Ethical consideration
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 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. In all cases, participants had the right to refuse to participate and to withdraw informed consent at any time without giving reasons. No financial incentives were given for participation in the study. Diagnosed pathologies were treated according to national guidelines and free of charge.