Prevalence of HIV-tuberculosis coinfection at the University Hospital of Tulear, Madagascar.

Screening for HIV is recommended for all TB patients but it has not yet been initiated in some regions of Madagascar. In this study, our main objective was to determine the seroprevalence of HIV infection in TB patients and secondarily to determine the risk factors favoring TB infection in these patients. This prospective cross-sectional study took place in the pneumology department of the University Hospital of Tulear from January to April, 2017. We diagnosed 75 patients with tuberculosis, 96.05% of them new cases. The sex-ratio was 1.81. Patients' mean age was 35 years. Two patients (2.66%) were coinfected with HIV. Among the new cases diagnosed, 62.66% had pulmonary tuberculosis with positive microscopy (TPM +). Two patients reported a person with tuberculosis among their family or close friends. Living with someone in poor hygiene conditions was reported by 82.66% of the cases. Overall, 24% were unemployed. These patients had quite varied ethnic origins. The prevalence of HIV infection in TB patients was higher than in the general population. Low income and low educational levels were the main risk factors for TB infection in Madagascar.

Description of 48 cases of multiple myeloma seen in the hematology laboratory of the CHU-Joseph Ravoahangy Andrianavalona, Antananarivo, Madagascar.

Monoclonal gammopathies are common abnormalities and their incidence increases with age. They are detected in roughly 3 % of people older over 50 years and up to 7 % of those over 70 years. Multiple myeloma (MM) is characterized by the proliferation of plasma cells within the bone marrow and excess secretion of monoclonal immunoglobulins. In Madagascar, late performance of biological examinations such as serum protein electrophoresis overestimates MM rates. We studied 54 patient records between March 2009 and January 2015 in the biology laboratory of the Joseph Ravoahangy Andrianavalona university hospital in Antananarivo (Madagascar). Monoclonal gammopathy was associated with multiple myeloma in most cases (88.9 %). Patients' median age was 64.2 years. Men were slightly more affected than women. It is discovered most frequently due to bone symptoms (83.3 %), and anemia is always present. Monoclonal gammopathy is mostly IgG. The bone marrow study showed medullary plasmacytosis. This disease appears most often in the elderly and has a slight male predominance. Bone marrow cytology is mandatory for diagnosis.

Trichomonas vaginalis among women raped in Antananarivo, 2005-2011.

Rape is a forensic emergency due to the possibility of sexually transmitted infections, including HIV/AIDS. Moreover, an upsurge is currently underway. The objective of this study was to determine the incidence of Trichomonas vaginalis in women undergoing tests at the Microbiology Unit of the Joseph Ravoahangy Andrianavalona Antananarivo Hospital after being raped. This retrospective descriptive study covers the 7-year period from 2005 to 2011 and reports the results of direct examination of the vaginal discharge after vulvar smears from rape patients. We studied the age of patients and the results of these direct smear examinations that tested for T. vaginalis. In our study, the number of women with T. vaginalis increased markedly with age. The mean age of the patients was 13.7 years (range: 2 to 41 years). Among the 232 rape victims tested, only 26 were positive for it (11.20%); trichomoniasis was thus rare among these women. T. vaginalis is a common cause of vaginitis in women and one of the most common infections transmitted by sexual assault. In children, the presence of T. vaginalis in vaginal sample is a strong indicator of sexual abuse. Other sexually transmitted infections can be transmitted during sexual abuse.

Profile and antimicrobial resistance to newly available drugs of urinary tract pathogens among Malagasy pregnant women.

Urinary tract infections are caused by growth of microorganisms anywhere in the urinary tract and pregnant women are particularly susceptible to it. Collection of baseline information regarding urinary tract bacterial profile and their antimicrobial susceptibility in pregnant women are important for treatment purposes. In order to determine the distribution of community-acquired urinary tract pathogens and estimate their susceptibility patterns to antimicrobial agents currently available in Antananarivo (Madagascar), we conducted a cross sectional preliminary survey (four months) on bacteria isolated from urine of pregnant women attending antenatal care clinic, Ambohimiandra Hospital Center. Fifty pathogens were isolated of which 21 (42%) were Gram-negative bacilli and 29 (58%) Gram-positive cocci. The most commonly isolated pathogen was Coagulase Negative Staphylococci (13 strains) for Gram-positive cocci and Escherichia coli (6 strains) for Gram-negative bacilli. Thirty three percent of Gram-negative bacilli were resistant to 3GC. One Klebsiella pneumoniae strain was found to be resistant to imipenem and one Group B Streptococci strain was vancomycin resistant. This development of resistance to newly available antimicrobial and the increase proportion of Gram-positive cocci strains imply that a drastic antimicrobial resistance surveillance need to be carried out to ensure appropriate empirical treatment.

Changing profile and increasing antimicrobial resistance of uropathogenic bacteria in Madagascar.

OBJECTIVES: We wanted to update the distribution of community-acquired uropathogens and to estimate their susceptibility profile to newly available antibiotics in Antananarivo (Madagascar). MATERIALS AND METHODS: We conducted a 3-year preliminary study (2011-2013) on bacteria isolated from the urine of patients at the Laboratory of Training and Research in Medical Biology (Antananarivo). RESULTS: Three hundred and fifty-seven pathogens were isolated: 234 (65.55%) Gram-negative bacilli and 123 (34.45%) Gram-positive cocci. The most commonly isolated bacteria were Escherichia coli (89 strains) followed by Staphylococcus aureus (48 strains). Thirty-three percent of Gram-negative bacilli were resistant to 3 CG. Forty percent of Klebsiella pneumoniae strains were significantly resistant to imipenem (P = 0.01). CONCLUSIONS: The increased resistance to newly available antibiotics and the increased rate of Gram-positive cocci strains require a drastic surveillance of antibiotic resistance to ensure appropriate empirical treatment.

Prevalence of hepatitis B virus serologic markers in pregnant patients in Antananarivo, Madagascar.

BACKGROUND AND OBJECTIVES: Hepatitis B virus (HBV) infection is a major public health problem in Madagascar. Its severity is related to the risk of chronicity, especially in case of neonatal contamination. Our objectives were to investigate the prevalence of HBV infection among pregnant patients at the Befelatanana obstetrics and gynecology teaching hospital department (BOGTH) by detecting HBsAg and to evaluate the risk of HBV mother to child transmission by screening for HBeAg. METHODS: We conducted a 6-month prospective study in the BTHOGD from February 2012 to July 2012. All pregnant patients consulting for antenatal care were screened for HBV serologic markers. RESULTS: The prevalence of HBsAg was 1.9% (20 out 1050 screened patients). The average age was 26.51 years (25-30 years). Most patients tested were unaware of their hepatitis B status and only 0.38% had been vaccinated before pregnancy. Only 1 (5%) of the 20 patients with HBsAg was positive for HBeAg. CONCLUSION: Hepatitis B is very frequent in pregnant patients in Madagascar and it is recommended that all pregnant patients be routinely screened for HBsAg. This screening of maternal infection would allow applying prophylactic measures to neonates to decrease the risk of disease chronicity.

Phenotypic and allelic profile of ABO and Rhésus D blood group system among blood donor in Antananarivo.

This study assessed the phenotypic and allelic profiles of ABO and Rhesus D blood group system among first time blood donors at the National Centre of Blood Supply of Antananarivo. We collected through this retrospective study all data registered during 7 years of practice (from 2003 to 2009). Age and sex were analysed with the result of ABO and RhD screening. They were tested both with Beth Vincent and Simonin tests which were performed in a plate, by using commercial monoclonal antibody (Diaclone(®) et Eryclone(®)), and home-made red cells tests. The Rh D was performed with the same commercial kits. The frequencies of alleles were calculated by using Bernstein method. Data about 45,857 donors were obtained. A male predominance (80.46%) was found and most of our donors were aged <40 (74.92%). 98.90% of the donors were Rh D positive. Phenotypic distribution of each ABO antigen was, respectively, 22.61, 29.66, 6.13 and 41.60% for A, B, AB and O antigen. Allelic frequencies of A, B and O were 0.1559, 0.1987 and 0.6454. These results confirmed the fact that Madagascan population had admixed ethnic origin.

Prevalence and trends of hepatitis C virus among blood donors in Antananarivo, from 2003 to 2009.

PURPOSE OF THE STUDY: Due to anemia and maternal, childhood and infancy diseases, blood transfusion is one of the most important medical cares given in sub-Saharan Africa, including Madagascar. World Health Organization encourages worldwide countries to maximize transfusion security. Until now, there was no data within a large population of blood donors. Therefore, the aim of this study was to assess the prevalence and time trends of hepatitis C virus (HCV) among all first-time blood donors coming into the National Centre of Transfusion Supply in Antananarivo. MATERIAL AND METHODS: This retrospective study was conducted at the National Centre of Transfusion Supply in Antananarivo from 2003 to May 2009. We looked up to all recorded results of systematic screening of blood donor candidates and we took data about all first-time blood donors, including age and gender. Forty-seven thousand five hundred and ten of 47,636 first-time blood donors were retained, the others were excluded due to lack of some data. RESULTS: The mean age of our donors was 33.3 years (35.8 for male, and 32.6 for female; P<<0.05). Eighty percent were male (38,225/47,510). HCV prevalence was 0.65% during the period of study and HCV positive donor candidates were older than HCV negative (mean age: 39.1 vs. 33.2; P<<0.05). It was in fact stable from 2003 to 2007, and then decreased. HCV prevalence was higher in women than in men (0.9 vs. 0.6; P<0.05), and it increased by age (P<0.05). CONCLUSION: Our study found a low prevalence of HCV among blood donors compared to many countries in Africa.

[Simplified preparation of test-red blood cells for ABO blood grouping in a laboratory in Madagascar]. / Préparation simplifiée d'hématies-tests pour le groupage sanguin ABO dans un laboratoire malgache.

INTRODUCTION: To ensure self-sufficiency and lower costs associated with reagent red blood cells, some medical laboratories produce their own test-red blood cells for plasma ABO blood grouping. However, given the vital importance of blood goup testing, it is essential to verify the reliability of these cells. The purpose of this study was to assess the quality of laboratory-made ABO test-red blood cells. MATERIAL AND METHODS: This study comparing house made and commercially available test-red blood cells was carried out at the Medical Biology Training and Research Laboratory in Madagascar. This laboratory is attended by people wishing to obtain their blood group card. RESULTS: In this population, no discrepancy was found between the red cell and plasma tests. Comparison of test-red blood cells with commercially available reagent red blood cells showed no difference in reactivity in the first four days of conservation. However a decrease in the reactivity of house made cells appeared on the 5th day. CONCLUSION: House made red blood cells are costless than commercially available reagent red blood cells mainly due to the simplified method of preparation. However, since laboratory-made cells progressivley lose antigenic reactivity quicly, production must be repeated regularly and good internal quality control is necessary to ensure reliability.

Prevalence of and risk factors for sexually-transmitted infections in hidden female sex workers.

OBJECTIVES: We wanted to determine the age-specific prevalence of selected sexually transmitted infections while assessing the risk factors among hidden female sex workers (HFSW). METHODS: One hundred HFSW over 15 years of age were recruited in an impoverished area of Antananarivo, Madagascar. After oral informed consent, blood and endocervical swabs were tested for specific antigens, antibodies, and pathogens using molecular, serologic, and microscopic examinations. A risk factor analysis was conducted with odds ratios and 95% confidence intervals. RESULTS: Thirty-two percent, 27, 12, and 7% of HFSW were infected respectively with Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis. Specific antibodies against, syphilis were detected in 11%. None were HIV-positive. The main factors associated with STI were: young age, being married, lower education level, early age for first intercourse, and a history of genital infection.

Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers.

We followed 1000 sex workers in Madagascar for 18 months to assess whether adding female condoms to male condom distribution led to increased protection levels and decreased sexually transmitted infections (STIs). For months 1-6, participants had access to male condoms only; in the final 12 months, they had access to male and female condoms. We interviewed participants about condom use every two months and tested for chlamydia, gonorrhoea and trichomoniasis every six months. Following six months of male condom distribution, participants used protection in 78% of sex acts with clients. Following female condom introduction, protection at months 12 and 18 rose to 83% and 88%, respectively. Aggregate STI prevalence declined from 52% at baseline to 50% at month 6. With the female condom added, STI prevalence dropped to 41% and 40% at months 12 and 18, respectively. We conclude female condom introduction is associated with increased use of protection to levels that reduce STI risk.

Results of a randomised trial of male condom promotion among Madagascar sex workers.

OBJECTIVES: To test the effect of supplementing peer promotion of male condom use with clinic based counselling, measured in terms of STI prevalence and reported male condom use. METHODS: 1000 female sex workers in Madagascar were randomised to two study arms: peer education supplemented by individual risk reduction counselling by a clinician (peer + clinic) versus condom promotion by peer educators only (peer only). STI testing was conducted at baseline and 6 months. Behavioural interviews were administered at baseline, 2, 4, and 6 months. RESULTS: At baseline, women in the peer only arm had prevalences of 16.0%, 23.6%, and 12.1% for chlamydia, gonorrhoea, and trichomoniasis respectively, with an aggregate prevalence of 38.2%. Baseline STI prevalences for the peer + clinic arm were slightly lower and 34.1% in aggregate. At 6 months, aggregate STI prevalence increased in the peer only arm to 41.4%, whereas the aggregate prevalence diminished slightly to 32.1% in the peer + clinic arm. In logistic regression analyses, the estimated odds ratios (ORs) for chlamydia, gonorrhoea, trichomoniasis, and aggregate STI were 0.7 (95% confidence interval 0.4 to 1.0), 0.7 (0.5 to 1.0), 0.8 (0.6 to 1.2), and 0.7 (0.5 to 0.9) respectively, comparing the peer + clinic arm with the peer only arm. The logistic regression OR for reported condom use with clients in the past 30 days increased from 1.1 at 2 months to 1.8 at 6 months, comparing the peer + clinic arm with the peer only arm, and was 1.4 overall (1.1 to 1.8). Adjustment for baseline factors changed the regression results little. CONCLUSIONS: The impact of male condom promotion on behaviour can be heightened through more concentrated counselling on risk reduction. Persistently high STI prevalence despite increases in reported condom use by sex workers supports the need for multidimensional control programmes.

[Study of idiopathic thrombopenic purpura in two pediatric services of Antananarivo city]. / Etude du purpura thrombopénique idiopathique dans deux services pédiatriques de la ville d'Antananarivo.

Idiopathic thrombocytopenic purpura (ITP), haematologic disease affecting the only blood platelets, is an acquired disease. It appears as cutaneous and mucosal bleedings preceded by a feverish syndrome. Cerebral haemorrhage is possible but very rare. If the disease occurs frequently in Europe and in the United States of America, there is a lack of data in Africa and in Madagascar. In order to fill this gap, the authors carried out retrospective and prospective studies in two paediatric units of Antananarivo for 32 months. They reported 4 cases of PTI of which clinical signs were moderate. As therapy, corticosteroids were used and were efficiency. It is desirable to settle a program allowing to survey sick children.

[Value of C-Reactive Protein (CRP) in childhood fever conditions]. / Intérêt de la C-Reactive Protein (CRP) dans les affections fébriles de l'enfant.

C-Reactive Protein (CRP) measurement is used to orientate the diagnosis of an inflammation especially in childhood febrish diseases. A retrospective study was carried out at the pediatric service of the General hospital of Befelatanana in Antananarivo for 48 months (1997-1998). The population of this study was continued of 361 patients taken from 714 febrish children. 384 CRP were performed. The initial CRP measurement allowed to differentiate 152 presumed bacterial infections: 49 respiratory tract infections, 62 in neurological pathology, 10 in digestive pathology, 19 in otorhinolaryngology pathology, 12 in urinary pathology, and 153 presumed viral infections: 86 respiratory tract infections, 29 in neurological pathology, 12 in digestive pathology, 26 in otorhinolaryngology pathology. There was a right correlation of CRP values and leukocyte levels in presumed bacterial infections. Specificity and sensibility of the test applied in different child febrish diseases were satisfactory. CRP measurement is easy and rapid to perform. It is useful and seems to be the appropriate method to diagnose childhood febrish diseases in countries where facilities are insufficient and financial possibilities limited.

[AIDS in Madagascar. I. Epidemiology, projections, socioeconomic impact, interventions]. / Le SIDA à Madagascar. I. Epidémiologie, projections, impact socio-économique, interventions.

Madagascar is still among the rare states of low prevalence of HIV. The seroprevalence rate is nevertheless rising. The aim of this study is to show the current view of the epidemic, its future tendency, its economical and social impact on people and what measures to be taken at the national scale. In Madagascar, we can state by 1995 20 cases of notified AIDS and probably 130 cases of non-notified AIDS. Seroprevalence data are collected every year by the National Reference Laboratory STD/AIDS. But, they are insufficient to estimate the number of infected people. So, they had been completed by a serosurveillance study of AIDS and syphilis in middle of 1995 and at the beginning of 1996. Pregnant women, persons with STDs and prostitutes are been screened in the six biggest cities of the Island. Results show, not only a high prevalence of syphilis, but also indicate that now, we have about 5,000 seropositive people in the country. Besides, by the number of people with STDs, it is estimated that one million Malgasy adults risk to be infected. Based on estimates of the epidemic, be it the cases of a high scenario, (Kenya) or of a low one (Thailand) by the year 2015, the seroprevalence rate could represent 3% or 15% of adults. Demographic consequences of the epidemic will be serious, particularly if HIV spreads quickly. Nevertheless, it does not stop the increase of population. Therefore, there will be more infected people with the disease, especially young people between 15 and 49 years old. The increase of dead people will be serious. Social consequences of the epidemic (case of high scenario) will be gravely felt, in particular by the rise of the number of AIDS orphans. Tuberculosis outbreak can be observed too. This disease is already a serious problem in Madagascar. At last, the epidemic will bring with it a high increase of money spent on health and will have grave consequences on agriculture, industry and commerce. Nevertheless, Madagascar still benefit a big luck which is the prevention of the epidemic not to be exploded in a near future. For this, struggle against it is particularly effective on its start. In addition to counselling given to infected people and care-given to patients, means of prevention of AIDS contamination in all target groups must be set up quickly. It is about broadcasting information on AIDS, community education, controlling other STDs e.g. (importance of medicaments' program), promoting the use of condoms and screening HIV new cases. Only an urgent coordination of everyone's efforts can control the epidemic of AIDS.

PIP: Studies were conducted in mid-1995 and at the beginning of 1996 in six sites in Madagascar on the seroprevalences of HIV and syphilis with the goal of estimating how many people were infected with HIV countrywide. The studies were conducted in Antananarivo, Fianarantsoa, Antsiranana, Toamasina, Toliary, and Mahajanga. 3135 pregnant women seeking prenatal care were included in the study, as well as 3047 sexually transmitted disease (STD) clinic clients, and 2227 prostitutes not registered with the STD services, but recruited in bars, hotels, and on the street. Study data together with epidemiological surveillance data led to the estimation that 0.07% of adults in the country were infected with HIV as of 1995, compared with 0.02% in 1989. There were 150 people with AIDS, 5000 people infected with HIV, and 1 million people at risk of exposure to the virus. In Madagascar, HIV is transmitted sexually in 96.8% of cases, perinatally in 2.4% of cases, and through blood transfusion in 0.8% of cases. As many men as women are infected, and 64% of all people infected with HIV are 20-39 years old. Projecting the course of the epidemic into the future, 3-15% of the country¿s adults could be infected with HIV in the year 2015, bringing seriously negative demographic and socioeconomic consequences. Madagascar¿s population will, however, continue to grow even should HIV be widely disseminated throughout the country. It is not too late for Madagascar to take measures to avert a major HIV/AIDS epidemic among its peoples.

[Aids in Madagascar. II. Intervention policy for maintaining low HIV infection prevalence]. / Le SIDA à Madagascar. II. Politique d'intervention pour maintenir la basse prévalence de l'infection par le VIH.

The HIV seroprevalence per 100,000 adults Malagasy rose from 20 in 1989, to 30 in 1992, and to 70 in 1995. In that year, the total number of HIV infected people in the Big Island was estimated at 5,000, the number of people sick with AIDS at 130, and the people at risk at more than 1,000,000. The latter are the persons infected with other STDs and individuals (or their partners) with risky sexual behaviour (e.g. numerous sexual partners, occasional sexual partners, and/or sexual contacts with commercial sex workers). The HIV prevalence rate is low as compared with those of other countries. Nevertheless, the spread of the HIV infection is alarming in some parts of the country and the risk factors are also present, namely: the high prevalence of STDs, numerous sexual partners, the low use of condoms in all groups, the development of tourism, the development of prostitution associated with social and economical problems, and internal and international migrations (with risky sexual contacts). Therefore, the still low but rising HIV prevalence in 1995 does not warrant complacency. To estimate the trend of HIV prevalence within the population, it is useful to know two different assumptions, as follows: firstly, a controlled evolution of the epidemic (low epidemic) and secondly, a very fast spread of the epidemic (high epidemic). If we consider the 5,000 individuals seropositive in July 1995, the Aids Impact Model (AIM) projection model shows that HIV seroprevalence rates among adults in 2015 might be between 3% (when the progression course of HIV epidemic is low) and 15% (when the progression course of HIV epidemic is high). By 2015 AIDS could have severe demographic, social, and economic impacts. Then, it is necessary to take measures to prevent contamination. Five major interventions are required: public information about AIDS, HIV transmission mechanism, and its prevention, communities education via the respected people and the notabilities to promote moral values, reduce the number of sexual partners, delay visit of sexual activity, and advice for infected couples; screening of blood donors and the supposed high risk group; control of STDs; reduction of the number of sexual partners; promotion of condom use, abstinence, and fidelity. To sum up, the fight against AIDS is not only the health professional workers' problem. It concerns all Malagasy people. Therefore, successfullness in prevention efforts to slow the epidemic needs concerted, collective, and long lasting actions from all sectors of the society for the nation's future and the well-being of the rising generations.