Antibiotic resistance of bacteria responsible for postoperative wound infections seen in the laboratory of the University Hospital of Befelatanana.

The management of postoperative wound infections is a major problem in hospitals due to the frequent ineffectiveness of antibiotic treatment. The objectives of this study are to identify the bacteria responsible for postoperative wound infections and to describe these antibiotic resistances in order to improve the management of these infections. It is a prospective study of 52 bacteriological results of postoperative wounds for a period of six months from January 2021 to June 2021 in the laboratory of the University Hospital of Befelatanana. This study showed 26 (50%) isolates of staphylococci, 17 (32.7%) isolates of enterobacteria, 6 (11.5%) isolates of streptococci and 3 (5.8%) isolates of nonfermenting gram-negatif bacilli. Antibiotic resistance, varies from 0% (vancomycin) to 92.3% (penicillin G) for staphylococci isolates, 0% (imipenem, amikacin) to 94.1% (amoxicillin) for enterobacteria isolates, 0% (vancomycin) to 50% (penicillin G) for streptococci isolates and 33% (imipenem, amikacin) to 100% (cotrimoxazole) for the isolates of nonfermenting gram-negatif bacilli. The knowledge of antibiotic resistance of bacteria responsible for postoperative wound infections allows better patient management.

Prioritizing COVID-19 vaccination efforts and dose allocation within Madagascar.

BACKGROUND: While mass COVID-19 vaccination programs are underway in high-income countries, limited availability of doses has resulted in few vaccines administered in low and middle income countries (LMICs). The COVID-19 Vaccines Global Access (COVAX) is a WHO-led initiative to promote vaccine access equity to LMICs and is providing many of the doses available in these settings. However, initial doses are limited and countries, such as Madagascar, need to develop prioritization schemes to maximize the benefits of vaccination with very limited supplies. There is some consensus that dose deployment should initially target health care workers, and those who are more vulnerable including older individuals. However, questions of geographic deployment remain, in particular associated with limits around vaccine access and delivery capacity in underserved communities, for example in rural areas that may also include substantial proportions of the population. METHODS: To address these questions, we developed a mathematical model of SARS-CoV-2 transmission dynamics and simulated various vaccination allocation strategies for Madagascar. Simulated strategies were based on a number of possible geographical prioritization schemes, testing sensitivity to initial susceptibility in the population, and evaluating the potential of tests for previous infection. RESULTS: Using cumulative deaths due to COVID-19 as the main outcome of interest, our results indicate that distributing the number of vaccine doses according to the number of elderly living in the region or according to the population size results in a greater reduction of mortality compared to distributing doses based on the reported number of cases and deaths. The benefits of vaccination strategies are diminished if the burden (and thus accumulated immunity) has been greatest in the most populous regions, but the overall strategy ranking remains comparable. If rapid tests for prior immunity may be swiftly and effectively delivered, there is potential for considerable gain in mortality averted, but considering delivery limitations modulates this. CONCLUSION: At a subnational scale, our results support the strategy adopted by the COVAX initiative at a global scale.

Existing human mobility data sources poorly predicted the spatial spread of SARS-CoV-2 in Madagascar.

For emerging epidemics such as the COVID-19 pandemic, quantifying travel is a key component of developing accurate predictive models of disease spread to inform public health planning. However, in many LMICs, traditional data sets on travel such as commuting surveys as well as non-traditional sources such as mobile phone data are lacking, or, where available, have only rarely been leveraged by the public health community. Evaluating the accuracy of available data to measure transmission-relevant travel may be further hampered by limited reporting of suspected and laboratory confirmed infections. Here, we leverage case data collected as part of a COVID-19 dashboard collated via daily reports from the Malagasy authorities on reported cases of SARS-CoV-2 across the 22 regions of Madagascar. We compare the order of the timing of when cases were reported with predictions from a SARS-CoV-2 metapopulation model of Madagascar informed using various measures of connectivity including a gravity model based on different measures of distance, Internal Migration Flow data, and mobile phone data. Overall, the models based on mobile phone connectivity and the gravity-based on Euclidean distance best predicted the observed spread. The ranks of the regions most remote from the capital were more difficult to predict but interestingly, regions where the mobile phone connectivity model was more accurate differed from those where the gravity model was most accurate. This suggests that there may be additional features of mobility or connectivity that were consistently underestimated using all approaches but are epidemiologically relevant. This work highlights the importance of data availability and strengthening collaboration among different institutions with access to critical data - models are only as good as the data that they use, so building towards effective data-sharing pipelines is essential.

A behavioural and HIV serological survey among detainees of Ankazondrano jail in Fianarantsoa, Madagascar.

Aims: The prevalence of HIV in the general population of Madagascar is 0.3%. Some population groups, especially detainees are vulnerable to this infection. Our study was the first combined HIV survey of the detainees of Ankazondrano jail in Fianarantsoa. The study aims to determine the serological status of the detainees related to HIV infection and their risky behaviours for this infection.Methods: A descriptive cross-sectional survey of the detainees 18 years old and over was carried out in Ankazondrano jail in Fianarantsoa during September 2020.Results: The prevalence of HIV in the sample was zero; 89.43% of the detainees reported to have heard about HIV; only 15.45% had a general knowledge about it; 76.42% of them knew that a condom is a way of protection against HIV infection; however, they had wrong responses about protection against this infection. In fact, 47.97% of the surveyed detainees thought that HIV is transmitted by mosquito bites and 65.04% thought that it is transmitted by shaking hands. Almost one quarter of the detainees reported that there is no risk of HIV contraction in jail.Conclusion: In this study, nevertheless, the prevalence of HIV is zero; detainees of Ankazondrano jail are a vulnerable group to HIV due to their lack of knowledge of this infection and the fact that they undertook risky behaviours.

Existing human mobility data sources poorly predicted the spatial spread of SARS-CoV-2 in Madagascar.

For emerging epidemics such as the COVID-19 pandemic, quantifying travel is a key component of developing accurate predictive models of disease spread to inform public health planning. However, in many LMICs, traditional data sets on travel such as commuting surveys as well as non-traditional sources such as mobile phone data are lacking, or, where available, have only rarely been leveraged by the public health community. Evaluating the accuracy of available data to measure transmission-relevant travel may be further hampered by limited reporting of suspected and laboratory confirmed infections. Here, we leverage case data collected as part of a COVID-19 dashboard collated via daily reports from the Malagasy authorities on reported cases of SARS-CoV-2 across the 22 regions of Madagascar. We compare the order of the timing of when cases were reported with predictions from a SARS-CoV-2 metapopulation model of Madagascar informed using various measures of connectivity including a gravity model based on different measures of distance, Internal Migration Flow data, and mobile phone data. Overall, the models based on mobile phone connectivity and the gravity-based on Euclidean distance best predicted the observed spread. The ranks of the regions most remote from the capital were more difficult to predict but interestingly, regions where the mobile phone connectivity model was more accurate differed from those where the gravity model was most accurate. This suggests that there may be additional features of mobility or connectivity that were consistently underestimated using all approaches, but are epidemiologically relevant. This work highlights the importance of data availability and strengthening collaboration among different institutions with access to critical data - models are only as good as the data that they use, so building towards effective data-sharing pipelines is essential.

The Challenge of Achieving Immunity Through Multiple-Dose Vaccines in Madagascar.

Administration of many childhood vaccines requires that multiple doses be delivered within a narrow time window to provide adequate protection and reduce disease transmission. Accurately quantifying vaccination coverage is complicated by limited individual-level data and multiple vaccination mechanisms (routine and supplementary vaccination programs). We analyzed 12,541 vaccination cards from 6 districts across Madagascar for children born in 2015 and 2016. For 3 vaccines-pentavalent diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine (DTP-HB-Hib; 3 doses), 10-valent pneumococcal conjugate vaccine (PCV10; 3 doses), and rotavirus vaccine (2 doses)-we used dates of vaccination and birth to estimate coverage at 1 year of age and timeliness of delivery. Vaccination coverage at age 1 year for the first dose was consistently high, with decreases for subsequent doses (DTP-HB-Hib: 91%, 81%, and 72%; PCV10: 82%, 74%, and 64%; rotavirus: 73% and 63%). Coverage levels between urban districts and their rural counterparts did not differ consistently. For each dose of DTP-HB-Hib, the overall percentage of individuals receiving late doses was 29%, 7%, and 6%, respectively; estimates were similar for other vaccines. Supplementary vaccination weeks, held to help children who had missed routine care to catch up, did not appear to increase the likelihood of being vaccinated. Maintaining population-level immunity with multiple-dose vaccines requires a robust stand-alone routine immunization program.

The COVID-19 epidemic in Madagascar: clinical description and laboratory results of the first wave, march-september 2020.

BACKGROUND: Following the first detection of SARS-CoV-2 in passengers arriving from Europe on 19 March 2020, Madagascar took several mitigation measures to limit the spread of the virus in the country. METHODS: Nasopharyngeal and/or oropharyngeal swabs were collected from travellers to Madagascar, suspected SARS-CoV-2 cases and contact of confirmed cases. Swabs were tested at the national reference laboratory using real-time RT-PCR. Data collected from patients were entered in an electronic database for subsequent statistical analysis. All distribution of laboratory-confirmed cases were mapped, and six genomes of viruses were fully sequenced. RESULTS: Overall, 26,415 individuals were tested for SARS-CoV-2 between 18 March and 18 September 2020, of whom 21.0% (5,553/26,145) returned positive. Among laboratory-confirmed SARS-CoV-2-positive patients, the median age was 39 years (IQR: 28-52), and 56.6% (3,311/5,553) were asymptomatic at the time of sampling. The probability of testing positive increased with age with the highest adjusted odds ratio of 2.2 [95% CI: 1.9-2.5] for individuals aged 49 years and more. Viral strains sequenced belong to clades 19A, 20A and 20B indicative of several independent introduction of viruses. CONCLUSIONS: Our study describes the first wave of the COVID-19 in Madagascar. Despite early strategies in place Madagascar could not avoid the introduction and spread of the virus. More studies are needed to estimate the true burden of disease and make public health recommendations for a better preparation to another wave.

[Adherence of private sector providers to uncomplicated malaria management policy in Madagascar]. / Adhérence des prestataires du secteur privé à la politique de prise en charge des cas de paludisme simple à Madagascar.

INTRODUCTION: This study aims to assess the adherence of private health providers to the use of malaria rapid diagnostic tests (RDTs) and to the prescription of artemisinin-containing combinations (ACT) in patients with uncomplicated malaria. METHODS: We conducted an analytical, retrospective and cross-sectional study in 11 Madagascar's health districts divided into four epidemiological strata in September and in October 2015. A total of 43 health providers from 39 private health care facilities (PHF) were interviewed and visited. RESULTS: Health providers declared having read the malaria management manual in 16.3% of cases (4/43). Only one quarter (25.6%) of health providers had RDTs in their office. ACT was reported as "first-line drug" for the treatment of uncomplicated malaria by 83.7% of health providers. In practice, 55.6% of health providers had doubts about the results of the RDTs. The use of antimalarial drugs, despite having had negative RDTs results (38.2%), was more frequent among those who had raised doubts (p = 0.03). Conversely, despite having had positive RDTs results, half of the health providers did not prescribe ACT (50%). The decision to not participate in periodic reviews by the Health District (p = 0.05) negatively influenced the adherence to the policies. CONCLUSION: The low adherence of private health providers to the national guidelines for the management of uncomplicated malaria raises questions about the importance of exercising more control over health providers activities.

[Resistant phenotypes of Escherichia coli strains responsible for urinary tract infection in the laboratory of the University Hospital Joseph Raseta Befelatanana, Antananarivo]. / Phénotypes de résistance des souches d'Escherichia coli responsables d'infection urinaire au laboratoire du Centre Hospitalo-Universitaire de Befelatanana Antananarivo.

INTRODUCTION: Urinary tract infection caused by Escherichia coli frequently occurs in the hospital environment. This study aims to describe resistant phenotypes of Escherichia coli strains to monitor their occurrence. METHODS: We conducted a descriptive retrospective study of 102 Escherchia coli strains responsible for urinary tract infection in the laboratory of the University Hospital Joseph Raseta Befelatanana, Antananarivo from January 2014 to October 2016. RESULTS: Beta-lactam antibiotic resistance screening identified high-level penicillinases 50% (n=51), Escherichia coli producing extended-spectrum beta-lactamases (ESBLs) 22.5% (n=23), high-level cephalosporinases 14.7% (n=15), penicillinases low level 5.9% (n=6), wild type strains 5.9% (n=6) and a strain ofEscherichia coli emerging strain high-level resistance. Aminoglycosides resistance was identified in 58 (56.9%) wild type phenotype, 29 (28.4%) strains sensitive to amikacin and 15 (14.7%) resistant to all aminoglycosides. Fluoroquinolones resistance was identified in 52 (51%) wild type strains, 9 (8.8%) strains sensitive to ciprofloxacin and 41 (40.2%) resistant to all fluoroquinolones. Women (25, 7%) (p= 0.25, NS), patients more than 60 years (38.7%) (p=0.02), patients hospitalized in the Department of Nephrology (53.8%) (p=0.04), with urinary disorder and kidney disease (29, 7%) (p= 0.2, NS) were the most affected by E-ESBL. CONCLUSION: Based on high multidrug resistance in Escherichia coli strains guidelines for the empirical treatment of urinary tract infections need to be revised.

Joint pain epidemiology and analgesic usage in Madagascar.

INTRODUCTION: To describe the epidemiology of joint pains and document analgesics usage in an African context. METHODS: Patients suffering from joint pain were recruited from nine sites located in Antananarivo, Madagascar, including 6 hospital services and 3 clinics. Doctors collected information on the etiology and characteristics of the patients' pain. Analgesics prescribed by these doctors were also documented. RESULTS: In total, 400 patients were enrolled in the study (52.5% women, mean age of 42.34 years ± 17.7 [4-86]). Pain of mechanical type was found in 260 participants, 65%; 95% CI [60.1% to 69.6%] and inflammatory type pains in 128 cases 32%; 95% CI [27.5% to 36.9%]. Mixed pains were found in 12 patients (3%). The median duration of pain prior to the consultation was 6.5 days. The average pain intensity was 57.9 ± 19.9 mm of a total of 100 mm maximum on a visual analogue scale, VAS. The etiologies of mechanical type pains were dominated by fracture, common low back pain and tendonitis. Arthrosis was the dominant cause of inflammatory type pain, followed by rheumatoid arthritis and gout. NSAIDs (74.5%) were the most frequently prescribed analgesics followed by paracetamol (49.5%), weak opioids (23%) and corticosteroids (12.25%). Two-thirds of medical prescriptions (65.3%) were of combined analgesics. CONCLUSION: These findings demonstrated that mechanical type pains were the main reason for consultations for joint pain in these situations in Antananarivo, Madagascar. The most frequently prescribed pain-relieving medications were NSAIDs, paracetamol, weak opioids and corticosteroids. This descriptive study may be a useful starting point for further epidemiological studies of pain in the African context.

[Blood count results from hypertensive patients seen in laboratory of CHU-HJRB Antananarivo in 2013]. / Hémogramme chez les hypertendus vus au laboratoire du CHU-HJRB d'Antananarivo en 2013.

INTRODUCTION: The blood count is a routine laboratory test prescribed to patients suffering from high blood pressure. This study aims to describe the results of blood count from hypertensive patients and to identify conditions associated. METHODS: This retrospective and descriptive study concerns the period from the 1st of December 2012 to 31 th of December 2013 in the laboratory of University Hospital Center CHU-HJRB of Antananarivo. All records of results from hypertensive patients who requested blood count have been exploited. RESULTS: Among 151 hypertensive patients, 91 (60.3%) had pathological blood counts. Of these, 64 (70.4%) showed one type of abnormality and 27 (29.6%) had multiple abnormalities. The anaemia (33.91%), the leukocytosis (33.04%), the polycythemia (10.43%) and the leukopenia (9.57%) are the most frequent. Among the multiple abnormalities, anaemia associated with leukocytosis is the most observed (29.6%). The microcytosis anaemia (41%) and the neutrophil polymorphonuclear leukocytosis are the most dominant (47.4%). Patients in nephrology (90%) and in endocrinology (81.3%) are the most concerned (p = 0,008). Hypertensive under 20 years old (100%) and women (61.5%) are the most affected (p > 0, 05). The seizures (100%), the edema of the lower limbs (100%) and diabetes (70%) are the signs and pathology most encountered. CONCLUSION: The blood count should be prescribed for all hypertensive patients to identify the affections that will be treated simultaneously with the high blood pressure. Thus, hypertensive patients will have a good follow-up and their life expectancy will be improved.

[Antibiotic consumption at Antananarivo University Hospital: prevalence and strategic challenges]. / Consommation d’'antibiotiques au Centre Hospitalier Universitaire d’Antananarivo : prévalence et défis stratégiques.

INTRODUCTION: Very few studies have been conducted on antibiotic consumption in Madagascar. The objective of this study was to describe antibiotic consumption in a tertiary university hospital in Antananarivo, Madagascar to more clearly define good antibiotic use strategies. MATERIALS AND METHOD: A one-day prevalence survey was conducted on 5 April 2011 in the 339-bed Befelatanana Hospital with a bed occupation rate of 65.5%. RESULTS: The prevalence of antibiotic therapy among the 222 patients hospitalised on the day of the survey was 57.2%. Almost one half (49.6%) of patients received a combination of at least two antibiotics. The classes of antibiotics most commonly prescribed were beta-lactam antibiotics (55.3%), imidazoles (14.9%), aminoglycosides (14.9%), quinolones (7.9%) and macrolides with 7% of prescriptions. Penicillins accounted for 55.5% of all beta-lactam antibiotic prescriptions, followed by third-generation cephalosporins. Children under the age of 14 years (p<0.019) and patients with invasive devices (p<10(-6)) received more antibiotics. Antibiotic prescription in the Emergency Room­Intensive Care Unit was significantly higher than in the other wards (p<0.01). CONCLUSION: A high rate of antibiotic use was observed in Befelatanana University Hospital. Beta-lactam antibiotics were the agents most commonly prescribed and the Emergency Room­Intensive Care Unit was the leading antibiotic prescriber. It is essential to set up a good antibiotic use policy.

[Factors associated with tuberculosis treatment non-compliance in Antananarivo city, Madagascar]. / Facteurs associés à l'abandon du traitement anti-tuberculeux dans la ville d'Antananarivo, Madagascar.

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.