Madagascar is a large and beautiful island in the Indian Ocean. However, according to the World Bank (April 2023), the poverty rate is estimated to be 80.2% and approximately 77% of the population has no access to limited-standard sanitation.1 In rural areas, 88% of the population lives on less than US$ 2.15 per day. Madagascar also faces many health challenges.
Infection with the parasite Taenia solium is endemic in Madagascar, and causes disease with some of the highest prevalence of porcine cysticercosis noted globally.2 Out of 114 districts, at least 53 have been identified as positive for taeniasis. This is not surprising considering the levels of poverty and sanitation, and that many backyard farmers keep pigs to support their livelihoods. Despite lacking accurate data on the burden of the disease, neurocysticercosis (the main disease caused by infection with T. solium) is assumed to be very high. The poor quality of data is due to lack of surveillance, of medical recording and reporting, the high cost of diagnostics and their limited access.
According to Dr Jean Adolin Rafanomezantsoa, Chief of the Health Centre and officer responsible for neglected tropical diseases (NTDs) in Betafo district: “Although we have no official statistics data on the number of neurocysticercosis cases, many suspected cases come to the health centres for consultation. These people suffer from strong headaches, epileptic seizures or have undergone treatment for chronic symptoms.”
Dr Sylvia Ramiandrasoa, an expert previously responsible for the taeniasis programme at the Ministry of Health of Madagascar, led a 3-year programme between 2015 and 2017. She said: “For 3 years we conducted mass drug administration covering around 70 000 people with the support of the WHO in the Vakinankaratra region. The programme was very successful in reducing the level of taeniasis but, one year later, the prevalence had increased to the original levels. That indicated to us that we needed to conduct a One Health programme involving interventions in pigs.” She continues to provide her expertise in the most recent One Health project.
Dr Diana Andria-Mananjara, a PhD candidate from FOFIFA (Centre National de Recherche Appliquée au Développement Rural) has been coordinating the One Health project locally from 2021 to 2023. This project was funded by the Livestock Vaccine Innovation Fund from the International Development Research Centre (Canada), led by the University of Melbourne (Australia); WHO was also one of the key partners. She explained that “three ministries were involved: the Ministry of Public Health, which led the actions related to the mass treatment in humans; the Ministry of Agriculture and Livestock, which was responsible for the vaccination and antiparasitic treatment of pigs; and the Ministry of Higher Education and Scientific research, which assessed the effectiveness of this integrated approach. Bringing multiple institutions to work together is not always an easy task, as each of them has their own priorities, structure and thinking. Initiating new projects can also challenging, but we overcame those challenges, and the final evaluation of this One Health project showed very good results. In August 2023, one year after the last mass treatment, we saw a big reduction of porcine cysticercosis from approximately 30% before the start of the project to 8%. This indicates a big decrease in parasite transmission and will result in less people being infected.”
Dr Mihaja Rakotoarinoro, also from FOFIFA, worked alongside Diana. She remarked on the importance of the sensitization and awareness activities: “To be successful and combat, prevent and even eliminate the human disease, the involvement of the community is essential. We need to sensitize the community and make them aware of the effects of the disease, and encourage their participation in the mass treatment and, in the case of pig farmers, on the vaccination and treatment of pigs.”
Dr Jose Nely is Head of the Department responsible for the fight against NTDs within the Ministry of Health in Madagascar. He has been working towards the integration of T. solium control with other programmes: “We are working on integrating the T. solium control programme with those for other diseases such as schistosomiasis. Both diseases use the same microscopy tests for surveillance (Kato-Katz) and the same drug for mass treatment, (praziquantel), providing good opportunities for synergies. This is not always easy as each programme has its own timings and priorities, but in the past couple of years we have been learning how to work together and it is becoming routine now, increasing the efficiency of both programmes.”
Dr Nivohanitra Razafindrabe from the Veterinary Services of Madagascar, commented on the effects of the One Health project from the animal side: “The vaccination and treatment of pigs have had many benefits for pig farmers beyond reducing T. solium infection. We have noticed that vaccinated pigs grow faster and sell at good prices. In the butchers we have seen a clear reduction in the number of cysticercosis cases since the pigs were vaccinated and dewormed. But to achieve good results, it is important to involve the local authorities at fokontany level and conduct awareness-raising activities, such as radio broadcasts and posters.”
Mrs Falia, a pig farmer from the Akazomirotra community, which has participated in the recent One Health project, commented: “We have taken part in the deworming medication against taeniasis and schistosomiasis distributed by the health centre and we vaccinate our pigs because when pigs are vaccinated there is no risk. In fact, I know someone who has cysticercosis. His treatment is very expensive, he complains about the cost of the medicines and he has to undergo several tests in town. That is the advantage of vaccinating pigs for human health.”
Mr Justin, a pig farmer in Soavina, Betafo district said: “I hope this project will spread throughout Madagascar because it will benefit farmers and protect human health.”
Very good progress has been made to control the diseases caused by T. solium infection in Madagascar, especially with the multisectoral approach, which must be encouraged; however, the results need to be consolidated and extended to the rest of the country with support from different partners in order to keep and accelerate the momentum, as Mr Justin rightly said!
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1 Poverty & Equity Brief, Madagascar, Africa Eastern & Southern, April 2023. Washington (DC): World Bank
2 Andria-Mananjara D, Rakotoarinoro M, Rakotoarison VC, Raliniaina M, Razafindraibe NP, Ravonirina C, et al. Confirmation by necropsy of a high prevalence of porcine cysticercosis in a rural district of Madagascar. Parasitology. 2023;150(9):852–857
Photos credits: LVIF cysticercosis project Madagascar