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Madagascar



Capital: Antananarivo

Time Zone: +3 hours. No daylight savings time in 2008.
Tel. Country Code: 261
USADirect Tel.: 0
Electrical Standards: Electrical current is 220/50 (volts/hz). European Style Adaptor Plug. Grounding Adaptor Plugs D, F.


Travel Advisory - Madagascar

Sub-Saharan Africa has the highest incidence of insect-transmitted diseases, such as malaria, and all travelers need products to prevent mosquito and tick bites. I recommend all travelers use a combination of DEET or Picaridin repellent on their skin and Permethrin fabric insecticide on their clothing for greater than 99% protection against mosquito and tick bites.

Dr. Rose Recommends for Travel to Madagascar


Resource Links

NaTHNaC
World Health Organization
CDC
Travel Health Services
Country Insights
Travel Warnings
Consular Information
Foreign Commonweatlh Office

Embassies

• U.S. Embassy
14-16 Rue Rainitovo
Antsahavola
Antananarivo
Tel: [261] (20) 22-212-57
Fax: [261] (20) 22-345-39
Website: http://www.usmission.mg

The High Commission in Tanzania represents Canadian interests in Tanzania, Madagascar, Seychelles and Comoros.
• The Canadian High Commission
38 Mirambo St.
Garden Avenue
Dar es Salaam
Tanzania
Telephone: [255] (22) 216-3300
Fax: [255] (22) 211-6897
Email: dslam@international.gc.ca

There is no British Embassy in Madagascar, but there are Honorary British Consuls in Toamasima (Tel: 00 261 20 5332548 or eMail: sealtmm@moov.mg) and Antananarivo (Tel: 00 261 20 2452180 or eMail: ricana@wanadoo.mg) who can be contacted by people in either region in emergencies only. All other enquiries should be directed to the British High Commission in Port Louis, Mauritius, which covers Madagascar.
• British High Commission
Les Cascades Building
Edith Cavell Street
Port Louis
Mauritius
Tel: [230] 202 9400 (Main)
Tel: [230] 202 9400 [230] 252 8006 Duty Officer (in case of genuine emergency out of office hours)
Fax: [230] 202 9407 Consular/Visa
Email: bhc@intnet.mu
Website: http://www.britishhighcommission.gov.uk/mauritius

Entry Requirements

HIV Test: Not required.

Required Vaccinations: Yellow fever certificate of vaccination is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas.

Passport Information

Passport/Visa: Madagascar is a developing island nation off the east coast of Africa. The primary languages are French and Malagasy. French is less spoken outside of major cities. Facilities for tourism are available, but vary in quality. Travelers seeking high-end accommodations should make reservations in advance. 

ENTRY/EXIT REQUIREMENTS: A passport and visa are required. Visas are available at all airports servicing international flights, but travelers who opt to obtain a visa at an airport should expect delays upon arrival. Visas obtained at the airport cannot be extended. Most international flights arrive in Antananarivo, but there are some limited international flights to/from the nearby islands of Comoros, Mayotte and Reunion from airports in Mahajanga, Toamasina (Tamatave), Nosy Be, Tolagnaro (Ft. Dauphin) and Antsiranana (Diego Suarez). There are also direct flights between Italy and Nosy Be. Evidence of yellow fever immunization is required for all travelers who have been in an infected zone within 6 months of their arrival in Madagascar.

Travelers may obtain the latest information and details on entry requirements from the Embassy of the Republic of Madagascar, 2374 Massachusetts Avenue NW, Washington, DC 20008; telephone (202) 265-5525/6; or the Malagasy Consulate in New York City, (212) 986-9491. Honorary consuls of Madagascar are located in Philadelphia, and San Diego. Overseas, inquiries may be made at the nearest Malagasy embassy or consulate. 
Visit the Embassy of Madagascar’s web site at http://www.embassy.org/madagascar for the most current visa information. 

Vaccinations: Recommended and Routine

Hepatitis A: Recommended for all travelers >1 year of age.

Hepatitis B: Recommended for all non-immune travelers who might be exposed to blood or body fluids from unprotected sexual contact; from injecting drug use with shared/re-used needles and syringes; from medical treatment with non-sterile (re-used) needles and syringes. Recommended for any traveler requesting protection against hepatitis B infection.

Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).

Rabies: Recommended for travelers spending time outdoors in rural areas where there is an increased the risk of animal bites, especially bites from dogs. Children are considered at higher risk because they tend to play with animals and may not report bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of exposure, but does not eliminate the need for treatment with two extra booster doses of vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.

Typhoid: Typhoid vaccine recommended for all travelers with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers.

Yellow Fever: A yellow fever vaccination certificate is required from travelers if they have been in a yellow fever infected zone within 6 months of their arrival in Madagascar.
. Vaccination not otherwise required or rrecommended.


Hospitals / Doctors

All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers’ diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance. For serious illnesses or complex medical procedures, travelers may wish to be medically evacuated to a destination with appropriate facilities.

The standard of medical facilities in the capital Antananarivo is limited and extremely limited outside the capital. There are foreign physicians in Antananarivo representing a broad range of specialties, but their training is variable and often not to U.S. standards. Most visitors seek treatment at private clinics where up-front payment is required. While routine medical operations can be carried out in Antananarivo, medical evacuation (usually to South Africa or Reunion) may be required in the event of a serious illness or accident. There are no decompression chambers in Madagascar.

• Saint Francois d'Assise Private Hospital
Lalana Dokotera Rajaonale
Ankadifotsy
Antananarivo
Tel: [261] (2) 230 95

Antananarivo Diagnostic Center
Lot IVL - 176
Anosivavaka, Ambohimanarina
Antananarivo
Tel: [261] (2) 30760

• Josephe Ravoahangy Hospital
Andrianavalona, Ampefiloha
Antananarivo
Tel: [261] (2) 279 79

• American Lutheran Hospital
Antananarivo

• Hospital Befelatnana
Antananarivo (1,300 beds)
General medical/surgical facility.

• Soavinandrimo Hospital
Tel: [261] (2) 397 51

• Regional Hospital
Diego Suarez
Tel: [261] (20) 82 210 61 / 215 13 (24h/24)

• Regional Hospital of Toamasina
rue Ratsimilaho
Tamatave
Tel: [261] (20) 53 320 18/53 320 21

Destination Health Info for Travelers

A Country Profile: Madagascar, located in the Indian Ocean off the eastern coast of Africa, is one of the largest islands on Earth. Its island location has thus far largely protected it from the HIV/AIDS epidemic ravaging the continent, with the estimated HIV prevalence rate of less than 1 percent at the time of the 2002 Barcelona Conference. More recent data, released in September 2003, suggests that the HIV rate on Madagascar is rising quickly and has now reached 1 percent. There is a high incidence of sexually transmitted infections (STIs) on Madagascar that points to a potential for a very rapid spread of HIV/AIDS if it should get a foothold on the island.
Those living in Madagascar are vulnerable to malaria, and the malaria death rate among children ages 0-4 is 904 per 100,000. Fewer than one percent of children sleep under treated bednets. The tuberculosis death rate is 57 per 100,000 for all ages, a very high rate for a country relatively untouched by HIV/AIDS.
• Doctors Without Borders/ Médecins Sans Frontières (MSF) has worked in Madagascar since 1987.
http://www.doctorswithoutborders.org/news/madagascar.cfm

AIDS/HIV: HIV prevalence appears to be low, even in the high-risk urban population. HIV prevalence in the 15-49 age group is estimated at 0.5%, but mnay be higher. (Source: www.Avert.org)
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with the body fluids of another person or their blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.

Animal/Marine Hazards: Animal hazards include centipedes, scorpions, and black widow spiders. Portuguese man-of-war, sea nettles, sea wasps, stingrays, and several species of poisonous fish are common in the country’s coastal waters and are potential hazards to unprotected swimmers.

Chikungunya Fever: Sporadic cases of chikungunya fever have been reported from Toamasina, and other areas, since mid-February 2006. Since 2005, outbreaks of this mosquito-transmitted viral illness have been reported throughout the Indian Ocean. Symptoms include fever, headache, fatigue, nausea, vomiting, muscle pain, rash, and joint pain. Acute Chikungunya fever typically lasts a few days to several weeks, but as with dengue, West Nile fever, and other arboviral fevers, some patients have prolonged fatigue lasting several weeks. No deaths related to chikungunya infection have been conclusively documented in the scientific literature.
• There is currently an outbreak of a dengue-like illness in the area. It is unclear whether this is dengue or chikungunya fever.
• To prevent this disease, and other arboviral illnesses, travelers should take measures to prevent mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night.

Cholera: Outbreaks are reported intermittently, particularly during the rainy season (December-April), but most travelers are at low risk for infection. Cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care.
• Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. (NEJM:http://content.nejm.org/cgi/content/short/354/23/2452)

Dengue Fever: The last large outbreak of dengue was reported from the port city of Toamasina in January 2006. Sporadic cases occur, but go undiagnosed. Dengue fever is a mosquito-transmitted, flu-like viral illness occurring in throughout much of Asia. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear.
• There is no vaccination or medication to prevent or treat dengue.

A dengue fever map is at: http://www.nathnac.org/ds/c_pages/documents/dengue_map.pdf

Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is endemic but levels are unclear. Sporadic cases may be underdiagnosed or underreported. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals, such as swine, and also deer and wild boar, may serve as a viral reservoirs. (HEV is one of the few viruses which has been shown to be transmitted directly from animals through food.) In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at >10%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic with a prevalence of 1.2% in the general population (http://www.ncbi.nlm.nih.gov/pubmed/9264746?dopt=Abstract). Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Leishmaniasis: Low risk. Incidence status undetermined.

Malaria: Risk is present year-round in the coastal areas, but transmission is more seasonal in the central highland plateau, occurring primarily November through May. There is minimal risk of malaria in Antananarivo and minimal risk in the towns of Antsirabe, Manjakandriana, and Andramasina. The highest risk of malaria occurs in the eastern coastal areas. Malaria occurs on the high plateau, formerly risk free. Falciparum malaria accounts for approximately 90% of cases. Other cases of malaria are due primarily to the P. vivax.

Chloroquine-resistant P. falciparum is reported. Prophylaxis with atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), or primaquine (G6-PD test required) is currently recommended when traveling to malarious areas.

A malaria map is located on the Fit for Travel website (www.fitfortravel.nhs.uk), which is compiled and maintained by experts from the Travel Health division at Health Protection Scotland (HPS). Go to www.fitfortravel.nhs.uk and select Malaria Map from the Madagascar page on the Destinations menu or A-Z Index.

Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing.
NOTE: Picardin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.
• Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours.

Other Diseases/Hazards: Brucellosis (umans acquire infection by ingestion of unpasteurized dairy products or, less commonly, ingestion of poorly cooked meat from infected animals, by direct or indirect exposure to the organism through mucous membranes or broken skin, or by inhalation of infectious material)
• Filariasis (mosquito-borne; endemic, primarily along the eastern border)
• Rabies (dogs main source of human infection)

Plague: Human cases are reported annually. At least 18 people died of bubonic plague in the April 2008. There have been cases of pulmonary plague in the rural area of Andilamena. Travelers should avoid contact with wild rodents (and their fleas) or patients with the pneumonic form of the disease. Doxycycline or tetracycline can be used prophylactically if exposure occurs.

Rabies: Rabies is endemic in Madagascar. Pre-exposure rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status. Note: If adequate rabies treatment is not available locally, medical evacuation is advised to a facility that can provide treatment.

Rift Valley Fever: In April 2008, an outbreak of Rift Valley fever was reported in five regions (Alaotra Mangoro, Analamanga, Itasy, Vakinakaratra and Anosy) across Madagascar. People may become infected with Rift Valley fever either by being bitten by infected mosquitoes, or through contact with the blood, other body fluids or organs of infected animals. Travellers should avoid mosquito bites and also avoid contact with domestic animals such as cows, goats and sheep, and avoid coming into contact with the blood, organs or body fluids of such animals.
• Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night.


Schistosomiasis: This disease is widely distributed. Urinary schistosomiasis predominates on the west coast and in the northern regions, while intestinal schistosomiasis predominates in the central and southern coastal zone of Toamasina Province; the coastal zone of Fianarantsoa Province, and inland, in areas at moderate elevations to the south of the central highlands. Risk-free areas include the vicinities of Antsiranana and Antananarivo, and the Presquile Peninsula, including Maroantsetra and Antalaha.
• Schistosomiasis is a parasitic flatworm infection of the intestinal or urinary system caused by one of several species of Schistosoma. Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, or streams. There is no risk in chlorinated swimming pools or in seawater.

Travelers' Diarrhea: High risk. Water distribution systems are found only in major urban areas and are old and in poor repair. Piped water supplies are frequently contaminated. Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized dairy products. Do not eat raw or undercooked food, especially meat, fish, raw vegetables. Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.

Tuberculosis: Tuberculosis is highly endemic in Madagascar with an annual occurrence was greater than or equal to 40 cases per 100,000 population. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.

Typhoid Fever: Typhoid fever is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all people (with the exception of short-term visitors who restrict their meals to hotels or resorts) traveling to or working in sub-Saharan Africa, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.