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Background: The Integrated Disease Surveillance and Response (IDSR) strategy was introduced in Madagascar in 2007. Information was collected by Healthcare structures (HS) on paper forms and transferred to the central level by post or email. Completeness of data reporting was around 20% in 2009-10. From 2011, in two southern regions data were transmitted through short messages service using one telephone provider. We evaluated the system in 2014-15 to determine its performance before changing or expanding it., Methods: We randomly selected 80 HS and interviewed their representatives face-to-face (42) or by telephone (38). We evaluated knowledge of surveillance activities and selected case definitions, number of SMS with erroneous or missing information among the last ten transferred SMS, proportion of weekly reports received in the last 4 weeks and of the last four health alerts notified within 48 h, as well as mobile phone network coverage., Results: Sixty-four percent of 80 interviewed HS representatives didn't know their terms of reference, 83% were familiar with the malaria case definition and 32% with that of dengue. Ninety percent (37/41) of visited HS had five or more errors and 47% had missing data in the last ten SMS they transferred. The average time needed for weekly IDSR data compilation was 24 min in the Southern and 47 in the South-eastern region. Of 320 expected SMS 232 (73%) were received, 136 (43%) of them in time. Out of 38 alerts detected, four were notified on time. Nine percent (7/80) of HS had no telephone network with the current provider., Conclusions: SMS transfer has improved IDSR data completeness, but timeliness and data quality remain a problem. Healthcare staff needs training on guidelines and case definitions. From 2016, data are collected and managed electronically to reduce errors and improve the system's performance.

Malaria transmission in Madagascar is highly variable from one region to the next, and the consequences of the disease on pregnant women and their foetuses are not fully documented. In midwestern Madagascar, the high-transmission lowlands in the west of the country meet the central plateaux, where malaria is unstable because of the high altitude and annual indoor spraying of DDT since 1993. We studied five of the region's main maternity clinics. We began by interviewing sample groups of women of childbearing age living within the vicinity of each clinic. This enabled us to determine the extent to which they had accessed and made use of available maternal health services during pregnancy and delivery, and, hence, to estimate the feasibility of boosting the prophylaxis. We then spent a whole year (from June 1996 to May 1997) observing deliveries at the five clinics in order to gauge the prevalence of placental infection and its consequences on birthweight in various transmission situations. Although only between 2 and 15% of the women said that they had taken prophylaxis during their previous pregnancy, the vast majority had benefited from preventive care: 97% had attended an antenatal visit on at least one occasion and 84% had had the assistance of medical or paramedical staff during delivery, even when their homes were situated relatively far away from the clinic (76%). In total, we observed 1637 deliveries with a mean placental malaria prevalence rate of 8.1%. Individual prevalence rates, however, were found to differ significantly between the maternity clinics situated in the east (minimum 2.1%) and west (maximum 26.2%) of the region. There were also marked variations in line with the seasonal fluctuations in entomological transmission. On the whole, a greater percentage of low birthweights (LBWs) was recorded at the lowland clinics than at the highland ones (17.1% vs. 9.7%), possibly because of the higher malaria infection rate in low altitude areas. On the other hand, the relative risk of LBW linked to placental infection was far greater in the highlands [4.9 (3.3-7.3)] than in the lowlands [1.9 (1.2-3.0)]. Although the rate of placental malaria among women inhabiting the country's central plateaux may be low, it means that transmission--and, hence, the risk of LBW because of placental infection--still persists in spite of the indoor DDT spraying programme. For maximum efficacy, we recommend a combination of vector control (extended to lower altitude areas outside the current OPID zone) and preventive care--i.e. individual chemoprophylaxis--for all highland women during pregnancy.