Prescription of medications for acute diarrhea in infants in Antananarivo, Madagascar.

AIM: To evaluate the professional practices of physicians in Antananarivo in managing acute diarrhea in infants. METHODS: This prospective study was conducted from March 19 to April 21, 2012, as an anonymous survey of randomly selected general practitioners and pediatricians working in the public or private sector in the city of Antananarivo. RESULTS: The survey included 125 physicians: 105 general practitioners, 11 pediatricians, and 9 other specialist physicians (7.2%) with pediatric activity. Only 4.8% of the physicians questioned had not received training about diarrhea in the previous two years. One doctor in 4 (25.6%) did not prescribe oral rehydration solution. The reasons given were lack of signs of dehydration (50%) and recommendation of other beverages (15.5%). Zinc prescription was rare (9.6%). Early refeeding was recommended by 41.6% of physicians. Almost half (47.2%) routinely use antibiotics, and 86.4% prescribe antidiarrheal medications. CONCLUSION: The WHO recommendations for the treatment of acute diarrhea in children are not followed. Continuing and repeated medical education is necessary.

Helicobacter pylori infection in children in Madagascar: risk factors for acquisition.

AIM: The aim of our study was to assess the prevalence, risk factors for acquisition and the clinical characteristics of H. pylori infection in Malagasy children. METHODS: A 2 year prospective study was conducted among 434 children from a rural (group A) and an urban area (group B). H. pylori status was evaluated by an ELISA serological test. Various demographic and clinical characteristics were recorded and subjected to statistical analysis. RESULTS: The prevalence of H. pylori infection was 39.6% and increased significantly from 18.1% for children <1 year old to 61.5% for children >10 years old. It was significantly higher in group B (46.9%) than in group A (26.4%). Using multivariate logistic regression modelling, a significant association was found between H. pylori infection and drinking spring water. Exposure to antibiotics during the previous year had no observable effect on H. pylori. CONCLUSION: The overall prevalence of H. pylori infection among Malagasy children was 39.6%. A significant association between H. pylori infection and drinking spring water was found.

[Cutaneous tuberculosis: a pediatric case in Madagascar]. / Tuberculose cutanée: une observation pédiatrique à Madagascar.

Cutaneous manifestation of tuberculosis is still observed in countries with high endemicity of tuberculosis such as Madagascar. The purpose of this report is to describe a case of nodular type cutaneous tuberculosis located in the subclavian region of a 5-month-old child living in Antananarivo, Madagascar. In absence of bacteriological evidence, diagnosis was based on epidemiological, clinical and histological findings. Treatment was successful using standard antituberculosis therapy. This case illustrates the diagnostic pitfalls associated with this type of tuberculosis.

[Neglected shoulders reported at the Befelatanana Maternity Hospital (Antananarivo, Madagascar)]. / Les épaules négligées vues à la maternité de Befelatanana à Antananarivo, Madagascar.

We conducted a retrospective study on neglected shoulders during 12 months at the Maternity Hospital of Befelatanana, 31 cases among 4685 deliveries were reported. The majority of the pregnancies are not under medical supervision and no ultrasound is carried out during the third trimester. There were 8 cases of uterine rupture, 2 haemorrhage shocks, 6 syndromes of prerupture, 6 umbilical cord prolapses at the third degree and 6 tears of the cervix. 20 caesarean sections have been performed as well as a turning of foetus in utero in 3 women, 4 hysterectomies, and a conservative suture with uterine tube ligation in the other cases. Often linked to a large multiparity the neglected shoulder remains quite frequent in developing countries such as Madagascar and regular prenatal consultations together with a rigorous clinical exam are highly recommended by the authors to make an early diagnosis and provide a better care management.

Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar.

OBJECTIVES: The diaphragm, a woman controlled, reusable contraceptive device, might prevent some sexually transmitted infections (STIs). We assessed the acceptability and feasibility of use of silicone Wide-Seal Arcing Diaphragms (Milex Products, Chicago, IL, USA) by sex workers in Madagascar. METHODS: Over 8 weeks, we evaluated method acceptability by examining patterns of and problems with women's diaphragm use. We also evaluated several measures of study feasibility, including recruitment and follow up methods. RESULTS: 91 women from three cities (Antananarivo, Tamatave, and Mahajanga) participated, and 87 (96%) completed follow up. At enrolment, participants reported a median of six sex acts with five clients in the previous week. During the follow up period, participants reported a median of three sex acts with three clients during the previous 2 days, and self reported continuous diaphragm use during the previous day increased from 87% to 93%. Seven women became pregnant (incidence 53 pregnancies per 100 woman years). Self reported use of male condoms and diaphragms was fairly constant over the study period: women reported condom use in 61% to 70% of acts and diaphragms in 95% to 97% of acts. The number of participants reporting diaphragm problems decreased from 15 (16%) at the first visit to six (7%) at the final visit. 20 women (22%) needed replacement devices during follow up because their original diaphragms were lost, were the wrong size, or became seriously damaged. CONCLUSIONS: Given the high use and steady decrease in reported problems during the study, we believe diaphragms are acceptable and feasible in this resource poor, low education sex worker population.

[Haemophilus influenzae, the second cause of bacterial meningitis in children in Madagascar]. / Haemophilus influenzae, deuxième cause des méningites bactériennes de l'enfant à Madagascar.

The Haemophilus influenzae b is one of the main germs causing bacterial meningitis in children in countries where the vaccine anti-Haemophilus influenzae b is not widely used. In Madagascar, no epidemiological study on this germ has been carried out. The objective of this research is to assess the role of Haemophilus influenzae meningitis in Antananarivo and to determine its epidemiological aspects and evolution. A multicentric study coordinated by the Institut Pasteur de Madagascar included all children less than 15 years old with infectious syndromes associated to a syndrome of meningial irritation and/or convulsion and/or coma. These children were admitted in the pediatric service of the three main hospitals in Antananarivo from June 1998 and June 2000. A lumbar puncture was performed on each child; the cerebrospinal fluid was set aside for cytobacterial and biochemical controls completed with an antimicrobial sensitivity testing and a soluble antigens research. Out of 160 case studies, the Haemophilus influenzae b arrives at the second place among the agents causing bacterial meningitis in children. This type of bacteria is the source of 32% of meningitis after the Streptococcus pneumoniae (34%). It affects 96% of children less than two years old, with a maximal frequency before the age of one year. The lethality rate is 28.6% and the neurological sequelae were observed in 31.4% of patients. Haemophilus influenzae is sensitive to the third generation cephalosporins but shows high resistance to chloramphenicol (42%), amoxicillin (29%) and gentamicin (22%). The relatively high frequency as well as the high lethality rate caused by the Haemophilus influenzae b meningitis, affecting selectively the children under two years old, bring in the need to introduce the anti-Haemophilus influenzae b vaccine in the national vaccination program in Madagascar. This vaccine has proved to be efficient in many countries where it has been used. Furthermore, in the probabilistic treatment of bacterial meningitis in children, the third generation cephalosporins should be used in the first place.

[Non-tubercular bacterial meningitis in children in Antananarivo, Madagascar]. / Les méningites bactériennes non tuberculeuses de l'enfant à Antananarivo, Madagascar.

OBJECTIVE: To determine the bacterial causal agents of meningitis and their pattern of resistance, in children more than one month to 14 years of age. METHODS: A 2 years, prospective study (June 1998 to June 2000) on bacterial meningitis in children was carried out in the main hospitals in Antananarivo. The enrollment criteria upon admission were fever with symptoms of meningitis and/or convulsions and/or coma. A lumbar puncture was systematically performed in each child. The aspect of the cerebrospinal fluid was described, the level of protein and glucose estimated, soluble antigens measured. Following the examination of a Gram straining, an aliquot of the fluid was cultured on specific medium. Antimicrobial sensitivity testing of isolated pathogens was performed. RESULTS: Bacterial meningitis was confirmed in 119 children: 95 (80%) and 111 (93%) were less than 12 and 24 months of age, respectively. The sex distribution was 1:1. Three predominant microorganisms were identified: Streptococcus pneumoniae (45%), Haemophilus influenzae b (43%) and Neisseria meningitidis (10%) of which ten of 12 cases were belonging to serogroup B. The other microorganisms isolated were E. coli (2%). S. pneumoniae were found to be sensitive to penicillin G and H. influenzae were found to be sensitive to the third generation cephalosporins. Seven percent of the S. pneumoniae strains were mildly resistant (R + I) to chloramphenicol and between 29 and 50% to aminoglucosides. A moderate resistance against gentamicin and amoxicillin was found in 22-29% of the H. influenzae strains. The mortality rate was high (31%) and among the surviving children 30% presented with neurosensitive disorders. CONCLUSION: According to these data we may recommend the inclusion of vaccination against H. influenzae in the children immunization program in Madagascar. The early diagnosis and treatment with appropriate antibiotics, such as third generation of cephalosporins, are other critical measures to be taken in order to reduce the risk of developing severe complications associated to bacterial meningitis.

Risk factors for fatal diarrhoea among dehydrated malnourished children in a Madagascar hospital.

OBJECTIVE: To examine mortality risk factors during rehydration among 6-35 month malnourished children with diarrhoea. DESIGN: Data collected prospectively during a clinical trial comparing two oral rehydration solutions (ORS). SETTING: Paediatric ward. SUBJECTS: Study children had either a weight-for-age Z-score below -2 or a weight-for-height below 70% of NCHS median. All had diarrhoea for < 5 days. 150 were enrolled and two were excluded for intercurrent infection. INTERVENTION: Children were randomly allocated to receiving 100 ml/kg of standard or rice-based ORS during the 6h following admission. Then they received 420 kJ/kg/day of high energy milk, progressively increased to 840 kJ/kg/day. RESULTS: Mortality rate was 16% and with no difference by ORS group. In univariate analysis, the risk of dying (mean odds ratio; 95% confidence interval) was significantly higher among girls (3.5; 1.4-8.9), in non-breast-fed children (3.7; 1.4-9.6) and in children with a low weight-for-height (5.1; 1.9-14.1). Low weight, moderate or severe dehydration, low plasma specific gravity or total plasma protein and longer duration of diarrhoea before inclusion also were significant risk factors. In multivariate logistic analysis, only absence of breast-feeding was associated with a higher risk of dying among girls with a low weight-for-height. Among them, eight out of nine died, compared to 15 out of 139 for other children. CONCLUSION: Breast-feedings protected severely malnourished girls against death from diarrhoea even when dehydration was corrected. Mechanisms underlying this selective effect are poorly understood.

Goat's milk as a substitute for cow's milk in undernourished children: a randomized double-blind clinical trial.

OBJECTIVE: This paper compares the effects of goat's milk and cow's milk on weight gain and fat absorption, in children with overt malnutrition. METHODS: Thirty hospitalized malnourished children aged from 1 to 5 years were included in a randomized double-blind trial. The children were fed either goat or cow's milk with a randomized will defined composition, added with vegetable oil, sugar, vitamins and minerals o achieve 1,000 kcal/liter. Children were offered 100 kcal/kg on the first day, with a regular daily increase in energy intake thereafter that reached 200 kcal/kg per day on the tenth day. RESULTS: Both groups of children had the same degree of malnutrition on inclusion. The mean weight-for-height Z score was -1.7 in both groups. One death with candidiasis occurred in the goat's milk group. Weight gain was similar in both groups: 8.5 g/kg/day (SE = 1.37) with goat's milk and 7.8 (SE = 1.9) with cow's milk. There was no significant difference in HEM intake: 157 ml/kg/day (SE = 4), vs 162 (SE = 4) for goat and cow's milk, respectively. Fat absorption coefficients on the 15th day of treatment were also similar in both groups. CONCLUSION: These results suggest that goat's milk has a nutritional value similar to that of cow's milk and could be used as an alternative to cow's milk for rehabilitating undernourished children.

[Oral rice-based rehydration solution (SRO), alternative of SRO of WHO in acute diarrhea in malnourished patients]. / La solution de réhydratation orale (SRO) à base de riz, alternative de la SRO de l'OMS dans la diarrhée aiguë des malnutris.

BACKGROUND: Although malnutrition is frequently associated with diarrhea, most oral rehydration solutions have been tested in well-nourished children. The study tests efficacy of rice, a traditional treatment for diarrhea in Madagascar. PATIENTS AND METHODS: 150 severely malnourished children, aged 6 months to 3 years, took part in this randomized trial. All the children were given oral rehydration solution, (100 ml/kg) in the first 6 hours. The first group (68 children) was given a solution containing glucose, (20 g/l). The second group (82 children) was given a solution containing rice powder (50 g/l). Treatment was then continued according to WHO recommendations, including feeding after rehydration (mixture of milk, oil and sugar). RESULTS: The age, weight, height, duration of diarrhea before admission, degree of dehydration and pathogens in stools of the two groups were comparable on admission. Only 2 patients were withdrawn from the trial. The percentage of death was the same in both groups: 16% of those given glucose and 15% of those given rice-based rehydration solution. The weight gains were similar in both groups; the duration of diarrhea was 89 +/- 6 hours in the glucose-fed groups and 68 +/- 4 hours for those given the rice-based rehydration solution (p < 0.02). CONCLUSIONS: Both glucose and rice-based rehydration solutions are equally effective for rehydrating severely malnourished children with acute diarrhea. The rice-based rehydration solution also reduces the duration of diarrhea.

The malaria epidemic in Antananarivo observed from Pediatric Service "A" of the Befelatanana General Hospital.

A recent malaria epidemic striking Antananarivo, the capital city of Madagascar, is shown from hospital records of Pediatric Service "A" of the Befelatanana General Hospital. From 1980 to 1988 malaria cases in this hospital service increased from 0.9% to 14.4% of all admissions (on average 1785 per year). The unexpected expansion is observed in 1984, 1985 and 1986 and since that time malaria has apparently maintained a stable endemic level. Malaria mortality as a proportion of general mortality in the service followed a parallel course but the case fatality rate remained constant during the whole period, in spite of the progressive increase of cerebral malaria (coma) cases. Hospitalized malaria children came mainly from Western and Southern urban and periurban areas of Antananarivo, more rarely from the central areas, the hilly zone, the North and the East of the city.