Madagascar Medical Expeditions

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Madex were incredibly excited to present two posters at the ASTMH (American Society of Tropical Medicine and Hygiene) in New Orleans in October. Dr James Penney and Dr Hannah Russell (Madex 2015-2017) travelled to the USA to share some of the work from previous expeditions with world experts in Tropical Medicine.

‘Our work was based on data from the 2016 expedition to the Marolambo District of Madagascar.  James had collated information about new education programmes we’d been implementing in Madagascar for his poster, and I had written about ultrasound research we’d done.

There were several symposiums on schistosomiasis during the weeklong conference where we learnt about some exciting developments.  We felt a little star –struck discussing ideas with schistosomiasis researchers that we have long admired!

We had some great feedback on our work, and left buzzing with new ideas for Madex2019 and beyond.’

Written by Dr Hannah Russell.
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16th-21st June 2019

After a quick overnight stop in Marofatsy, we continued the rest of our 25km trek to Betampona. We were greeted in Betampona with a lovely reception from the school teachers, headmaster, local doctor and village chiefs. Everyone was served a cup of warm lemon tea which went down a treat after a very wet hike!

Work was quickly underway with microscopes set up, information talks taking place and consenting of the children. Some issues with the generator meant Steve, Hannah and Graham, as well as about 15 men from the village soon became electricity experts.

Alice went out to continue looking for snails at different water contact sites around the village and in particular looked for biomphalaria snails – the snail that is involved in the life cycle of schistosomiasis mansoni. (intestinal schistosomiasis).

After a couple of days of collecting snails and leaving them in the sunshine in water to allow them to shed the parasite, Alice very excitedly was able to stain and see the parasite down the microscope! This is the first time this has been done in this part of Madagascar!

There were some big cheers from everyone including the locals and teachers!

This is a big step for confirming the presence of schistosomiasis mansoni. in this region, and in particular for informing and educating local people about its presence and the bodies of water they should try to avoid. It is also very important for helping the population visualise and understand the parasite and it’s impact better.

At the end of our time in Betampona Steve, Manu, Tahiry and Gina had to head back to Marolambo and then onto Tana due to work commitments. The team felt smaller very quickly and everyone was very grateful for their help in the first 2 weeks!

Onwards to Vohidamba!

Written by Caitlin and Heather

Madex work is finally underway. After being greeted with a wonderful meal cooked by Madame Chez Martin herself, we have all settled well in Marolambo. Yesterday was the first day spent as a full MadEx team in Marolambo and it was a busy one!!

The morning started with a circuit of research methods for the children in Marolambo. This was compiled of 5 research stations laid out in the local school classroom.

1. Questionnaires: The Malagasy team stay with the children and help them to fill out a questionnaire regarding their health behaviours and understanding of schistosomiasis before education.

2. Anthropometrics: Robbie and Steve took the height and weight of the children

3. Anaemia and Malaria testing – Caitlin and Hannah tested each of the children for malaria and anaemia.

4. Novel ultrasound – Heather performed an abdominal examination and basic ultrasound scan of the liver of each children

5. Ultrasound – Graham performed a full ultrasound scan of the liver of each child

Alongside all of this Alice has been hard at work looking for snails in the Marolambo waters (another blog post to come about this).

Having completed a day of research methods the new members of the team are now familiar with the programme and can replicate this in the next villages.

The afternoon was the start of the MadEx team fitness regime (as well as part of the research methods for the study) – the afternoon was bleep test time!! The children all participated in a bleep test which was led by some MadEx team members (who realised they lack some fitness). This is used as a measure of cardiovascular fitness. Robbie, who loves a spreadsheet, is keeping track of the team’s bleep test scores for the expedition!

The evening was spent handling the ‘pipi’ (children’s urine samples) and carrying out the urine tests for schistosomiasis (CCAs).

Today has consisted of more ultrasound for Graham and Heather while Steve and Hannah were on the hunt for a few power solutions – solar powering two ultrasounds is looking promising!

Manu, Gina, Tahiry, Jenny and Antsa, the Malagasy doctors and students in the team have all been busy carrying out an education programme. This year we are working on developing lesson plans with teachers and involving them in the delivery of the education in order to improve sustainability of the education.

Everyone’s having a great time and enjoying a sunnier day today! Looking forward to getting our hands on some of the ‘caca’ (stool samples) to start on some microscopy tonight!

The UK team have arrived at Madex home Tana Jacaranda

So today’s the day!! The rest of the team will fly out to Marolambo to meet the other 5 who flew out yesterday. The last few days have been busy for us all. We have had several meetings including meetings with the Madagascan Head of Neglected Tropical Diseases, Madagascan Head of Communicable Disease and the Dean of the Faculty of Medicine at the University of Antananarivo. In between these meetings we have managed to fit in some ultrasound training, kit purchasing (including and official Madex stamp) and several local beers! Not to mention we are now all fluent in French (especially Steve) – “parce que the truck fell in the ditch”!when explaining the 2015 expedition to Dr Louis, Head of NTDs.

Hannah and Graham teaching the team the ultrasound methodology

Let’s hope this journey to Marolambo goes smoother than Caitlin and Alice’s journey to Madagascar at the weekend! They had a luxurious evening spent on Amsterdam airport floor after missing their transfer by 10 minutes. Nevertheless, they got on the next plane to Paris, a slight diversion, and joined Robbie and Steve on their flight to Madagascar! Eventually the whole team were together by Midnight on Sunday.

We met all of the Malagasy team yesterday who are just as excited as we are and we can’t wait to get started on our research!

See you on the other side!!!!

Madex 2019 team

Robbie trying out his leech socks affectionately packed by Yvonne

Tahiry and our taxi driver to the university

Written by Heather Lawson

With not long left until Madex 2019 is underway we thought it would be a good time to introduce the 2019 UK team..

In just 11 days (yes, we can’t believe it either), the MadEx team will be flying out to Madagascar for the 2019 expedition. In preparation for this, the team met up in the big smoke (London) last weekend to finalise arrangements and run over the plans and methods together as a group. We thought it would be good to share with you our exciting plans and update you on some of the work we have been doing over the last year.

To begin, let’s introduce the 2019 UK team. We have yet another enthusiastic and hardworking team heading out to Madagascar who will consist of:

Expedition Lead – Caitlin Sheehy: Caitlin is the Expedition Lead for 2019, and was part of the 2018 expedition, where she gained invaluable experience as a field researcher. She will qualify as a doctor from The University of Manchester in July 2019. She helped organise and took part in a health outreach project in Northern Uganda in 2016 and is a former member of the student Global Health Society committee. She has a masters in Public Health in addition to her medical studies, and is currently spending her final semester in a hospital in Lyon, France.

Expedition Medic and Field researcher (sonography) – Dr Hannah Russell: Hannah completed her Foundation Years as a doctor in 2018 after graduating from the University of Manchester in 2016. Hannah has just finished studying a Diploma in Tropical Medicine and Hygiene at the Liverpool School of Tropical Medicine. Hannah was one of the original MadEx team members; a member of the 2015 and 2016 expedition team where she took on the role of field researcher, expedition medic and lead for the ultrasound work (2016 project). Hannah will be the expedition medic for MadEx 2019.

Field researcher – Robbie Kornitschky: Robbie is currently in his 4th year of medicine at Manchester. From his first year Robbie has been part of the Manchester Wilderness Medicine Society as well has having a strong interest in research and public health. Before coming to Manchester he undertook a biochemistry degree in Bristol. Afterwards he worked in science communication and public engagement for two years and volunteers as part of the Bristol Science Film Festival to this day.

Field researcher – Heather Lawson: Heather is currently a 4th year medical student at the University of Sheffield and will beworking with the MadEx team as part of her elective. Heather as an interest in public health,paediatrics and psychiatry and holds a BSc in Global Health which she completed atthe University of Manchester in addition to her medical studies. Currently Heather is acommittee member for of the Sheffield Students for Global Health and was formerly a member of the committee of Manchester Friends of MSF committee.

Biologist – Alice Reid: Alice Reid is currently a MSc student at the Liverpool School of Tropical Medicine studying Biology and control of parasites and disease vectors. Alice will be the malacologist for the 2019 MadEx expedition, in which she will continue researching the prevalence of Biomphalaria pfeifferi and the evidence of shedding cercariae in water contact areas. This research will be a follow on from Daniel Ripley’s previous work during the 2018 MadEx expedition. Alice has a particular interest in trematode infections and has acquired microscopy skills in identifying different species of Schistosomiasis during her Masters course. The freshwater survey of molluscs conducted during MADEX 2019 will be for Alice’s dissertation.

Field researcher (sonography) – Dr Graham Dodge: Graham is a consultant radiologist, with an interest in GI/hepato-biliary imaging, at Brighton and Sussex University Hospitals NHS Trust. He will be the ultrasound expert on the 2019 expedition. Graham previously worked in clinical management at BSUH NHS trust but recently gave that up and completed the Clipper Round the World 2017-2018 sailing race as part of the Liverpool 2018 crew. He now wants to develop wider imaging interests especially in low and middle income countries.

Dr Stephen Spencer: Steve founded MadEx in 2014 while he was still a medical student at the University of Manchester. He has an undergraduate degree in Zoology and since graduating from Manchester in 2015, he has been working as a doctor in Bristol. He will be accompanying the team for the first two weeks of the expedition in Madagascar.

So that’s the team…. Now, what have we done so far and what will we be doing?

The last few months have been pretty crazy. Getting ethical approval, applying for grants, coordinating with the Ministry of Health in Madagascar, coordinating with the Malagasy team, sorting flights/hotels/transfers, finalising the methodology and presenting previous research.  That’s to name a few. Although the phrase “I’m sure it’ll be obvious when we’re there” was used a lot last weekend, I think we all agree we are finally at a point where we feel ready to head to Madagascar and start our work. 

We arrive in Madagascar on Sunday 9thJune 2019 before spending 4 weeks in the field, which looks as jam packed as ever. This year, we will be starting a five year longitudinal study as well as continuing with the research done over the last 5 years. We will be visiting the same villages as previous years to study and treat schistosomiasis. We will be be getting well acquainted with poo samples and continue to monitor the prevalence and disease intensity of schistosomiasis within these villages as well as carry on with the education programmes, morbidity assessments and mass drug administrations established by MadEx in previous years. 

This year, we will also be adding two new components to our research. 

  • With Graham’s expertise, we are lucky to have an expert in the field of radiology meaning we can perform more extensive imaging on the children to assess for schistosomiasis-related morbidity. In addition, some of us less skilled radiographers (the rest of us!) will be trialling out a new ultrasound technique to compare its accuracy to Graham’s ultrasound. 
  • We will also be extending our research to pre-school children this year and researching the prevalence of schistosomiasis amongst preschool aged children in the same villages. 

Both of these components continue to expand on the research carried out by MadEx. Our project has been funded and supported by many people and organisations, whom we are really grateful for and would not be able to do our work without them. 

Between now and Saturday 8th June we still have lots to do and undoubtedly many hurdles to cross, however, MadEx 2019 is just around the corner and we are all very excited!

Kate lead the team and porters from Marolambo to Ambohitelo. Gorgeous vegetation lined the banks of the Nosivolo making my first trek in Africa spectacular. The sunlight breaking through the towers of bamboo projects a vivid green shimmer atop the river, creating a beautiful foreground to the mountain scene behind. Admiring the scenery made the hour-long walk fly by and we soon arrived in Ambohitello, greeted by a gaggle of children singing choruses of “Madex Madex”, and, amusingly, “bye bye”.

 

Following meetings with the village chief and elders we are shown to our accommodation – the village school hut. Children fill the doors and windows, clambering to steal a view of their new guests. I later realise they would remain a semi-permanent fixture throughout the entire expedition. We quickly setup camp before finishing the day with a swift game of football with the village children on the school field.

 

The next day the snail team (Rizy and I) met Emile, the local guide from Ambohitelo who would help us through the work. Emile was a local to Ambohitelo who had lived there his entire life and so knew the local geography well. Following our trip with Emile we returned back to the school-hut, our home away from home. Chicken and rice for lunch. Delicious. The food in Madagascar is wonderful, and this thought was later vindicated by a dinner of prawns in a creamy sauce prepared by the local women. Oh, and, of course, be vary be (lots and lots of rice!!).

 

The next morning was one to remember. The sheepish look on my face paired with a duo of giggling Malagasy men gave me away immediately. “Dan, what have you done…..” asked the team. Before I detail my morning exploits let’s put some context on the situation. Firstly, five days of a delicate stomach in Antananarivo and Marolambo had rendered me wary of even the slightest gurgle or sloshing sound. Understandably so, I tell myself. Secondly, dawn in rural Madagascar is dark, and the inky black sky is punctuated exclusively by the incandescents of the stars and their reflection in the moon. No street lights. No light pollution. Just pure, untainted nighttime. Now, back to my sheepish appearance. Early that morning I was awaken by a now characteristically loud stomach gurgle. In my haste, I grab my phone as a torch, bundle it into my pocket and dash to the long-drop. Stomach troubles dealt with I open the door to leave, take one step forward, and feel something fall from my pocket. I turn around, and, to my horror, witness my phone hurtling towards the floor. In the split second, I distinctly remember being thankful it was on a trajectory away from the long-drop, and my thick rubbery case which had saved my phone several times before would surely play the hero once again. “It is OK” I tell myself. But, to my horror, my knight in shining armour turned villain. The thick rubber case rendered my phone a rather wonderful bouncy ball, ricocheting off the floor and plunging my phone down a 10ft drop into a pile of, well, you can imagine. The girls were all at the stream showering and so I detailed my problem to my trusty snail team partner Rizy, who (with slightly too much delight in his voice for my now grumpy self’s liking) skipped off to the village to seek help. Two men were the first to arrive, and both found the situation utterly hilarious. “Dan, what have you done…..” ask the girls as they returned from their shower. By this time, a group of men were fashioning a baseball glove shaped object from leaves and lashing it onto the end of a 10ft branch. I reluctantly admitted to my error, miming it so the fifty-strong audience of Malagasy onlookers could have a laugh. After all, why not allow something positive to come from this experience I thought. The audience is now rolling around in fits of laughter, miming using a telephone to me. To lift my solemn mood, the team tells me that they think the men are not able to reach my phone and that it’s gone forever. Thanks for that, guys. However, a brief moment later, they are made to eat their words (and presumably put off eating their breakfast) as a glove-shaped leaf full of the long-drop’s contents surfaces, with the top-corner of a white iPhone poking out from the gloop. At this point I don’t know whether I’m glad to see my phone again or not, but before I can comprehend my feelings toward the situation I am interrupted by the sight of a local in surgical gloves running towards the river with my phone to wash it clean.“Tsisy tsisy” I proclaim, chasing the man down towards the Nosivolo. I retrieved my phone, cleaned it, and, to my surprise, it still functions.

 

Following my rather hectic morning I start walking back to the school-hut for a breakfast of croissants, fresh fruit and yoghurt – well, that’s what I tell myself. In reality I am greeted with the Malagasy staple of rice. Breakfast finished I head for a wash in the stream. A quiet washing spot exists shrouded by trees and herbaceous plants in the crystal clear water of this freshwater spring. Regretfully I do not possess the necessary vocabulary to accurately guide you to this enchanting forest enclave, but can merely suggest you imagine the most secluded, beautiful stream and then some. I have never before been anywhere so peaceful. Shower complete, phone retrieved and feeling full of rice I consider the morning a success, before heading out on my next snail adventure with Rizy and Emile.

 

Later that afternoon we trek out of the village to the house of a past village chief. The terrain is tricky – steep muddy hills are made treacherous by sprawling, gnarly tree roots, which are dimly lit by a rapidly disappearing sun. Dusk is coming. We arrive at the house atop the hill to find the ex-chief, his wife, child, and mother greeting us with open arms. Sour oranges, salt, and sugar cane are distributed amongst us as we pile into their beautiful mountain retreat and share stories of our adventures. Kind words are exchanged, and photographs are taken with the family before we leave for the evening. The walk back across the hills was made even more spectacular by the beautiful sunset – a common sight on a Malagasy evening. As I lay in bed feeling satisfied with the team’s exploits in the first village, I cannot help but think of the adventures to come in the next village, and that I could not have come across seven people more wonderful to share this experience with.


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The Madex team is comprised of students and doctors from both the University of Manchester, UK and the University of Antanarivo, Madagascar. Our project is funded through donations and contributions from team members, various organisations and from donors. As such any contributions would be greatly appreciated!

Thank You!

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As we checked into Manchester airport for Madagascar, we got some odd looks. The man at the desk did not even known that Madagascar was a real country.
I understood what he meant. Despite the many months of preparation for this trip, Madagascar had been this far off place; I still had no idea what to expect. 20 hours of traveling later, including a moment of panic when our plane’s destination was announced as Mauritius, we were over Madagascar. From the plane we could see the landscape laid bare by years of slash and burn farming, dotted with coloured roofs and the circular ditches that defended ancient farmers. We landed in Antananarivo (or “Tana”). Its name, translated as “city of a thousand hills”, is an apt description, with steep terrain crowded by small brightly coloured houses, stretching for miles. After a white-knuckle taxi journey we arrived at the hotel Tana-Jacaranda, and could finally relax.

We are a team from the University of Manchester, England, consisting of Dr Stephen Spencer and medical students James Penney, Hannah Russell and myself, Cortland Linder. We have come to Madagascar to study and treat a disease called Schistosomiasis. During our expedition, we will be assessing the burden of disease in children and also running educational programs to teach children safe hygiene. Although our trip is just beginning, this is really a culmination of a project that has consumed the full year. We have passed the intimidating Manchester ethics review board, planned our scientific methodology and expedition logistics and collaborated with the University of Antananarivo and the Department of Health, Madagascar. Our project has been funded and supported by many people and organisations, without whom this expedition would not have been possible. We are really grateful for their help.These last few months have been a bit manic, each member juggling expedition preparation with work while more and more unforeseen difficulties arise. However, with help we have somehow managed to get everything together in time.

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James and I have flown out to Madagascar first to establish contact with the Malagasy team members, interview and recruit medical students, and buy anything we forgot. This will keep us busy; we’ve focused so much on bringing the kit we have left some pretty basic items behind. Preparing to barter hard for nail clippers and toothbrushes. This leaves little time to sightsee, but there is no better way of getting to know a city than by working in it. We are finding our way round, communicating in a mix of French, English, and even a bit of Malagasy (For those who’ve read this far, “Salama” means hello… thats about our limit). As we go, we consistently discuss and refine our research methods and educational programs, as we really want our project to be enjoyable for the children. Everything must be prepared by Thursday. Steve, Hannah and another doctor Steph will arrive in Tana and we will be off almost immediately into the field.
But for now, thats all folks!
Check in soon,

Corty

I was sad to see Hannah and Steph go. They have been extraordinary members of the team and we all felt a little bit empty after they left. However, our schedule was tight and researched continued, while we slowly settled into Vohidamba.

One of the most common topics of discussion during these weeks has been quality of life for the villagers. The landscape is so immensely beautiful that it is easy to idealise the people here. Vohidamba, for example, is a village of about 300 wooden huts huddled on a floodplain that backs on to a steep hill. In the evening, one can see smoke from hearth fires seep through the thatched roofs, splitting beams of a setting sun. Around the village, the Nosivolo River winds, passing into the west as a golden, sunlit streak specked by little green islands, cutting its way through giant forested hills. This is the background of daily life for all the villages, a stunning mix of extreme isolation and beauty.

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Fields near Marufatsu

However, it is clear that problems run deep and occupy much of daily life. Houses are small, often crammed with several generations of family, and without electricity save the odd solar panel. Even in Marolambo, the central town, electricity depends on fuel import and road condition, meaning there is only 4 hours of electricity a day. During our stay, roads were so poor that the town was without electricity for 5 days. Access to clean water is also limited. In most villages there are taps with spring water, but these may be a 5-10 minute walk. In Ambohitelo, spring water was more than 15 minutes walk away; with the Nosivolo running directly next to the village, it is not surprising that most villagers drink and bathe directly from the river. Furthermore, although rice and bananas are abundant, meat is rare and most are malnourished. General health is poor, education is limited and in this isolated area, one doctor cares for 12,000 people.

Nevertheless, people here do seem to be happy. Even the sternest-looking Malagasy will crack into an enormous grin on greeting. There is an extremely strong feeling of community. Each village has both an elected chief and a Tangelamana, or village elder. Both are highly respected and run all village affairs, creating a unique blend of ability and wisdom. Everywhere, guests are treated to long greetings and unending warmth and generosity. At one point, a chief even slept with us in our hut, as his wife and children were spending the night in another village. As everyone knows everyone else, families and villagers look out for each other and crime appears to be low. During our trip, we were robbed on two separate occasions. However, both times, items were returned by chiefs or relatives within a day. Indeed, during our first evening in Ambohitelo, the robber was dragged into our hut by several other local boys, tried by the village elders, tied up and taken back to Marolambo, all before 11pm. Although sometimes unsettling, we feel privileged to witness village affairs and politics so rarely seen by outsiders.

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Village Tangelamana

Our work in Vohidamba finished, we proceeded on to Betampona, the most isolated village of our trip. On arrival we were joined by one of the Malagasy students, Elodie, and her guitar. It was quite an entrance, within about 20 minutes she had every child in the village singing their hearts out. Most interesting was a song that encouraged the children to wash regularly. Our first night we went to a town party, where we danced inthe local Malagasy style with two drunk policemen. It was a strange experience. The 3 days in the village passed quickly and are honestly a bit hazy for me as I was sick on one of them. Before we knew it we were hiking the 25km back to the central town Marolambo.

We spent a week in Marolambo, researching and treating children in the nearby village Ampasimbola and Marolambo itself. Having been living for the past two weeks on rice for breakfast, lunch and dinner, we were spoiled in Marolambo. A hearty breakfast of rice cakes, pastries and battered bananas was normally found in a wooden stall run by Madame Olivette, a Malagasy realisation of Molly Weasley. For dinner, we ate at Chez Martin, the only restaurant in Marolambo. How the cook, a hardened pregnant lady, could produce hundreds of delicious Zebu brochettes and shredded Papaya in such a remote area is a mystery. With one glazed, immobile eye, glistening with sweat and wearing only an apron, she laboured over glowing embers in her dark, lean-to kitchen like a hardened blacksmith in a forge.

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Steph is continully mistaken for a Malagasy

As our expedition comes to a close, we often discuss the future of the Madex project. Our goal is to continue testing the burden of Schistosomiasis in the region, while establishing sustainable projects to reduce the disease. Regular Mass Drug Administration (MDA) is effective in reducing Schistosomiasis, but cannot operate alone. This was highlighted during the MDA in Ampasimbola, when only 30% of the children turned up to be treated. Although this was more than 100 children, we were disappointed after the 70%+ attendance rates we had seen in other villages. We later learnt that the chief of the village did not properly inform the villagers of our work. Furthermore, many of the families in the village were either unaware of the risks of Schistosomiasis or suspicious of the treatment. It was clear to us that the lack of support from both people and leaders of this village stemmed from insufficient education about Schistosomiasis. With Ampasimbola behind us, we approached the MDA of Marolambo more thoroughly, and we managed to treat 900 children in a single morning. This was very rewarding and reaffirmed our optimism that our project can succeed. Nevertheless, the experience in Ampasimbola has contributed to our growing comprehension of the immense importance of education. We plan to expand Schistosomiasis education in future expeditions, not only to compliment MDA, but to ensure sustainable efforts to reduce Schistosomiasis after the Madex project finishes.

Finally, after 3 weeks, it was time to say goodbye. It had been an extraordinary journey, helped every step by amazing people. I enjoyed my time immensely and was fervently hoping for our plane to be delayed. Unfortunately, it arrived, and our bags packed, we hiked up to the small landing strip, which lay on the plateau of one of the taller hills. A rainy day; mist lay on the Nosivolo valley, with only the tips of forested hills from the other side of the basin reaching through the clouds. As the plane landed, we had a lasting image of five villagers, walking away over the crest of the plateau, their faded red patterned umbrellas sharp against the white mist. 40 minutes later, we were back in Antananarivo.

Hopefully we will be back soon!

Corty