To counter the spread of cholera in Mayotte, the government has until now only carried out targeted, restricted vaccinations. Injections were initially offered only to caregivers, then only to those close to patients, in addition to other measures deemed more effective. Thus, only 7,000 people have benefited from them since March 2024, the date the epidemic began in the overseas department.
But in recent days, the public authorities have changed strategy. Fearing a greater spread of the bacteria transmitted by dirty water, the government has discreetly raised its vaccination ambitions. The health authorities have thus started to vaccinate at a much greater intensity, without any real announcements having been made on this subject.
Vaccines are now being offered in fourteen of the archipelago’s many shantytowns. These areas are considered to be at higher risk from cholera because they are densely populated and lack access to clean water. In total, more than 40,000 people are expected to benefit from this strategic development in the coming weeks, according to a notice from the High Council of Public Health (HCSP) published on June 26.
A risk of dissemination across the entire island
The HCSP, responsible for evaluating health strategies, has spoken out in favor of such a change, due to the current “epidemic dynamics”. This is indeed not favorable. In total, more than 210 people have been contaminated in four months, and two have died, each time in the shanty towns. France has never seen such a spread for 132 years. Although transmissions are no longer “exponential”, cases continue to increase.
The institution acknowledges a relative “control” of the situation in places, such as in Koungou, the very first local source of contamination, at one time the most intense. No cases have emerged for a month, which is good news. But the epidemic is far from being “under control”, contrary to what Health Minister Frédéric Valletoux announced during a visit in early May. As things stand, “a risk of the bacteria spreading across the entire island” remains, writes the High Council.
During his visit, the Minister of Health had mentioned a “step-by-step” strategy, in reference to the different vaccination scenarios established by the HCSP on April 15, 2024. These range from vaccination focused solely on contaminated households to distribution open to the general population. However, such a sudden expansion of beneficiaries, which corresponds to the last resort imagined by the institution, has never been publicly discussed. And for good reason: at the time, the State did not have enough doses to make such a change in scale.
Stocks so far insufficient
Caught off guard by the disease, whose return to French soil was considered impossible by many experts a short time ago, France only had a stock of a few thousand doses at most at the start of the epidemic. In mid-April, the department only had enough in reserve to vaccinate 4,000 people, according to ARS statements at the time. The State therefore had to increase its efforts, for many months, to find suppliers in a market already saturated with orders.
A difficult task. Because since 2021, cholera cases have doubled every year in the world. With East Africa at the forefront, particularly affected, because of the unsanitary conditions there, but also the droughts and floods that have increased in recent years. At the same time, very few laboratories market vaccines against this disease, because only the poorest countries usually need them. Sanofi produced them, but stopped in 2022 due to lack of profitability. It is therefore difficult to obtain these treatments.
The UN does have an emergency stockpile. It is thanks to it that the Comoros, the country from which the first patients recorded in Mayotte came, launched a mass vaccination. But the international organization was also caught off guard: “The need is estimated at 74 million doses, well beyond global production capacity, and well above our reserves, which are around 52 million for 2024,” says Dr. Philippe Barboza, in charge of cholera at the WHO. It is therefore unthinkable to go begging for injections from the UN.
A step forward, but not enough to stop cholera
After a lot of phone calls and maneuvering, lots were finally found, notably from European distributors, L’Express learned. Enough to limit the congestion of the Mahoran healthcare system, the least equipped in France, with only 1.56 beds per 1,000 inhabitants. Already in high demand, the only hospital in the archipelago fears the peak of the gastroenteritis season, expected in the coming weeks.
But as broad as it is now, this revamped vaccination strategy will not be enough to make the disease disappear. Nor even to stop it: “The two vaccines that France has obtained, Vaxchora and Dukoral, are 85% effective and reduce transmission, but they only protect for a few months,” explains Antoine Flahault, an epidemiologist at the Institute of Global Health in Geneva. Immunized people will therefore very quickly find themselves susceptible to the infernal diarrhea of cholera again.
Above all, less than half of the shanty towns in Mayotte are eligible. In the absence of other measures, the bacteria can only continue to circulate. Especially since these difficulties are compounded by the thorny issue of vaccination adherence. While confidence in the vaccine is high, many residents have ignored the authorisations to assemble their makeshift homes. A majority arrived in France illegally. They are the main victims of cholera, but the fear of being evicted could make them flee when healthcare workers arrive in the targeted areas.
The thorny issue of vaccinating migrants
The issue is incendiary in Mayotte. The local population, more precarious than elsewhere, is often reluctant to share the healthcare system. The citizen groups that had blocked the island at the beginning of the year to protest against illegal immigration did not hesitate to impose a filtering of health centers, to prevent foreigners from getting treatment. State Medical Aid (AME) and Universal Medical Coverage (CMU) have also been eliminated in the department, for fear of a migratory “pull factor”.
Contacted by L’Express, the Health Crisis Center of the Ministry of Health assures that “vaccination is offered to all people residing in the targeted areas”, and therefore to migrants. But in fact, it will be difficult to reach this entire public. “Especially since the police continue the Wambushu and Place Nette XXL operations against immigration and trafficking. These checks and evictions, set up by the Ministry of the Interior, even occur during vaccination. In some neighborhoods, people no longer come because they are associated with repression,” testifies an ARS employee.
Not asking for the identity card of vaccination recipients is a necessity, from a health perspective. But this strategy is delicate, given the anti-migrant sentiment and the political situation. Requesting widespread vaccination for French people who want it, citizen groups, supported by many elected officials, could view these distributions very negatively. Is this why no national communication has been made? Contacted, the ARS simply mentioned the “principle of reserve” which applies during election periods.
Delays in access to water, the most effective response
Many pitfalls, even though vaccination is considered a secondary lever in the battle against the bacteria: in its opinion, the HCSP first calls for intensifying measures to facilitate access to water in the department. Because if vaccines are not effective and available enough to end cholera, a connection to clean water and functional sewers is enough to eradicate the disease, if you wash your hands regularly.
It is precisely thanks to modern water management that most Western countries have been protected from epidemics of the bacteria, and this since the 19th century. But in Mayotte, a territory of all crises, 30% of the population does not have a tap at home. Temporary pipes could have been drawn as soon as the first imported cases were brought in, but this was not done, at least not sufficiently at the first outbreaks of contamination, as revealed by L’Express. However, these are the only truly effective tools in this area.
One hundred taps must be installed urgently in the shanty towns. Announced in May, only half of these devices have actually been installed, according to our information. “This work is accumulating delays. Officially, it is because of stories of legal distance to be respected between the network and the taps”, says our source within the ARS. According to her, the objective set by the government remains in any case insufficient to hope to extinguish cholera on the island. And when they are installed, these accesses are often sabotaged. A situation conducive to the perpetuation of the bacteria on the island. And a time bomb, for the next government.
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