Knowledge, experiences, and practices of women affected by female genital schistosomiasis in rural Madagascar: A qualitative study on disease perception, health impairment and social impact.

BACKGROUND: Female genital schistosomiasis (FGS) is a neglected manifestation of urogenital schistosomiasis caused by S. haematobium. The disease presents with symptoms such as pelvic pain, vaginal discharge and bleeding and menstruation disorders, and might lead to infertility and pregnancy complications. The perspectives of women with FGS have not been studied systematically. The aim of the study was to understand knowledge, experiences, and practices of women with FGS. METHODS: We performed a qualitative study with seventy-six women diagnosed of having FGS, in the Ambanja district in Northwest Madagascar. Data collection was either through focus group discussion (N = 60) or in an individual semi-structured interview (N = 16). FGS was diagnosed by colposcopy. The data was analysed using Mayring´s qualitative content analysis. RESULTS: Knowledge on how the disease is acquired varied and ideas on prevention remained vague. Patients suffered from vaginal discharge and pelvic complaints. Some women expressed unbearable pain during sexual intercourse and compared their pain to an open wound being touched. FGS considerably impaired women´s daily activities and their quality of life. Infertility led to resignation and despair, conflicts with the partner and to social exclusion from the community. Women fearing to sexually transmit FGS refrained from partnership and sexual relations. Many women with FGS reported stigmatisation. A coping strategy was to share strain with other women having similar complaints. However, concealing FGS was a common behaviour which led to social isolation and delayed health care seeking. CONCLUSIONS: Our study underlines that FGS has an important impact on the sexual health of women and on their social life in the community. Our results highlight the importance of providing adequate health education and structural interventions, such as the supply of water and the provision of sanitation measures. Further, correct diagnosis and treatment of FGS in adolescent girls and women should be available in all S. haematobium-endemic areas. TRIAL REGISTRATION: The qualitative study was embedded in a randomised controlled trial (RCT) in which two doses of praziquantel were compared (https://clinicaltrials.gov/ct2/show/NCT04115072).

Cervical lesion proportion measure using a digital gridded imaging technique to assess cervical pathology in women with genital schistosomiasis.

Female genital schistosomiasis (FGS) is characterized by a pattern of lesions which manifest at the cervix and the vagina, such as homogeneous and grainy sandy patches, rubbery papules in addition to neovascularization. A tool for quantification of the lesions is needed to improve FGS research and control programs. Hitherto, no tools are available to quantify clinical pathology at the cervix in a standardized and reproducible manner. This study aimed to develop and validate a cervical lesion proportion (CLP) measure for quantification of cervical pathology in FGS. A digital imaging technique was applied in which a grid containing 424 identical squares was positioned on high resolution digital images from the cervix of 70 women with FGS. CLP was measured for each image by observers counting the total number of squares containing at least one type of FGS associated lesion. For assessment of inter- and intra-observer reliability, three different observers measured CLP independently. In addition, a rubbery papule count (RPC) was determined in a similar manner. The intraclass correlation coefficient was 0.94 (excellent) for the CLP inter-rater reliability and 0.90 (good) for intra-rater reliability and the coefficients for the RPC were 0.88 and 0.80 (good), respectively. The CLP facilitated a reliable and reproducible quantification of FGS associated lesions of the cervix. In the future, grading of cervical pathology by CLP may provide insight into the natural course of schistosome egg-induced pathology of the cervix and may have a role in assessing praziquantel treatment efficacy against FGS. Trial Registration: ClinicalTrials.gov, trial number NCT04115072; trial URL https://clinicaltrials.gov/ct2/show/NCT04115072?term=Female+genital+schistosomiasis+AND+Madagascar&draw=2&rank=1.

High-resolution infrared thermography: a new tool to assess tungiasis-associated inflammation of the skin.

BACKGROUND: Tungiasis is highly prevalent in low- and middle-income countries but remains often under diagnosed and untreated eventually leading to chronic sequels. The objective of the study was to assess whether tungiasis-associated inflammation can be detected and quantified by high-resolution infrared thermography (HRIT) and whether after removal of the parasite inflammation resolves rapidly. METHODS: Patients with tungiasis were identified through active case finding. Clinical examination, staging, and thermal imaging as well as conventional photography were performed. In exemplary cases, the embedded sandfly was extracted and regression of inflammation was assessed by thermal imaging 4 days after extraction. RESULTS: The median perilesional temperature was significantly higher than the median temperature of the affected foot (rho = 0.480, p = 0.003). Median perilesional temperature measured by high-resolution infrared thermography was positively associated with the degree of pain (rho = 0.395, p < 0.017) and semi-quantitative scores for acute (rho = 0.380, p < 0.022) and chronic (rho = 0.337, p < 0.044) clinical pathology. Four days after surgical extraction, inflammation and hyperthermia of the affected area regressed significantly (rho = 0.457, p = 0.005). In single cases, when clinical examination was difficult, lesions were identified through HRIT. CONCLUSION: We proved that HRIT is a useful tool to assess tungiasis-associated morbidity as well as regression of clinical pathology after treatment. Additionally, HRIT might help to diagnose hidden and atypical manifestations of tungiasis. Our findings, although still preliminary, suggest that HRIT could be used for a range of infectious skin diseases prevalent in the tropics. TRIAL REGISTRATION: ISRCTN11415557, Registration date: 13 July 2011.

Gynecological manifestations, histopathological findings, and schistosoma-specific polymerase chain reaction results among women with Schistosoma haematobium infection: a cross-sectional study in Madagascar.

BACKGROUND: The pathophysiology of female genital schistosomiasis (FGS) is only partially understood. This study aims to describe the histopathological findings, polymerase chain reaction (PCR) results, and gynecological manifestations of FGS in women with different intensities of Schistosoma haematobium infection. METHODS: Women aged 15-35 years living in an S. haematobium-endemic area in Madagascar underwent pelvic and colposcopic examinations. Small biopsy specimens were obtained from lesions and examined histopathologically. Schistosoma PCR was done on urine, biopsy, cervicovaginal lavage, and genital mucosal surface specimens. RESULTS: Sandy patches and rubbery papules were found in 41 of 118 women (35%). Rubbery papules reflected an intense cellular immune reaction dominated by eosinophils, epithelial erosion, and viable ova. There was a significant decrease in the prevalence of rubbery papules with age, even after adjustment for urinary ova excretion. The sandy patches with grains showed moderate cellular immune reaction and ova (viable and/or calcified). They were most prevalent in cases with low-intensity urinary S. haematobium infection. Forty-two percent of women with Schistosoma-negative urine specimens had at least 1 genital specimen test positive for Schistosoma by PCR. CONCLUSIONS: The results indicate a diversity of lesions caused by S. haematobium and a dynamic evolution of the genital lesions. Schistosoma PCR may give an indication of the diagnosis.

Eosinophil granule proteins ECP and EPX as markers for a potential early-stage inflammatory lesion in female genital schistosomiasis (FGS).

BACKGROUND: Genital granulomas induced by Schistosoma haematobium eggs can manifest as different lesion types visible by colposcopy; rubbery papules (RP), homogenous sandy patches (HSP) and grainy sandy patches (GSP). Pronounced tissue eosinophilia is a candidate marker for active S. haematobium pathology, as viable schistosome egg granulomas often are eosinophil rich. Here it was investigated whether eosinophil granule proteins ECP (eosinophil cationic protein) and EPX (eosinophil protein-X) in urine and genital lavage can be used as markers for active FGS lesions. METHODS: Uro-genital samples from 118 Malagasy women were analysed for ECP and EPX by standard sandwich avidin/biotin amplified ELISA. PRINCIPAL FINDINGS: The women with RP lesions had significantly higher levels of ECP and EPX in both lavage and urine. Furthermore, women with RP lesions were significantly younger than those with GSP. This could indicate that RP lesions might be more recently established and thus represent an earlier inflammatory lesion stage. CONCLUSION: ECP in genital lavage might be a future tool aiding the identification of FGS pathology at a stage where reversibility remains a possibility following praziquantel treatment.

Rotavirus genotypes in children in the community with diarrhea in Madagascar.

In the context of the possible introduction of a preventive vaccine against rotaviruses in Madagascar, the G and P genotypes distribution of the rotaviruses circulating in the children in Madagascar was studied, and the presence of emerging genotypes and unusual strains were assessed. From February 2008 to May 2009, 1,679 stools specimens were collected from children ≤5 years old with diarrhea. ELISA was used for antigen detection, and molecular amplification of VP7 and VP4 gene fragments was used for genotyping. Rotavirus antigen was detected in 104 samples (6.2%). Partial sequences of VP7 and VP4 genes were obtained from 81 and 80 antigen-positive stools, respectively. The most frequent G and P types combinations detected were G9P[8] (n = 51; 64.6%), followed by G1P[8] (n = 15; 18.9%), and G1P[6] (n = 8; 10.1%). A few unusual G-P combinations, such as G4P[6] (n = 3; 3.8%), G9P[6] (n = 1; 1.3%), and G3P[9] reassortant feline human virus (n = 1; 1.3%) were identified. Both VP4 and VP7 sequences in one of the three G4P[6] isolates were closely related to those in porcine strains, and one was a reassortant human porcine virus. These findings give an overview of the strains circulating in Madagascar and should help public health authorities to define a vaccine strategy.

Case-control study of the etiology of infant diarrheal disease in 14 districts in Madagascar.

BACKGROUND: Acute diarrhea is a major cause of childhood morbidity and mortality worldwide. Its microbiological causes and clinico-epidemiological aspects were examined during the rainy seasons from 2008 to 2009 in 14 districts in Madagascar. METHODS: Stool specimens of 2196 children with acute diarrhea and 496 healthy children were collected in a community setting. Intestinal parasites were diagnosed by microscopy and bacteria by culturing methods. Rota-, astro and adenoviruses were identified using commercially available ELISA kits and rotaviruses were confirmed using reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: Intestinal microorganisms were isolated from 54.6% of diarrheal patients and 45.9% of healthy subjects (p = <0.01). The most common pathogens in diarrheic patients were intestinal parasites (36.5%). Campylobacter spp. and Rotavirus were detected in 9.7% and 6.7% of diarrheic patients. The detection rates of Entamoeba histolytica, Trichomonas intestinalis and Giardia lamblia were much greater in diarrheal patients than in non diarrheal subjects (odds ratios of 5.1, 3.2, 1.7 respectively). The abundance of other enteropathogens among the non diarrheal group may indicate prolonged excretion or limited pathogenicity. CONCLUSION: In developing countries, where the lack of laboratory capacities is great, cross sectional studies of enteropathogens and their spatial distribution, including diarrheal and non diarrheal subjects, are interesting tools in order to advise regional policies on treatment and diarrheic patient management.

Antimicrobial resistance in pathogens causing nosocomial infections in surgery and intensive care units of two hospitals in Antananarivo, Madagascar.

BACKGROUND: In developing countries, knowledge of antimicrobial resistance patterns is essential to define empirical therapy. METHODOLOGY: All the surgery and intensive care wards of two hospitals in Antananarivo were included to study the antimicrobial susceptibility of the pathogenic bacteria causing nosocomial infections. A repeated cross-sectional survey was conducted between September 2006 and March 2008, one day per week. Isolates were identified using classical methods, and resistance to antibiotics was assessed according to the recommendations of the Antibiogram Committee of the French Microbiology Society. RESULTS: Clinical specimens from 706 from 651 patients were collected. Of the 533 bacterial pathogens, 46.7% were Enterobacteriaceae, 19.3% were Staphylococcus aureus, and 19.1% were pathogens from the hospital environment (Pseudomonas aeruginosa and Acinetobacter baumannii).Frequencies of resistance were high, particularly in Enterobacteriaceae; however, the rate of Staphylococcus aureus isolates resistant to oxacillin (13.6 %) was moderate and all these isolates were susceptible to glycopeptids. The percentages of isolates susceptible to ceftazidim were 81.8% for E. coli, 60.9% for Klebsiella, and 52.5% for Enterobacter spp. Resistance to third-generation cephalosporins was due to extended spectrum betalactamases (ESBL). Multivariate analysis showed that diabetes (adjusted OR: 3.9) and use of an invasive procedures (adjusted OR: 3.5) were independent risk factors for resistance to third-generation cephalosporins. CONCLUSION: A nationwide surveillance programme is needed to monitor the microbial trends and antimicrobial resistance in Madagascar.

Coexistence of urogenital schistosomiasis and sexually transmitted infection in women and men living in an area where Schistosoma haematobium is endemic.

BACKGROUND: In settings in which adequate laboratory service is lacking, the coexistence of urogenital schistosomiasis and sexually transmitted infections (STIs) poses a diagnostic challenge for health care providers in the management of patients with urogenital complaints. METHODS: Symptoms were recorded with use of a semistructured questionnaire at baseline and in follow-up surveys after STI and Schistosoma haematobium infection had been assessed and systematically treated as part of a community-based study of 253 women and 236 men, aged 15-49 years, living in an area of Madagascar where S. haematobium is endemic. RESULTS: Of those infected with S. haematobium, 35% of the women had concordant STI (e.g., infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and/or Trichomonas vaginalis), compared with 17% of the men. Both S. haematobium infection and STI were significantly more common among younger individuals, aged 15-24 years, than among older individuals. A broad spectrum of urogenital symptoms was reported. However, one-half of the women and men who had positive test results for an STI or for S. haematobium infection were asymptomatic. Gross hematuria and dysuria were, in multivariate analysis, associated with S. haematobium infection, as were genitopelvic discomfort in women and ejaculation pain in men. The association became stronger with higher intensity of infection. In bivariate analysis but not in the multiregression model, STI was associated with vaginal discharge and genitopelvic discomfort in women and was associated with urethral discharge in men. CONCLUSIONS: The rationale for empirical antischistosoma treatment of adolescents and younger adults in areas where S. haematobium is endemic, with praziquantel alone or in combination with existing anti-STI regimens, is discussed.

Age-specific seroprevalence of hepatitis A in Antananarivo (Madagascar).

BACKGROUND: Hepatitis A virus (HAV) is an enteric, viral, infectious disease endemic in many developing countries such as Madagascar. Infection is often subclinical or asymptomatic in children; however, symptomatic acute infections become more common with increasing age. In some developing countries, improvements in living conditions have led to changes in the epidemiological pattern of HAV infection. There are very few reports on the prevalence of HAV in Madagascar. This study was to determine the seroprevalence of hepatitis A virus antibodies in relation to age in the city of Antananarivo, Madagascar. METHODS: Serum samples collected in 2004 during a cross-sectional survey of individuals aged between two and 24 years from Antananarivo were tested for anti-HAV antibody using a commercial enzyme immunoassay kit. Subjects were investigated using a standardized social and medical history questionnaire. RESULTS: 926 subjects were enrolled including 406 males and 520 females. There were 251 children under 10 years old and 675 subjects between 10 and 24 years old. Of the 926 serum samples tested, 854 (92.2%) were positive for anti-HAV antibodies. The number of seropositive samples was similar for males and females. The overall seroprevalence was 83.7% (210/251) for children under 10 years old and 95.5% (644/675) for subjects aged between 10 and 24 years (p < 0.001). CONCLUSION: Despite improvements in sanitary conditions and hygiene over the last few years, the prevalence of HAV in Antananarivo is high. Only children under five years old remain susceptible to HAV infection. Immunization against HAV is not needed at the present time in the Madagascan population, but should be recommended for travellers.

Hepatitis C virus infection and genotypes in Antananarivo, Madagascar.

The prevalence of hepatitis C virus (HCV) genotypes in Madagascar is not well known. Serum samples were obtained from 2,169 individuals selected by random sampling in the population living in Antananarivo city. Using HCV antibody test (Monolisa anti-HCV Plus version 2), 36 (1.7%) of the 2,169 samples were positive. The presence of HCV RNA was determined by using reverse transcription polymerase chain reaction amplifying the 5'-untranslated region (UTR): HCV RNA was detected in 17 of the 36 HCV antibodies positive samples. The genotype was determined using BLAST tool with another 5'-UTR fragment. The phylogenetic analysis of the polymerase (NS5b) and envelope (E1/E2) fragment sequences showed a low level of diversity compared to the high diversity in other African countries: subtype 1b (nine cases, 52.9%) and genotype 2 (eight cases, 47.1%) including subtype 2b (six cases), subtype 2k (one case), and one unclassified subtype. BLAST search with the 5'-UTR fragment sequence of this unclassified subtype identified that strain as subtype 2a.

Seroprevalence of malaria in inhabitants of the urban zone of Antananarivo, Madagascar.

BACKGROUND: Antananarivo, the capital of Madagascar, is located at an altitude of over 1,200 m. The environment at this altitude is not particularly favourable to malaria transmission, but malaria nonetheless remains a major public health problem. The aim of this study was to evaluate exposure to malaria in the urban population of Antananarivo, by measuring the specific seroprevalence of Plasmodium falciparum. METHODS: Serological studies specific for P. falciparum were carried out with an indirect fluorescent antibody test (IFAT). In a representative population of Antananarivo, 1,059 healthy volunteers were interviewed and serum samples were taken. RESULTS: The seroprevalence of IgG+IgA+IgM was 56.1% and that of IgM was 5.9%. The major risk factor associated with a positive IgG+IgA+IgM IFAT was travel outside Antananarivo, whether in the central highlands or on the coast. The abundance of rice fields in certain urban districts was not associated with a higher seroprevalence. CONCLUSION: Malaria transmission levels are low in Antananarivo, but seroprevalence is high. Humans come into contact with the parasite primarily when travelling outside the city. Further studies are required to identify indigenous risk factors and intra-city variations more clearly.

Sexual behavior and sexually transmitted infections in men living in rural Madagascar: implications for HIV transmission.

BACKGROUND: Madagascar is in the midst of a large HIV epidemic. Therefore, it is important to obtain relevant epidemiologic data that can be used to develop a preventive strategy. GOAL: The goal of the study was to assess sexual behavior and sexually transmitted infections (STIs) among men living in two coastal villages and one highland village with different levels of endemicity of urogenital schistosomiasis. STUDY DESIGN: Data were obtained from cross-sectional studies on male reproductive health. All men aged 15 to 49 years were offered enrollment. RESULTS: Of 401 men evaluated, 6.5% had used a condom and 45.6% reported having multiple partners in the previous 3 months. Symptoms of urethritis during the previous 7 days were reported by 128 men (31.9%). Urethritis was associated with the youngest age group (15-19 years) and the coastal villages, in which HIV antibodies were found in 0.9% and 2.5%, respectively. The prevalence of Schistosoma hematobium was 31.0% and 55.0% in these two villages, whereas none of the men in the highland village were infected. In bivariate analyses, urogenital schistosomiasis was associated with reported symptoms of urethritis, but it acted as a confounder in multivariate analyses. CONCLUSION: Several risk factors for HIV propagation exist in these rural areas in Madagascar. Young men in particular should be targeted for HIV/STI prevention. Treatment of urogenital schistosomiasis could be considered part of the syndromic STI treatment in areas where S hematobium is endemic, for patients seeking primary care for urethritis.