BackgroundMalnutrition accounts for 45% of mortality in children under five years old, despite a global mobilization against chronic malnutrition. In Madagascar, the most recent data show that the prevalence of stunting in children under five years old is still around 47.4%. This study aimed to identify the determinants of stunting in children in rural areas of Moramanga and Morondava districts to target the main areas for intervention.MethodsA case-control study was conducted in children aged from 6 to 59.9 months, in 2014–2015. We measured the height and weight of mothers and children and collected data on child, mother and household characteristics. One stool specimen was collected from each child for intestinal parasite identification. We used a multivariate logistic regression model to identify the determinants of stunting using backwards stepwise methods.ResultsWe included 894 and 932 children in Moramanga and in Morondava respectively. Stunting was highly prevalent in both areas, being 52.8% and 40.0% for Moramanga and Morondava, respectively. Stunting was most associated with a specific age period (12mo to 35mo) in the two study sites. Infection with Trichuris trichiura (aOR: 2.4, 95% CI: 1.1–5.3) and those belonging to poorer households (aOR: 2.3, 95% CI: 1.6–3.4) were the major risk factors in Moramanga. In Morondava, children whose mother had activities outside the household (aOR: 1.7, 95% CI: 1.2–2.5) and those perceived to be small at birth (aOR: 1.6, 95% CI: 1.1–2.1) were more likely to be stunted, whereas adequate birth spacing (≥24months) appeared protective (aOR: 0.4, 95% CI: 0.3–0.7).ConclusionInterventions that could improve children’s growth in these two areas include poverty reduction, women’s empowerment, public health programmes focusing on WASH and increasing acceptability, and increased coverage and quality of child/maternal health services.

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.

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-PVR. 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 (CI95%: 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 in favour 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.

Background Post-exposure prophylaxis (PEP) is highly effective at preventing human rabies deaths, however access to PEP is limited in many rabies endemic countries. The 2018 decision by Gavi to add human rabies vaccine to its investment portfolio should expand PEP availability and reduce rabies deaths. We explore how geographic access to PEP impacts the rabies burden in Madagascar and the potential benefits of improved provisioning. Methodology & principal findings We use spatially resolved data on numbers of bite patients seeking PEP across Madagascar and estimates of travel times to the closest clinic providing PEP (N = 31) in a Bayesian regression framework to estimate how geographic access predicts reported bite incidence. We find that travel times strongly predict reported bite incidence across the country. Using resulting estimates in an adapted decision tree, we extrapolate rabies deaths and reporting and find that geographic access to PEP shapes burden sub-nationally. We estimate 960 human rabies deaths annually (95% Prediction Intervals (PI): 790–1120), with PEP averting an additional 800 deaths (95% PI: 640–970) each year. Under these assumptions, we find that expanding PEP to one clinic per district (83 additional clinics) could reduce deaths by 19%, but even with all major primary clinics provisioning PEP (1733 additional clinics), we still expect substantial rabies mortality. Our quantitative estimates are most sensitive to assumptions of underlying rabies exposure incidence, but qualitative patterns of the impacts of travel times and expanded PEP access are robust. Conclusions & significance PEP is effective at preventing rabies deaths, and in the absence of strong surveillance, targeting underserved populations may be the most equitable way to provision PEP. Given the potential for countries to use Gavi funding to expand access to PEP in the coming years, this framework could be used as a first step to guide expansion and improve targeting of interventions in similar endemic settings where PEP access is geographically restricted and baseline data on rabies risk is lacking. While better PEP access should save many lives, improved outreach, surveillance, and dog vaccination will be necessary, and if rolled out with Gavi investment, could catalyze progress towards achieving zero rabies deaths.

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