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The 2017 plague outbreak in Madagascar was unprecedented in the African region, resulting in 2417 cases (498 confirmed, 793 probable and 1126 suspected) and 209 deaths by the end of the acute urban pneumonic phase of the outbreak. The Health Emergencies Programme of the WHO Regional Office for Africa together with the WHO Country Office and WHO Headquarters assisted the Ministry of Public Health of Madagascar in the rapid implementation of plague prevention and control measures while collecting and analysing quantitative and qualitative data to inform immediate interventions. We document the key findings of the evidence available to date and actions taken as a result. Based on the four goals of operational research - effective dissemination of results, peer-reviewed publication, changes to policy and practice and improvements in programme performance and health - we evaluate the use of evidence to inform response to the outbreak and describe lessons learned for future outbreak responses in the WHO African region. This article may not be reprinted or reused in any way in order to promote any commercial products or services.

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.

To redefine strategy and policy to cure or to prevent malaria, there is a need to get relevant and updated data on Plasmodium sp sensitivity level to antimalarial drugs. Thus, in September 1999, the Madagascan Ministry of Health and the Institut Pasteur de Madagascar (IPM) formed a network named RER for malaria resistance surveillance. To alleviate the lack of experienced medical teams within the health centres, and due to technical and logistic matters, as part of the network activities, it was decided to give a start with the in vitro studies which are carried out at IPM. In vitro sensitivity testing is done by use of the isotopic method. Results from the study done in 2001 demonstrate that the Madagascan P. falciparum isolates are susceptible to amodiaquine (n = 215), to cycloguanil (n = 56), to pyrimethamine (n = 98) and to quinine (n = 214). One isolate (1/110 i.e. 0.9%) of mefloquine-resistant phenotype is detected from the Eastern region. P. falciparum susceptibility to chloroquine is satisfactory with 95.4% (206/216) of in vitro sensitive isolates. RER arises from the partnership and collaboration between the Madagascan Ministry of Health and the IPM. The network set-up is presented. The usefulness of the in vivo approach, and the in vitro investigations (chemosusceptibility test and screening of mutations accounting for resistance to chloroquine) to monitor the emergence and the dissemination of drug-resistant parasites in Madagascar as well as in the subregion of the Indian Ocean is discussed.

The seventh cholera pandemic reached Madagascar in March 1999, 30 years after its appearance in East Africa. Two waves of infection were observed during the first year. The second wave was the stronger of the two. It occurred in the warm rainy season and spread over six provinces of the country. The incidence of cholera was from 0.1% to 2% and the hospital case fatality rate was between less than 2% and 6%, depending on the geographical area and the period. This outbreak has raised the awareness of communities and their leaders with respect to the environmental, practical and cultural factors that increase the risk of diseases transmitted by feces.

In 1996 and 1997, a knowledge, attitude and practice survey concerning seafood poisonings was conducted in 560 villages spread along the Madagascar coasts, gathering 585,000 people. 175 serious and 205 mild seafood poisonings after fish, shark and turtle meals occured during the period 1930 to 1996. Squales (mainly Sphyrnidae and Cacharinidae familiesi) are the most often responsible of serious poisoning (48% of episodes), then other fishes (37%), and mainly of the Clupeidae family (herrings, sardinels), then marine turtles (11%), with Eretmochelys imbricata and Chelonia mydas, and finally crabs (4%). Neurological symptoms are predominant in squale poisonings, neurological symptoms associated with gastrointestinal symptoms are present in 50% of all kind of seafood poisoning episods. Most of episods incame on the East Coast (mainly Toamasina and Antisiranana Region) and on the South-West Coast (Toliara Region). Mild seafood poisonings are spread along all the Coasts but central East Coast; fishes are the most often responsible (41% of episodes). Gastro-intestinal symptoms are the most conmon. More than 50% of t interviewed people knows about poisoning risks with some kind of marine animals, but less than 20% practice preventive measures such as giving a piece of fished animal to a domestic animal before eating. These results are used to plan a comprehensive epidemiological surveillance and control programme.

Malaria remains one of the major public health problems in Madagascar. For malaria, most of the eco-epidemiological facies of the African continent are found on this large island because of its geo-climatic diversity. These include the subequatorial facies on the east coast, the tropical facies on the west coast, the high-altitude tropical facies in the center and the subdesert facies in the south. In the first two facies, the stable type of malaria is encountered, where the major vectors are A. gambia and A. funestus. In the other two facies, the transmission of the disease is highly unstable yet causes deadly epidemics, principally from A. arabiensis. Malaria is even imported to a few inhabited zones situated above 1,500 m in altitude and to the centers of the large cities. The strategies of the fight against malaria consist of the following; early and correct health care of the cases throughout the country, supported by the community; drug prophylaxis for the target group of pregnant women; and eradication of adult insects in the central highlands, supported by an efficient surveillance. The utilization of mosquito bed nets impregnated with insecticide has not yet gone beyond the trial period. However, despite the efforts undertaken and the expenses run through by the national program, the fight against malaria is still far from covering the entire population. The high costs of spraying within the homes, the expanse of the country and the poor accessibility of many regions during the season of transmission, and insufficient sanitary coverage of the rural population in terms of quality and quantity, constitute the principal constraints of the fight. The current reorganization of the health service in Madagascar constitutes a favorable opportunity to establish a new approach for the fight against malaria. This is geared towards the participation of the decentralized health structures and the contribution of the community in the conception and the achievement of their respective strategies for the fight, supported by the central Service of the Fight Against Malaria. This new decentralized approach seems more appropriate to respond to the demands of the specific and selective strategies of the fight, better adapted to the different facies described above, and to render the National Program of the Fight Against Malaria more efficacious.