Epidemic waves of cholera in the last two decades in Mozambique.

INTRODUCTION Africa is increasingly affected by cholera. In Mozambique, cholera appeared in the early 1970s when the seventh pandemic entered Africa from the Indian subcontinent. In the following decades, several epidemics were registered in the country, the 1997-1999 epidemic being the most extended. Since then, Mozambique has been considered an endemic area for cholera, characterized by yearly outbreaks occurring with a seasonal pattern. At least three pandemic variants are thought to have originated in the Indian subcontinent and spread worldwide at different times. To understand the epidemiology of cholera in Mozambique, whether the disease re-emerges periodically or is imported by different routes of transmission, we investigated clinical V. cholerae O1 isolated during 1997-1999 and 2012-2014 epidemics. METHODOLOGY By detecting and characterizing seven genetic elements, the mobilome profile of each isolate was obtained. By comparing it to known seventh pandemic reference strains, it was possible to discern among different V. cholerae O1 variants active in the country. RESULTS During 1997-1999, epidemic strains showed two different genetic profiles, both related to a pandemic clone that originated from India and was reported in other African countries in the 1990s. Isolates from 2012-2014 outbreaks showed a genetic background related to the pandemic strains currently active as the prevalent causative agent of cholera worldwide. CONCLUSIONS Despite cholera being endemic in Mozambique, the epidemiology of the disease in the past 20 years has been strongly influenced by the cholera seventh pandemic waves that originated in the Indian subcontinent.