Sofala study_BCG coverage rate.pdf

8142019 Sofala study_BCG coverage ratepdf

httpslidepdfcomreaderfullsofala-studybcg-coverage-ratepdf 15

Hindawi Publishing Corporationuberculosis Research and reatmentVolume 983090983088983089983091 Article ID 983091983089983090983088983094983093 983092 pageshttpdxdoiorg983089983088983089983089983093983093983090983088983089983091983091983089983090983088983094983093

Research ArticleImmunisation with BCG in the Maringue DistrictSofala Province Mozambique

Dario Consonni1 Marina Margarida Montenegro Agorostos Karagianis2

and Giuseppe Bufardeci3

983089 Epidemiology Unit Department of Preventive Medicine Fondazione IRCCS Carsquo GrandamdashOspedale Maggiore PoliclinicoVia San Barnaba 983096 983090983088983089983090983090 Milan Italy

983090

Sofala Province Health Directorate Beira Mozambique983091 AISPO Beira Mozambique

Correspondence should be addressed to Dario Consonni darioconsonniunimiit

Received 983089983094 February 983090983088983089983091 Revised 983096 April 983090983088983089983091 Accepted 983089983089 April 983090983088983089983091

Academic Editor Brian Eley

Copyright copy 983090983088983089983091 Dario Consonni et alTis is an openaccess article distributed underthe CreativeCommons AttributionLicensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Objectives We evaluated immunisation with Bacille Calmette-Guerin (BCG) among newborns in 983090983088983089983089 in the Maringue DistrictSoala Province Mozambique which includes seven health units Te study was motivated by the act that in official reportsimmunisation coverage was unreliable (more than 983089983088983088) Methods Te office o maternal-child health o the central Maringue-

Sede health unit provided the number o live newborns in 983090983088983089983089 at the maternal clinics o the seven health units and an estimate o the number o home deliveries From vaccination registers we abstracted records o BCG vaccinations administered in the period983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090 to children born in 983090983088983089983089 Results Te number o live newborns was 983091983091983093983091 Overall the number o BCG vaccinations administered was 983090983096983097983091 with a coverage o 983096983094983091 Conclusion In this study we could only calculate an approximatecoverage estimate because o unavailability o adequate individual inormation Recording practices should be changed in order toallow use o individual inormation and linkage across different inormation sources and thus a more precise vaccination coverageassessment

1 Introduction

In Mozambique a nationwide immunisation program (Ex-tended Programme o Immunisation EPI in PortuguesePrograma Alargado de Vacinacao PAV) was started in 983089983097983095983097

[983089] Since perormance was poor in 983090983088983088983093 a comprehensiveMulti Year Plan (cMYP) was launched with a view to devisingstrategies in line with the WHOUNICEF Global Immuni-sation Vision and Strategy (GIVS) [983090] with the objective toreach at least 983097983088 national vaccination coverage and at least983096983088 coverage in every district Te current immunisationschedule includes Bacille Calmette-Guerin (BCG) at birthoral polio vaccine (OPV) at birth 983094 983089983088 and 983089983092 weeksDiphtheria Pertussis etanus Hepatitis B (DP-HepB) at 983094983089983088 and 983089983092 weeks measles at 983097 months [983089]

In reports rom the Ministry o Health (983090983088983088983092ndash983090983088983088983096) im-munisation coverage percentages were largely variable acrossyears and sometimes unreliable (gt983089983088983088) [983089] Te reasons or

these anomalous 1047297gures are at least two (983089) Te denominator(ie the number o children lt983089 year so-called ldquogrupo alvordquotarget group) is only presumed In act it is calculated by taking a 1047297xed percentage (983092) o the whole population(almost 983090983091 million people in 983090983088983089983089-983090983088983089983090) [983090] (983090) Te reerence

periods o immunisation and birth data are different thatis part o the immunisation doses administered in a givenyear are given to inants born in the previous year Also theWHO website on Mozambique reports highly variable andunusually high (gt983097983097983093) percentages [983091] Te 983090983088983089983088 estimateswere as ollows BCG983097983088 DP-HepB third dose 983095983092OPVthird dose 983095983091 measles 983095983088 Similarly in the official reportso the Maringue District Soala Province which includesseven health units (Unidade de Saude US) (Figure 983089) BCGcoverage in 983090983088983089983089 was clearly unreliable (983089983088983096983094) Te reasonsare the same seen previously or the national coverage In thedistrict the target group is estimated as 983092times 983096983092983095983089983097 (the pop-ulation o the district) = 983091983091983096983097



983090 uberculosis Research and reatment

Mozambique

SofalaProvince

Maringue District

F983145983143983157983154983141 983089 Map o theMaringueDistrictindicatingthe locationo the

seven health units (Unidade Sanitaria US) Maringue-Sede Canx-ixe Gumbalatsai Nhamacala Phango Senga-Senga and Subue

Associazione Italiana per la Solidarieta tra i Popoli(AISPO) Milan Italy is a nongovernmental organisationrecognised by the Italian Ministry o Foreign Affairs [983092] In983089983097983097983093 AISPO started operating in Mozambique Soala Prov-ince Te activities include constructionextension o healthcentres support or mobile teams to perorm vaccinationson the 1047297eld and proessional training o get reliable immu-nisation coverage estimates AISPO decided to make anindependent assessment o BCG immunisation coverage inthe Maringue District BCG is an important vaccine not only because o its protective efficacy against serious childhoodtuberculosis but also as ldquothe gatewayrdquo to EPI and child tar-geted health packages In this paper we describe the projectand report results regarding BCG coverage Te kind o study we are illustrating can be useul to periodically andindependently test the method proposed by the WHO andused by the Ministry o Health However we also documentdifficulties in obtaining precise coverage estimates based oncurrent recording practices

2 Methods

Afer 1047297eld surveys and recognition o the available inorma-tion we realized that a study using individual records wasnot easible Tereore we opted or a study using routinely collected grouped data Since this study was retrospective anddid not involve individual inormation ethical approval wasnot required

983090983089 Identi1047297cation of Live Newborns Te central Maringue-Sede health unit provided (983089) the number o live newbornsin 983090983088983089983089 at the seven maternal clinics in each health unitrecorded in the birth registers (Registo de Maternidade) (983090)an estimate o the number o home deliveries We veri1047297edthe reliability o the recorded number o alive newborns by

consulting the birth registerso three health units (Maringue-Sede Canxixe and Phango) Agreement was goodmdashourestimate 983089983096983094983091 estimate made by the central Maringue-Sede983089983096983092983088

983090983090 Identi1047297cation of Vaccinated Children Each health unit

keeps two registers o vaccinations (Livros de Registo deVacinacao de Criancas) ldquoPosto Fixordquo or vaccinations per-ormed at the health unit and ldquoBrigada Movelrdquo or immunisa-tion campaigns perormed in the territory with mobile teamsTe registers contain inormation on sex and date o birth o the newborn and dates o vaccination or each typedose o

vaccine Place o birth is not recorded so they do not allow to identiy the inants born at the health unit and those bornat motherrsquos home Note that when a vaccine dose has beenadministered in another health unit a simple tally sign () iswritten instead o the date From these registers we countedthe number o BCG vaccinations actually administered (iewith a date recorded in the register omitting vaccinations

marked with a tally to avoid multiple counting) to childrenborn in 983090983088983089983089 Although BCG should be administered at birththis is not always the case or several reasons includingchildren born in the community temporary or permanentunavailability o BCG vaccines because o logistic problems(rerigerator ailures or lack o stored vaccines) Tereore inorder to catch late vaccinations we recorded all vaccinationsadministered through June 983090983089983088983090

983090983091 Statistical Analysis Te proportion o inants vaccinatedwith BCG was calculated by dividing the number o BCGdoses administered in 983090983088983089983089 and in the 1047297rst hal o 983090983088983089983090 by thenumber o newborns in 983090983088983089983089 Te 983097983093 con1047297dence interval o the proportionwas calculated using the Agresti-Coull ormu-la [983093] available in the sofware Stata 983089983090 [983094]

3 Results

Te numbers o children born in 983090983088983089983089 and o BCG dosesadministered in 983090983088983089983089ndash983090983088983089983090 are shown in able 983089 We providedetailed results to give a picture o the births and o vacci-nation activities in the district However calculation o BCGcoverage at the health unit level makes little sense becausechildren resident in the territory o a given health unit may be vaccinated elsewhere or several reasons For examplein the Canxixe health unit the rerigerator when vaccineswere stored ailed in 983090983088983089983089 with a dramatic decrease o the

percentage o vaccinated children (983089983091983088983092983096983096 = 983090983094983094) Logisticproblems have probably occurred also in the Gumbalatsaiwhich also shows a very low coverage (983092983097983090983090983089 = 983090983090983090)Te newly established Phango health unit started vaccinationactivities in April 983090983088983089983089 Te other health units somehow compensated or these problems For example in Maringue-Sede the number o BCG vaccinations(983089983092983091983094) waslarger thanthe number o newborns (983089983090983095983088)

Te number o newborn deliveries in the whole districtwas 983091983091983093983091 o which 983091983088983093983097 (983097983089983090) at the maternal clinic o thehealth unit and 983090983097983092 (983096983096) in the community Percentageso home deliveries across health units ranged rom 983088983092 to983089983097983089 In the study period only the Maringue-Sede health



uberculosis Research and reatment 983091

983137983138983148983141 983089 Number o children born in 983090983088983089983089 and o Bacille Calmette-Guerin (BCG) vaccinations administered to them in the period 983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090 in the Maringue District Soala Province Mozambique

Health unit (period o BCG data collection)

Children born alive in 983090983088983089983089 BCG vaccinations

At the health unit Home deliveries otal Year 983090983088983089983089 Year 983090983088983089983090 otal

Maringue-Sede 983089983089983095983090 983097983096 983089983090983095983088 983089983091983088983091 983089983091983091 983089983092983091983094

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983091 983095983095 983089983088983088 983097983088983095 983097983091 983089983088983088

Canxixe 983092983093983090 983091983094 983092983096983096 983089983090983091 983095 983089983091983088

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983094 983095983092 983089983088983088 983097983092983094 983093983092 983089983088983088

Gumbalatsai 983089983096983093 983091983094 983090983090983089 983092983092 983093 983092983097

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983091983095 983089983094983091 983089983088983088 983096983097983096 983089983088983090 983089983088983088

Nhamacala 983090983097983091 983095 983091983088983088 983090983094983095 983089983094 983090983096983091

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983095983095 983090983091 983089983088983088 983097983092983091 983093983095 983089983088983088

Phango 983090983089983094 983092983093 983090983094983089 983090983088983096 983090983089 983090983090983097

(983089983097983088983092983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983096983090983096 983089983095983090 983089983088983088 983097983088983096 983097983090 983089983088983088

Senga Senga 983092983092983092 983090 983092983092983094 983091983092983090 983094983092 983092983088983094

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983097983094 983088983092 983089983088983088 983096983092983090 983089983093983096 983089983088983088

Subue 983090983097983095 983095983088 983091983094983095 983091983092983090 983089983096 983091983094983088

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983088983097 983089983097983089 983089983088983088 983097983093983088 983093983088 983089983088983088

otal 983091983088983093983097 983090983097983092 983091983091983093983091 983090983094983090983097 983090983094983092 983090983096983097983091

983097983089983090 983096983096 983089983088983088 983097983088983097 983097983089 983089983088983088

unit perormed BCG vaccinations campaigns with mobileteams on the territory (983089983088983088 doses administered in 983090983088983089983089 and983094983091 in the 1047297rst hal o 983090983088983089983090) Te total number o administereddoses was 983090983094983090983097 (983097983088983097) in 983090983088983089983089 and 983090983094983092(983097983089) in the 1047297rst hal o 983090983088983089983090 Te number o BCG vaccinations perormed in theseven health units was 983090983096983097983091 BCG coverage was 983090983096983097983091983091983091983093983091 =983096983094983091 (983097983093 con1047297dence interval 983096983093983089ndash983096983095983092)

4 Discussion

In the period 983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090 we estimated in theMaringue District a BCG coverage o 983096983094983091 or children bornin 983090983088983089983089 Tis 1047297gure is only approximate because we could notrely on careully recorded individual data From BCG resultswe can plausibly iner that or other vaccinationsthe coveragepercentages are lower because they require several dosesadministered weeks to months afer delivery In act alsonational data shows a lower coverage or the other vaccina-tions [983091]

In interpreting the result we must take into accountseveral implicit limits in the use o grouped data First the

number o home deliveries was obtained based on children visits afer birth at the health unit Tis number might havebeen underestimated In a worst-case scenario assuming anunderestimate o 983093983088 (ie 983090983097983092 more children born in thecommunity) the BCG coverage would be 983095983097983091 Second parto the babies could have been vaccinated later in the secondhal o 983090983088983089983090 However this number is likely to be quite smallconsidering that most children (983097983088983097) have been vaccinatedin their birth year (983090983088983089983089) Tird some children (especially those living near the borders o the Maringue District) may have been vaccinated in nearby districts On the other handa reversal 1047298ow o children living outside may have been

vaccinated within the Maringue District Unortunately we

were unable to estimate the net balance because we could notrely on individual data

Beore carrying this study using grouped data we hadconsidered other design options Te 1047297rst option was a clas-sical cross-sectional sample survey called ldquo983091983088 times 983095rdquo whichinvolves the enrolment o at least 983095 children in 983091983088 randomly selected villages [983095] Tis type o study suggested by WHO

in developing countries would also allow to perorm a BCGscar counting (that would give a direct picture o the quality o immunisation) Unortunately thiswas not easible or twomain reasons lack o demographics data and the very largenumber o small amily units spreading over a territory o several tens o kilometres Te second option a cohort study using recorded individual data was also ineasible becausedata linkage was not possible In act the register o birthsonly records the name o the mother while the vaccinationregister initially records motherrsquos name and at ollowing

vaccination visits the childrsquos name Availability o individualinormation would have allowed identi1047297cation o childrenborn outside and inside the district Moreover individ-

ual inormation would be especially important to identiy theunvaccinated children and the reasons or noncomplianceand 1047297nally to target interventions

Te de1047297ciencies in the process o immunisation datacollection and reporting that we described earlier were alsonoted by other studies perormed in Mozambique A study evaluated routine surveillance data as a tool to investigatemeasles outbreaks in Maputo (983089983097983097983096) and Manica Province(983090983088983088983090) [983096] It wasconcluded that the reporting system did notprovide the data needed by EPI managers to make evidence-based decisions and precluded in-depth analysis to monitormeasles epidemiology in the country An improvement o routine surveillance and health inormation systems (HISs)




was thereore recommended A study carried out in 983090983088983088983091in the Nassa Province Cuamba District evaluated practiceso record keeping and reporting o immunisation data by means o semistructured interviews participant observationand review o the data collection materials [983097] Te authorsconcluded that in ldquoMozambique and other country settings

[

] poor data quality constitutes a bottle neck or goodinormation systems as well as good decision makingrdquo Morerecent evaluations (November 983090983088983088983095 through October 983090983088983088983096)in three districts (Beira City Dondo and Caia) o the SoalaProvince ound that HISs were sufficiently reliable and con-sistent supporting their use in primary health care programmonitoring and evaluation [983089983088] On the other hand theauthors underlined the need to enhance the design testingand subsequent use o operational research tools to urtherexpandthe quality anduse o routine data by healthmanagersand policymakers

5 Conclusion

In this study using routinely collected inormation we esti-mated a BCG coverage o 983096983094983091 in the Maringue DistrictTis 1047297gure is only approximate because o the unavailability o adequate individual inormation Our study also under-linesde1047297ciencies o current recording practiceswhichshouldbe changed in order to allow use o individual inormationand linkage across different inormation sources (preerably using computerised archives) and thus a more precise assess-ment o vaccination coverageWeconcur with theauthorso arecent editorial that ldquoa major challenge or [ ] Mozambiqueis to strengthen local capacity or data collection manage-ment and analysesrdquo [983089983089]

Conflict of Interests

Te authors declare that they have no con1047298ict o interests

Acknowledgments

Te authors wish to thank the personnel o the health unitso Maringue District or their collaboration Dr RenatoCorrado (AISPO President) and Dr Federico Chiodi Daelli(AISPO Operational Director) Tis project entitled ldquoSupportto health development in the Maringue District SoalaProvince Phase IIrdquo was supported by the Ministry o ForeignAffairs o the Italian Republic (Contract 983097983093983090983092AISPOMOZ)

References

[983089] Republic o Mozambique Ministry o Health and NationalImmunisation Program ldquoComprehensive Multi-Year Plan(cMYP) 983090983088983089983090ndash983090983088983089983094rdquo July 983090983088983089983090

[983090] UNICEF ldquoTe Global Immunization Vision and Strategy (GIVS)rdquo httpwwwwhointimmunizationgivsen

[983091] WHO ldquoImmunization Pro1047297lemdashMozambiquerdquo httpappswhointimmunization monitoringenglobalsummarycountry-pro1047297leresultcmC=moz

[983092] Associazione Italiana per la Solidarieta tra i Popoli (AISPO)httpwwwaispoorg

[983093] A Agresti and B A Coull ldquoApproximate is Better than ldquoExactrdquoor Interval Estimation o Binomial Proportionsrdquo AmericanStatistician vol 983093983090 no 983090 pp 983089983089983097ndash983089983090983094 983089983097983097983096

[983094] StataCorp Stata Release 983089983090 Statistical Sofware College Sta-tion ex USA StataCorp LP 983090983088983089983089

[983095] P S Levy and S Lemeshow Sampling of Populations Methods

and Applications chapter Wiley New Jersey NY USA 983092thedition 983090983088983088983096

[983096] J V Jani I V Jani C Araujo S Sahay J Barreto and G BjuneldquoAssessment o routine surveillance data as a tool to investigatemeasles outbreaks in Mozambiquerdquo BMC Infectious Diseases vol 983094 article 983090983097 983090983088983088983094

[983097] J C Mavimbe J Braa and G Bjune ldquoAssessing immunizationdata quality rom routine reports in Mozambiquerdquo BMC PublicHealth vol 983093 article 983089983088983096 983090983088983088983093

[983089983088] S Gimbel M Micek B Lambdin et al ldquoAn assessment o routine primary care health inormation system data quality inSoala Province Mozambiquerdquo Population Health Metrics vol983097 article 983089983090 983090983088983089983089

[983089983089] C G Victora R E Black J Boerma andJ Bryce ldquoMeasuring

impact in the Millennium development Goal era and beyonda new approach to large-scale effectiveness evaluationsrdquo TeLancet vol 983091983095983095 no 983097983095983093983097 pp 983096983093ndash983097983093 983090983088983089983089



Submit your manuscripts at

httpwwwhindawicom




Mozambique

SofalaProvince

Maringue District

F983145983143983157983154983141 983089 Map o theMaringueDistrictindicatingthe locationo the

seven health units (Unidade Sanitaria US) Maringue-Sede Canx-ixe Gumbalatsai Nhamacala Phango Senga-Senga and Subue

Associazione Italiana per la Solidarieta tra i Popoli(AISPO) Milan Italy is a nongovernmental organisationrecognised by the Italian Ministry o Foreign Affairs [983092] In983089983097983097983093 AISPO started operating in Mozambique Soala Prov-ince Te activities include constructionextension o healthcentres support or mobile teams to perorm vaccinationson the 1047297eld and proessional training o get reliable immu-nisation coverage estimates AISPO decided to make anindependent assessment o BCG immunisation coverage inthe Maringue District BCG is an important vaccine not only because o its protective efficacy against serious childhoodtuberculosis but also as ldquothe gatewayrdquo to EPI and child tar-geted health packages In this paper we describe the projectand report results regarding BCG coverage Te kind o study we are illustrating can be useul to periodically andindependently test the method proposed by the WHO andused by the Ministry o Health However we also documentdifficulties in obtaining precise coverage estimates based oncurrent recording practices

2 Methods

Afer 1047297eld surveys and recognition o the available inorma-tion we realized that a study using individual records wasnot easible Tereore we opted or a study using routinely collected grouped data Since this study was retrospective anddid not involve individual inormation ethical approval wasnot required

983090983089 Identi1047297cation of Live Newborns Te central Maringue-Sede health unit provided (983089) the number o live newbornsin 983090983088983089983089 at the seven maternal clinics in each health unitrecorded in the birth registers (Registo de Maternidade) (983090)an estimate o the number o home deliveries We veri1047297edthe reliability o the recorded number o alive newborns by

consulting the birth registerso three health units (Maringue-Sede Canxixe and Phango) Agreement was goodmdashourestimate 983089983096983094983091 estimate made by the central Maringue-Sede983089983096983092983088

983090983090 Identi1047297cation of Vaccinated Children Each health unit

keeps two registers o vaccinations (Livros de Registo deVacinacao de Criancas) ldquoPosto Fixordquo or vaccinations per-ormed at the health unit and ldquoBrigada Movelrdquo or immunisa-tion campaigns perormed in the territory with mobile teamsTe registers contain inormation on sex and date o birth o the newborn and dates o vaccination or each typedose o

vaccine Place o birth is not recorded so they do not allow to identiy the inants born at the health unit and those bornat motherrsquos home Note that when a vaccine dose has beenadministered in another health unit a simple tally sign () iswritten instead o the date From these registers we countedthe number o BCG vaccinations actually administered (iewith a date recorded in the register omitting vaccinations

marked with a tally to avoid multiple counting) to childrenborn in 983090983088983089983089 Although BCG should be administered at birththis is not always the case or several reasons includingchildren born in the community temporary or permanentunavailability o BCG vaccines because o logistic problems(rerigerator ailures or lack o stored vaccines) Tereore inorder to catch late vaccinations we recorded all vaccinationsadministered through June 983090983089983088983090

983090983091 Statistical Analysis Te proportion o inants vaccinatedwith BCG was calculated by dividing the number o BCGdoses administered in 983090983088983089983089 and in the 1047297rst hal o 983090983088983089983090 by thenumber o newborns in 983090983088983089983089 Te 983097983093 con1047297dence interval o the proportionwas calculated using the Agresti-Coull ormu-la [983093] available in the sofware Stata 983089983090 [983094]

3 Results

Te numbers o children born in 983090983088983089983089 and o BCG dosesadministered in 983090983088983089983089ndash983090983088983089983090 are shown in able 983089 We providedetailed results to give a picture o the births and o vacci-nation activities in the district However calculation o BCGcoverage at the health unit level makes little sense becausechildren resident in the territory o a given health unit may be vaccinated elsewhere or several reasons For examplein the Canxixe health unit the rerigerator when vaccineswere stored ailed in 983090983088983089983089 with a dramatic decrease o the

percentage o vaccinated children (983089983091983088983092983096983096 = 983090983094983094) Logisticproblems have probably occurred also in the Gumbalatsaiwhich also shows a very low coverage (983092983097983090983090983089 = 983090983090983090)Te newly established Phango health unit started vaccinationactivities in April 983090983088983089983089 Te other health units somehow compensated or these problems For example in Maringue-Sede the number o BCG vaccinations(983089983092983091983094) waslarger thanthe number o newborns (983089983090983095983088)

Te number o newborn deliveries in the whole districtwas 983091983091983093983091 o which 983091983088983093983097 (983097983089983090) at the maternal clinic o thehealth unit and 983090983097983092 (983096983096) in the community Percentageso home deliveries across health units ranged rom 983088983092 to983089983097983089 In the study period only the Maringue-Sede health








Maringue-Sede 983089983089983095983090 983097983096 983089983090983095983088 983089983091983088983091 983089983091983091 983089983092983091983094

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983091 983095983095 983089983088983088 983097983088983095 983097983091 983089983088983088

Canxixe 983092983093983090 983091983094 983092983096983096 983089983090983091 983095 983089983091983088

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983094 983095983092 983089983088983088 983097983092983094 983093983092 983089983088983088

Gumbalatsai 983089983096983093 983091983094 983090983090983089 983092983092 983093 983092983097

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983091983095 983089983094983091 983089983088983088 983096983097983096 983089983088983090 983089983088983088

Nhamacala 983090983097983091 983095 983091983088983088 983090983094983095 983089983094 983090983096983091

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983095983095 983090983091 983089983088983088 983097983092983091 983093983095 983089983088983088

Phango 983090983089983094 983092983093 983090983094983089 983090983088983096 983090983089 983090983090983097

(983089983097983088983092983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983096983090983096 983089983095983090 983089983088983088 983097983088983096 983097983090 983089983088983088

Senga Senga 983092983092983092 983090 983092983092983094 983091983092983090 983094983092 983092983088983094

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983097983094 983088983092 983089983088983088 983096983092983090 983089983093983096 983089983088983088

Subue 983090983097983095 983095983088 983091983094983095 983091983092983090 983089983096 983091983094983088

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983088983097 983089983097983089 983089983088983088 983097983093983088 983093983088 983089983088983088

otal 983091983088983093983097 983090983097983092 983091983091983093983091 983090983094983090983097 983090983094983092 983090983096983097983091

983097983089983090 983096983096 983089983088983088 983097983088983097 983097983089 983089983088983088


4 Discussion















[


5 Conclusion




Acknowledgments


References

















httpwwwhindawicom








Maringue-Sede 983089983089983095983090 983097983096 983089983090983095983088 983089983091983088983091 983089983091983091 983089983092983091983094

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983091 983095983095 983089983088983088 983097983088983095 983097983091 983089983088983088

Canxixe 983092983093983090 983091983094 983092983096983096 983089983090983091 983095 983089983091983088

(983088983089983088983089983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983097983090983094 983095983092 983089983088983088 983097983092983094 983093983092 983089983088983088

Gumbalatsai 983089983096983093 983091983094 983090983090983089 983092983092 983093 983092983097

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983091983095 983089983094983091 983089983088983088 983096983097983096 983089983088983090 983089983088983088

Nhamacala 983090983097983091 983095 983091983088983088 983090983094983095 983089983094 983090983096983091

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983095983095 983090983091 983089983088983088 983097983092983091 983093983095 983089983088983088

Phango 983090983089983094 983092983093 983090983094983089 983090983088983096 983090983089 983090983090983097

(983089983097983088983092983090983088983089983089ndash983089983092983088983093983090983088983089983090) 983096983090983096 983089983095983090 983089983088983088 983097983088983096 983097983090 983089983088983088

Senga Senga 983092983092983092 983090 983092983092983094 983091983092983090 983094983092 983092983088983094

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983097983097983094 983088983092 983089983088983088 983096983092983090 983089983093983096 983089983088983088

Subue 983090983097983095 983095983088 983091983094983095 983091983092983090 983089983096 983091983094983088

(983088983089983088983089983090983088983089983089ndash983091983088983088983094983090983088983089983090) 983096983088983097 983089983097983089 983089983088983088 983097983093983088 983093983088 983089983088983088

otal 983091983088983093983097 983090983097983092 983091983091983093983091 983090983094983090983097 983090983094983092 983090983096983097983091

983097983089983090 983096983096 983089983088983088 983097983088983097 983097983089 983089983088983088


4 Discussion















[


5 Conclusion




Acknowledgments


References

















httpwwwhindawicom





[


5 Conclusion




Acknowledgments


References

















httpwwwhindawicom




httpwwwhindawicom

Documents

Sofala study_BCG coverage rate.pdf