[Contextual factors regarding the effectiveness of tuberculosis control in Madagascar: a nationwide validity study]. / Facteurs contextuels de l'efficacité du contrôle de la tuberculose à Madagascar : étude de validité au niveau national.

INTRODUCTION: This study assesses the nationwide applicability of results from a study in the tuberculosis (TB) diagnostic and treatment centers (DTCs) in a sample of six districts in Madagascar, which identified adaptations of national guidelines and local initiatives that might explain the effectiveness of individual DTCs in improving adherence to TB treatment and thus reducing treatment default. OBJECTIVE: To assess, at a national level, the importance of these adaptations/initiatives for TB treatment adherence. METHODS: This analytical cross-sectional study assessed the responses to a questionnaire based on the previously identified adaptations/initiatives, which was sent to the heads of all 205 DTCs in Madagascar. RESULTS: Decentralization of TB care decreased the rate of patient default. The private DTCs report better results than public DTCs. Adaptations/initiatives in relation to local contexts often lead to good results. The relation between some adaptations/initiatives and continued adherence sometimes varies with the local context of the DTC; the same initiatives can result in better adherence or in higher of treatment default rates, depending on the setting. CONCLUSION: These initiatives should be applied after adaptation to the context.

[Relation between Shistosoma mansoni and hepatosplenomegalies]. / Relation entre Schistosoma mansoni et hépatosplénomégalies à Madagascar.

INTRODUCTION: Although they remain a neglected transmissible disease, affecting mainly people in poor countries, the combined forms of schistosomiasis are second only to malaria as a major parasitic disease. Although both urinary and intestinal schistosomiasis are endemic in Madagascar, this study focuses only on the intestinal forms. The symptoms may remain unnoticed or be ignored, for the seriousness of intestinal schistosomiasis is due mainly to its hepatosplenic complications. OBJECTIVES: To estimate the etiological fraction of Schistosoma mansoni involved in hepatomegaly (HM), splenomegaly (SM) and hepatosplenomegaly (HSM), with or without signs of portal hypertension (PHT). METHODS: This file-based retrospective study includes patients admitted to the University Hospital of Antananarivo, Madagascar, between January 2005 and July 2008, who presented with HM, SM, HSM and/or PHT. The case was attributed to schistosomiasis if blood serology, tested with ELISA, was positive for this parasite. The statistical analysis used three approaches: a cross-sectional approach, a longitudinal approach (retrospective cohort), and a "case-control" approach. RESULTS: Of 7308 admissions during this period, 269 (4%) were diagnosed with a hepatosplenic complication and were retained. The average age (+/- standard deviation) was 47.8 (+/- 16.4) years. HM accounted for 55.4% of cases, SM 18.9%, HTP 18.6% and HSM 18.6%. Serology was positive for schistosomiasis in 21.6% of cases. The sex ratio (men:women) for these cases was 1.9, and 67.3% of the patients were aged 30 years or older. The main schistosomiasis complications were SM (n=22) and HTP (n=22). The age group most affected depended on the specific complication: for HM, 28.6% of patients were aged between 40 and 49 years; for HSM, 57.1% were aged between 30 and 40 years. The prevalence of SM was lower in subjects between 50 and 59 years of age (4.5%) than the other complications. Patients with positive serology results were significantly younger than those with negative results, or whose serology was not checked (37.8 years vs. 50.5 years, p < 0.001). Stratification according to complication showed that the etiological fraction of schistosomiasis was 76% for patients with SM, 79% for HTP, 58% for HSM and 4.9% for HM. The retrospective cohort and the case-control analyses both showed that a history of dysentery and frequent contact with water were the main factors associated with complicated schistosomiasis. It is important to note that urban and rural residents had the same risk of developing schistosomiasis with complications (OR: 0.9 [0.4; 1.9]). CONCLUSION: This study showed that schistosomiasis infection is strongly associated with hepatosplenic pathologies. One of the shortcomings of the study is the absence of any analysis of the course and outcome in the study patients. Nevertheless, the course of oesophageal varices, SM or HSM in patients with HTP indicates that schistosomiasis was often fatal.

[Results of tuberculosis control programs in Madagascar from 1996 to 2004]. / Etat des lieux de la lutte contre la tuberculose à Madagascar de 1996 à 2004.

OBJECTIVE: Madagascar's national tuberculosis control program has been operational since 1991. The purpose of this article is to provide up-to-date information about the results of this program. METHOD: Data from reports sent to the Tuberculosis Control Department between 1996 and 2004 by diagnosis and treatment centers were retrospectively studied. Special focus was placed on new cases of tuberculosis identified by positive smear. RESULTS: During the study period the annual incidence of new cases of tuberculosis confirmed by positive smear increased from 65 to 82 per 100,000 inhabitants. The highest incidence of new cases was observed in the active population. The treatment success rate rose from 64.4% to 70.8% in patients with positive smear tests. The dropout rate decreased from 21% to 16.5%. However discrepancies were observed between the number of cases diagnosed and number of cases treated. CONCLUSIONS: These findings indicate that tuberculosis control improved slowly over the study period. However these data do not allow identification of strategies to improve program performance. This will require detailed review of data taking into account the context in which they were obtained.

[Prenatal consultations and perinatal mortality in Madagascar]. / Consultations prénatales et mortalité périnatale à Madagascar.

OBJECTIVES: One of the contributions for improving maternal and child health consists in reducing the perinatal death rate. This rate reaches 20.5 per 1000 births in the health district of Fianarantsoa-II. This study is carried out to determine the factors related to this problem. MATERIALS AND METHODS: A case control study included mothers having had perinatal death and mothers having had a live birth in 2005. RESULTS: Our findings show significant relationship of certain factors with perinatal mortality: complications during the pregnancy, no medical care for these complications, poor knowledge about complications and symptoms, inadequate iron intake. Differences were also found on message transmitters and dissemination means. CONCLUSION: In rural areas, it is necessary to address the antenatal care quality by early risk management. A project entitled Plan périnatalité is proposed, so as to reduce by 50% the perinatal mortality rate in the health district of Fianarantsoa-II.