title: Contemporary epidemiological overview of malaria in Madagascar: operational utility of reported routine case data for malaria control planning.
abstract: BACKGROUND
  Malaria remains a major public health problem in Madagascar. Widespread scale-up of intervention coverage has led to substantial reductions in case numbers since 2000. However, political instability since 2009 has disrupted these efforts, and a resurgence of malaria has since followed. This paper re-visits the sub-national stratification of malaria transmission across Madagascar to propose a contemporary update, and evaluates the reported routine case data reported at this sub-national scale.
  
  
  METHODS
  Two independent malariometrics were evaluated to re-examine the status of malaria across Madagascar. First, modelled maps of Plasmodium falciparum infection prevalence (PfPR) from the Malaria Atlas Project were used to update the sub-national stratification into 'ecozones' based on transmission intensity. Second, routine reports of case data from health facilities were synthesized from 2010 to 2015 to compare the sub-national epidemiology across the updated ecozones over time. Proxy indicators of data completeness are investigated.
  
  
  RESULTS
  The epidemiology of malaria is highly diverse across the island's ecological regions, with eight contiguous ecozones emerging from the transmission intensity PfPR map. East and west coastal areas have highest transmission year-round, contrasting with the central highlands and desert south where trends appear more closely associated with epidemic outbreak events. Ecozones have shown steady increases in reported malaria cases since 2010, with a near doubling of raw reported case numbers from 2014 to 2015. Gauges of data completeness suggest that interpretation of raw reported case numbers will underestimate true caseload as only approximately 60-75 % of health facility data are reported to the central level each month.
  
  
  CONCLUSIONS
  A sub-national perspective is essential when monitoring the epidemiology of malaria in Madagascar and assessing local control needs. A robust assessment of the status of malaria at a time when intervention coverage efforts are being scaled up provides a platform from which to guide intervention preparedness and assess change in future periods of transmission.
authors.affiliation: Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH, 44106-4983, USA. rosalind.howes@zoo.ox.ac.uk.|Department of Zoology, University of Oxford, Oxford, OX1 3PS, UK. rosalind.howes@zoo.ox.ac.uk.
authors.forename: Rosalind E
authors.initials: RE
authors.lastname: Howes
authors.affiliation: National Malaria Control Programme, Ministry of Health, Androhibe, Antananarivo, Madagascar.|Department of Public Health, Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar.
authors.forename: Sedera Aurélien
authors.initials: SA
authors.lastname: Mioramalala
authors.affiliation: National Malaria Control Programme, Ministry of Health, Androhibe, Antananarivo, Madagascar.
authors.forename: Brune
authors.initials: B
authors.lastname: Ramiranirina
authors.affiliation: National Malaria Control Programme, Ministry of Health, Androhibe, Antananarivo, Madagascar.
authors.forename: Thierry
authors.initials: T
authors.lastname: Franchard
authors.affiliation: National Malaria Control Programme, Ministry of Health, Androhibe, Antananarivo, Madagascar.
authors.forename: Andry Joeliarijaona
authors.initials: AJ
authors.lastname: Rakotorahalahy
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, OX3 7BN, UK.
authors.forename: Donal
authors.initials: D
authors.lastname: Bisanzio
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, OX3 7BN, UK.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.affiliation: Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH, 44106-4983, USA. paz@case.edu.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Zimmerman
authors.affiliation: National Malaria Control Programme, Ministry of Health, Androhibe, Antananarivo, Madagascar. aratsimbasoa@gmail.com.|Department of Public Health, Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar. aratsimbasoa@gmail.com.|Faculty of Sciences, University of Antananarivo, Antananarivo, Madagascar. aratsimbasoa@gmail.com.
authors.forename: Arsène
authors.initials: A
authors.lastname: Ratsimbasoa
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000458:organization & administration; D018562:Disease Transmission, Infectious / Q000517:prevention & control; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008270:Madagascar / Q000453:epidemiology; D016778:Malaria, Falciparum / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission*; D008297:Male; D019371:Topography, Medical
keywords: Madagascar; Malaria; Outbreaks; Routine health information systems data; Surveillance