[Adoption: an alternative to assisted reproductive techniques?]. / L'adoption, alternative à l'Assistance médicale à la procréation ?

Information on adoption must be given to couples who seek treatment for medically-assisted procreation. But is adoption a real alternative? What are the chances for a couple who consults to see its desire for adoption be achieved according to its own situation, the characteristics of the child he wants, and the general situation of adoption? Can adoption, just like assisted procreation, often described by the couples as a "obstacle course", go parallel? Or should one try adoption once assisted reproduction failed? Is the couple willing to suffer the social and legal control of adoption after having supported the medical control of the ART? In all cases, the reality is that two out of three couples engaged in assisted reproduction will have a child whereas scarcely more than one candidate to adoption will be offered to adopt a child after three or four-years procedure.

[Epidemiological stratification of malaria in the Comoro archipelago]. / Stratification épidémiologique du paludisme dans l'archipel des Comores.

In the Comoros Islands, the level of malarial endemicity varies greatly from one island to the other, even though the total area (4 islands) covers less than 2,300 km2 and has a population of some 600,000 people only. The epidemiological stratification is based on the diversity of human and physical characterisation. They both determine the presence and the behaviour as well as the size of the vector's populations. Vectorial dynamics can explain varying levels of endemicity given parasitological indicators and specific morbidity. Analyzing these criteria shows up different epidemiological features and serves as a basic guideline for malaria control. The efficiency of this control depends on the relationships between the intensity and the length of the transmission, in the framework of protection mechanisms; it is of crucial importance for clinical treatment. Further elements are the age of the patient, the season and the geographic situation of the area. Stratification provides explanations for these relationships and helps to define antimalarial programmes adapting to each situation a range of therapeutic and antivectorial methods. The availability and accessibility of anti-malarial medicine is the minimum requirement for reducing mortality: domestic spray insecticides for reducing transmission are effective for several years and should be followed by the use of mosquito nets or curtains impregnated with pyrethrinoids, and in the particular case of Grande Comore, the use of larvivorous fish. As anywhere else, the economic development, which is dependent on political stability, is the essential basis for malaria control.

[Annual risk of tuberculosis infection in Madagascar: study from 1991 to 1994]. / Le risque annuel d'infection tuberculeuse à Madagascar: étude réalisée de 1991 à 1994.

This article reports the results of a national tuberculin skin test survey of childhood age group. The survey period was from december 1991 to june 1994. For the calculation of annual risk of tuberculous infection, 1544 schoolchildren, aged 6 to 10 years old, without scare related to BCG, were included. The antigen used was tuberculin PPD Mérieux; in order to define a mode of positivity, this tuberculin was first tested with 250 confirmed pulmonary tuberculous patients: the mode was 16mm. With the hypothesis of a cut-off point of positivity at 14 mm, the prevalence of tuberculous infection was found at 9.6% (with a confidence interval of 1.6%); then, the annual risk of tuberculous infection was calculated at 1.21% (from 1% to 1.42%). With the hypothesis of a mode at 16 mm, the prevalence of tuberculous infection was found at 10.2% (with a confidence interval of 2.3%); then, the annual risk of tuberculous infection was calculated at 1.29% (from 0.97% to 1.59%). Considering separately two age groups, the annual risk was 1.25% for 6-8 years old children and 1.32% for 9-10 years old children. In conclusion, the authors stress the important constraints in the achievement of such a survey in developing countries. Though the difficulties that arised, the standardised methodology used in this survey gives reliable information. These results could be compared with those of future surveys using the same methodological approach.

[The reconquest of the Madagascar highlands by malaria]. / La reconquête des Hautes Terres de Madagascar par le paludisme.

A strong malaria epidemic with a high mortality rate occurred on the Madagascar Highlands in 1986-88. Vector control and free access to antimalaria drugs controlled the disease. The authors have searched for the causes of the epidemic to propose a strategy avoiding such events. The Highlands on Madagascar were known as malaria free. In 1878 a very severe epidemic flooded all the country. Development of irrigated ricefields which house both An. arabiensis and An. funestus had created a new anthropic environment. Moreover manpower imported from malarious coastal areas for rice cultivation and also for building large temples, could have brought P. falciparum. After several outbreaks the disease became endemic up to 1949. In 1949 a malaria eradication programme based on DDT spraying and drug chemoprophylaxis and chemotherapy was launched. By 1960 malaria was eliminated and DDT spraying cancelled. Only 3 foci were kept under surveillance with irregular spraying until 1975. The prophylaxis and treatment centres ("centres de nivaquinisation") were kept open up to 1979. The catholic dispensary of Analaroa, 100 km N.E. of Tananarive, opened in 1971 and worked without interruption up to now. The malaria diagnosis has always been controlled by microscopy. Its registers are probably the more reliable source of information on malaria in the area. They show that malaria was already present on the Highlands in 1971 but at a low prevalence; in 1980 when the "centres de nivaquinisation" were closed the number of cases increased by three times the progressive increase of the number of cases became exponential from 1986 to 1988 which was the peak of the epidemic; malaria remained at a high level until the end of 1993; yearly DDT spraying since 1993 have decreased the number of malaria cases among the dispensary attendants by 90%. The epidemic peak of 1988 was well documented by the Pasteur Institute of Madagascar around Tananarive. Before the epidemic started it was observed a come back of An. funestus which had been previously eliminated of most of the villages by DDT spraying. More than an epidemic the malaria increase in 1988 was a reconquest by malaria of the land from which it had been eliminated in the years 1950. This episode became dramatic because the lack of immunity of the population and the shortage of medicaments. The global warming which was advocated to explain the epidemic has no responsibility because the temperature on the Madagascar Highlands has not changed during the last 30 years. Also the cyclones do not seem to have played any role. It is very likely that the gradual decline of control measures, first DDT spraying, later drug distributions, had the main responsibility in the Highlands drama. Everywhere An. funestus reached a high level during the time where the parasite reservoir was rebuilding. They synergised each other. These findings should be taken in account in drawing the strategy planning for the next years.

[Rice: source of life and death on the plateaux of Madagascar]. / Le riz source de vie et de mort sur les plateaux de Madagascar.

Since the 17th century, Europeans travelling in Madagascar described the contrast between the fever-free Plateau and the fever-ridden coasts. The former were inhabited by people of Asiatic origins and the latter by African migrants. At the end of the 18th century, "Merina" kings developed land irrigation and rice cultivation, using manpower from the coasts. Since then, rice has become a monoculture covering most of the arable lands of the Highlands. The first malaria epidemic occurred in the Tananarive area in 1878, and rapidly spread throughout the Plateau. The mortality rate was high. A second epidemic in 1895 may have been a resurgence of the previous one. Subsequently, malaria became meso-epidemic despite control measures, mainly consisting of larvivorous fishes, quinine treatment and prophylaxis. In 1949, an eradication program was launched based on DDT house-spraying and chloroquine prophylaxis in children. It was very successful on the Highlands where malaria disappeared, in 1962. Spraying was cancelled and only three small foci remained under surveillance. In 1987 and 1988, a malaria outbreak devastated the plateau. Subsequently, intensive spraying operations brought the situation under control by 1993. The main malaria vector on the Madagascar Highlands is An. funestus. More than 95% of its breeding sites are in the rice fields just before the harvest and afterwards in the fallow lands. The vector peak and the corresponding peak of malaria cases occur between February and May, depending on the farming calender. The second but less important vector, An. arabiensis, breeds in the rice fields just after seeding when the surface water is sunlit. Although rice fields remain the main source of this vector, it also breeds in rainwater pods and borow-pits. Malaria vectors on the plateau are products of human activities of rice cultivation, which is the basis of the economy. The epidemiological importance of rice fields varies greatly from one country to another. In Southeast Asia, the rice fields harbor several anopheline species most of which are only vectors of P. vivax. In West Africa where malaria is holoendemic, they produce large populations of An. gambiae; however, the malaria pattern is unaltered and remains at peak levels. In the dry areas of southern Madagascar, the vector An. funestus and meso-hyperendemic malaria are restricted to areas of cultivated rice. In West and Central Africa, An. funestus is never found in rice fields even though it is common in marshes. In Madagascar, this vector breeds in irrigated rice fields. Because it is practically impossible to control anophelines in rice fields by chemical, biological and ecological methods on the Highlands of Madagascar, house-spraying remains the best method for mass malaria control. Bed-nets impregnated with pesticides may offer an alternative, but their use is resisted by the local population.

[Particularities and stratification of malaria in Madagascar]. / Particularités et stratification du paludisme à Madagascar.

The first factor is the malaria parasite, for which the species P. falciparum and P. vivax are important. Secondly, the transmission determines the disease stability and challenges the host's immunity. The third factor is the human host, consisting of people of both African and Asiatic origin, the latter of whom are more susceptible to P. vivax. Human activities such as cultivating rice fields are of paramount importance for the proliferation of the vectors. The vectors A. gambiae, A. arabiensis and A. funestus are very similar to those of the African continent. These vectors are not endemic on Madagascar, suggesting that they were recently introduced to the island where 95% of the fauna species are endemic. On the Plateau and in the South, the rice fields provide most of the breeding places for A. gambiae s.l. and A. funestus. Five epidemiological belts are found in Madagascar which are very similar to their analogs on continental Africa (fig. 1). These facies include the equatorial belt on the east coast and the tropical belt on the west coast north of Morondava, the Plateau belt analogous to the southern African continent, the southern Madagascar belt which is similar to the Sahelian areas, and finally the zones above 1,500m, which are essentially free of malaria. The first two facies have a stable type of malaria, and in the following two, malaria is unstable. These areas include the Plateau, the area of the severe epidemics which occurred between 1985 and 1988 with more than 50,00 deaths. Malaria control is based on a variety of strategies to respond to the epidemiological heterogeneity of the disease. Spraying within the homes with DDT, used on the Plateau after 1988, was and still is very successful.

[A contribution to the history of understanding the epidemiology of plague in Madagascar]. / Contribution de l'histoire à la compréhension de l'épidémiologie de la peste à Madagascar.

Plague appeared in Madagascar in 1898, the pandemic coinciding with the French conquest. Until 1921, harbor epidemics occurred in Tamatave, Majunga, Diégo-Suarez, Fort-Dauphin, Vatomandry. In 1921, probably favored by the building of roads and railways, plague takes root on the High Lands where it becomes endemic above 800 meters. The vaccine achievement by Girard and Robic with the EV strain, and its mass application from 1935 by Estrade, Milliau, Brault, Seyberlich and Jan Keguistel, allowed to control the disease. The D.D.T. and sulfamids discovery makes the urban epidemics almost disappear, allowing it to subsist as only rural sporadic or familial cases with a low mortality. The mass vaccination can be stopped in 1959. Since 1988 the diseases incidence has been increasing, probably in relation with the quasi disappearance of deinsectisation and antibiotics. Nevertheless, urban epidemics are still rare and limited in a parallel direction to the substitution, in the city, of Rattus rattus, main reservoir and victim of the disease, by Rattus norvegicus, less sensitive to the infection.

[Evolution of Plasmodium falciparum drug sensitivity in Madagascar from 1982 to 1993 and operational consequences]. / Evolution de la chimiosensibilité de Plasmodium falciparum a Madagascar de 1982 a 1993 et conséquences operationnelles.

Madagascar was one of the first African countries with reported chloroquine drug resistance of P. falciparum. Suspected as early as 1975, it was confirmed in 1981. Hereafter, regular tests in vivo and in vitro have been performed and allow for a study of drug resistance development. In 742 standard in vivo tests at the dose of 25 mg/kg of chloroquine that were executed between 1983 and 1993, R I resistance levels could be found in 8.5% of cases, R II was found in 8.2%. No resistance at R III levels was detected. The overall situation for in vitro is equally favorable. In 406 tests 78% of samples proved sensitive. The investigations undertaken by the Pasteur Institute of Madagascar, by the Institute for Tropical Medicine and Epidemiology in Paris and by the Unit of Epidemiological Surveillance within the Malagasy Ministry of Health raise a number of questions: Taking to account the various causes for imprecision in measurement and in evaluation (variations in parasite density, microscopic detection levels, bio-availability of the drug) of the groups of R I and R II how significant are the variations observed in numbers and proportions of resistance levels R I and R II? How important are the effects of auto-medication? Can they be correctly evaluated by Bergquist's test? How explain the low level of drug resistance in a country close to East Africa, in which chemoprophylaxis has been widely practiced and in which insufficient dosage for treatment is common? The absence of R III resistance in vivo permit for chloroquine to remain the first line treatment for malaria in Madagascar.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical epidemiology of plague in Madagascar (current data)]. / Epidémiologie clinique de la peste à Madagascar (Données actuelles).

After a recall of the epidemiological cycle of plague, the authors describe the course of this disease from 1989 to 1992. Out of 2676 pathological samples suspected of plague, 2105 biological examinations were carried out. 312 cases were confirmed and 335 considered as probable. 93% of those positive cases come from the plague triangle located in the Central Highlands and delimited by Ambatondrazaka, Miarinarivo and Fianarantsoa and they occur during the rainy season (November to March). However, an outbreak of urban epidemics is possible on the coast during the cold season. The most frequent clinical form had been bubonic plague (90%). Plague did not much concern young children and men are affected more often than women. Clinically, toxi-infectious syndrome, lymph node reaction and hemoptoïc spits can be noted. The 1989-1992 results are compared with those of the two previous studies.

[Epidemiological stratification of malaria in Madagascar]. / Stratification épidémiologique du paludisme à Madagascar.

Madagascar is considered as a sub-region of the Afrotropical geographical Region in spite of the high endemicity of 95% of the invertebrates. Nevertheless the three malaria vectors An. gambiae s.s., An. arabiensis and An. funestus are quite similar to those of the continental Africa. This support the hypothesis of their recent introduction. Plasmodium falciparum is the dominant parasite but the prevalence of P. vivax is not negligible. It is linked to the Asian component of the human population. P. malariae and P. ovale are of minor importance. The main epidemiological "facies" of Africa are found in Madagascar. The equatorial facies on the East Coast is characterized by a high transmission all year long. In the tropical facies on the West Coast transmission is seasonal (7 months at least). In both areas, malaria is stable and the inhabitants acquire a high immunity before the age of ten; most of the severe cases touch children below 10. The three vectors can be found but An. gambiae s.s. is dominant. In the exophilic southern facies the transmission is seasonal (two to four months). The only vector is An. arabiensis. Malaria is unstable and severe epidemics occur during the years of high rainfall. All age groups are vulnerable because the population is not immune in the Plateaux facies above 1,000 m., malaria is unstable. Severe epidemics occurred in 1987-1988. The vectors are An. Arabiensis and An. funestus. The occurrence of P. falciparum on the Plateaux seems linked to the development of irrigation of rice farming in the XIXth century. Most of the anopheles breeding places on the Plateaux are dependent on rice cultivation. Urban development has brought the inhabitants of the suburbs in close contact with rice fields. Despite the high number of anopheline bites the number of malaria cases remains by far lower than in the neighbouring rural areas. Regional migrations inside the island bring non-immune populations, from the south and the plateaux, in highly malarious areas of the coast, where the migrants are exposed to high risk. In spite of 40 years of uncontrolled use, chloroquine can still cure most, if not all, of malaria cases. Control measures appropriated to the different areas of Madagascar are discussed.

[Anemia among schoolchildren 5 to 14 years old in Sainte Marie (Madagascar)]. / Note sur l'anémie des enfants de 5 à 14 ans scolarisés à Sainte Marie (Madagascar).

The Island of Sainte Marie is located at 6 km from the Eastern Coast of Madagascar. The climate is a muggy tropical one, with an average temperature rising above 20 degrees C all along the year and precipitations superior to 2500 mm. In 1990, a clinical surveillance of ten affections has been performed by every health units of the Island: paludal syndromes, nutrition disorders and anemia have been the focus of symptomatic definition. Blood samples have been taken from 100 pupils of the village of Ambodiforaha for hemogram determination and research of malaria hematozoon. Four pupils out of five show biological anemia, more than 10% suffer from acute anemia (less than 3.5 millions of red blood cells for each microliters, hematocrit inferior to 30, less than 9 g of hemoglobin for 100 ml). 87% suffer from nutritional anemia, 17% from iron-deficient anemia. Those figures cannot be found in health statistics. There is a high rate of nutritional and iron deficient anemia, but the problem is not well perceived or not at all by the health system. Anemia must be related to the strength of paludal transmission, to the importance of nutrition disorders and the prevalence of intestinal parasitosis. A better knowledge of the epidemiology of anemias and their morbid consequences would allow the setting of a prevention programme useful for children under 5 years and for pregnant women.

[Antibody levels against circumsporozoitic protein of Plasmodium falciparum and their use as epidemiological indicators of malaria transmission in FIR of Comoros]. / Niveaux d'anticorps contre la protéine circumsporozoïtique de Plasmodium falciparum et leur utilisation en tant qu'indicateurs épidémiologiques de la transmission du paludisme en RFI des Comores.

Epidemiological survey on prevalence of Plasmodium falciparum anti-circumsporozoite antibodies (Ab-CS) was carried out in 21 villages of Comoros FIR, at the beginning of 1988 rainy season. Evaluation of anopheline indoor resting densities was also carried out at the same time. Frequencies of antibody-positive subjects vary considerably in the different villages, according to the Anopheles gambiae and A. funestus densities per room, which are determined by ecological factors. Ab-CS prevalence varies in the sample population from 5.5% in 3-4 years children to 40% in those of 5 years. Starting from 6-7 years group, prevalence increased steadily reaching a plateau by 30 years of age. The detection of Ab-CS levels in a sample population is a good tool to evaluate malaria transmission levels, especially where the epidemiological situation does not allow a reliable entomological evaluation.

[Impact of the use of larvivorous fish Poecilia reticulata on the transmission of malaria in FIR of Comoros]. / Impact de l'utilisation du poisson larvivore Poecilia reticulata sur la transmission du paludisme en RFI des Comores.

Field tests were conducted in the Grande Comore Island, Federal Islamic Republic of Comoros, in order to evaluate the potential of the larvivorous fish Poecilia reticulata for the control of the malaria vector Anopheles gambiae s.s. Due to the high permeability of soil, Anopheles breeding sites in all island occurs only in the man-made water reservoirs. The study was carried out from November 1987 to November 1988 within a framework of a malaria and filariasis control programme, supported by WHO and UNDP in collaboration with the Government of the FIR of Comoros. All larval breeding places of An. gambiae existing in the village of Hantsambou were recorded (59 ablutions basins and 61 cisterns) and provided initially with 3-5 specimens of P. reticulata/m3 in November 1987, after the importation of the larvivorous species from Mayotte Island. The percentage of breeding places positive for An. gambiae decreased from 41% to 6% after one year. Pyrethrum spray catch showed a reduction of indoor resting density from 5.5 to 0.3, while the ma value, number of Anopheles bites/man/night, obtained by night-biting catches, decreased from 6.3 to 1.2. At the same time of the reduction of entomological indices parasite index for P. falciparum and spleen rate drop steadily in 5-9 years school children. The tested vector control method, well accepted by the community, could be implemented in malaria control through primary health care, being the ecological conditions in the entire island very peculiar.