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A surprising feature of the SARS-CoV-2 pandemic to date is the low burdens reported in sub-Saharan Africa (SSA) countries relative to other global regions. Potential explanations (e.g., warmer environments1, younger populations2–4) have yet to be framed within a comprehensive analysis accounting for factors that may offset the effects of climate and demography. Here, we synthesize factors hypothesized to shape the pace of this pandemic and its burden as it moves across SSA, encompassing demographic, comorbidity, climatic, healthcare and intervention capacity, and human mobility dimensions of risk. We find large scale diversity in probable drivers, such that outcomes are likely to be highly variable among SSA countries. While simulation shows that extensive climatic variation among SSA population centers has little effect on early outbreak trajectories, heterogeneity in connectivity is likely to play a large role in shaping the pace of viral spread. The prolonged, asynchronous outbreaks expected in weakly connected settings may result in extended stress to health systems. In addition, the observed variability in comorbidities and access to care will likely modulate the severity of infection: We show that even small shifts in the infection fatality ratio towards younger ages, which are likely in high risk settings, can eliminate the protective effect of younger populations. We highlight countries with elevated risk of ‘slow pace’, high burden outbreaks. Empirical data on the spatial extent of outbreaks within SSA countries, their patterns in severity over age, and the relationship between epidemic pace and health system disruptions are urgently needed to guide efforts to mitigate the high burden scenarios explored here.

IntroductionPregnancy triggers an alteration of the immune functions and increases the risk of developing the active tuberculosis (TB) symptoms in exposed women. The effect of pregnancy on the Mycobacterium tuberculosis-specific immune responses used for most of the TB immunodiagnostic assays is not well documented. Here we investigated the changes in the M. tuberculosis-specific IFN-γ production in age-matched pregnant and non-pregnant women according to their TB exposition status.MethodsWe conducted a prospective cohort study on HIV-seronegative pregnant and non-pregnant women with compatible pulmonary TB symptoms addressed to TB healthcare facilities in Antananarivo, Madagascar. Active pulmonary TB was bacteriologically assessed with culture from sputum samples. Clinical data and blood samples were collected at inclusion and after 6 months of follow-up for each individual included. Whole blood samples were stimulated with QuantiFERON TB-Gold Plus (QFT-P) assay antigens. Plasma IFN-γ concentrations were then assessed by ELISA.ResultsA total of 284 women were investigated for the study including 209 pregnant women without confirmed TB (pNTB), 24 pregnant women with bacteriologically confirmed active TB (pATB), 16 non-pregnant women with active TB (ATB), and 35 non-pregnant healthy donors (HC). At inclusion, IFN-γ responses are lower in the pregnant women compared to their age-matched non-pregnant counterparts and independently of their TB status. Among the pregnant women, higher concentrations of M. tuberculosis-specific IFN-γ were observed in those exposed to TB, but with a lower magnitude in the active TB compared to the latently infected pregnant women (p < 0.05 with TB1 and p < 0.01 with TB2). After 6 months of follow-up, the M. tuberculosis-specific IFN-γ responses return to their baseline concentrations except for the pregnant women treated for TB for which none of the QFT-P positive reversed to negative (0%, 0/10) at the end of their TB treatment.ConclusionThese results support the concept of specific immune priorities characterized by a concomitant reduction in inflammatory immunity during pregnancy and corroborate the important role of activating the M. tuberculosis-specific immune responses to control the infection when the pregnant women are exposed to the pathogen.

Poor geographic access can persist even when affordable and well-functioning health systems are in place, limiting efforts for universal health coverage (UHC). It is unclear how to balance support for health facilities and community health workers in UHC national strategies. The goal of this study was to evaluate how a health system strengthening (HSS) intervention aimed towards UHC affected the geographic access to primary care in a rural district of Madagascar. For this, we collected the fokontany of residence (lowest administrative unit) from nearly 300 000 outpatient consultations occurring in facilities of Ifanadiana district in 2014–2017 and in the subset of community sites supported by the HSS intervention. Distance from patients to facilities was accurately estimated following a full mapping of the district’s footpaths and residential areas. We modelled per capita utilization for each fokontany through interrupted time-series analyses with control groups, accounting for non-linear relationships with distance and travel time among other factors, and we predicted facility utilization across the district under a scenario with and without HSS. Finally, we compared geographic trends in primary care when combining utilization at health facilities and community sites. We find that facility-based interventions similar to those in UHC strategies achieved high utilization rates of 1–3 consultations per person year only among populations living in close proximity to facilities. We predict that scaling only facility-based HSS programmes would result in large gaps in access, with over 75% of the population unable to reach one consultation per person year. Community health delivery, available only for children under 5 years, provided major improvements in service utilization regardless of their distance from facilities, contributing to 90% of primary care consultations in remote populations. Our results reveal the geographic limits of current UHC strategies and highlight the need to invest on professionalized community health programmes with larger scopes of service.

Introduction:la malnutrition par insuffisance d´apport alimentaire reste un défi majeur des pays à faible et moyen revenu. La présente étude vise à identifier les constructions socioculturelles qui interviennent dans les présentations de la malnutrition. Méthodes:une étude qualitative a été réalisée dans la région Amoron´i Mania, Madagascar. Les participants sont constitués par les femmes enceintes, les mères et pères de famille, les grand-mères ainsi que les acteurs de la santé comme les matrones, les agents communautaires et les agents de santé. Au total, 24 entretiens individuels semi-directifs et 6 focus groups ont été réalisés pour collecter les données. L´analyse thématique a été utilisée. Résultats:la malnutrition renvoie à une idée de manque d´aliments et de sous-alimentation. Elle tourne autour de la consommation quantitative du riz, des faits socioculturels et des problèmes de ressources financières. Les groupes vulnérables étaient principalement les enfants et les femmes enceintes. La perception de la malnutrition avec ses signes était grave, mais c´est une situation à laquelle la population a fini par s´adapter. Ainsi, des moyens ont été mis en œuvre par les familles pour lutter contre la malnutrition. Conclusion:le contexte socioculturel module les connaissances et la perception sur les causes, les manifestations et le caractère vulnérable ou non d´un individu ainsi que sur la gravité de la malnutrition.

The COVID-19 pandemic has wreaked havoc globally, and there has been a particular concern for sub-Saharan Africa (SSA), where models suggest that the majority of the population will become infected. Conventional wisdom suggests that the continent will bear a higher burden of COVID-19 for the same reasons it suffers high burdens of other infectious diseases: ecology, socio-economic conditions, lack of water and sanitation infrastructure, and weak health systems. However, so far SSA has reported lower incidence and fatalities compared to the predictions of standard models and the experience of other regions of the world. There are three leading explanations, each with very different implications for the final epidemic burden: (1) low case detection, (2) differences in COVID-19 epidemiology (e.g. low R0), and (3) policy interventions. The low number of cases to date have led some SSA governments to relax these policy interventions. Will this result in a resurgence of cases? To understand how to interpret the lower-than-expected COVID-19 case data in Madagascar, we use a simple age-structured model to explore each of these explanations and predict the epidemic impact associated with them. We show that the current incidence of COVID-19 cases can be explained by any combination of the late introduction of first imported cases, early implementation of non-pharmaceutical interventions (NPIs), and low case detection rates. This analysis reinforces that Madagascar, along with other countries in SSA, remains at risk of an impending health crisis. If NPIs remain enforced, up to 50,000 lives may be saved. Even with NPIs, without vaccines and new therapies, COVID-19 could infect up to 30% of the population, making it the largest public health threat in Madagascar until early 2021, hence the importance of conducting clinical trials and continually improving access to healthcare.RésuméLa pandémie de COVID-19 a eu des conséquences néfastes partout dans le monde, et il y a une préoccupation particulière pour l’Afrique subsaharienne (ASS), où des modèles suggèrent que la majorité de la population sera infectée. Il est craint que le continent supportera un fardeau plus élevée de COVID-19 pour les mêmes raisons qu’il souffre d’avantage d’autres maladies infectieuses: écologie, conditions socio-économiques, manque d’infrastructures d’eau et d’assainissement, et faiblesse des systèmes de santé. Cependant, jusqu’à présent, l’ASS a rapporté une incidence et une mortalité bien inférieure à celle des prévisions des modèles pour cette région, ainsi qu’au nombre observé dans d’autres régions du monde. Il y a trois explications principales pour ce phénomène, chacune ayant des implications très différentes pour le fardeau épidémique final: (1) détection faible des cas, (2) différences dans l’épidémiologie COVID-19 (par exemple faible R0), et (3) interventions et politiques mises en place. Le faible nombre de cas à ce jour a conduit certains gouvernements d’ASS à assouplir ces interventions. Cela entraînera-t-il une résurgence de cas? Pour comprendre comment interpréter le fait que les cas COVID-19 rapportés sont plus faibles que prévu à Madagascar, nous utilisons un modèle de transmission structuré par groupe d’âge pour explorer chacune de ces explications et prédire l’impact épidémique qui leur est associé. Nous montrons que l’incidence actuelle des cas de COVID-19 peut s’expliquer par l’effet cumulé de l’introduction tardive des premiers cas importés, la mise en œuvre rapide d’interventions non pharmaceutiques (INP) et de faibles taux de détection des cas. Cette analyse renforce le fait que Madagascar, ainsi que d’autres pays d’Afrique subsaharienne, reste à risque d’une crise sanitaire imminente. Si les INP restent appliqués, jusqu’à 50 000 vies pourraient être sauvées. Même avec des INP, tant qu’il n’y aura pas des vaccins ni des nouvelles thérapies efficaces, COVID-19 pourrait infecter jusqu’à 30% de la population, ce qui constituerait la plus grande menace pour la santé publique à Madagascar jusqu’au début de 2021, d’où l’importance de la réalisation des essais cliniques et de l’amélioration continuelle de l’accès aux soins.Summary BoxThe lower-than-expected number of reported cases of COVID-19 in Madagascar can be explained by a combination of the relatively late introduction of the disease, low detection rates, and low transmission rates due to the early and effective implementation of non-pharmaceutical interventions that reduced contact rates.COVID-19 is predicted to be the largest public health problem in Madagascar in 2020, but non-pharmaceutical interventions at an effectiveness similar to those seen in the first few months could save up to 50,000 lives.Health systems in SSA remain at risk of an impending health crisis due to COVID-19, stressing the importance of ongoing clinical trials and improving health care access.

Summary box Measles vaccination is often referred to as a ‘best buy’ in public health, because of the high case fatality rate associated with infection, alongside the existence of a safe and inexpensive vaccine. The current WHO recommendation is that all children have access to two doses of the measles vaccine.1 In 2011, countries in the WHO African region adopted a measles elimination goal to be reached by 2020. In the last decades, substantial gains have been made in numbers of cases and deaths averted. Yet, an important feature of measles epidemiology is that large outbreaks can occur following years of (apparently) successful control. This phenomenon is known as a ‘posthoneymoon period’ outbreak.2 The ‘honeymoon’ consists of the period following vaccine introduction where cases drop substantially. This ‘honeymoon’ is at …

A surprising feature of the SARS-CoV-2 pandemic to date is the low burdens reported in sub-Saharan Africa (SSA) countries relative to other global regions. Potential explanations (e.g., warmer environments1, younger populations2–4) have yet to be framed within a comprehensive analysis accounting for factors that may offset the effects of climate and demography. Here, we synthesize factors hypothesized to shape the pace of this pandemic and its burden as it moves across SSA, encompassing demographic, comorbidity, climatic, healthcare and intervention capacity, and human mobility dimensions of risk. We find large scale diversity in probable drivers, such that outcomes are likely to be highly variable among SSA countries. While simulation shows that extensive climatic variation among SSA population centers has little effect on early outbreak trajectories, heterogeneity in connectivity is likely to play a large role in shaping the pace of viral spread. The prolonged, asynchronous outbreaks expected in weakly connected settings may result in extended stress to health systems. In addition, the observed variability in comorbidities and access to care will likely modulate the severity of infection: We show that even small shifts in the infection fatality ratio towards younger ages, which are likely in high risk settings, can eliminate the protective effect of younger populations. We highlight countries with elevated risk of ‘slow pace’, high burden outbreaks. Empirical data on the spatial extent of outbreaks within SSA countries, their patterns in severity over age, and the relationship between epidemic pace and health system disruptions are urgently needed to guide efforts to mitigate the high burden scenarios explored here.

Poor geographic access can persist even when affordable and well-functioning health systems are in place, limiting efforts for universal health coverage (UHC). It is unclear how health facilities and community health workers contribute to achieving UHC. Using geographic information from thousands of patients in a rural district of Madagascar we evaluate how a health system strengthening (HSS) intervention aimed towards UHC affects the geography of primary care access. We find that facility-based interventions (user-fee exemptions, improved readiness) achieved high utilization rates only among populations who lived in close proximity to supported facilities. Scaling only facility-based HSS programs across the district would result in large gaps in health care access for the majority of the population. Community health provided major improvements in service utilization for children regardless of their distance from facilities. Our results have implications for UHC policies and suggest that greater emphasis on professionalized community health programs is essential.

Chronic kidney disease is defined as an inability of the kidney to perform its normal functions and which persists beyond three months. Nowadays, the estimated glomerular filtration rate based on plasmatic creatinine level remains the gold standard to assess renal function. In Madagascar, we miss national data concerning the epidemiology of chronic kidney disease probably due to the complexity of carrying out the serum creatinine assays. The recent availability of creatinometer using a creatinine strip test with capillary creatinine facilitated the determination of the creatinine level in epidemiological study.This simple technique allowed us to plan a pilot study in Antananarivo, the capital of Madagascar. The main objective was to assess the prevalence of chronic kidney disease determined from capillary creatinine level. The secondary objective was to determine the factors associated with chronic kidney disease in Madagascar. It is an analytical cross-sectional study over a period of three months. Chronic kidney disease is defined as a decrease of the glomerular filtration rate of capillary creatinine less than 60mL/min/1.73mAt the end of the study, 210 people were randomized for screening. The average age was 40 years old with 14.9 as standard deviation. The sex ratio (male/female) was 1.76. The prevalence of chronic kidney disease was 13.8% with extreme values of 9,1 and 18.5. With chronic kidney disease, high blood pressure (hypertension) and diabetes were found respectively in 41.3 and 17.2%. Chronic kidney disease affected mainly in 72.4% of population aged 25 to 54 years old.This is the first study in Africa to screen chronic kidney disease using a creatinine strip test. This prevalence is relatively different compared to other African countries. The limits of the study are the absence of a subsequent control and/or double control of the creatinine, which definitively confirms the chronicity of kidney disease, the absence evaluation of the urinary sediments to determine proteinuria. Nevertheless, the results of our study can be used as data awaiting the results of a multicenter studies. To determine the national prevalence of chronic kidney disease, screening in the six provinces is currently in progress.

Introduction In October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes the epidemiology of the outbreak and determines public health implications for measles elimination in Madagascar. Methods Data have been collected using line list developed for the outbreak. Serum samples were collected within 30 days of rash onset for laboratory testing; confirmation was made by detection of measles immunoglobulin M (IgM) antibody. Results A total of 2,930 samples were analysed in the laboratory among which 1,086 (37%) were laboratory confirmed. Measles cases age ranged from a minimum of 1 month to a maximum of 88 years. The median and the mean were 7 years and 9 years respectively. Children between 1 to 9 years accounted for 50.6% of measles cases. Attack rate (39,014 per 1,000,000 inhabitants) and case fatality rate (1.2%) were highest among children aged 9-11 months. A total of 67.2% cases were unvaccinated. As of March 14th, 2019, all the 22 regions and 105 (92%) health districts out of 114 were affected by the measles outbreak in Madagascar. Conclusion Measles outbreak in Madagascar showed that the country is not on the track to achieve the goal of measles elimination by 2020.

Introduction la malnutrition par insuffisance d´apport alimentaire reste un défi majeur des pays à faible et moyen revenu. La présente étude vise à identifier les constructions socioculturelles qui interviennent dans les présentations de la malnutrition. Méthodes une étude qualitative a été réalisée dans la région Amoron´i Mania, Madagascar. Les participants sont constitués par les femmes enceintes, les mères et pères de famille, les grand-mères ainsi que les acteurs de la santé comme les matrones, les agents communautaires et les agents de santé. Au total, 24 entretiens individuels semi-directifs et 6 focus groups ont été réalisés pour collecter les données. L´analyse thématique a été utilisée. Résultats la malnutrition renvoie à une idée de manque d´aliments et de sous-alimentation. Elle tourne autour de la consommation quantitative du riz, des faits socioculturels et des problèmes de ressources financières. Les groupes vulnérables étaient principalement les enfants et les femmes enceintes. La perception de la malnutrition avec ses signes était grave, mais c´est une situation à laquelle la population a fini par s´adapter. Ainsi, des moyens ont été mis en œuvre par les familles pour lutter contre la malnutrition. Conclusion le contexte socioculturel module les connaissances et la perception sur les causes, les manifestations et le caractère vulnérable ou non d´un individu ainsi que sur la gravité de la malnutrition.

Background: Talking about sex, sexuality, sexual health in many countries, including Madagascar, is very difficult because of the sacred and taboos that surround these questions but especially because of certain puritanism. The objective of this study was to assess the knowledge, attitudes and practices of adolescents in matters of sexual health.Methods: A retrospective, descriptive cross-sectional study was carried out in adolescents aged 10 to 19 seen in Ambohidratrimo district. The data were collected during the month of June and July 2019 and relate to data for the twelve months before the survey.Results: A total of 210 adolescents were recruited whose average age was 15.82±2.75 years and the sex ratio was 1:04. Eighty-six percent of the adolescents surveyed had heard of sexual health. Nine out of 10 adolescents would go to a health worker if they contract an STI. Almost a quarter or 23.8% of respondents declared having already had sexual intercourse.Conclusions: At the end of this study on the knowledge, attitudes and practices of adolescents on sexual health, they certainly have knowledge but considered average. Therefore, there is a need for sexuality education, seeking to improve knowledge and understanding of sexual development, human procreation, healthy and adapted sexual behavior and different means of contraception, on the part of adolescents, but also with the aim of improving communications between adolescents and their parent.

Background: Teenagers are defined by world health organization as persons between 10 and 19 years of age. When this generation has a sexual intercourse, it is considered to be early. The main aim of this investigation is to identify associated factors of precocious sexual intercourse.Methods: A cross-sectional study was conducted at the high schools in Antsirabe town among teenagers.Results: Among 636 teenagers, 19.8% are prematurely initiated. The median age of first sexual experience is 16 years of age. The average age for this first sexual experience takes place at 15.5 (1.4) years of age for boys and at 16.6 (1.2) years for girls. One kind of sociodemographic profile is associated to the first precocious sexual intercourse. Poor school performance, urban life, alcohol, tobacco and drug use are also significantly associated with this precocious sexual experience. From the relationship standpoint, 6= lack of sexual education by the head of household, the absence of religious diligence, the influence of customs, internet access and accession a social network are indeed associated to this problem.Conclusions: In order to meet these results, the ministry of public health should design on Facebook, education program about forward sexuality.

Background Trends in cause-specific mortality in most African countries are currently estimated from epidemiological models because the coverage of the civil registration system is low and national statistics on causes of death are unreliable at the national level. We aim to evaluate the performance of the death notification system in Antananarivo, the capital city of Madagascar, to inform cause-of-death statistics. Methods Information on the sex of the deceased, dates of birth and death, and underlying cause of death were transcribed from death registers maintained in Antananarivo. Causes of death were coded in ICD-9 and mapped to cause categories from the Global Burden of Disease 2016 Study (GBD). The performance of the notification system was assessed based on the Vital Statistics Performance Index, including six dimensions: completeness of death registration, quality of cause of death reporting, quality of age and sex reporting, internal consistency, level of cause-specific detail, and data availability and timeliness. We redistributed garbage codes and compared cause-specific mortality fractions in death records and estimates from the GBD with concordance correlation coefficients. Results The death notification system in Antananarivo performed well on most dimensions, although 31% of all deaths registered over the period 1976–2015 were assigned to ICD codes considered as “major garbage codes” in the GBD 2016. The completeness of death notification, estimated with indirect demographic techniques, was higher than 90% in the period 1975–1993, and recent under-five mortality rates were consistent with estimates from Demographic and Health Surveys referring to the capital city. After redistributing garbage codes, cause-specific mortality fractions derived from death notification data were consistent with GBD 2016 for the whole country in the 1990s, with concordance correlation coefficients higher than 90%. There were larger deviations in recent years, with concordance correlation coefficients in 2015 at 0.74 (95% CI 0.66–0.81) for men and 0.81 (95% CI 0.74–0.86) for women. Conclusions Death notification in Antananarivo is a low-cost data source allowing real-time mortality monitoring, with a potential to improve disease burden estimates. Further efforts should be directed towards evaluating data quality in urban centers in Madagascar and other African countries to fill important data gaps on causes of death. Electronic supplementary material The online version of this article (10.1186/s12963-019-0190-z) contains supplementary material, which is available to authorized users.

Background: Seasonal variation affects nutrition particularly in contexts where people's food consumption depends on their production of food. Assessing the effect of the season on nutrition status can help us to identify strategies to address undernutrition. This study aims to measure the variations in food consumption and the incidence of undernutrition according to season, and to identify the factors associated with the incidence of undernutrition. Methods: A cohort study was conducted among 608 mothers aged between 18 and 45 years living in the Amoron'i Mania Region of Madagascar. Inclusion in the study occurred during the post-harvest season, and mothers were followed until the end of the next lean period (7 months). A dichotomous variable of the frequency of consumption of various foods was used to establish variation in food consumption. Body Mass Index < 18.5 kg/m2 and Middle Upper Arm Circumference < 220 mm were used to measure incidence of undernutrition. A generalized linear model was used to identify factors associated with the incidence of undernutrition and to derive relative risks. Results: During the lean season, the frequency of consumption of leafy green vegetables, peanuts, fish, and eggs decreased significantly. In contrast, the frequency of fruit, legumes, and non-leafy green vegetables consumption increased significantly. The prevalence of undernutrition (based on the BMI and/or MUAC) among mothers increased from 19.6% in the post-harvest period to 27.1% in the lean period (p < 0.001). The incidence of undernutrition (based on the BMI and/or MUAC) during the follow-up was 12.2%. The factors related to undernutrition were low and medium score of movable property possession (Adjusted RR = 3.26 [1.33-7.94] and Adjusted RR = 2.48 [1.01-6.10]), no toilet (Adjusted RR = 1.76 [1.07-2.91]), and pregnancy (Adjusted RR = 2.92 [1.42-6.04]) (based on the MUAC only for pregnancy). Conclusion: This study highlights the variation in the frequency and type of food consumption and subsequent deterioration in mothers' nutritional status during the lean season. Economic, hygiene, and reproductive factors were associated with undernutrition. Analyzing the existing interventions to fight maternal undernutrition is necessary to determine whether or not seasonality is considered and addressed., SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction The prison population in low-income countries is a group vulnerable to undernutrition, particularly incarcerated women. The aim of the study is to assess the nutritional status of women in prison and to determine the social profile and prison conditions related to undernutrition. Methods A cross-sectional study was conducted among 125 women prisoners in Antanimora prison located in the city of Antananarivo, Madagascar. All women detained for 3 months or more at the time of the survey were included in the study. Data collection was conducted in May and June 2013. A survey of women and anthropometric measurements were carried out to collect the data. Results The proportion of undernourished female prisoners is 38.4%. Five percent of pregnant and lactating women and 44.3% of non-lactating and non-pregnant women are undernourished. The factors related to undernutrition of women prisoners are: taking two meals a day instead of three meals (p = 0.003), insufficient energy intake (p < 0.001), incarceration duration of more than 10 months (p < 0.001), absence of family visits (p = 0.013) and lack of financial assistance from family (p = 0.013). Conclusion Improving the prisoners' diets and assistance from family both help to fight against prisoner undernutrition in prisons.

Weight gain during pregnancy has effects on growth and development during intrauterine life. Data for this subject is not available for Madagascar. This study aims to measure the weight gain during pregnancy, to identify its determinants and to assess its effect on the baby's weight at birth. A retrospective cohort study was carried out on pregnant women who gave birth in three maternity wards in the city of Antananarivo. The study included women who followed the first early prenatal consultation and who had their weight noted in the pregnancy notebook, during this prenatal consultation. Weight gain during pregnancy was assessed by using the difference in weight during the early prenatal visit and the weight before delivery. Recommendations from the Institute of Medicine were used to classify weight gain during pregnancy. Of the 380 pregnant women included in the study, 76.3% did not obtain the needed weight gain during pregnancy, 20% obtained normal weight gain and 3.7% obtained excess weight gain. In a multivariate analysis, the good nutritional status of women (body mass index

Introduction: Madagascar has one of the highest prevalence’s of malnutrition worldwide. Dietary practice is an important element to consider in the fight against malnutrition. This study aims to describe mothers’ dietary patterns and dietary diversity and to identify characteristics associated with this dietary diversity. Methods: A cross sectional study was carried-out among 670 non-pregnant mothers aged 18 to 45, who had delivered more than 6 months earlier and were living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. A food frequency questionnaire were used to assess the dietary pattern and the women’s dietary diversity score was established from the 24-hour recall data. Results: Almost all (99%) of mothers ate rice every day and 59% ate green leaves. Fifty three percent of mothers had consumed fruit less than once per week, 55% for legumes, 67% for vegetables and 91% for meat. Dietary diversity score ranged from 1 to 7 and 88% of mothers had a low dietary diversity score (, SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction: Women's dietary habits are very important due to the specific nutritional requirements for reproduction. This study aimed to describe women's dietary habits during pregnancy and breastfeeding and to identify factors influencing these habits. Methods: We conducted a qualitative study of pregnant and breastfeeding women living in Amoron'i Mania region, Madagascar. Eight focus groups (6-10 women per group) and 23 individual interviews were carried out to collect data. Thematic analysis was used and focused on the description of women's dietary habits on the basis of dietary behaviours as well as of sociocultural and economic determinants of the described habits. Results: During pregnancy and breastfeeding, women's dietary habits did not vary considerably except at the very beginning of breastfeeding. They had a little diversified and monotonous diet, poor in fruit and vegetables and poor in proteins. At the very beginning of breastfeeding, during the practice of "mifana" tradition, women had a diet more rich than usual. These dietary habits were influenced by the type of agricultural products in the region and by their availability during the year (self-consumption)as well as by purchasing power (in case of shortage) and tradition. Conclusion: Mothers' dietary habits appear to be inadequate. This study highlights the importance of improving knowledge of the determinants of mothers' dietary behaviours., SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction L'alimentation des mères est très importante à cause des besoins nutritionnels spécifiques pour la reproduction. La présente étude vise à décrire les habitudes alimentaires des mères pendant la grossesse et l'allaitement et répertorier les facteurs influençant ces habitudes. Méthodes Une étude qualitative a été menée auprès des femmes enceintes et allaitantes vivant dans la région Amoron'i Mania, Madagascar. Huit focus group (6 à 10 femmes par groupe) et 23 entretiens individuels ont été réalisés pour collecter les données. L'analyse thématique a été utilisée et a porté sur la description des habitudes alimentaires à partir de la conduite de l'alimentation des femmes et sur les déterminants socioculturels et économiques des habitudes décrites. Résultats Pendant la période de grossesse et d'allaitement, l'habitude alimentaire des femmes ne varie pas considérablement exceptée au tout début de l'allaitement. Elles ont une alimentation faiblement diversifiée et monotone, pauvres en fruits et légumes et pauvre en protéines. C'est au tout début de l'allaitement, pendant la pratique de la tradition appelée « mifana », que les femmes bénéficient d'une alimentation plus riche que d'habitude. Ces habitudes alimentaires sont influencées par le type de productions agricoles de la région et leur disponibilité dans l'année (autoconsommation), le pouvoir d'achat (en cas de pénurie) ainsi que la tradition. Conclusion L'habitude alimentaire des mères semble inadéquate. Approfondir les connaissances sur les déterminants de leur pratique alimentaire est nécessaire.

Aim To evaluate the population’s knowledge about tuberculosis (TB) in Madagascar; assess the attitudes, risks, and misconceptions associated with the disease; evaluate the population’s practices for disease management; propose recommendations to authorities based on the study.

Background: Oral contraception is the second hormonal contraceptive method most used in the world. Currently, self-medication with oral contraceptives experienced resurgence, most often with no medical supervision. This study aims to estimate the prevalence of self-medication with oral contraceptives, identify the socio-economic status and identify the reasons why women aged 21 to 49 of the Urban District of Antananarivo (UDA) practice self-medication with oral contraceptives. Methods: A cross-sectional survey was conducted, where an interviewer-administered questionnaire has been used to collect data. Targeted female respondents aged 21-49 were asked about their contraceptive use during the twelve months preceding the survey. Results: Self-medication prevalence rate is 59.1%, considering oral contraception users. Moreover, it is higher among married women, those aged

Background: Maternal mortality is associated with an ever-worrying trend in Madagascar. The partograph, set up by the WHO, is topical when it comes to maternal and child mortality-reducing strategies, especially in developing countries. This study assesses the effect of partograph use on maternal and neonatal mortality in maternity wards of ten basic health centres (BHC) and three hospitals located in the districts of Avaradrano, Atsimondrano, Ambohidratrimo, including the district hospital (DH) of Ambohidroa. Methods: Across-sectional survey was conducted in selected districts, using parturients’ medical records during year 2010. Data were derived from the partographs of women meeting the following criteria: a spontaneous onset of labour, an uniparous pregnancy, a term birth, a foetal cephalic presentation, with no extra complication. Results: Neither maternal nor neonatal death was found where a partograph has been used. Partograph use rate is 64.8%. The main reasons for not using partographs include absence of training and lack of skilled health personnel. 128 abnormalities were identified with a correct management rate of 60.9%. Conclusions: Although implementation of the partograph appears to be easy and inexpensive, its use still collides with huge difficulties. It requires a qualified aid and a suitable environment to have a positive and significant impact on maternal and perinatal mortalities related to birth.

Introduction Tuberculosis infection may remain latent, but the disease is nevertheless a serious public health issue. Various epidemiological studies on pulmonary tuberculosis have considered the spatial component and taken it into account, revealing the tendency of this disease to cluster in particular locations. The aim was to assess the contribution of Knowledge Attitude and Practice (KAP) to the distribution of tuberculosis and to provide information for the improvement of the National Tuberculosis Program. Methods We investigated the role of KAP to distribution patterns of pulmonary tuberculosis in Antananarivo. First, we performed spatial scanning of tuberculosis aggregation among permanent cases resident in Antananarivo Urban Township using the Kulldorff method, and then we carried out a quantitative study on KAP, involving TB patients. The KAP study in the population was based on qualitative methods with focus groups. Results The disease still clusters in the same districts identified in the previous study. The principal cluster covered 22 neighborhoods. Most of them are part of the first district. A secondary cluster was found, involving 18 neighborhoods in the sixth district and two neighborhoods in the fifth. The relative risk was respectively 1.7 (p

A retrospective epidemiological study of patients' medical records (n = 442) was conducted in one of the tuberculosis (TB) treatment centers in the city of Antananarivo, to identify risk factors of treatment default. Results show that males give up treatment more than women (OR=1,81 [1,13; 3,03]). Among those living farthest away from the center, patients younger than 30 years old tend to be more irregular in the follow-up of their treatment (OR=3,43 [1,16; 10,15]). There is no statistically significant relationship between TB treatment default and the patient's age, the clinical form, the therapeutic regime or the place of residence. Managers of treatment centers should be more aware and vigilant regarding male and young TB patients presenting these characteristics and should adapt methods and means for follow-up according to these risk factors.

Background: In developing countries, HIV infection is the main disease leads to tuberculosis (TB) active. Each tuberculosis (TB) patient of TB diagnosis and treatment centers in Antananarivo city should receive HIV serology counseling. The TB-diabetes association is rarely considered. In general population in Madagascar HIV was 0.37% in 2010 and Diabetes affects about 3% of the population. This study aims to estimate the prevalence of HIV infection and diabetes among TB patients. Methods: A descriptive study in three TB diagnosis and treatment centers in Antananarivo city was conducted between July 15, 2013 and October 30, 2013. TB Patients aged 18 years and older were enrolled. They completed HIV and blood glucose testing after informed consent. Results: Among 156 TB patients, one case is HIV positive [0.6% (0.1 - 3.6)] and two are indeterminate [1.3% (0.4 - 4.6)]. The HIV infection case relates to an extrapulmonary TB. Nine cases of diabetes were diagnosed [5.8% (3.1 - 10.6)], and four of them had their diabetes status before the study. Six diabetic are between 40 and 50 years. Among TB patients, diabetes prevalence is nine times higher than HIV prevalence (P = 0.01). Conclusion: As for people living with HIV, diabetics should benefit TB prevention and routine screening of TB. Creating mechanism of collaboration between the diabetes program and TB program should be one of heath priorities.