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.

[Linear tuberculoid leprosy along the lines of Blaschko: a very rare presentation]. / Lèpre tuberculoïde de disposition linéaire blaschkoïde: une présentation exceptionnelle.

BACKGROUND: Leprosy continues to be present in certain regions throughout the world, and the dermatologist plays a central role in its diagnosis. Herein we report a case of tuberculoid leprosy that is atypical in terms of its linear presentation which appears to follow the lines of Blaschko. PATIENTS AND METHODS: A patient from Mayotte was referred to the neurological department for suspected tuberculoid leprosy. He was presenting a deficiency of the ulnar nerve together with neuronal hypertrophy and cutaneous involvement. Dermatological examination revealed linear hypo-aesthetic hypopigmented lesions on the arm and forearm. The atypical clinical presentation also suggested to us pigmented mosaicism or post-inflammatory pigmentation. The biopsy showed granulomatous epithelial dermatitis with perinervous involvement. Imaging examinations confirmed the presence of neuronal hypertrophy. A diagnosis of linear tuberculoid leprosy was made. DISCUSSION: This case illustrates the need to bear in mind a diagnosis of leprosy in the event of hypopigmented lesions, even where they are linear and of Blaschkoid appearance. Several potential hypotheses may account for this particular topographical pattern.

Malaria attacks due to P. vivax or P. ovale in two French military teaching hospitals (2000 to 2009).

CONTEXT: Non-falciparum malaria is less studied than Plasmodium falciparum malaria, both in endemic and non-endemic zones. PATIENTS AND METHOD: A retrospective study was made of the medical files of patients managed for attacks of malaria due to Plasmodium vivax or Plasmodium ovale, between 2000 and 2009, in two French military teaching hospitals. RESULTS: Seventy-five percent of attacks occurred after a stay in French Guiana, in the Comoros Archipelago, or in the Ivory Coast Republic. The most frequent symptoms two months after coming back were a flu-like syndrome with headaches, and occasional digestive symptoms, without any difference between the first attack and recurrence. One third of patients presented with anemia, 78% with thrombocytopenia, and 12% with liver dysfunction. DISCUSSION: This study was the most important made in France on imported non-falciparum malaria. Military patients and immigrants accounted for a majority of patients due to the specificity of military hospitals and local recruitment. Clinical and biological features were not specific and did not allow guiding the diagnosis. Diagnostic tools were less sensitive for P. ovale. CONCLUSION: Patient management could be optimized by more efficient diagnostic tools, specific guidelines for the diagnostic and therapeutic management, and a dedicated medical training for family practitioners as well as hospitals practice.

[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.

[Malaria among immigrants, experience of a Parisian hospital (2006-2010)]. / Paludisme chez les migrants, expérience d'un hôpital parisien (2006-2010).

In recent days immigrants represent the main risk group for imported malaria in northern countries. Most of them are migrants returning to their country of origin to visit friends and relatives (VFR). We retrospectively examined the main clinical, biological, and therapeutic data of all malaria cases in immigrants from 2006 to 2010 in Tenon hospital, Paris. The hospital is situated in a Paris district with an important African community. During the study period 239 imported malaria cases were observed in adults of which 199 were immigrants, 186 VFR, and 13 recently arrived. Most cases were from sub-Saharan Africa and Comoro islands. Chimioprophylaxis was not taken in 81.2% of VFR. It was inadequate in 43.7% and not taken correctly in 84.4%. Plasmodium falciparum was the most frequent species identified: 190/199 (95.5%). Severe P. falciparum malaria was observed in 25 cases (13.2%); two of them were recently arrived. One patient, African VFR, died. In this series two high-risk groups were represented: HIV-infected patients and pregnant women. Six of the HIV patients had severe malaria and all pregnant women had anemia. Our results are similar to those observed recently in other European countries. Mean age of VFR is increasing and the risk for severe P. falciparum malaria became identical to the one observed in non-immune travelers. Protection measures remain still insufficient in this population of travelers.

Improving minority blood donation: anthropologic approach in a migrant community.

BACKGROUND: As a result of blood group polymorphism, distinctive blood types have evolved in populations around the world. In countries with large migrant populations, finding rare blood types for transfusion can be challenging. This is especially true for sub-Saharan African immigrants living in countries with predominantly European populations. This problem is further compounded by hereditary disorders such as sickle cell disease and by traditional cultural values that discourage routine donation. STUDY DESIGN AND METHODS: The purpose of this report is to describe the drive to recruit more safe rare blood type donors in a Comorian immigrant community living in Marseilles, France. With a culturally adapted message developed on an anthropologic approach and working in close collaboration with scientific and medical members of the Comorian community, it is proposed that this population be sensitized with the gift of blood. RESULTS: Targeted collection of specific sub-Saharan African blood types was achieved. Taking into account the high rate of infectious markers among products collected in this targeted collection, however, it was decided to promote blood donation in this minority by addressing people directly toward our principal blood center site. Since setup of this adapted communication, regular donors present themselves spontaneously without community pressure. Infectious markers rate is then equal to general blood donor population's rate. CONCLUSION: The results of this drive demonstrate the utility of an anthropologic approach and cultural mediation in identifying donors with specific blood types in migrant communities and recruiting second-generation donors. The techniques described in this study could also be applied to collection of other tissues including organs and peripheral blood progenitor cells in minorities.

Distribution of killer-cell immunoglobulin-like receptor (KIR) in Comoros and Southeast France.

Killer-cell immunoglobulin-like receptors (KIRs) expressed by natural killer cells are cell surface molecules able to recognize groups of HLA class I alleles. The number and distribution of KIR genes vary among individuals and populations. The aim of this study is to analyse the KIR gene content in a Comorian population in order to investigate genetic relationships with other populations and to reconstruct past migration events. The Comorian population consisted of 54 unrelated immigrants living in France and a control population consisted of 38 individuals from Southeast France. We investigated the presence or absence of 15 KIR genes, two pseudogenes expressed and non-expressed forms of KIR2DL5 and the two major subtype full-length and deleted forms of KIR2DS4. All individuals were typed positive for the framework genes, i.e. KIR2DL4, KIR3DL2 and KIR3DL3, and the two pseudogenes KIR3DP1 and KIR2DP1. The frequencies of full-length KIR2DS4 (*00101/00102/002) were lower in the French population (F = 29%) than in the Comorian population (F = 72%) (P(c) < 0.05). No significant differences were found for other KIR genes. A total of 11 genotypes were identified in the Southeast French population and 22 genotypes in the Comorian population. The most common genotype (2DL1, 2DL3, 2DL4, 3DL1, 3DL2, 3DL3 and 2DS4) accounted for 41% in the Comorian population and 34% in the Southeast French population. Principal component analysis using KIR gene data from 20 populations was performed to determine genetic differences and relations between populations. The Comorian population exhibited closest kinship with Africans and Asians. As KIR gene content is heterogeneous among ethnic groups, it can probably be used to assess the genetic relationships among populations from different geographic areas.

[Perceived health and migration: a new sanitary approach?]. / Santé perçue et migration : une nouvelle approche pour l'intégration sanitaire ?

BACKGROUND: Six percent of the French population is foreign. Paradoxically, there are in France few recent data about the health of these communities. Because a lot of different foreign communities are living in Marseille, it seemed important for us to examine the health of one of these populations. The difficulties encountered in studying the health status in the general population allow us to propose a measure based on perceived health opinion. Our first objective was to state that perceived health status of one community differs between its original country and its emigration country, taking into account the level of morbidity. Our second objective was to show that the perceived health status in the emigration population was close to the one observed in France. METHODS: Two cross-sectional studies were performed in the Comoro Islands and in Marseille, a French south eastern city. The perceived health was assessed with the Duke Health Profile (DHP); the objective health was assessed by a specific questionnaire developed in the USA: the Ridit. The comparisons were conducted, taking into account the major confounding factors. RESULTS: Emigrated people relate higher perceived health status, than those living in the Comoro Islands, for the main dimensions assessed by DHP: physical (71.0 +/- 23.8 vs. 55.9 +/- 23.0), mental (74.6 +/- 19.3 vs. 50.0 +/- 18.5), general health (68.3 +/- 16.3 vs. 61.4 +/- 12.7) and perceived health (62.7 +/- 32.9 vs. 57.1 +/- 48.2). Social health score is the only one which is lower (59.2 +/- 21.8 vs. 77.6 +/- 18.3). The health status levels of the emigrated people are close to those reported in France. The variations of perceived health scores are coherent with those of the objective health indicators. CONCLUSIONS: If these results were confirmed, then this approach, based on self perceived health assessment, could be recommended to study health needs, and the management care, prevention and health promotion impact among these specific communities.

Molecular basis of haemoglobinopathies and G6PD deficiency in the Comorian population.

INTRODUCTION: The Comoro archipelago is characterised by a high prevalence of red cell genetic disorders such as G6PD deficiency and haemoglobinopathies, being a region endemic for malaria. Over the last 15 years, the city of Marseilles in France has become the main destination for Comorian immigrants. This Comorian community includes patients with sickle cell disease, sickle cell/beta-thalassaemia trait, thalassaemias and G6PD deficiency. MATERIALS AND METHODS: Allele frequencies for haemoglobin S, beta-thalassaemia and G6PD deficiency were determined from neonatal and prenatal screenings of the Comorian community. Haemoglobin fractions were detected by isoelectrofocalisation, and the quantitation of HbS, HbA, HbA(2) and HbF was performed by cation exchange high performance liquid chromatography. The molecular study involved 31 alleles carrying the betaS mutation (Cd 6 [A-->T]), six beta-thalassaemic alleles and 17 G6PD-deficient alleles, selected from a group of carriers or affected subjects. RESULTS: Allele frequencies were 3% for haemoglobin S, 1% for beta-thalassaemia trait and 9.5% for G6PD deficiency. Molecular analysis had revealed that the African alleles are predominant, being present in almost all the subjects studied. Mediterranean alleles were found for all the beta-thalassaemia mutations and for three G6PD chromosomes out of 17. CONCLUSION: These data are consistent with the mixed Arab and African origin of the population of the Comoro Islands, and are of clinical interest in prenatal and newborn screening plans.

[Evolutive visceral malaria and hyperimmune palustral splenomegaly: a difficult distinction]. / Paludisme viscéral évolutif et splénomégalie palustre hyperimmune: une distinction difficile.

One case of hyperreactive malarial splenomegaly is reported for a Comores Island patient living in France and having thus lost his protective immunity. Plasmodium falciparum was detected in a bone marrow aspiration, whereas peripheral venous blood samples were negative. A three-month treatment of sulfadoxine + pyrimethamine was effective with a complete regression of splenomegaly and biological disorders.

[Calcified splenic abscess, colonic fistula and ascites in a chronic carrier of Salmonella typhi]. / Abcès splénique calcifié, fistule colique et ascite chez un porteur chronique de Salmonella typhi.

We report the unusual case of a patient with chronic carriage of Salmonella typhi who presented with partially calcified splenic abscess linked to colic fistula and ascitis. The colic fistula could be secondary to ischemic necrosis by left colon compression due to spleen large abscess. Fistula was evidenced by abdominal computed tomography scan and confirmed by barium enema. The possible etiologies of ascitis are either tuberculosis or ascitic peritonitis secondary to the fistulisation; nevertheless, the role of segmentary portal located hypertension cannot be completely excluded. The splenic abscess was probably due to Salmonella typhi which was only isolated from stool specimens. The calcified splenic abscess was the evidence that the infection had occurred first. In addition, the isolation of Salmonella typhi in stool cultures six months after the subject had returned from the Comores proved the chronic carriage. Treatment by splenectomy and left colectomy was successful in this patient.