Rectal Carriage of Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacilli in Community Settings in Madagascar

BACKGROUND: Extended-spectrum ß-lactamase-producing Enterobacteria (ESBL-PE) emerged at the end of the 1980s, causing nosocomial outbreaks and/or hyperendemic situations in hospitals and long-term care facilities. In recent years, community-acquired infections due to ESBL-PE have spread worldwide, especially across developing countries including Madagascar. OBJECTIVES: This study aimed to determine the prevalence and risk factors of intestinal carriage of ESBL-PE in the community of Antananarivo. METHODS: Non-hospitalized patients were recruited in three health centers in different socio economic settings. Fresh stool collected were immediately plated on Drigalski agar containing 3 mg/liter of ceftriaxone. Gram-negative bacilli species were identified and ESBL production was tested by a double disk diffusion (cefotaxime and ceftazidime +/- clavulanate) assay. Characterization of ESBLs were perfomed by PCR and direct sequencing . Molecular epidemiology was analysed by Rep-PCR and ERIC-PCR. RESULTS: 484 patients were screened (sex ratio  = 1.03, median age 28 years). 53 ESBL-PE were isolated from 49 patients (carrier rate 10.1%). The isolates included Escherichia coli (31), Klebsiella pneumoniae (14), Enterobacter cloacae (3), Citrobacter freundii (3), Kluyvera spp. (1) and Pantoae sp.(1). In multivariate analysis, only the socioeconomic status of the head of household was independently associated with ESBL-PE carriage, poverty being the predominant risk factor. CONCLUSIONS: The prevalence of carriage of ESBL in the community of Antananarivo is one of the highest reported worldwide. This alarming spread of resistance genes should be stopped urgently by improving hygiene and streamlining the distribution and consumption of antibiotics

Mortalité et santé à Madagascar. La transition sanitaire dans la zone de Moramanga, Madagascar

Thèse de doctorat sous la direction de Gilles Pison (professeur au Muséum national d'histoire naturelle et chercheur associé à l'Institut national d’études démographiques (INED) et la co-direction de Laurence Baril (directrice de l'Institut Pasteur du Cambodge

Mortality and health in Madagascar : the health transition in Moramanga district, Madagascar

A Madagascar, comme de nombreux pays en développement, le système d'enregistrement et de certification médicale des décès n'est pas suffisamment exhaustif pour générer des estimations représentatives au niveau national de la mortalité par cause de décès. L'ambition de cette thèse est de contribuer à améliorer nos connaissances sur les changements sanitaires dans un pays à statistiques imparfaites en fournissant une étude de cas détaillée, celle du district de Moramanga à Madagascar. Une cohorte de population a été établie à Moramanga, un district localisé à 110km à l'est de la capitale. La zone d'étude comptait environ 70000 habitants en 2014 répartis en zone rurale et urbaine. Chez les enfants de moins de 15 ans, le risque de décès dans la tranche d'âge 0-14 ans était de 68.1 pour 1000 naissances vivantes. La distribution des causes de décès est largement dominée par les maladies infectieuses, néonatales et nutritionnelles qui représentent. 79.5% des décès d'enfants de moins de 5 ans. Pour les enfants âgés de 5 à 14 ans, la plupart des morts violentes étaient dues à des noyades, des brûlures et des accidents de la route. Chez les adultes, le risque de décéder de maladies cérébrovasculaires ou de diabète était 3 fois plus élevé chez ceux ayant déjà eu un antécédent d'hypertension artérielle ou de diabète, ajusté sur l'âge, et sans différence entre milieu urbain et rural ; suggérant ainsi que la prévention et les prises en charge des maladies chroniques demeurent encore insuffisant dans la zone d'étude.In Madagascar, as in many developing countries, the system of civil registration and medical certification of deaths is not exhaustive to generate nationally representative estimates of mortality by cause of death. This work would contribute to improve our knowledge on health changes in a statistically imperfect country as Madagascar by providing a detailed case study, in the Moramanga district. A population cohort had been established in Moramanga, a district located 110km east of the capital since 2012. The study area counted about 70,000 inhabitants in 2014 split into urban and rural areas. Among children under 15 years of age, therisk of death in the 0-14 age group was 68.1 per 1000 live births. The distribution of causes of death was largely dominated by infectious, neonatal and nutritional diseases, which account for 79.5% of under-five deaths. For children aged 5 to 14, most external deaths were due to drowning, burns, and road accidents. Among adults, the risk of dying from cerebrovascular disease or diabetes was 3 times higher among those with a history of high blood pressure or diabetes, adjusted for age, and with no difference between urban and rural areas, suggesting that prevention and management of chronic disease still remains insufficient in the study area

Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information

International audienceObjectives: To learn what complications some women experienced in Madagascar following use of misoprostol for abortion and what treatment they received post-misoprostol use.Study design: This was a qualitative study in 2015–16 among women who had experienced complications after use of misoprostol, with or without additional methods, for abortion, what information they received before use, what dosage and regimens they used, what complications they experienced and what treatment they received post-use. We initially conducted in-depth, semi-structured interviews with 60 women who had undergone an abortion that resulted in complications. The results presented here are based on interviews with the sub-set of 19 women who had used misoprostol.Results: The 19 women were aged 16–40, with an average age of 21–26 at interview and average age of 18–21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and healthcare providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines, and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain, and/or infection.Conclusions: This study provides data on complications from the use of misoprostol as an abortifacient in Madagascar. Healthcare providers need training in correct misoprostol use and how to treat complications. Law and policy reform are needed to support such training and to ensure the provision of safe abortion services in the public health system.Implications: Healthcare providers who provide abortion care and treatment of abortion complications need training in correct misoprostol use and treatment of complications. Women and pharmacy workers also need this information. Law and policy reform are needed to allow training and provision of safe services. Further research is needed on the extent and impact of incorrect misoprostol administration

Determinants of COVID-19-related knowledge and disrupted habits during epidemic waves among women of childbearing age in urban and rural areas of the Malagasy Middle East

Abstract Background With regard to the coronavirus disease (COVID-19) pandemic in Madagascar, little is known about the knowledge, the perceptions and the impacts of this disease on women of childbearing age. People’s knowledge of COVID-19 can have an impact on their attitudes towards seeking care. The aim of the current study is to determine the knowledge of COVID-19 and associated determinants among women of childbearing age in Moramanga. Methods A cross-sectional study based on questionnaire administration was used among women of childbearing age. Data collection was conducted from August to October 2021. A scoring method was applied to evaluate their knowledge level and perceptions about COVID-19 and its impacts on their lives. A binary stepwise logistic regression was performed to determine the sociodemographic determinants of their knowledge level about COVID-19. Results A total of 885 women of childbearing age from urban and rural Moramanga areas were interviewed. Approximately 49.8% (441/885) lived in urban areas, and 50.2% (444/885) lived in rural areas. Approximately 35.3% (322/885) of the participants had a good level of knowledge of COVID-19. Multivariate analysis showed that the probability of having a good level of knowledge of COVID-19 had a significant statistical association (p value < 0.05) with living in an urban area [AOR: 2.89; 95% CI (1.89–4.42)], telephone ownership [AOR: 1.71; 95% CI (1.16–2.53)], radio ownership [AOR 2.2; 95% CI (1.43–3.38)], watching TV [AOR = 1.95; 95% CI (1.34–2.83)] and reading journal papers [AOR = 3.74 95% CI (1.69–8.27)]. Conclusions Almost a third of the sampled women of childbearing age had a good level of knowledge of COVID-19. Access to information through telecommunications technologies increases the chances of being better informed about the disease. To avoid the negative repercussions of infectious disease epidemics, it is necessary to improve the awareness of childbearing women about these diseases by taking demographic features of the population into account

Inequalities in cause-specific mortality in children and adolescents in the Moramanga health survey, Madagascar

Objectives One child or young adolescent dies every 10 min in Madagascar and large disparities in survival persist. We estimated cause-specific mortality in a cohort of children aged 0–14 in the Moramanga district and explored how causes of death shape these inequalities. Methods Children were followed prospectively between 2012 and 2017. Causes of death were established based on verbal autopsies. Incidence rate ratios were estimated in Poisson regression models. Results The risk of dying before age 15 was 68.1 per thousand live births. Risks of dying were highest in the first year of life (31.2‰) and lowest in children aged 10–14 (6.4‰). The male-to-female sex ratios of mortality increased with age and reached 2.3 among adolescents aged 10–14. Communicable, nutritional and neonatal causes accounted for 79.5% of deaths below age 5 and 47.0% above age 5. Mortality was positively associated with household poverty, lack of education of the household head, and rural residence. Conclusions Interventions should be designed with an equity lens to reduce large disparities in survival and be tailored to the needs of each age-group

Hypertension, a Neglected Disease in Rural and Urban Areas in Moramanga, Madagascar

International audienceBackgroundHypertension is one of the main risk factors of cardiovascular diseases. In Madagascar,studies on hypertension in urban and rural communities are scarce.ObjectivesThe aim of this study was to determine the prevalence of hypertension and identify associated risk factors in adults living in a health and demographic system in Moramanga, Madagascar. MethodsThe study included people aged 15 years old and above living in a health and demographic system in Moramanga. A household census was performed in 2012 to enumerate the population in 3 communities in Moramanga. In addition to the questionnaire used in the initial census, a standardized questionnaire and blood pressure were taken twice after 5 and 10 minutes of rest. In urban areas, heights and weights were also measured to calculate the body mass index. ResultsThere were 3621 and 4010 participants respectively in rural and urban areas. Prevalence of hypertension in rural population was 27.0%(IC95%[25.6–28.5]) and 29.7% (IC95% [28.3– 31.1]) in urban population. Among hypertensive subjects, 1.7% (17/979) and 5.3% (64/ 1191) were on antihypertensive treatment for at least 1 month before the survey in rural and urban population, respectively. In rural areas, increasing age (65 years and older vs 18–25 years OR = 11.81, IC95% [7.79–18.07]), giving more than 3 positive responses to the usual risks factors of hypertension (OR = 1.67, IC95% [1.14–2.42]) and singles in comparison with married people (OR = 1.61, IC95% [1.20–2.17]) were associated to hypertension in a logistic regression model. In urban areas, increasing age (65 years and older vs 18–25 years OR = 37.54, IC95% [24.81–57.92]), more than 3 positive responses to the usual risks of hypertension (OR = 3.47, IC95% [2.58–4.67]) and obesity (OR = 2.45, IC95% [1.56– 3.87]) were found as risk factors. ConclusionHypertension is highly prevalent in rural areas although it is significantly less treated. As a result, a major epidemic of cardiovascular diseases is at risk in Madagascar’s progressively aging societ

Frequency, risk factors, and complications of induced abortion in ten districts of Madagascar: results from a cross-sectional household survey

Background Madagascar has restrictive abortion laws with no explicit exception to preserve the woman’s life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions. Methods We interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion. Results For 2005–2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4–23.0) per 1000 person-years among sexually active women (aged 18–49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8–37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not. Conclusions Incidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies

Factors influencing maternal healthcare seeking in a highland region of Madagascar: a mixed methods analysis

Abstract Background In Madagascar, maternal mortality remains stable and high (426 deaths per 100,000 live births). This situation is mainly due to a delay or lack of use of maternal healthcare services. Problems related to maternal healthcare services are well documented in Madagascar, but little information related to maternal healthcare seeking is known. Thus, this paper aims to identify and analyze the factors that influence the utilization of maternal services, specifically, the use of antenatal care (ANC) during pregnancy and the use of skilled birth attendants (SBAs) at delivery. Method We used quantitative and qualitative approaches in the study. Two communes of the Vakinankaratra region, which are located in the highlands, were the settings. Data collection occurred from October 2016 to July 2017. A total of 245 pregnant women were included and followed up in the quantitative survey, and among them, 35 participated in in-depth interviews(IDIs). Logistic regressions were applied to explore the influencing factors of antenatal and delivery healthcare seeking practices through thematic qualitative analysis. Results Among the 245 women surveyed, 13.9% did not attend any ANC visits. School level, occupation and gravidity positively influenced the likelihood of attending one or more ANC visits. The additional use of traditional caregivers remained predominant and was perceived as potentially complementary to medical care. Nine in ten (91%) women expressed a preference for delivery at healthcare facilities (HFs), but 61% of births were assisted by a skilled birth attendant (SBA).The school level; the frequency of ANCs; the origin region; and the preference between modern or traditional care influenced the use of SBAs at delivery. A lack of preparation (financial and logistics problems) and women’s low involvement in decision making at delivery were the main barriers to giving birth at HFs. Conclusion The use of maternal healthcare services is starting to gain ground, although many women and their relatives still use traditional caregivers at the same time. Relatives play a crucial role in maternal healthcare seeking. It would be necessary to target women’s relatives for awareness-raising messages about ANC and childbirth in healthcare facilities and to support and formalize collaborations between traditional healers and biomedical caregivers