to investigate the trends in measles cases.



Methods Up    Down

Three teams, each composed of two residents of the Mozambican Field and Laboratory Epidemiology Training Program (FELTP), a surveillance technician, and a program supervisor, were formed. The teams used a measles case investigation form in use by the National Health System (NHS) to collect socio-demographic (age, gender, province and level of education), clinical, and laboratory data (positive and negative). Measles cases were actively searched in the registry books and vaccination coverage was checked through the Extended Vaccination Program (EPI) monthly summary books.


Vaccination and surveillance data were collected for January to June of 2019 and 2020. Case surveillance data were collected from January to May 2020. The investigation teams worked in the provinces of Cabo Delgado, Nampula, Niassa, Tete, and Zambézia. The study population included all suspected and confirmed measles cases reported in all 26 districts that reported cases in those five provinces.


Case Definitions




A suspected case was any patient who, regardless of age and vaccination status, had a fever and a maculopapular rash in a cephalo-caudal direction, accompanied by cough, runny nose or conjunctivitis [2].


Measles outbreak


At least 3 cases with positive measles IgM testing from the same district/health facility in the same month [10].


Vaccinated child


A child was considered vaccinated against measles if they received two doses: the 1st dose between 9 and 12 months of age and a 2nd booster dose between 18 and 23 months of age. The number of doses of each case was confirmed based on the data provided and case report forms.


Data Analysis


Microsoft Office Excel 2013 was used for data storage and SPSS - 21 for data analysis. A descriptive analysis of the socio-demographic characteristics of the study population was performed. Rates and proportions were calculated to describe variable frequencies. To describe measures of central tendency, the median and range were calculated. We used the measure of association to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for associations between measles case status and categorical variables. A significance level of 0.05 was used.


The association between vaccination status and laboratory confirmation and suspected cases was assessed. For the association of measles cases who vaccinated and who did not vaccinate, the chi-square (X2) test was performed with the level of significance (p<0.05); 2 cases were excluded who did not have the information about the vaccination status. Every suspected case that had a negative result was used as a comparison group.


Ethical considerations


Ethical approval was not required for this study because it was conducted as a component of the measles outbreak investigation during the COVID-19 pandemic in Mozambique.



Results Up    Down

A total of 417 suspected measles cases were reported in the study period, of which 20.1% (84) were confirmed through laboratory testing. Of the confirmed cases, 92.8% (78/84) had documented information about the patient´s symptoms, including date of symptom onset. Among the confirmed cases, 58.3% (49/84) were female, and 37.0% (31/84) were between 5 and 9 years of age. The ages of confirmed cases ranged from 6 months to 55 years, with a median of 4 years.


Epidemiological week 21 had the highest number of confirmed cases reported, with 3 cases in Zambézia, 5 in Tete, and 2 in Cabo Delgado. No confirmed cases were reported in weeks 16, 22, or 23 Figure 1.


Among the 84 confirmed cases, 3 had missing age information and 2 had unknown vaccination histories. Among the 82 confirmed cases with known vaccination histories, 64.6% (53/82) were unvaccinated. Vaccinated individuals are 0.4 times less likely (X>1) to have measles than unvaccinated individuals (OR=0.60; 95% CI: 0.36-0.99) Table 1.


The results for the others variables were missing due to very low frequencies.


Vaccination coverage


In the first six months of 2019, Tete exhibited the highest vaccination coverage rate for the 1st dose, peaking in May at 121%. Other provinces also demonstrated in the months of 2019 high coverage, such as 115% in Cabo Delgado in February, 110% in Niassa in March. Zambezia demonstrated the lowest coverage in the first dose in each month from January to June 2019, except in March when Cabo Delgado reported 59% coverage. Regarding the 2nd vaccine dose in the 2019 period, the highest coverage rates were achieved in Niassa in February with 124%, Cabo Delgado with 103% in March, and Nampula in May with 86%. Zambezia demonstrated the least coverage in all months when compared to other provinces.


For the 1st vaccine dose in 2020, Tete province demonstrated consistent coverage, with the highest in April with 118%. Niassa and Zambezia peaked in March with 114% and 106% respectively. Cabo Delgado showed the lowest second dose coverage rates in all months compared to other provinces. For the second vaccine dose in 2020, Niassa had the highest vaccination coverage in March with 94%, followed by Nampula in February with 80%. Cabo Delgado had the lowest second dose coverage rate in all months of 2020 Figure 2.


It was not possible to have the data of the province for the periods January, February and March 2019 and 2020 respectively due to the fact that it was not made available by the province. Decreased notification was observed in all provinces except Nampula, which increased from 82 to 176 cases. Niassa had the highest detection rate with 9.4/100,000 inhabitants and the rate of adequate samples was above 80% in all provinces except Cabo Delgado Table 2.



Discussion Up    Down

The provinces under study recorded an increase in cases which may be a result of the low vaccination coverage resulting from the declaration of a state of emergency on 31 March in the country. Of the 84 confirmed cases in the 5 provinces, 66.6% (56/84) of had not been vaccinated. Lack of vaccination may result mainly from caregiver responsibility to bring the child to the vaccination centre, refusal caused by lack of knowledge of the importance of vaccination for the child, loss of the vaccination booklet, difficulties in accessing vaccination centers due to long distances, and inadequate scheduling of vaccine administration [11]. Vaccination is a cost-effective way to reduce infant morbidity and mortality [12]. Complete vaccination with both doses only confers 97% protection, thus explaining why vaccinated children still developed measles [13]. In addition, some children have immune reactions to the vaccine as children after 7 days get a mild form of measles, and 3 to 4 weeks get a mild form of mumps [14]. The World Health Organization (WHO) recommends that children receive the 2nd dose to ensure immunity, since about 15% of vaccinated children do not develop immunity from only the 1st dose. The results of this study show that vaccinated individuals are 0.4 times less likely (X > 1) to have measles than unvaccinated individuals, thus showing the need to vaccinate children. Besides non-vaccination, which is a risk factor, there are other factors that can contribute to measles cases, such as poor management of the cold chain that can influence the quality of the vaccines to be administered to children allowing them to remain susceptible to infection by the virus and may also be related to a child's weak immune system combined with malnutrition and a history of travel to measles-affected areas and contact with a neighbour or family member [15-17].


The provinces of Tete, Niassa, and Zambezia exhibited first dose coverage rates above 100% in 2020. This can be partially explained by births occurring outside of health facilities, thus excluding them from health records and artificially inflating the coverage rate. Epidemiological weeks 16, 22, and 23 reported no cases of measles, which may be related to an emergency period that may have had an influence on reducing the investigation of suspected cases and therefore confirmed cases.


Vaccination coverage rates started to decrease after March, which may have been influenced by the implementation of a state of emergency on March 31st. The state of emergency limited active community searches and may have caused fear among caregivers of contracting COVID-19 when bringing their children for vaccination. Cabo Delgado, the province with the lowest coverage rates, was experiencing an ongoing conflict, forcing populations to move across district or provincial lines. Other factors may also contribute to low coverage, such as inadequate knowledge among caregivers of vaccination benefits, high costs associated with visiting and travelling time to a health facility, and poor management of the vaccine supply chain [12].


Inadequate vaccination among children has caused measles to reappear in several countries that had achieved, or were close to achieving, elimination. The World Health Organization (WHO) continues to strengthen the global network to ensure timely diagnosis and tracking of the international spread of measles, allowing for more coordinated vaccination activities.


During the period 1980-2017 first dose coverage has globally stagnated at 85%, leaving many communities at risk. Coverage of the second dose, although increasing, is at 67% [18]. All five provinces were able to meet the target detection rate (≥80%) in both periods, thus demonstrating that the state of emergency had little influence on the quality of samples. The state of emergency may have had an impact on the provinces that have reported cases and is likely to have influenced measles surveillance activities, thus the need to intensify surveillance to prevent the spread of the disease.



Conclusion Up    Down

The declaration of the state of emergency of COVID-19 in March likely had a negative impact on vaccine coverage as there was a reduction in coverage the subsequent period, when compared to the same period in 2019. The increased case count in the 5 provinces confirms the existence of a measles outbreak, which may have been a result of inadequate vaccination coverage. No change in surveillance indicator data was observed after the state of emergency declaration.


In order to improve the provision of services, it is recommended to continue with epidemiological surveillance actions so that it is possible to locate susceptible groups capable of allowing uncontrolled viral circulation; intensify the health education process aiming at the continuity of vaccination coverage to eradicate measles; conduct regular community-based health education campaigns.

What is known about this topic

  • Measles is a notifiable disease in Mozambique requiring immediate epidemiological investigation.
  • Measles monitoring in Mozambique is carried out through the hospital-based Weekly Information Bulletin with notification being done from health facilities.
  • Since 2015 two doses of measles vaccine have been given, the first at 9 months of age and the second is given at 18 months

What this study adds

  • Of the provinces that have reported suspected cases of measles only three and that have recorded an increase in suspected cases in the period January to June 2019 to 2020 of the same periods.
  • Strengthening measles surveillance in the context of COVID-19 surveillance by intensifying activities aimed at timely reporting of suspected cases.
  • The state of emergency declared on 31 March 2020 due to COVID 19, resulted in reduced vaccination coverage in the provinces studied.



Competing interests Up    Down

The authors declare no competing interests.



Authors' contributions Up    Down

Fabião Maússe, Beatriz Nhamtunbo and Dionisia Balate were responsible for the data collection, analysis, and interpretation. Erika Valeska Rossetto and Judite Monteiro supervised the study protocol and manuscript development. Cynthia Semá and Erika Valeska Rossetto were responsible for reviewing the paper and approving the final version for submission. All authors have read and approved the final version of the manuscript.



Acknowledgements Up    Down

The Provincial Health Directorates of Niassa, Cabo Delgado, Nampula, Zambezia, and Tete; FELTP colleagues for supporting data collection: Samuel Novunga, Eduardo Chicanequisso and Neusa Fataha; the District Health, Women’s, and Social Services. The authors would like to thank Zandile Nukeri for her support in paper revision.



Tables and figures Up    Down

Table 1: Relationship between vaccination status, sex and outcome. January to June-2020

Table 2: Measles surveillance indicators, Mozambique, 2019-2020

Figure 1: Distribution of the number of confirmed measles cases in the provinces of Niassa, Cabo Delgado, Nampula, Zambezia, and Tete, Mozambique, January to June 2020.

Figure 2: Measles surveillance indicators in Niassa, Cabo Delgado, Nampula, Zambezia and Tete from January to June, 2019-2020



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Outbreak Investigation

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

Outbreak Investigation

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

Outbreak Investigation

Increase in measles cases in five provinces of Mozambique during the emergence of COVID-19

The Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). The contents of this journal is intended exclusively for public health professionals and allied disciplines.