Excess mortality associated with the 2009 A(H1N1)v influenza pandemic in Antananarivo, Madagascar.

It is difficult to assess the mortality burden of influenza epidemics in tropical countries. Until recently, the burden of influenza was believed to be negligible in Africa. We assessed the impact of the 2009 influenza epidemic on mortality in Madagascar by conducting Poisson regression analysis on mortality data from the deaths registry, after the first wave of the 2009 A(H1N1) virus pandemic. There were 20% more human deaths than expected in Antananarivo, Madagascar in November 2009, with excess mortality in the ⩾50 years age group (relative risk 1·41). Furthermore, the number of deaths from pulmonary disease was significantly higher than the number of deaths from other causes during this pandemic period. These results suggest that the A(H1N1) 2009 virus pandemic may have been accompanied by an increase in mortality.

[Malaria in the central highlands of Madagascar: control strategies]. / Paludisme sur les hautes terres centrales de Madagascar: stratégies de lutte.

The purpose of this article is to present data on malaria in the central highland plateaux of Madagascar and strategies to improve the national malaria control program. Use of rapid diagnosis strips, early home-based fever management with pre-packaged chloroquine treatment kits and proposed new therapeutic combination based on artemisinine are discussed for management of patients with high suspicion of malaria attack. Preventive measures including alternated targeted and full-house indoor spraying for vector control, use of insecticide-impregnated bednets, implementation of intermittent preventive treatment in risk groups, optimization of the epidemic early detection and warning system using the Lot Quality Assurance Sampling method for epidemiological investigation if the alert threshold is exceeded, and provision of rapid diagnosis strips are presented.

Paludisme sur les Hautes Terres Centrales de Madagascar : strategies de lutte

Le present article presente le paludisme sur les Hautes Terres Centrales de Madagascar et les strategies pour ameliorer les composantes du programme national de lutte contre le paludisme. Pour la prise en charge du patient suspect d'acces palustre; l'utilisation des bandelettes de diagnostic rapide; la prise en charge precoce a domicile par la chloroquine pre-emballee et les reflexions sur les nouvelles combinaisons therapeutiques a base d'artemisinine sont discutees. Pour les mesures de prevention; l'alternance des pulverisations intra domiciliaires ciblees et generalisees dans la lutte antivectorielle; l' utilisation de moustiquaires impregnees d'insecticides; le passage au traitement preventif intermittent pour les groupes a risque; l'amelioration du systeme de surveillance et d'alerte epidemique par l'utilisation de la methode de Lot Quality Assurance Sampling pour l'investigation epidemiologique en cas de depassement du seuil d'alerte et la mise a disposition des bandelettes de diagnostic rapide sont etudies

In vitro sensitivity of Plasmodium falciparum to amodiaquine compared with other major antimalarials in Madagascar.

Chloroquine has been used in Madagascar since 1945 and remains the first-line treatment for uncomplicated cases of malaria. Low-grades of resistance type R1 and R2 have been reported. Thus, in vitro tests were performed in order to monitor the drug sensitivity of Plasmodium falciparum from different study sites, with the aim of identifying alternatives to chloroquine. Chloroquine IC50 values ranged from 0.2 nM to 283.4 nM (n = 190, mean IC50 = 52.6 nM; 95% CI = 46.1-59.1 nM). Fifteen isolates (7.9%) were chloroquine-resistant. One mefloquine-resistant isolate was detected (1/139). The test isolates were sensitive to amodiaquine (n = 118), quinine (n = 212), pyrimethamine (n = 86) and cycloguanil (n = 79). The median IC50 for amodiaquine was 12.3 nM (mean IC50 = 15.3 nM, 95% CI = 13.3-17.3 nM). Amodiaquine was 3.4 times as active as chloroquine in vitro and 7 times as active as quinine against P. falciparum. These results indicate that amodiaquine may be a potent alternative to chloroquine in Madagascar. There was positive correlation between tested quinoline-containing drugs activities, which suggests in vitro cross-susceptibility.

Validity of Lot Quality Assurance Sampling to optimize falciparum malaria surveys in low-transmission areas.

To control the reappearance of malaria in the Madagascan highlands, indoor house-spraying of DDT was conducted from 1993 until 1998. Before the end of the insecticide-spraying programme, a surveillance system was set up to allow rapid identification of new malaria epidemics. When the number of suspected clinical malaria cases notified to the surveillance system exceeds a predetermined threshold, a parasitological survey is carried out in the community to confirm whether or not transmission of falciparum malaria is increasing. Owing to the low specificity of the surveillance system, this confirmation stage is essential to guide the activities of the control programme. For this purpose, Lot Quality Assurance Sampling (LQAS), which usually requires smaller sample sizes, seemed to be a valuable alternative to conventional survey methods. In parallel to a conventional study of Plasmodium falciparum prevalence carried out in 1998, we investigated the ability of LQAS to rapidly classify zones according to a predetermined prevalence level. Two prevalence thresholds (5% and 15%) were tested using various sampling plans. A plan (36, 2), meaning that at least 2 individuals found to be positive among a random sample of 36, enabled us to classify a community correctly with a sensitivity of 100% and a specificity of 94%. LQAS is an effective tool for rapid assessment of falciparum malaria prevalence when monitoring malaria transmission.

Malaria in the highlands of Madagascar after five years of indoor house spraying of DDT.

The central region of Madagascar is a vast area of highlands (altitude 700-2000 m). Malaria transmission has re-established itself here since the last epidemic of 1985-90 and has caused the deaths of 40,000 persons according to the Minister of Health. To combat the main malaria vector in the region, Anopheles funestus, annual programmes of indoor house spraying of DDT were carried out between December 1993 and January 1998 in most rural areas at altitude 1000-1500 m. A parasitological and serological study was then conducted in the highland schools to evaluate the impact of the programme and set up a database on the region. Using a cluster-sampling method 2 independent selections were conducted (one of 130 sites, the other of 40 sites). During the study, 13,462 schoolchildren were examined, 71% living in sprayed villages. Parasite prevalence among schoolchildren declined as altitude increases, from 11% at 700-900 m to 0.4% at > 1500 m. Below 1500 m, the impact of the spraying on the prevalence of the parasite was very clear (an average decrease of from 20% to 2.7% below 1000 m and of from 4.5% without spraying to 0.8% at 1000-1500 m). Geographical analysis of the data showed that the marginal regions remained the most affected by malaria (especially outside spraying zones), and persistence of 'pockets of transmission' at 1000-1500 m, essentially in areas where spraying has never been used. In 9 schools, anti-Plasmodium antibodies were sought by indirect immunofluorescence on thick smears of parasitized red blood cells. The seroprevalence ranged from 22% to 63%, which suggests that the parasite is still circulating in the region. Even though our data show that vector control continues to be very successful in the Madagascan highlands, rapid reinfection could occur and must be monitored following spraying. To this end, the Minister for Health, with the support of the Italian Co-operation, has placed the region under epidemiological surveillance since 1997. An alert system for the timely detection of the sources of epidemics and the targeting of the antivectoral campaign is also in operation. Our study suggests that this strategy should be reinforced by the spraying of DDT in the marginal zones in order to consolidate the results obtained at higher altitudes.

[Geographic approach in malaria control in the central highlands of Madagascar]. / Approche géographique dans la lutte contre le paludisme dans la région des Hautes Terres Centrales à Madagascar.

Following the severe malaria outbreak in the central highlands in Madagascar in 1986, a vector control program by use DDT pm 75 house-spraying has been implemented to operate in areas located at altitudes between 1000 and 1500 m. Early treatment with chloroquine has also been incorporated in the control program. To detect areas at particular high risk for malaria outbreak the Geographic Information System (GIS) has been applied and tested. The study has shown that the system can be used in malaria surveillance in order to identify areas in which an intense distribution of Anopheles funestus can be anticipated and, hence, targeted in spraying campaigns. The system may also be used to monitor changes in anti-malarial drug resistance, in addition, to control of other vector-born diseases.

Approche geographique dans la lutte contre le paludisme dans la region des Hautes Terres Centrales a Madagascar

"Geographic Information System as a supplementary tool in malaria control in Madagascar"" : Following the severe malaria outbreak in the central highlands in Madagascarin 1986; a vector control program by use DDT pm 75 house-spraying has been implemented to operate in areas located at altitudes between 1000 and 1500 m. Early treatment with chloroquine has also been incorporated in the control program. To detect areas at particular high risk for malaria outbreak the Geographic Information System (GIS) has been applied and tested. The study has shown that the system can be used in malaria surveillance in order to identify areas in which an intense distribution of Anopheles funestus can be anticipated and; hence; targeted in spraying campaigns. The system may also be used to monitor changes in anti-malarial drug resistance; in addition; to control of other vector-born diseases."

Prevalence of Mycobacterium bovis in human pulmonary and extra-pulmonary tuberculosis in Madagascar.

The prevalence of human tuberculosis (TB) due to Mycobacterium bovis was determined in Madagascar in 1994-1995. A prevalence of M. bovis of 1.25% was observed among sputum smear-positive patients and 1.3% among extra-pulmonary TB patients. This study was conducted in urban areas and will be extended to rural zones, where the majority of the population lives.

Replacement of streptomycin by ethambutol in the intensive phase of tuberculosis treatment: no effect on compliance.

SETTING: Seven tuberculosis clinics in the National Tuberculosis Programme of Madagascar. OBJECTIVE: To compare the treatment efficacy and tolerance of regimens including either streptomycin or ethambutol for patient compliance during initial treatment of smear-positive tuberculosis. DESIGN: The 1023 patients included in the study were randomly divided into two treatment groups-one to receive streptomycin (S), isoniazid (H), rifampicin (R) and pyrazinamide (Z) (SHRZ), and the other to receive EHRZ, where streptomycin was replaced by ethambutol (E). During the 2-month intensive phase, drug delivery was completely supervised. The same 6-month continuation regimen was then given in both groups. Follow-up consisted of a clinical and bacteriological examination at the end of the second, fifth and eighth months. RESULTS: There was no significant difference between the two regimens as regards compliance with treatment, the number of patients lost or who died, or for bacteriological response during the intensive phase. EHRZ was better tolerated. During the continuation phase, the results of the two groups remained comparable, but treatment failures occurred earlier in the patients who had received streptomycin. CONCLUSION: Patient compliance was not better with streptomycin. The ethambutol-containing regimen was as efficient as the other, and better tolerated. There is no argument for preferring streptomycin in the intensive phase of treatment of smear-positive tuberculosis.

[Profile of the patients lost to treatment in the National Anti-Tuberculosis Program in Madagascar]. / Profil des malades perdus de vue en cours de traitment dans le Programme national de lutte contre la tuberculose à Madagascar.

A national anti-tuberculosis program has been in operation in Madagascar since 1991. Despite the significant efforts made in the management, education and surveillance of patients, the number of patients lost to treatment remains high (18.8%). Noncompliance with treatment is the principal cause of treatment failure and of the development of resistance to tuberculosis drugs. This study investigated the profile of the patients who discontinue treatment. The study population consisted of the patients withdrawing from a clinical trial carried out between August 1994 and September 1996. The aim of the trial was to compare several treatments in routine practice conditions in Madagascar. The treatments tested were streptomycin (S) or ethambutol (E) associated with isoniazid (H), rifampicin (R) or pyrazinamide (Z) for the first two months, followed by 6 months of treatment H and thiacetazone (T). The trial involved four public and three private diagnosis and treatment centers in Antananarivo, Fianarantsoa and Mahajanga. A total of 1, 023 patients were included in the trial and 192 (18.8%) withdrew during the eight-month treatment period. We tracked down 109 of these patients (56.8%) and 19 patients came back to the treatment center on their own initiative for a checkup. The rate of response to a recall letter sent by mail was low. The 106 patients interviewed mostly gave professional, financial or family reasons for discontinuing treatment. Many patients stopped the treatment as soon as they began to feel better. To reduce the number of patients discontinuing treatment, the National Anti-Tuberculosis Program should improve the education of patients and their families.

Anti-tuberculosis drug resistance in Madagascar in 1994-1995.

SETTING: A new tuberculosis control programme has been implemented in Madagascar since 1991. A survey on Mycobacterium tuberculosis resistance to the major drugs was conducted between August 1994 and December 1995. OBJECTIVE: To determine primary and acquired resistance in pulmonary tuberculosis patients in four main cities. DESIGN: Were included 401 randomly sampled new smear positive patients (36.2% of declared new patients) and 137 recurrent cases (72.9% of declared cases) from 8 centres. Drug susceptibility testing was performed on Löwenstein Jensen medium according to the proportion method. RESULTS: The male to female ratio was 1.35:1 in new patients (age range 11-74 years) and 1.98:1 in recurrent patients (age range 16-76 years). The primary resistance rate to any drug was 20% (95% Confidence Interval [CI] 16-23) and the acquired resistance rate 40% (95% CI 32-48, P < 2.10(-7). Primary resistance to one drug was 18% (95% CI 15-22), mainly attributable to streptomycin resistance (14.5%). Multidrug resistance (MDR) to isoniazid and rifampicin was 0.25% (95% CI 0-0.7) for primary resistance and 5% (95% CI 2.6-10.6) for secondary resistance. No difference was observed between sexes or ages. CONCLUSION: This survey conducted in big cities gives a very negative picture of resistance in Madagascar.

[Tuberculosis in the prison milieu at Antananarivo from 1990 to 1993]. / La tuberculose en milieu carcéral à Antananarivo de 1990 a 1993.

Within 42 months, from June 1990 to December 1993, 454 cases of tuberculosis have been recorded in the central remand home of Antananarivo. The tubercular prevalence observed was there eight times superior to that of the global population of Madagascar. Among the 360 pulmonary tuberculosis, only one did not have any bacteriological proof; among the 94 extrapulmonary tuberculosis, 37 have been proved by histology or bacteriology. Among the extrapulmonary tuberculosis, pleurisies were obviously preeminent (79/94). Association of tubercular localizations could be observed with 21% of the patients. New cases of smear-positive pulmonary tuberculosis (PMT+) represented 81% of all the PMT+, recurrences were 9% and revivals 10%. Since February 1991, the 8 months short course regimen was the standard applied; before, the lack of stock did not allowed any standardization. The PMT+ new cases recovery rate increased from 42.5% in 1990 to 74% in 1993, whereas lethality decreased from 23% in 1990 to 8% in 1993. Patient dropouts were noted only with released or escaped individuals. Treatment failure rate was 4%. The diminution of cases despite the constancy of prisoners number and the carrying out of activities by the same health team make questionable the explanatory factors of the burst of tuberculosis-diseases in a prison milieu. Because of the importance of prison tubercular foci in terms of public health and the satisfactory results obtained, the Programme proposes to apply the model of partnership developed between the Tonga soa NGO and the prison administration to other prisons in Madagascar.

[Role of catholic centers in the control of tuberculosis]. / Place des centres catholiques dans la lutte contre la tuberculose.

This study briefly reports the results of a survey conducted by the National Tuberculosis Control Programme (NTCP) to asses the Catholic Centres and particularly the leper colonies activities of tuberculosis control. Among the 34 Catholic Centres taking care of the lepers, 11 take part in the NTCP. Within less than 3 years, most of these centres have taken charge of twice more tuberculous patients: the number of cases increased from 540 to 1045. Leprosy prevalence is constantly decreasing, thus multibacillary leprosy cases declared by these centres decreased of 28% from 1992, to 1994. Centres which did not begin conversion would feel this necessity soon. Germs responsible for leprosy and for tuberculosis are "first cousins". Technical and operational approaches for the control of both affections are very much alike. Those considerations logically induce to propose the conversion of antileprosy centres for tuberculosis control. Other arguments are partially exposed in this work. The Central Division knows the existence of 28 Catholic Centres throughout the country, taking charge of tuberculous patients. In 1994, they put more than 1600 patients under treatment, thus 15% of the tubercular in Madagascar. Those Catholic Centres implementing tuberculosis control programme ought set up a "federation" as a privileged interlocutor for the NTCP and for the financial backers when allowing support. Responsibles of the Programme expect to convince Centres of the necessity of conversion and of the interest of tuberculosis control.

[Role of the Lutheran Non-Governmental Health Organization in tuberculosis control]. / Rôle del l'Organisation Non Gouvernementale Luthérienne à but Sanitaire (SALFA) dans la lutte antituberculeuse.

Ever since its establishment in Madagascar, the Lutheran Church has been very active in medical field. In 1983, the creation of a medical non governmental organization called SALFA (Sampanasa Loteriana momba ny Fahasalamana) gave a new impulse. Since 1987, the SALFA has been seriously involved in the management of tuberculous patients. This document is a synthesis of actions conducted by SALFA whose experience in tuberculosis control is widely recognized by the Health Department and specially by the National Tuberculosis Control Program (NTCP). With an annual average of 1250 tuberculosis taken in charge, this NGO assumes 10% of the whole of the Program work. The diagnosis work is good (more than 85% Of PMT+) and therapeutic follow up of patients is excellent (more than 80% of the cured); those two elements of screening-treatment, basis of all tuberculosis control program incited us to describe this exemplary program.

[Comparison of routine therapeutic protocols used in Madagascar for the treatment of smear-positive pulmonary tuberculosis (preliminary results)]. / Comparison de protocoles thérapeutiques utilisés en routine á Madagascar dans le traitement des tuberculoses pulmonaires á microscopie positive (Résultats préliminaires).

A survey was undertaken in April 1993 to compare the respective benefits of 2 regimens containing either streptomycin (SHRZ) or ethambutol (EHRZ) in the first two months of treatment of smear-positive pulmonary tuberculosis in Madagascar. This operational research was justified by the risks related to the use of parenteral streptomycin in a country where single use material is rare and its purpose was to provide arguments for an eventual recommendation to replace this drug by oral ethambutol which is also less expensive. 907 patients were included. The compliance was not significantly different between the 2 groups, although it was traditionally assumed to be better with streptomycin. The frequency of side effects was significantly lower with EHRZ. Overall treatment failure rates were not significantly different, but all of 6 patients who were negative at 5 months and were again positive at 8 months had received EHRZ. This point obliged to be careful before concluding, because 24% of patients were lost for follow-up. A 2 years surveillance will be necessary to compare the frequency of recurrences.

[Laryngeal tuberculosis in Antananarivo]. / Les laryngites Tuberculeuses á Antananarivo.

From September 1989 to December 1992, 49 patients had been observed at the Centre Hospitalier de Soavinandriana and 31 cases at the prison infirmary of Antananarivo from April 1990 to December 1992. The 31 laryngeal tuberculosis observed in prison existed among 9.1% of tubercular patients, were associated to 10.9% of pulmonary tuberculosis and represented 24.2% of extrapulmonary tuberculosis. The 49 laryngeal tuberculosis of the CENHOSOA were present among 4.6% of tubercular patients, were associated to 7.9% of pulmonary tuberculosis and represented 8.4% of all the extrapulmonary tubercular localizations. Voice disorders, even if always present, rarely represented (<30%) a reason for tuberculosis discovery. Comparison with the whole of tuberculosis cases showed that laryngitis was not most frequent in retreatments and that there was no statistically significant difference in death risk. Laryngeal tuberculosis being mostly in the shadow of pulmonary tuberculosis, it develops in the same way under the same treatment, except when a very ancient laryngitis has given rise to irreversible fiber lesions. Recall of this very early known localization is made in a didactic perspective: in a developing country, all chronical voice disorders must induce to research of tuberculosis.

Mitochondrial phosphate transport. N-ethylmaleimide insensitivity correlates with absence of beef heart-like Cys42 from the Saccharomyces cerevisiae phosphate transport protein.

The mitochondrial phosphate transport protein (PTP) has been purified in a reconstitutively active form from Saccharomyces cerevisiae and Candida parapsilosis. ADP/ATP carriers that copurify have been identified. The PTP from S. cerevisiae migrates as a single band (35 kDa) in sodium dodecyl sulfate gels with the same mobility as the N-ethylmaleimide-alkylated beef heart PTP. It does not cross-react with anti-sera against beef heart PTP. The CNBr peptide maps of the yeast and beef proteins are very different. The rate of unidirectional phosphate uptake into reconstituted proteoliposomes is stimulated about 2.5-fold to a Vmax of 170 mumol of phosphate min-1 (mg PTP)-1 (22 degrees C) by increasing the pHi of the proteoliposomes from 6.8 (same as pHe) to 8.0. The Km for Pi of this reconstituted activity is 2.2 mM. The transport is sensitive to mersalyl (50% inhibition at 60 microM) and insensitive to N-ethylmaleimide. We have purified peptides matching the highly conserved motif Pro-X-(Asp/glu)-X-X-(Lys/Arg)-X-(Arg/lys) (X is an unspecified amino acid) of the triplicate gene structure sequence of the beef heart PTP. The N-ethylmaleimide-reactive Cys42 of the beef heart protein, located between the two basic amino acids of this motif (Lys41-Cys42-Arg43), is replaced with a Thr in the yeast protein. This substitution most likely is responsible for the lack of N-ethylmaleimide sensitivity of the yeast protein and mersalyl thus reacts with another cysteine to inhibit the transport. Finally it is concluded that Cys42 has no essential role in the catalysis of inorganic phosphate transport by the mitochondrial phosphate transport protein.

Photoaffinity labelling of the purine-cytosine permease of Saccharomyces cerevisiae.

8-Azidoadenine was used as a photoaffinity reagent to characterize the purine-cytosine permease of Saccharomyces cerevisiae. It is a potent competitive inhibitor of cytosine uptake and irradiation of the cells incubated with the label induced the irreversible inactivation of cytosine uptake. Addition of excess cytosine prevented this labelling which was restricted to the outer face of the plasma membrane since it was not accumulated by the cells. In the strain with the amplified purine-cytosine permease gene the maximum cytosine uptake rate was increased 4-5-fold relative to wild type without a modification of the Michaelis constant of uptake (Kt); no uptake could be measured in the deleted strain. The relative amounts of specific labelling determined for the cells and for membrane preparations were 0, 1 and 4 for the null, the wild-type and the amplified strains, respectively. One major band specifically labelled by [3H]azidoadenine, corresponding to a polypeptide with an apparent molecular mass of 45 kDa, was observed in the wild type, amplified in the strain carrying the multicopy plasmid and not detected in the deleted strain. Therefore this polypeptide corresponds to the purine-cytosine permease.