Health, illness and cancer in Mayotte: Multicultural experiences in a medically underserved French Territory.

The island of Mayotte is part of the French territory and one of the European Union's Outermost Regions but there is a significant lack of data and research on health and cancers in Mayotte. This article reviews the literature on health, disease and cancer in Mayotte, from the perspectives of social science and epidemiology. It starts by shedding light on the specificities of Mahoran demography and society, and shows the healthcare infrastructure is insufficient to meet the population's needs. It then reviews social science studies on health and illness in Mayotte and shows that the political issue of migration permeates the management and the experiences of health on the island. It ends with a focus on the epidemiology of cervical cancer and a review of the available data on screening, treatment and prevention. The article concludes with a quick review of ongoing research and urgently calls for more data and research on this critical public health issue.

Impact of East Coast fever on Grande Comore: assessment taking a participatory epidemiology approach.

East Coast fever (ECF), one of the most serious tick-borne diseases in sub-Saharan and eastern Africa, was introduced to the island of Grande Comore in 2002 through zebu import from Tanzania, resulting in at least a 10% loss of livestock. A participatory epidemiology initiative was launched in 2015 to gain a better understanding of ECF epidemiology. Thirty-six villages were investigated involving 36 focus group sessions and 120 individual questionnaires. Farmers' knowledge of ECF and of priority diseases affecting the country was assessed, and the impacts of ECF and other major diseases were compared by a scoring method. The results showed that 69.4% (95% CI [51.3, 87.5%]) of the farmers had good to very good knowledge of ECF. The most important cattle diseases on Grande Comore were considered to be East Coast fever, heartwater, babesiosis, and cutaneous diseases. About 58% of the farmers (95% CI [49.2, 66.8%]) use curative treatments when cattle were sick. Between January and September 2015, the ECF incidence was estimated at 18.5% (95% CI [15.5, 21.4%]), and 87.5% (95% CI [72.7, 100%]) of the cattle infected by ECF died. The ECF incidence estimated in our study was found to be less when compared to that observed in Tanzania even though the climatic conditions in the Union of the Comoros are suitable for the biological vector of ECF, the tick species Rhipicephalus appendiculatus. Access to chemical treatment and its effectiveness against ECF, as well as controlling borders and organizing quarantine, are discussed.

[Poisoning with Jatropha curcas: 24 cases reported to Paris and Marseille Poisons Centers]. / Intoxications par pignons d'Inde (Jatropha curcas): 24 observations rapportées aux centres antipoison de Paris et Marseille.

Jatropha curcas L. is an inedible plant belonging to the Euphorbiaceae family that is growing in subtropical zones of all continents. We report a series of 24 cases of poisoning with J. curcas seeds or fruits reported to poison centers in Paris and Marseille between December 2000 and June 2014. Fifteen adults and 9 children ingested J. curcas seeds or fruits. All patients experienced gastrointestinal disorders, within the first hours following ingestion: nausea, vomiting, diarrhea and abdominal pain. Laboratory investigations performed in 10 patients revealed minor abnormalities: CK elevation (8 cases), dehydration (5 cases) with moderate elevation of serum creatinine levels (3 cases), and mildly increased serum bilirubin (8 cases). Complete remission of all clinical signs was observed within 48 hours in the 20 cases for which the outcome was known. Previously published cases of J. curcas poisoning were very similar to ours: As in our series, gastrointestinal disorders were always present. They were sometimes associated with neurological or cardiovascular signs, and hepatic or renal disorders; these were generally interpreted as complications of severe gastroenteritis, although direct toxic effects could not be formally excluded. In most cases, simple supportive measures were sufficient to ensure complete recovery within 24-48 hours. J Curcas poisoning incidence is certainly increasing because the plant is cultivated to produce biodiesel and is now largely present in most subtropical countries. As a consequence, local health professionals should be informed of the toxic properties of this plant.

[Dental health status of 15 year-old schoolchildren in Comoros]. / Etat de santé dentaire des élèves de 15 ans aux Comores.

The epidemiological situation of decay evolves differently in the world. In industrialized countries, prevalence has declined significantly due to preventive measures, while in developing countries many studies have shown that caries was increasing. The aim of this study was to assess the state of dental health of schoolchildren aged 15 in Grand Comore (Comoros). This was a descriptive cross-sectional study on 15 year-old schoolchildren in colleges in Grande Comore who agreed to be examined. Four hundred schoolchildren were chosen by a stratified sampling weighted according to the area of living. Three groups of indicators of dental caries were used: the components D, M and F, the average DMFT and prevalence. The WHO modified questionnaire for the assessment of dental health was used to collect data; continuous data were compared by Student t test and qualitative ones by Chi-square test. Fifty two percent of schoolchildren were male and 63.5% lived in urban area. From the 888 teeth bearing the stigmata of decay, 83.2% were decayed, 12.5% missed and 4.3% filled. These components of DMF were associated with sex (p = 0.039) and not with area (p = 0.12). The 2.22 DMFT average was not associated with sex (p = 0.58) neither with area (p = 0.57). The caries prevalence was higher in rural than in urban areas (p = 0.001) and was not associated with sex (p = 0.61). These results suggest that schoolchildren need decay treatments. The dental programs will have much more success when they will be integrated into more comprehensive programs to promote schoolchildren health.

[Critical analysis of requirements for scientific assessment as a basis for good governance: case of the chikungunya epidemic on Reunion Island and Mayotte in 2005 and 2006]. / L'analyse critique du respect des conditions de bonne gouvernance en matière d'evaluation scientifique des risques: le cas de l'epidémie de chikungunya a La Réunion et a Mayotte en 2005 et 2006.

The constitutional precautionary principle as applied in laws governing health care at the community level requires rigorous scientific assessment. The goal of this assessment is to provide authorities with sound evidence as a basis for implementing precautionary measures in function of degree of risk and other parameters such as the level of public health protection that is high in the EU. As the political authority, the government can act independently of conclusions issued by scientific commissions provided that the commission's level of expertise meets national and European standards and that research methodology and findings are consistent with scientific data published in the international literature. These requirements were not meet for the chikungunya pandemic that struck France on Reunion Island and Mayotte from 2004 to 2006. This epidemic that was preceded by many outbreaks in Indonesia between 2001 and 2003 began in Africa and then swept across the Indian Ocean to India and Asia. After an overview of the scientific assessment, this article raises arguments supporting possible allegations of gross misgovernance by the state and experts.

[Reality of healthcare access for migrant children in Mayotte]. / La réalité de l'accès aux soins des enfants de migrants à Mayotte.

The implementation of the social security system in 2005 in Mayotte has resulted in the end of free healthcare for all non-affiliated residents, primarily Comorians, due to the absence of the State Medical Aid (AME) in this department. Doctors of the World France opened a paediatric clinic in December 2009. The sociomedical data were collected during 5286 consultations in 2010. Analysis of these data demonstrates a link between access to healthcare for children and the residential status of their parents. The analysis concerns 2,350 patients met during consultations held by Doctors of the World France in Mayotte in 2010. The data have been electronically recorded and analysed by the Sphinx software. The results show that there are several obstacles to healthcare resulting in non-attendance. This situation is made worse if one of the parents has an irregular residential status and all the more so if both the parents have an irregular status. Affiliation to the social security system, however, improves the situation. The results show a delay in accessing healthcare, a poor vaccination programme and disturbing data on severe acute malnutrition. The specific healthcare measures in Mayotte do not respect the International Convention on the Rights of the Child. Direct affiliation to the social security system for children would entail a reduction in health insecurity for the children of parents with irregular residential status. It would also be necessary to reduce the factors that provoke fear of displacement, which would facilitate physical access to consultations.

[Migration, health and access to care in Mayotte Island in 2007: lessons learned from a representative survey]. / Migration, santé et recours aux soins à Mayotte en 2007: enseignements d'une enquête représentative en population générale.

BACKGROUND: Mayotte Island, located in the Indian Ocean, is a French overseas departmental community with certain specificities: recent development of sanitary institutions, significant immigration, free access to care for legal residents but with co-payments for irregular residents, the absence of many of the social benefits which exist in mainland France and poor or non-existent health information systems. We report here the first population-based survey describing the links between health, migration and healthcare utilization in this territory. METHODS: Cross sectional population-based study using a three-stage random sample (geographic areas, households, individuals). In all, 2105 individuals were interviewed either in French, Shimaore or Kibushi (response rate=96%), using a questionnaire adapted to the context of Mayotte Island after a preliminary qualitative survey. Descriptive analyses and logistic regression models were performed. RESULTS: Foreigners make up 40% of the Mayotte population (total 186,452 inhabitants), of which one-quarter are children born in Mayotte and 80% have no regular residence status. The median length of residence of migrant foreigners is 10 years. Foreigners represent a majority of the female population, of the 20 to 35 years old population and of the urban areas. Main determinants for migration were economical (50%) or family-related (26%). Health was stated as a cause of migration by 11% of migrants. The social situation of foreigners is more precarious and their perceived health poorer than those of the French. Their access to care is also perceived as more difficult. We did not observe any notable difference in terms of frequency of healthcare attendance over the last 12 months between the two groups, but foreigners have consulted less often private GPs and more often traditional practitioners than French. CONCLUSION: In this overseas French island, the migrant population is numerous and resident for a long time. Their main motivations to immigrate are economic and family-related. They report hurdles to healthcare related with their precarious living conditions, including their illegal residence status.

[Tuberculosis epidemiology in Mayotte Island]. / Epidémiologie de la tuberculose à Mayotte.

Mayotte is a French territory island, part of the Comoros Archipelago in the Indian Ocean with 200,000 inhabitants. The tuberculosis control program started in 1976, although available epidemiological data remains incomplete. We conducted a retrospective hospital-based survey in 202 outpatients and hospital medical records from the Hospital Centre of the main city to contribute to the epidemiological evaluation of tuberculosis patterns. The tuberculosis frequency remains unchanged since 2000. It affects a young population partly coming from the other neighbouring Comoro Islands (69%) with illegal immigrate status (53% in 2004). The systematic diagnostic screening efficiency of the condition appears marginal. Pulmonary involvement is the most frequent clinical manifestation (78%), although severe extrapulmonary manifestations are not exceptional. Co-infection with HIV and multi resistance to antituberculosis agents are not frequent. Up to 60% of cases have been proven to be bacteriologically linked. The notification rate remains critically low with an estimate of 39% of notifications to the local sanitary authorities in charge of secondary cases screening. The case coverage seems limited both by low socio-economical status and poor health facility accessibility The loss of follow up is dramatically high, 41% on the overall period, and up to 51% in 2004. Our results make mandatory the reinforcement of a tuberculosis survey and control involvement within the context of this French territory. Screening, care and follow up are to be implemented particularly for vulnerable and precarious groups and for patients.

[Malaria in Mayotte: epidemiology, diagnostic, prevention and treatment]. / Bilan du paludisme à Mayotte. Epidémiologie, diagnostic, prevention et traitement.

Mayotte is a little French island, located in the Indian ocean, between Madagascar and Mozambic. Officially there is a population of 150000 inhabitants, but in fact, there are probably about 200000 people, largely due to numerous illegal immigrants, especially coming from Anjouan the nearest Comorian island. There is only one hospital, with 252 beds. The malaria incidence reaches about 3000 cases per year; and treatments until august 2001 were generally haphazard. This is changing with the use of the Optimal rapid diagnostic test (DiaMed, Cressier Switzerland). More precise statistics should be available in the coming years. In 2000, 252 patients were hospitalised with malaria fever. Preventive measures were scarce. These have been reenforced this year, with the arrival of an entomologist, the use of reenforced pesticide pulverisation in high-risk areas, the distribution of impregnated bednets to pregnant women, and media based information campaigns. Common drugs resistance is becoming a real concern in Mayotte. First-line treatment was: chloroquine; second-line: sulfadoxine-pyrimethamine, and third-line: quinine. In vitro studies have shown high levels of resistance, therefore another antimalarial drug therapy will be introduced at the end of the year: first-line: artemether-lumefantrine, second-line: mefloquine or halofantrine, third-line: quinine. To conclude, solutions exist but a real policy from the decision makers is necessary to implement them. The eradication of malaria remains a dream, but we can expect "zero death" in Mayotte, considering that the fight against this disease may help to start a regional health program.

[Epidemiological stratification of malaria in the Comoro archipelago]. / Stratification épidémiologique du paludisme dans l'archipel des Comores.

In the Comoros Islands, the level of malarial endemicity varies greatly from one island to the other, even though the total area (4 islands) covers less than 2,300 km2 and has a population of some 600,000 people only. The epidemiological stratification is based on the diversity of human and physical characterisation. They both determine the presence and the behaviour as well as the size of the vector's populations. Vectorial dynamics can explain varying levels of endemicity given parasitological indicators and specific morbidity. Analyzing these criteria shows up different epidemiological features and serves as a basic guideline for malaria control. The efficiency of this control depends on the relationships between the intensity and the length of the transmission, in the framework of protection mechanisms; it is of crucial importance for clinical treatment. Further elements are the age of the patient, the season and the geographic situation of the area. Stratification provides explanations for these relationships and helps to define antimalarial programmes adapting to each situation a range of therapeutic and antivectorial methods. The availability and accessibility of anti-malarial medicine is the minimum requirement for reducing mortality: domestic spray insecticides for reducing transmission are effective for several years and should be followed by the use of mosquito nets or curtains impregnated with pyrethrinoids, and in the particular case of Grande Comore, the use of larvivorous fish. As anywhere else, the economic development, which is dependent on political stability, is the essential basis for malaria control.