title: Onchocerciasis, an undiagnosed disease in Mozambique: identifying research opportunities.
abstract: BACKGROUND
  The objective of this paper is to summarise and critically review the available data about onchocerciasis in Mozambique, in order to report epidemiological and clinical aspects related to the disease and identify gaps in knowledge. The paper is intended to raise awareness of the existence and importance of this disease and to define research priorities.
  
  
  METHODS
  We examined the scarce epidemiological data at our disposal: two diagnostic studies in 1997 and 1998 (first reports on the existence of onchocerciasis in Mozambique), and two Rapid Epidemiological Mapping of Onchocerciasis (REMO) surveys in 2001 and 2007. We examined differences in study designs and methodologies as well as the differing geographical locations to explain the divergence in findings among the studies.
  
  
  RESULTS
  Evidence indicates that onchocerciasis is hypoendemic in Mozambique (with national and imported cases), but still largely remains an undiagnosed illness. There is no awareness of the clinical aspects of the disease and nor of the differential diagnosis with lepromatous leprosy and dermatitis caused by Scabies spp. The use of skin biopsy and a symptom screening questionnaire, combined with nodule rate, in the first two studies may have captured even atypical or subacute presentations. Both REMO surveys relied solely on nodule detection and in the six years between the two studies, the prevalence of nodules detected more than doubled.
  
  
  CONCLUSIONS
  The epidemiology and clinical aspects of the disease are unknown in Mozambique. Since the last REMO took place in 2007 and since the population is subject to large-scale movement and displacement, it is important to develop tools to identify and analyse populations that are at high risk for onchocerciasis. Cases of onchocerciasis may be misdiagnosed as leprosy or scabies that fail to improve despite being subjected to treatment against leprosy. Techniques to enable a differential diagnosis need to be established by training health professionals on the recognition of this undiagnosed disease. It is equally necessary to identify the blackfly vectors and where they breed.
authors.affiliation: Department of Microbiology, Universidade Eduardo Mondlane, Maputo, Mozambique. enoormahomed@gmail.com.|Department of Medicine, University of California, San Diego, CA, USA. enoormahomed@gmail.com.|Universidade Lúrio, Reitoria, Bairro de Marrere, Rua 4250, Km 2,3, Caixa Postal 360, Nampula, Moçambique. enoormahomed@gmail.com.
authors.forename: Emilia V
authors.initials: EV
authors.lastname: Noormahomed
authors.affiliation: Department of Medicine, University of California, San Diego, CA, USA.
authors.forename: Kevan
authors.initials: K
authors.lastname: Akrami
authors.affiliation: Department of Parasitology, Universidad de Granada, Granada, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Mascaró-Lazcano
mesh_terms: D035843:Biomedical Research; D001706:Biopsy; D003937:Diagnosis, Differential; D007918:Leprosy / Q000473:pathology; D009073:Mozambique / Q000453:epidemiology; D009855:Onchocerciasis / Q000175:diagnosis / Q000453:epidemiology* / Q000473:pathology*; D012532:Scabies / Q000473:pathology; D012867:Skin / Q000473:pathology
keywords: Leprosy; Mozambique; Onchocerca volvulus; Onchocerciasis; Scabies