Ethics approval and consent to participate
Ethical approval was obtained from the National Ethics Committee of Madagascar (ref. no. N°052-MSANP/CERBM) and the Ethics Committee Hamburg State Medical Chamber, Germany (ref. no. PV7309). All participants were informed of the aims and procedures of the study in the Malagasy language. Participation in the study was voluntary, and informed consent for participation was obtained from the participant by signature or, in the case of illiteracy, by thumbprint in the presence of an independent witness.