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. 2020 Oct 5;13(1):1816044. doi: 10.1080/16549716.2020.1816044

Table 2.

Summary of evidence supporting or opposing three possible explanations for the low number of reported cases of COVID-19 in Madagascar.

  Supporting Opposing
Low detection rates
  • High proportion of asymptomatic cases [34]

  • Strict testing criteria

  • Low healthcare seeking rates for acute respiratory infections [35]

  • Diagnostic practices that limit the window of detection

  • Recent evaluation of health system preparedness via the International Health Regulations meant health systems were on high alert for an outbreak [20]

Epidemiological differences
  • Trained-immunity due to vaccinations or high prevalence of endemic disease could increase population’s resistance to infection [14]

  • Transmission rate may be lower in sparsely populated areas [13]

  • Virus survival is lower in humid, warm environments

  • Limited role for climate during pandemic phase of the outbreak [16]

  • Past influenza outbreaks were not limited by sparse transport networks in SSA [17]

Early and effective NPIs
  • Lockdown in population centers implemented three days after first imported case

  • Limiting travel on fragmented paved road network can easily disrupt within-country movement