Background: Adverse events (AE) in male circumcision are “any injuries, harm, or undesired outcomes occurring during or following male circumcision (MC) that would not have occurred if the client had not undergone the procedure” (USAID). AEs are categorized by severity (mild, moderate and severe), timing (intra or post-operative), nature (bleeding, etc), and surveillance (passive or active). AE occurrence is a proxy for quality management and provision, and influences MC acceptability. Thus, efforts try to both understand the program- and beneficiary-related etiologies of AE and monitor AE, particularly in large scale MC programs, given the potential risks involved.
Methods: We report on AE identified within males circumcised in Mozambique by Jhpiego, from 2009-2017 with more than 700,000 VMMC procedures provided through a national program. Data on AE events in Mozambique VMMC program were analyzed, using descriptive statistics and trends. AEs were calculated per age group and severity (moderate or severe).
Results: Out of 718,090 procedures, there were 1,826 moderate and severe AEs (0.25% rate, peaking at 2.3%, in the first month), with 1,650 moderate (90.4%) and 176 severe (9.6%). The three most common AEs (80% of AE) were infection (41%), hematoma (23%) and excessive bleeding (16%). Damage to the penis and pain accounted for 6% each. Most moderate AEs were infections (44.2%), and most severe AE were hematomas (59.1%). The most affected age was 10 to 14 years, with 40% of the AEs, followed by 15 to 19, and 20 to 24 years, with 24% each. By age strata, AE were 0.2% (10-14), 0.22%(15-19; 35-49), 0.8% (50+); 0.29%(30-34); 0.37%(25-29); 0.57%(20-24).
Conclusions: A high volume VMMC program has the potential to dramatically reduce AE occurrence, overtime. The high prevalence of infection as an AE may be related to both client and provider factors, which require further consideration; parents and caregivers need to understand proper wound care; providers need to assure proper technique during MC procedures. A challenging limitation is that AE reporting depends on providers recognizing, documenting and addressing adverse events, therefore results should be carefully backed by an active surveillance system to improve the reliability of data and seek those opportunities for quality improvement.