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A mission to the Comoros Islands

Epidemiologist Epco Hasker goes to the exotic Comoros Islands to investigate high leprosy incidence
In May 2016 I made a short trip to the Comoros Islands, together with my colleagues Bouke de Jong from the Department of Biomedical Sciences (ITM) and Philip Suffys from FIOCRUZ from Brazil.

The Comoros are a group of four islands in the Indian Ocean, north of Madagascar. Until 1975 all four islands were a French colony; one of the islands (Mayotte) is still a part of France today, the other three (Grande Comore, Anjouan and Mohéli) now make up the independent ‘Union des Comores’. Since its independence in 1975, the country has witnessed over 20 coups or attempted coups, Wikipedia has lost count. The country is very poor and was ranked 159th in the 2014 Human Development Index.

Before joining ITM in 2008 I had, for 15 years, been working on TB and leprosy, so I was immediately interested when I was asked to cooperate in a project on leprosy. What aroused my interest was not only the idea of working on leprosy again but also the Comoros. When I looked on the map to find out exactly where the islands are situated, I immediately saw visions of palm tree lined beaches and everything that goes with it. I must admit that my enthusiasm was slightly dampened when I read on the Lonely Planet website that: ‘Women are expected to show modesty and cover up, and alcohol is a no-no for both sexes’ but still I was happy to get involved in the project.

The study subject too was very interesting since leprosy is supposed to have been ‘eliminated as a public health problem’ 10 to 15 years ago. This success was mainly a result of treating the backlog of existing cases with a one-year treatment instead of a lifelong treatment. Once released from treatment you are no longer a leprosy patient, so the numbers were greatly reduced. Unfortunately the number of new patients arising each year did not go down that much and has been stable over the past 5 years. On the Comoros, despite over 20 years of well-organized leprosy control efforts, the leprosy incidence has not gone down at all and is among the highest in the world.

After a long overnight flight from Paris to La Réunion and a second flight to Grande Comore, we arrived in the capital Moroni. Despite their idyllic location, it was immediately clear that the Comoros are not a major tourist destination. Road infrastructure is poor and tourist infrastructure non-existing.

We were warmly welcomed by the director of the National Tuberculosis and Leprosy Control Program who took us to our hotel near the center of Moroni, a quiet little town with a beautiful old medina. There are some beaches but the few foreigners we came across seemed to be businessmen or people working for aid agencies, not tourists. We enjoyed a nice evening meal, with a bottle of wine. Apparently the Lonely Planet is not always right.

The next morning we continued our journey to the island of Anjouan, which is half the size of Grand Comore but densely populated. With almost 900 inhabitants per square kilometer it has more than twice the population density of Belgium, in addition it is mountainous with little arable land. Over the past 5 years, from Anjouan’s 380,000 inhabitants 300-400 new leprosy patients have been diagnosed each year. Leprosy incidence on Anjouan is thus about 40 times higher than in the rest of Africa. The aim of our visit was to set up a study to investigate the reasons behind this.

We were lodged in a beachside hotel with a swimming pool and a terrace overlooking the Indian Ocean. Unfortunately there was no water in the pool (here our 2004 copy of the Lonely Planet was right) but there was a sandy beach, used mostly by local youths playing football.

The local leprosy control team provided us with records on all leprosy patients diagnosed on the island since 2000 and we started mapping them to identify possible transmission hotspots. The next day we accompanied the team on a screening campaign in the village of Vouani, which was carried out in a very well-organized and professional manner. To our surprise no less than six new leprosy patients were diagnosed in our presence, most of them children.

The remaining days were spent drafting a research proposal, together with the Anjouan leprosy control team and the director of the national TB and leprosy control program. They turned out to be very much interested in learning more about geographic information systems and mapping and invited me to come back later in the year to conduct a training, an invitation I happily accepted. We now hope our project application will be successful so these beautiful islands may become part of our regular working environment.

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