# Confirmation by necropsy of a high prevalence of porcine cysticercosis in a rural district of Madagascar

Diana Edithe Andria Mananjara, Mihajamanana Rakotoarinoro, Valisoa C. Rakotoarison, Modestine Raliniaina, Nivohanitra Perle Razafindraibe, Claudia Ravonirina, Tantely Randriamparany, Harentsoaniaina Rasamoelina-Andriamanivo, Raphael Rakotozandrindrainy, Eric Cardinale, et al.

► To cite this version:

Diana Edithe Andria Mananjara, Mihajamanana Rakotoarinoro, Valisoa C. Rakotoarison, Modestine Raliniaina, Nivohanitra Perle Razafindraibe, et al. Confirmation by necropsy of a high prevalence of porcine cysticercosis in a rural district of Madagascar. Parasitology, 2023, 150 (9), pp.852-857. 10.1017/S0031182023000653. hal-05181744

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Distributed under a Creative Commons Attribution 4.0 International License
Research Article

**Cite this article:** Mananjara DEA *et al* (2023).
Confirmation by necropsy of a high prevalence of porcine cysticercosis in a rural district of Madagascar. *Parasitology* **150**, 852–857.
https://doi.org/10.1017/S0031182023000653

Received: 28 May 2023
Revised: 27 June 2023
Accepted: 28 June 2023
First published online: 7 July 2023

**Keywords:**
cysticercosis; Madagascar; necropsy; pig;
prevalence; *Taenia solium*

**Corresponding author:**
Marshall W. Lightowlers;
Email: marshall@unimelb.edu.au

Confirmation by necropsy of a high prevalence
of porcine cysticercosis in a rural district of
Madagascar

Diana Edithe Andria Mananjara¹, Mihajamanana Rakotoarinoro¹,
Valisoa C. Rakotoarison¹, Modestine Raliniaina¹, Nivohanitra P. Razafindraibe²,
Claudia Ravonirina³, Tantely Randriamparany⁴, Harentsoaniaina Rasamoelina-
Andriamanivo⁵, Raphaël Rakotozandrindrainy⁶, Eric Cardinale⁷,⁸ ID,
Marshall W. Lightowlers⁹ ID, Meritxell Donadeu⁹,¹⁰ and Kabemba E. Mwape¹¹

¹National Center for Applied Research on Rural Development (FOFIFA), BP04 Rue Farafaty Ampandrianomby, Antsirabe, Antananarivo 101, Madagascar; ²Veterinary Services, Ministry of Agriculture and Livestock, Madagascar; ³Regional Directorate of Agriculture and Livestock Vakinankaratra, Madagascar; ⁴National Veterinary Diagnostic Laboratory, Anosimasina Itaosy, Antananarivo 102, Madagascar; ⁵Indian Ocean Commission/SEGA-One Health Network, Ebène, Mauritius, Madagascar; ⁶University of Antananarivo, Antananarivo 101, Madagascar; ⁷CIRAD, Montpellier, France; ⁸University of La Réunion; ⁹Department of Biosciences, Melbourne Veterinary School, 250 Princes Highway, Werribee, Victoria 3030, Australia; ¹⁰Initiative for Neglected Animal Diseases (INAND), Constantia Park, Pretoria, South Africa and ¹¹Department of Clinical Studies, School of Veterinary Medicine, University of Zambia, Lusaka 10101, Zambia

Abstract

Neurocysticercosis is recognized as an important health issue in the Malagasy population. To date, investigations into prevalence of infection with the causative agent, *Taenia solium*, in the parasite's natural animal intermediate hosts, have relied on serological methods which have been found to be non-specific. We determined the prevalence of porcine cysticercosis among pigs from a contiguous area of the Betafo and Mandoto administrative districts, Vakinankaratra Region, Madagascar. One hundred and four slaughter-weight pigs were examined by detailed necropsy examination including slicing of the heart, tongue, masseter muscles, diaphragm and carcase musculature. Thirty-seven animals (35.6%) were found infected with *T. solium*, representing one of the highest rates of infection ever reported, worldwide. These findings highlight the importance of *T. solium* in Madagascar and support the need for increased efforts to prevent the parasite's transmission to reduce its burden on the health of the Malagasy population.

**Introduction**

Cysticercosis in humans caused by infection with the larval stage of the parasite *Taenia solium*
is one of the number of diseases recognized by the World Health Organization as neglected
tropical diseases (World Health Organization, 2015). Infections in the brain cause neurocys-
ticercosis, which in endemic areas is considered to be the most frequent preventable cause of
seizure disorders (Ndimubanzi *et al.*, 2010). The parasite is transmitted by pigs, in which it is
ranked as the most important foodborne parasitic infection from a global perspective
(Robertson *et al.*, 2013; Havelaar *et al.*, 2015).

*Taenia solium* is endemic in Madagascar, where it has been reported since 1901 (Migliani *et al.*, 2000; Carod and Dorny, 2020). Neurocysticercosis is widespread in Madagascar (Andriantsimahavandy *et al.*, 2003), with infection levels in school-aged children a particular concern (Zafindraibe *et al.*, 2017; Carod *et al.*, 2021). It is the main cause of secondary child-hood epilepsy (Carod and Dorny, 2020) and a major cause of late-onset epilepsy (Andriantsimahavandy *et al.*, 1997) in Madagascar.

The prevalence of porcine cysticercosis in Madagascar has been the subject of numerous stud-
ies, where infection has been determined either by meat inspection procedures or serology
(Rasamoelina-Andriamanivo et al., 2014; Porphyre et al., 2015, 2016). Meat inspection procedures
are understood to underestimate the prevalence of porcine cysticercosis because of a bias towards
identification of heavily infected carcases only (Boa et al., 2002; Dorny et al., 2004; Phiri et al., 2006;
Sithole et al., 2019). Initial descriptions of serological assays for porcine cysticercosis, such as the
detection of antibodies detected in enzyme-linked immunoelectrotransfer blot (Gonzalez et al.,
1990; Tsang et al., 1991) or circulating parasite-derived antigens (Dorny et al., 2004) suggested
that both methods provided both highly specific and sensitive diagnosis. More recently, however,
both methods have been evaluated critically against diagnosis at necropsy, the gold standard, and
both were found to greatly overestimate infection levels due to poor specificity (Gavidia et al., 2013;
Chembensofu et al., 2017; Sithole et al., 2019; Kabululu et al., 2020). These deficiencies limit the
reliability of currently available data on the prevalence of porcine cysticercosis in Madagascar. To

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<figure><img src="image_2.png" /></figure>

CAMBRIDGE
UNIVERSITY PRESS
our knowledge, there has not been an accurate assessment of porcine
cysticercosis in pigs from Madagascar by necropsy.

In this study, we evaluated the prevalence of porcine cysticercosis in 104 randomly selected, slaughter-age pigs from the districts of Mandoto and Betafo in Vakinankaratra Region, Madagascar by detailed necropsy.

**Materials and methods**

Study design

The study was undertaken in a single contiguous area of central Madagascar comprising parts of the 2 administrative districts of Vakinankaratra Region, Betafo and Mandoto (Fig. 1). The area is located in the highlands of Madagascar, where 93% of the population are farmers and live in rural area (INSTAT, 2020). The site selection was based on an observed predominance of pig farming, especially in extensive system where pigs are free roaming (CREAM, 2013). In addition, local veterinarian report records indicated a high prevalence of porcine cysticercosis at meat inspection (Dr Claudia Ravonirina, pers. comm.).

A census was conducted in June 2021 to identify the character-
istics of pig farming system, the number of pigs and farmers in
the area, especially those who have pigs reaching slaughter weight
for local consumption. Thus, a list of farmers who practice free
roaming system and who have 1 or more pigs around 50 kg (average
slaughter weight) per Fokontany (lowest administrative level; group
of 4 or 5 villages) was obtained and used as a sampling frame for the
study. Pigs for necropsy assessment were sampled at random and in
proportion to the approximate number of pigs resident in each of
the 48 Fokontany in which the project was undertaken. Sample
size (104 animals) was calculated from a population of 45 000 pigs
distributed in 20 Fokontany, each ranging from 350 animals
upwards per Fokontany, with the samples assumed to be aggregated.
The expected initial necropsy prevalence was assumed to be 15%.
Sample size was calculated with a power of 90 and 99% confidence
interval. Calculations were undertaken in R via Monte-Carlo simu-
lations. One animal only was obtained from each farmer, although
inadvertently 3 farmers were found to have provided 2 pigs each.

Post-mortem procedures

The pigs were transported to Antananarivo, at the National
Laboratory for Veterinary Diagnostics where they were

euthanized by professional slaughter staff according to normal
commercial practices. Necropsy procedures were similar to
those described by Sah et al. (2017) and Nsadha et al. (2021),
with the exception that the abdominal, thoracic organs (except
for the heart) and the brain were not assessed for infection.
This was based on recent analyses and data which indicate that
T. solium cysticerci are rarely found in sites other than striated
muscles and brain, except possibly in the case of exceptionally
heavy infections (Gauci et al., 2019), and that animals that had
undergone whole-body necropsy and had cysts in the brain also
had cysts present in the muscle tissue (Lightowlers, 2020). Prior
to slaughter, the weight of the animals was estimated by an experi-
enced animal handler. Following slaughter, the abdominal organs
were discarded, except for the heart. All carcase parts were care-
fully labelled to ensure the identity of the individual animal was
retained. The masticatory muscles (internal and external, both
left- and right-hand side), diaphragm and tongue were dissected
from the head and the carcase bisected longitudinally. The carcase
parts were refrigerated overnight at 4°C.

Examination for T. solium cysts

The muscles of the right-hand side of the carcase as well as the
masseters, tongue, full diaphragm and heart were dissected
from the bodies and sliced by hand at approximately 3 mm inter-
vals to reveal all cysts. Where the number of cysts in the carcase
musculature was determined to be >1000, the number was not
counted and simply recorded as >1000. Where no cysts were iden-
tified, the left-hand side of the carcase was assessed for possible
infection in a similar way. The total number of cysts in the ani-
mals was estimated by inclusion of a figure for the left-hand
side carcase musculature being a doubling of the number found
in the right-hand side musculature. Cysticerci were recorded as
viable where they were translucent vesicles filled with transparent
fluid and having a visible white scolex. Non-viable lesions were
recorded separately in cases where vesicles were non-translucent,
containing a dense white or yellowish fluid and having no scolex
and in cases of fibrosed or calcified lesions.

Case definition of confirmed porcine cysticercosis

An animal was determined to be a confirmed case of porcine
cysticercosis if 1 or more viable cysticerci were found in the

<figure><img src="image_3.png" /><figcaption>Figure 1. Map showing the location of the project area in central Madagascar.</figcaption></figure>
muscles, or if more than 1 non-viable lesion was detected in the muscles.

## Data analysis

All statistical analysis was performed in R software. The prevalence of infected animal with cysts and viable cysts were calculated with their 95% confidence interval (CI). Univariate analysis through parametric $\chi^2$ test was used to compare the proportion of animal with different intensities of infection according to the viability of cysts and the sex of pigs. The significant difference threshold of 0.05 was considered.

## Results

*Taenia solium* infections detected in pigs from the study areas are detailed in Table 1. Among 104 animals that were necropsied, 37 pigs [35.6% (CI 26.4–45.6%)] were found to be infected. Among infected animals, 86% were found to harbour viable cysts (representing 30.8% of all animals necropsied). Nineteen animals (51% of the infected animals) were found to harbour both viable and non-viable cysts, with a further 5 animals (14%) having only non-viable cysts. Five animals were detected with a single, unidentified non-viable lesion in the striated muscle tissue; these individuals were not classified as being infected. Of the 2 animals inadvertently obtained from each of 3 farmers, 1 pair was uninfected, 1 had both animals infected and 1 pair had 1 infected and 1 uninfected animal.

The proportion of animals with different intensities of infection with viable cysts, or viable plus non-viable cysts, and the proportion of total cyst numbers in male and female animals are shown in Fig. 2. There was no statistically significant difference in the proportion of animals infected with different intensities of infection with respect to either total cysts or viable cysts [$\chi^2$ test for trend (Abramson, 2004) and Fisher's exact test]. Similarly, there was no statistically significant difference in the proportion of animals of different weight classes, as shown in Fig. 3, in relation to their intensity of infection (total cysts).

Among infected pigs (37 pigs), cysts (viable and non-viable) were found in the carcase musculature (97%), tongue (70%), masseters (62%), diaphragm (54%) and heart (43%).

<figure><img src="image_4.png" /><figcaption>**Figure 2.** Proportions of slaughter-weight pigs from the Mandoto/Betafo districts of Madagascar infected with *Taenia solium* cysts. (A) Burden of viable and non-viable cysts; (B) burden of infection (total cyst numbers) in female and male pigs.</figcaption></figure>

## Discussion

A high rate of *T. solium* infection in Malagasy pigs was found for the first time using a specific and accurate methodology. Several previous reports have described porcine cysticercosis in Madagascar using serological methods that are now considered to have poor specificity (Lightowlers *et al.*, 2016). The presence of the parasite and its importance for the human population have been evident from the level of neurocysticercosis in the

<table><caption>**Table 1.** Numbers and proportions of pigs with *Taenia solium* cysts (viable or non-viable) and burden of infection detected at necropsy among animals derived from adjoining areas of Mandoto and Betafo districts, Madagascar</caption><thead><tr><th rowspan="2">Description</th><th rowspan="2">Number of animals necropsied</th><th colspan="2">Infected with viable cysts</th><th colspan="2">Infected with cysts (viable or non-viable)</th></tr><tr><th>Number of animals</th><th>Percentage (95% CI)</th><th>Number of animals</th><th>Percentage (95% CI)</th></tr></thead><tbody><tr><td>Male</td><td>56</td><td>15</td><td>26.8 (15.8–40.3)</td><td>17</td><td>30.4 (18.8–44.1)</td></tr><tr><td>1–10 cysts</td><td></td><td>3</td><td></td><td>3</td><td></td></tr><tr><td>11–100 cysts</td><td></td><td>4</td><td></td><td>4</td><td></td></tr><tr><td>101–500 cysts</td><td></td><td>6</td><td></td><td>6</td><td></td></tr><tr><td>&gt;500 cysts</td><td></td><td>2</td><td></td><td>4</td><td></td></tr><tr><td>Female</td><td>48</td><td>17</td><td>35.4 (22.2–50.5)</td><td>20</td><td>41.7 (27.6–56.8)</td></tr><tr><td>1–10 cysts</td><td></td><td>5</td><td></td><td>7</td><td></td></tr><tr><td>11–100 cysts</td><td></td><td>4</td><td></td><td>4</td><td></td></tr><tr><td>101–500 cysts</td><td></td><td>5</td><td></td><td>4</td><td></td></tr><tr><td>&gt;500 cysts</td><td></td><td>3</td><td></td><td>5</td><td></td></tr><tr><td>Total</td><td>104</td><td>32</td><td>30.8 (22.1–40.5)</td><td>37</td><td>35.6 (26.4–45.6)</td></tr></tbody></table>
<figure><img src="image_5.png" /><figcaption>**Figure 3.** Proportion of infected pigs with *Taenia solium* from the Mandoto/Betafo districts of Madagascar in relation to their weight class at necropsy.</figcaption></figure>

Malagasy population, which has been apparent for many years (Carod and Dorny, 2020).

Among the 104 slaughter-age animals that were necropsied, 37 pigs (35.6%) were found to be infected with *T. solium*. High rates of porcine cysticercosis have been detected at necropsy in pigs from other parts of the world, particularly Zambia (Dorny et al., 2004; Chembensofu et al., 2017), Mozambique (Pondja et al., 2012), Nepal (Sah et al., 2017) and Peru (Gonzalez et al., 1990). The rate of infection in the pigs examined in this study ranks Madagascar as among the highest rates of infection ever recorded. Risk factors for *T. solium* transmission occur in Madagascar, such as free-roaming pigs, unsupervised home slaughter, consumption of undercooked pork and open-air defecation in rural areas (Rasamoelina-Andriamanivo et al., 2013); however, it is unclear why the prevalence of porcine cysticercosis was particularly high in the study area compared with other regions of the world where similar risk factors pertain.

The precise burden in the infected animals that were necropsied animals in this study was not determined. After detailed assessment of the masseter muscles, tongue, diaphragm, heart and the right-hand side of the carcase by slicing and inspection of all the tissue, those animals in which at least 1 viable *T. solium* cysticercus was found had the number in the remaining half carcase musculature estimated by doubling that found in the right-side carcase. A similar calculation was made for the burden in the left side of the carcase after finding at least 2 non-viable lesions in the right side and other tissues examined. The brain was not examined because current evidence indicates that infections in the brain are exclusively, or almost exclusively, found only in animals where cysts are also present in the striated muscles (Lightowlers, 2020). Other organs were not examined for cysts because, although *T. solium* cysticerci have been found in a variety of organs other than striated muscle and nervous tissues, they occur relatively rarely and appear to occur principally in animals that have an exceptionally heavy burden of infection (Gauci et al., 2019). In this study, we were interested particularly in the

proportion of animals that were infected with *T. solium*, rather than a precise determination of the burden in individual animals.

The presence of many cases of neurocysticercosis among the Malagasy population has been a concern for many years (Andriantsimahavandy et al., 1997; Carod and Dorny, 2020) and stimulated interest in the adoption of measures to reduce transmission of the parasite. With support from the World Health Organization, Ramiandrasoa et al. (2020) undertook annual mass drug administration (MDA) of the Malagasy population for 3 consecutive years with taeniacide in an area comprising approximately 95 000 inhabitants. Comparison of the levels of taeniasis before and 16 months after the last treatment indicated that the MDA had little impact on transmission of the parasite. Other attempts to reduce transmission of *T. solium* exclusively through the use of taeniacides have generally had limited impact (Lightowlers, 2013; de Coster et al., 2018). Mathematical modeling of *T. solium* control through the exclusive application of taeniacides annually in the human population, even for a decade, suggests that the disease would re-establish relatively rapidly (Braae et al., 2019).

Effective control of *T. solium* transmission will require interventions in both the pig population as well as the human population (Lightowlers, 2013; Gabriel et al., 2017; Braae et al., 2019). Combined use of interventions in pigs and humans has led to the elimination of the parasite's transmission (Garcia et al., 2016; Gabriel et al., 2020); however, the strategies adopted to date have been complex and expensive. New, more sustainable approaches are needed for the control of *T. solium* transmission, both in Madagascar as well as in the other areas of the world where neurocysticercosis remains an unacceptable burden on the human populations.

**Data availability.** Data supporting results are provided within the article. Additional information may be available on request.

**Acknowledgements.** The authors wish to thank the following who contributed to the arduous task of performing the necropsies: the local veterinary team of Mandoto and Betafo, the Department of Agriculture and Livestock
Vakinankaratra, the National Center for Applied Research for Rural Development - Department of Zootechnical, Veterinary and Piscicultural Research (FOFIFA/DRZVP), the National Laboratory for Veterinary Diagnostics, the Direction of Veterinary Services.

**Author contributions.** M. D. and M. W. L. conceived the study and obtained the funding. M. Ral., D. E. A. M., M. Rak. and V. C. R. coordinated the field activities and necropsies. C. R. assisted with the field activities. T. R. assisted with preparation for, and participated in the necropsies. H. R.-A., R. R. and E. C. advised on the study design. K. E. M. supervised and participated in the necropsies. D. E. A. M. and M. W. L. drafted the manuscript and all authors contributed to the final manuscript.

**Financial support.** Funding for the project was provided by the Livestock Vaccine Innovation Fund, grant number 109273-001. The Livestock Vaccine Innovation Fund is supported by the Bill & Melinda Gates Foundation (BMGF), Global Affairs Canada (GAC) and Canada's International Development Research Centre.

**Competing interests.** None.

**Ethical standards.** Ethics approval for the study was granted by the National Animal Ethics Committee of Madagascar, approval number 001-21/CENA.

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