Summary Background Madagascar accounts for 75% of global plague cases reported to WHO, with an annual incidence of 200–700 suspected cases (mainly bubonic plague). In 2017, a pneumonic plague epidemic of unusual size occurred. The extent of this epidemic provides a unique opportunity to better understand the epidemiology of pneumonic plagues, particularly in urban settings. Methods Clinically suspected plague cases were notified to the Central Laboratory for Plague at Institut Pasteur de Madagascar (Antananarivo, Madagascar), where biological samples were tested. Based on cases recorded between Aug 1, and Nov 26, 2017, we assessed the epidemiological characteristics of this epidemic. Cases were classified as suspected, probable, or confirmed based on the results of three types of diagnostic tests (rapid diagnostic test, molecular methods, and culture) according to 2006 WHO recommendations. Findings 2414 clinically suspected plague cases were reported, including 1878 (78%) pneumonic plague cases, 395 (16%) bubonic plague cases, one (<1%) septicaemic case, and 140 (6%) cases with unspecified clinical form. 386 (21%) of 1878 notified pneumonic plague cases were probable and 32 (2%) were confirmed. 73 (18%) of 395 notified bubonic plague cases were probable and 66 (17%) were confirmed. The case fatality ratio was higher among confirmed cases (eight [25%] of 32 cases) than probable (27 [8%] of 360 cases) or suspected pneumonic plague cases (74 [5%] of 1358 cases) and a similar trend was seen for bubonic plague cases (16 [24%] of 66 confirmed cases, four [6%] of 68 probable cases, and six [2%] of 243 suspected cases). 351 (84%) of 418 confirmed or probable pneumonic plague cases were concentrated in Antananarivo, the capital city, and Toamasina, the main seaport. All 50 isolated Yersinia pestis strains were susceptible to the tested antibiotics. Interpretation This predominantly urban plague epidemic was characterised by a large number of notifications in two major urban areas and an unusually high proportion of pneumonic forms, with only 23% having one or more positive laboratory tests. Lessons about clinical and biological diagnosis, case definition, surveillance, and the logistical management of the response identified in this epidemic are crucial to improve the response to future plague outbreaks. Funding US Agency for International Development, WHO, Institut Pasteur, US Department of Health and Human Services, Laboratoire d'Excellence Integrative Biology of Emerging Infectious Diseases, Models of Infectious Disease Agent Study of the National Institute of General Medical Sciences, AXA Research Fund, and the INCEPTION programme.

BackgroundFollowing the outbreak of chikungunya in the Indian Ocean, the Ministry of Health directed the necessary development of an early outbreak detection system. A disease surveillance team including the Institut Pasteur in Madagascar (IPM) was organized to establish a sentinel syndromic-based surveillance system. The system, which was set up in March 2007, transmits patient data on a daily basis from the various voluntary general practitioners throughout the six provinces of the country to the IPM. We describe the challenges and steps involved in developing a sentinel surveillance system and the well-timed information it provides for improving public health decision-making.MethodsSurveillance was based on data collected from sentinel general practitioners (SGP). The SGPs report the sex, age, visit date and time, and symptoms of each new patient weekly, using forms addressed to the management team. However, the system is original in that SGPs also report data at least once a day, from Monday to Friday (number of fever cases, rapid test confirmed malaria, influenza, arboviral syndromes or diarrhoeal disease), by cellular telephone (encrypted message SMS). Information can also be validated by the management team, by mobile phone. This data transmission costs 120 ariary per day, less than US$1 per month.ResultsIn 2008, the sentinel surveillance system included 13 health centers, and identified 5 outbreaks. Of the 218,849 visits to SGPs, 12.2% were related to fever syndromes. Of these 26,669 fever cases, 12.3% were related to Dengue-like fever, 11.1% to Influenza-like illness and 9.7% to malaria cases confirmed by a specific rapid diagnostic test.ConclusionThe sentinel surveillance system represents the first nationwide real-time-like surveillance system ever established in Madagascar. Our findings should encourage other African countries to develop their own syndromic surveillance systems.Prompt detection of an outbreak of infectious disease may lead to control measures that limit its impact and help prevent future outbreaks.

Background: Rabies is a widespread disease in African domestic dogs and a serious public health problem in developing countries. Canine rabies became established in Africa during the 20th century, coinciding with ecologic changes that favored its emergence in canids.

Summaryobjectives To describe the principal characteristics and epidemiological trends for human plague in modern times based on the largest reported series of cases from the highly active Malagasy focus.methods We used a file of 20 900 notified cases of suspected plague, 4473 of which were confirmed or probable, to carry out a statistical analysis of incidence and mortality rates and associated factors for 5-year periods from 1957 to 2001.results Our analysis of trends showed (1) an increase in the incidence rate and the number of districts affected, (2) an increase in the proportion of bubonic forms (64.8-96.8%) at the expense of the pneumonic forms (35.2-3.2%) more frequent in elderly subjects and (3) a decrease in case fatality rate (CFR, 55.7-20.9%) associated with five factors: clinical form, season, province, urban/ rural and period considered. The median age of patients was 14 years and more men than women were affected.conclusions Since the end of the 1980s, the incidence of plague in Madagascar has increased in both rural and urban areas, because of multiple socioeconomic and environmental factors. However, the plague mortality rate has tended to decrease, together with the frequency of pneumonic forms, because of the strengthening of control measures. Making dipstick tests for the rapid diagnosis of human cases and epizootics in rats available for health structures should make it possible to raise the alarm and to react rapidly, thereby further decreasing morbidity and CFR.

Background Influenza and respiratory syncytial virus ( RSV ) infections are responsible for substantial global morbidity and mortality in young children and elderly individuals. Estimates of the burden of influenza‐ and RSV ‐associated hospitalization are limited in Africa. Methods We conducted hospital‐based surveillance for laboratory‐confirmed influenza‐ and RSV ‐associated severe acute respiratory illness ( SARI ) among patients of any age at one hospital and a retrospective review of SARI hospitalizations in five hospitals situated in Antananarivo during 2011‐2016. We estimated age‐specific rates (per 100 000 population) of influenza‐ and RSV ‐associated SARI hospitalizations for the Antananarivo region and then extrapolated these rates to the national level. Results Overall, the mean annual national number of influenza‐associated SARI hospitalizations for all age groups was 6609 (95% CI : 5381‐7835‐rate: 30.0; 95% CI : 24.4‐35.6), 4468 (95% CI : 3796‐5102‐rate: 127.6; 95% CI : 108.4‐145.7), 2141 (95% CI : 1585‐2734‐rate: 11.6; 95% CI : 8.6‐14.8), and 339 (95% CI : 224‐459‐rate: 50.0; 95% CI : 36.3‐74.4) among individuals aged <5, ≥5, and ≥65 years, respectively. For these same age groups, the mean annual number of RSV ‐associated SARI hospitalizations was 11 768 (95% CI : 10 553‐12 997‐rate: 53.4; 95% CI : 47.9‐59.0), 11 299 (95% CI : 10 350‐12 214‐rate: 322.7; 95% CI : 295.6‐348.8), 469 (95% CI : 203‐783‐rate: 2.5;95% CI : 1.1‐4.2), and 36 (95% CI : 0‐84‐rate: 5.8; 0.0‐13.5), respectively. Conclusion The burden of influenza‐ and RSV ‐associated SARI hospitalization was high among children aged <5 years. These first estimates for Madagascar will enable government to make informed evidence‐based decisions when allocating scarce resources and planning intervention strategies to limit the impact and spread of these viruses.