Geospatial distribution, clinical profile, and reported associations of Endomyocardial fibrosis in Mozambique: a systematic review and meta-analysis

Abstract

Background Endomyocardial fibrosis (EMF) is a neglected restrictive cardiomyopathy reported predominantly in tropical regions. In Mozambique, the published evidence is fragmented, geographically concentrated, and based on heterogeneous study designs. This systematic review summarizes the available evidence on the geographic distribution, clinical and echocardiographic profile, complications, and factors reported in association with EMF in Mozambique. Methods This systematic review followed PRISMA 2020 and was prospectively registered in PROSPERO (CRD420251108231). PubMed, Embase, Scopus, ScienceDirect, the Virtual Health Library, USC Library, and Google Scholar were searched through June 2025. Eligible records included observational studies, case series, and case reports involving Mozambican populations with EMF. Case reports and case series were retained primarily for descriptive clinical information and were not treated as population-level prevalence evidence. Two reviewers independently screened records and extracted data, with cross-checking by a third reviewer. Risk of bias was assessed according to study design. Because the included studies differed substantially in population, diagnostic approach, sampling strategy, and denominator, quantitative pooling was considered exploratory and was not interpreted as a national summary prevalence. Results Of 552 records identified, 33 underwent full-text assessment and nine studies published between 1979 and 2016 met the inclusion criteria. The evidence was concentrated in southern Mozambique, particularly Inhambane, Maputo, and Gaza. Reported prevalence estimates varied from 0.23% in an autopsy series to 19.8% in a community echocardiographic survey in Inharrime, Inhambane. A later cross-sectional survey in the same district reported 8.5% among children. Tricuspid regurgitation and right atrial enlargement were among the most frequently reported cardiovascular/echocardiographic findings. Atrial thrombosis was frequently reported among documented complications. Parasitic infections, hypereosinophilia, malnutrition, poverty, and limited healthcare access were reported in some studies, but the available evidence does not establish causal relationships. Conclusions Published evidence suggests that EMF has been documented particularly in southern Mozambique, with substantial variation in reported burden according to study setting and diagnostic method. The absence of published epidemiological data from central and northern Mozambique prevents reliable inference about the national geographic distribution or national prevalence of EMF. Larger, geographically representative studies using standardized diagnostic criteria are needed.