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La lutte antivectorielle en France

 | 
Didier Fontenille
, 
Christophe Lagneau
, 
Sylvie Lecollinet
, 
et al.

From legal framework to governance

How is governance organized?1

Texte intégral

  • 1 In this chapter, references to the CD-ROM concern question 3: “How is governance organized?”.

1Local constraints have often led to adaptations of the legal and regulatory machinery deemed to govern vector control. This has generated a certain disparity of situations which the reform introduced by article 72 of the law of 13 August 2004 should remedy. The départements concerned are inscribed on the list established by order of 23 April 1987, which is still in force: Reunion Island, Guadeloupe, Martinique, French Guiana, Mayotte, Corsica (Haute-Corse and Corse-du-Sud).

REUNION ISLAND

2Situations here are clear-cut between the times pre- and post-chikungunya epidemic of 2005-2006.

Organization up to 2005

3Reunion Island has been equipped with a vector-control service since 1914. named the Service de Prophylaxie, it is mainly aimed at anopheline control owing to a strong malaria mortality rate (2,000 deaths per year in the mid xxth Century). In 1977-1978, it was a severe dengue epidemic that hit the island (affecting nearly 150,000 people) whereas in the late 1970s malaria was considered as eradicated.

4As time progressed, vigilance gradually slackened, especially over the 20 years after the decentralization laws began to be applied (1985). This trend prevailed until the 2004 dengue epidemic. The vector control service, which had shrunk from a 230 strong staff to just 40 or so in the early 2000s, then decided to favour work with municipal councils (communes) and groupings of municipal councils. For this purpose the service trained 250 environment mediators.

During the chikungunya epidemic (2005-2006)

5At the height of the epidemic, the law of 2004, which recommended transfer of competence to the département, appeared difficult to put into practice. On 23 February 2005, the Minister of Health agreed to postpone the date of enforcement to 1 January 2006, which was again put back when the epidemic continued. It was October 2005 before a strengthened control protocol was set in place. This reinforced control system consisted of rallying municipal councils and the public to engage in mechanical control schemes. A communication campaign was also organized along with training of 400 municipal agents who were kitted out with the necessary equipment. In addition the Regional Health and Social Services Department (DRASS) was expanded with the recruitment of 20 agents working under contract.

6In the face of the sheer size of the epidemic (45,000 cases recorded just for the fifth week of 2006), vector control became a systematic operation from February 2006 in all urban districts, with personnel involved constantly increasing (up to 3,000). Between June and November 2006 (southern winter), thanks to the immunity the population had acquired combined with the effects of the control campaign against the insect vector, the epidemic lost its virulence. A protocol known as “Reinforced vigilance” has been implemented to reduce vector density, intervene in reported cases and keep up a general state of mobilization. The communication campaigns are being continued, the DRASS is training instructor-communication workers, partnership is opening up to associations and treatments becoming weekly for the most susceptible areas (ravines, cemeteries).

7The return of the southern summer starts in December and brings the fear of a third epidemic peak. This prompted the drawing-up of the Chik plan which aims to prevent such a resurgence of epidemic, assess it, control the vectors and intervene for each case.

Renewal of the vector control service

8The vector control service of the DRASS currently has a force of about 200 agents (compared with 45 in June 2006). Its major tasks are: control malaria; also control the expansion of arbovirus epidemics, with the setting in place of a structured strengthened system for gaining knowledge about the vector and share out the available resources according to a graded re-active intervention system.

Table 2 – Structure and means

Table 2 – Structure and means

Reinforced prophylaxis service (SPR) within the Public Interest Group (GIP)

9The SPR was founded in 2006 by prefectoral order on 11 October and put in place on 30 October. Its assigned tasks are three-fold: day-to-day coordination of the different partners’ actions; have available for epidemic situations a clearly identified organization to conduct mosquito extermination and health education actions; engage the municipal councils in durable mosquito control schemes. The service is constituted without capital: its means of action are supported exclusively by the State, which also assigns a controller to monitor its financial management (article n° 6-1 of decree 881034 of 7 November 1998).

10The members of this GIP, whose director is appointed by the prefect, are the State (which takes the chairmanship role), the regional council, the département council, the mayors’ association, the municipal councils and Public Intercommunal Cooperation Establishments (EPCI). Its constitutional convention was approved by the prefect of Reunion Island on 31 October 2006. The SPR is doted with an Operational Technical Committee (CTO) gathering together the officers of the municipal technical services and those in charge of vector control. It is the CTO’s responsibility for preparing decisions to put before the administration board concerning equipment and materials, human resources, the operational control methods and intervention protocols.

11At first (up to 15 August 2007), the GIP operated in the context of the overall Chik system with a Prefecture Operations Centre (COP) and, in subprefectures, Advanced Command Posts (PCA) to coordinate operations between the various partners: the DRASS vector control service (the only permanent staff of the SPR), the département council and the municipalities, and also the regional council and EPCIs, the latter to a lesser extent.

12When the crisis measures are launched, leadership and coordination of the SPR are entrusted to the DRASS, whereas the assisted posts of the département council are placed at the municipalities’ disposal (extra to their own personnel), the regional council and the EPCI withdrawing from operations. The département council’s involvement was therefore greatly reduced. Moreover, its GIP membership was valid for only two years. From the human resources point of view, it was temporary personnel (under assisted contracts), for crisis situations only, who were engaged. Municipal councils’ involvement proved to be intensified, however. They now appear to be the most active and legitimate partners.

13A comprehensive array of legal instruments enables them to engage in insect vector control, owing in particular to the general policing power conferred on mayors (see CD-ROM), but also to the sound grassroots knowledge of their areas and populations. Municipalities also draw on clubs and societies and their local services to spread information and raise awareness among the public. Most treatment operations targeting districts or ravines are performed by the DRASS and the municipalities as a joint effort, which makes immediate intervention possible if necessary.

GUADELOUPE

14Guadeloupe was equipped with a vector control service much earlier than certain other areas, owing to its location in the tropical Caribbean. This service nevertheless experienced a substantial fall in its personnel (from 125 agents in the 1980s, to 65 at present), largely following the disappearance from the scene of locally contracted cases of malaria transmission in the late 1960s.

Organization of the vector control service

15The vector control service used to operate under the authority of the Director of the Department of Health and Social Development (DSDS), until the law of 13 August 2004. The application of that law places it theoretically under the aegis of Guadeloupe département council (agreement signed on 11 April 2006). After a number of reservations (notably about the separation between the power for defining measures and power for execution of these measures, judged to be arbitrary), the département council accepted the principle of this transfer.

16The service is under the management of a head of department (a public health officer) who devotes no more than 70 % of his time to it, and consists mainly of health assistants. The system is partly installed in premises made available by the département council and partly spread among five technical posts (Marie-Galante, Saint-Martin, Saint-Barthélemy, Baillif, Jarry).

Strategy

17A dengue Epidemic Surveillance, Early Warning and Management Programme (PSAGE) was drawn up in partnership with the Antilles-French Guiana Interregional Epidemiology Unit (CIRE) (Fort-de-France), the Martinique mosquito eradication service, Guadeloupe vector control service and Martinique and Guadeloupe Health Watch Units. This PSAGE lays out both the protection strategy and the emergency procedures. A special section is devoted to chikungunya risk. In an epidemic period, the head of the anti-vector service produces bimonthly action plans to adapt the control strategy to the development of the epidemic.

18In the context of the application of article 72 of the law of 13 August 2004, a review of the situation has been conducted in view of the prospected transfer to the département council which stipulates the forthcoming duties of the different actors.

19However, this true steering role comes against a limit independent of the parties involved. The entomo-epidemiological situation of the island of Guadeloupe prompts efforts largely to focus on Aedes aegypti, the vector mosquito of dengue virus. Now, the island of Saint-Martin is divided into Dutch and French parts, and Juliana international airport (in the Dutch area) is the Caribbean’s second busiest airport for traffic. In spite of the International Health Regulations (IHR) specifications, the reliability of information on dengue epidemic development in the Dutch part seems uncertain: too many deviations manifest between their epidemiological data and those of the French part. The DSDS services are seeking to improve this situation by developing a protocol for information exchange with Saint-Martin government health authorities.

Table 3 – Vector control organisation

Table 3 – Vector control organisation

Weaknesses

20A number of difficulties are directly linked to the geographical configuration: the service’s resources and facilities for action must be spread between the different islands, some of which lie several hundred kilometres from ‘mainland’ Guadeloupe. This raises several questions:

  • what can be the future for vector control in the two islands in the North of the area (Saint-Martin, Saint-Barthélemy)? If the draft organic law on overseas territories is passed, will these isles become authorities with no attachment to the département council of Guadeloupe? Their small size would make the existence of an autonomous vector-control service unviable;

  • how can schemes take into account the wide diversity of ways of life between the islands? For example, freshwater is relatively abundant on Guadeloupe, but in Saint-Martin its scarcity and excessively high cost make people resort to rainwater collection tanks. Another example: the question of languages. In Saint-Martin the high proportion of non French-speaking inhabitants (owing to easy passage through the borders between the two parts of the island) makes it imperative that service agents speak English or Papiamento.

21In parallel, the collaboration should be redefined with the Health and Social Service Technical Association Association technique d’utilité sanitaire and sociale (ATUSS), whose objective is to promote the economic development of Petit-Canal, Port-Louis, Anse-Bertrand and Morne-à-l’Eau. In accordance with an agreement between the DSDS and ATUSS on mosquito eradication in the northern part of Grande-Terre, the association receives an allocation of anti-vector products from the DSDS. Yet, the 1964 law already explicitly stipulated that mosquito destruction be assigned solely to public organizations. And in its extension to vector control, article 72 of the law of 13 August 2004 confirms this option. The département council in any case does not wish to have ATUSS as a negotiating partner. In law, the agreement would continue concluded with the municipalities concerned.

22Furthermore, the département council does not intend to see itself constrained in the role of execution, in spite of the loss of its control over strategy (reserved for the State by the law of 13 August 2004). It hopes to have its own resources to devise its strategy. The setting-up of an inter-department convention between Guadeloupe and Martinique, and even French Guiana, is hardly feasible given the isolation of the different elements (therein lies a weakness of the 2004 law). Whatever happens, the Watch system and the partnerships must be strengthened. Health Watch has hinged on the Antilles-French Guiana CIRE and the Health Guadeloupe Watch Unit (CVS) since 2003, itself underpinned by a 50-strong network of sentinel practitioners. It would be worthwhile to develop the network further in the Pointe-à-Pitre area seeing that the population density is high.

MARTINIQUE

23Vector control has essentially been targeting Aedes aegypti, the main dengue and yellow fever vector, since the disappearance of epidemic malaria.

Organization of the vector control service

24Up to 1990, it was the Departmental Health and Social Affairs Service (DDASS) which ran these vector control operations. The département council for its part undertook complementary mosquito destruction actions in 1990 while equipping itself with the necessary means and personnel. The originality of the Martinique situation lies in the fact that, from 1990, mosquito destruction and vector control activities were brought closer together and coordinated, which materialized a State-département convention (1 November 1990) stipulating the respective modes of action and utilisation of human and material means.

Table 4 – Vector control organisation

Table 4 – Vector control organisation

Note * The Ministry of Health reimburses the département with the whole of its salarial expenditure by means of the General decentralization endowment (DGD).

25On the eve of the transfer of vector control from the State to the département, the mutualization of human resources (48 persons making up 32 from DSDS and 16 from the département council) is working perfectly. However, the operating credits are not pooled, which makes day-to-day management complicated. This is why the setting-up of a public interest group (GIP) was envisaged in the 1990s in order to link the involvement of the State, the département council and the municipal councils. This joint project agreement Entente martiniquaise pour la démoustication was not retained in the end.

Strategy

26An approach was launched to improve the effectiveness of actions undertaken through the setting-up of two bodies: the scientific committee on infectious and tropical diseases, a place for interdisciplinary exchange aiming to lay a scientific basis for dengue control strategies, and the epidemic event management unit whose role is political and decision-making. It is chaired by the Prefect, and it validates the dengue PSAGE. Members of this unit are: the Chairman of the département council, the Chairman of the mayors’ association, the director of the Health and Social Development, the director of the ARH, the director general of the CHU Lamentin hospital, the director of the Trinité Hospital Centre, the Commander of the Armed Forces in the Antilles.

27The PSAGE was signed by all the partners on 13 July 2006. A similar PSAGE has been devised for chikungunya. There is a dual objective: contractualize the role and tasks of partners involved in dengue control, and provide the tools necessary for running the programme’s different actions.

28Transfer of vector control to the département council should not present any difficulties owing to the pre-existing organization. The situation of Departmental entomologist remains to be clarified, however, even though the DSDS has not to date called the mutualization of personnel into question (see CD-ROM). The provision of material means should be the subject of later riders.

Strengths and weaknesses

  • Strength: the coordination of mosquito destruction and vector-control actions and the pooling of means (State/département) from 1991 are in certain respects exemplary, including a plan of the results. This collaboration was all the more justified in that the classic distinction between mosquito vector breeding sites and nuisance mosquito breeding sites is less and less relevant. Besides this, the pooling of means helps provide effective continuity between entomological surveillance, early warning and the response brought to a situation.

  • Weakness: the statutory double hierarchy creates tensions between personnel. This duality of allegiance also shows through in the field of information and communication, as a 2003 internal communication audit testifies (“Diagnosis of inter-personnel relations-analysis and proposals”).

  • Caution: service managers and their hierarchy must take care that the atypical position of the mosquito eradication service does not induce a detrimental effect of distancing it from the other DSDS services whose support is essential.

  • Strength: in the late 1980s the vector control service took on a medical entomologist who conducts parallel scientific work in relation to this activity.

  • Strength: the proximity of the Antilles-French Guiana CIRE (with headquarters in Martinique) has favoured the process of integration of the entomological surveillance and the vector control. Its principal tool for exchange of epidemiological data, the Bulletin d’alerte et de surveillance Antilles Guyane (Basag) is addressed systematically to the Panamerican Health Organization (OPS), the Caribbean Programme Coordination Office of the WHO, the Caribbean Epidemiological Centre (CAREC) and its veterinary equivalent (CaribVEt).

  • Strength: the distinction applied between the scientific committee and the management unit provides the opportunity for open discussion within the scientific body, free from the constraints of management and power issues.

  • Caution: the municipalities’ contribution to the control of mosquito breeding sites must not be neglected. The town of Schoelcher has been used as pilot site for cooperation between the departmental mosquito eradication service and the municipal services. Much remains to be done in public health and hygiene (122 sites have been listed as the most productive sites). Overall, recourse to restringent powers provided for by the 1964 law or departmental health regulations has been exceptional. Moreover, no agent of the mosquito destruction service is sworn by oath.

FRENCH GUIANA

29Malaria and dengue have helped govern the organization of the Departmental Disinfection Service.

Organization of the service

30This Departmental Mosquito Eradication Service (SDD), run by the French Guiana département council, is responsible for vector control. It operates on behalf of the State on the basis of a convention (article 2 of convention n° 257/DDASS/DIR of 25 October 1993 between the State, the département council and French Guiana Pasteur Institute). It works under the supervision of an administration manager, joined in May 2006 by an entomologist. It comprises several stations spread between French Guiana’s different urban areas, but often the personnel have not had the benefit of specific training. Its material resources are notoriously inadequate.

Strategy

31The diversity of vectors necessitates a strategy adapted to each case that takes into account the ecology and biology of the vector. The strategy applied appears to be a compromise between mosquito destruction and vector control activities, and actions for Aedes aegypti control. The scientific guidance now comes under the State’s responsibility, having long been effected by the French Guiana Pasteur Institute.

Operational problems

32An old dispute over the amount of reimbursement to be paid by the State for the SDD’s vector control mission has still not been settled. The allocation from the State for this (fixed by agreement n° 257 /DDASS/DIR of 28 December 1995) has been transferred only once, even though pre-2006 vector control could not be considered to fall within the competence of the département. The chairman of the French Guiana département council asked the Minister of Health (18 April 2006) for an additional contribution and an exceptional allocation of crisis funds.

MAYOTTE

33Vector control essentially targeted anophelines (owing to malaria risk), along with a close watch maintained on other pathologies (filariasis transmitted by mosquitoes of the genus Culex), until the chikungunya crisis arrived.

Organization of the service

34The vector control and medical entomology service is a department of the Health and Social Affairs Service (DASS) of Mayotte. It is headed by health and sanitation engineer and has a 74-strong team of agents including one entomologist.

Strategy

35A new control strategy was set in place from 2002. It is founded on the mutualization of teams’ resources and equipment by concentration of the whole system on one sector. All service personnel work under the responsibility of the team manager in charge of the sector where the intervention is to be executed. The chikungunya epidemic in 2006 demanded the settingup of a crisis force which concretized as reinforcement of the teams.

36Currently the service is up against a difficulty in recruiting permanent agents to replace personnel in the older age group. Mayotte’s isolation is penalizing during an epidemic phase of a disease and control methods should be improved more systematically.

Operational problems

37One of the problems stems from difficulties with the integration process which should be completed in 2010. A specific status, stemming from special legislative provisions applied to the island, means that the agents made available by the departmental council are in fact being integrated into the State civil service. And this produces a paradox: article 72 of the law of 13 August 2004 provides for the transfer of vector control teams to départements (therefore to Mayotte in this case), and yet at the same time the personnel become civil servants of the State.

38Moreover, coordination between action of the vector control service and health watch operations is more difficult in Mayotte owing to its attachment to CIRE of Reunion Island/Mayotte. In addition, the numbers of medical doctors on the island are insufficient for forming a network of sentinel practitioners.

39Another point is the irregular standards of vector control in the community in spite of a substantial communication drive led by the DASS.

40Cooperation of municipalities is imperative if waste disposal and treatment is to be improved, but the present situation is riddled with problems.

41The département council is not favourable to a system in which its role would be limited to one of execution of instructions issued by the State. It demands to be able to take part in the planning and management.

CORSICA: HAUTE-CORSE

42The service responsible for vector control, inherited from the antimalaria service set up in 1930, was reactivated from 1972 after a brief membership of Corsica to the Interdepartmental Agreement for Mosquito Eradication (EID) from the Mediterranean coast.

Context and organization of the service

43In 1976, Corsica was separated into two départements which led to the creation of Haute-Corse’s own malaria control service. It was incorporated into the département council’s services in the early 1980s. After the introduction in 1987 of article 18-1 into the Public Health Code, which stipulated that this competence was assigned to the State, the service nevertheless remained attached to the département council by derogation. However, owing to a dispute over the level of costs taken care of by the State, the département council unilaterally declared at the end of 2002 that it was stopping vector control. The département did continue to run a partial system of malaria control but, by precaution, the State services took over between 2003 and 2005 through the intervention in Haute-Corse of the vector control service of Corsica and Corse-du-Sud DSS. Paradoxically, the département council’s mosquito destruction service did become involved in surveillance of Aedes albopictus, by installing the first egg-laying traps on behalf of the Mediterranean EID.

Table 5 – General organization

Table 5 – General organization

Note * This service consists of 32 agents.

Operational problems

44For about 20 years vector control was the centre of a succession of disputes between the State and the département council (see CD-ROM).

45Currently, the State’s main expectation vis-à-vis the département of Haute-Corse is an improvement in the results of field operations, as the information the vector control service sends is not full or detailed enough.

46Another question concerns the place of the city of Bastia and its Municipal Hygiene and Health Service (SCHS). An antimalarial campaign restricted to common sites for mosquito vectors was run from 2003 to 2006. Since 1 January 2006 Haute-Corse département council took up complete control measures again and, in particular, answered State calls after the discovery of the colonization of Aedes albopictus in Bastia in May 2006. Article 3 of decree n° 2008-791 of 20 August 2008 activated the transfer of the competent State vector control services to the département (this mea-sure includes Corse-du-Sud).

CORSICA: CORSE-DU-SUD

47The vector control service here was also inherited from the departmental malaria control service founded in 1930. The constitution of the two Corsican départements in 1976 led to the setting-up of Corse-du-Sud’s own malaria control service.

Table 6 – General organization

Table 6 – General organization

Note * The vector control service is composed of 23 agents. Moreover, the sanitation engineer who is in charge of the health-environment service devotes 10 % of his time to it.

Operational problems

48There are some obstacles in common with those observed in Haute-Corse, for the same reasons: problems linked to application of the 1964 law, lack of contact and liaison between the vector control service and other parties (such as State services, Corsica Environment Agency).

49Two zoning orders have been taken (see CD-ROM). However, the département council put forward several reasons for not signing the agreement proposed in June 2006 on the seconding of personnel from vector control (see CD-ROM). It was not hostile to the transfer, but was in dread of taking on a service that was not working optimally without proper staffing, whereas risks of a mosquito vector-related epidemic outbreak could not be excluded. The council were also afraid of seeing the State suddenly ordering new vector control measures (for example, if the mosquito vector of chikungunya appeared) which would entail costs beyond the amounts budgeted to compensate for the transfer. As already indicated, the transfer has however been effective since publication of decree n° 2008-791 of 20 August 2008.

RECOMMENDATIONS
■ Human Health
: envisage a single legislative package to govern control against insect and other haematophage arthropod vectors of diseases affecting humans.
■ Animal Health: maintain a specific legislation for control against insect and other haematophage arthropod vectors of diseases affecting animals. It would be advisable to mutualize competences, particularly those of medical entomologists.
■ Strengthen the message that the prevention of vector-borne diseases is a public health issue which thus falls within the general competence of the State.
■ Integrate vector control into the assigned roles of future Regional Health Agencies (ARS) and reiterate that crisis management is the responsibility of département prefects.
■ Make sure that vector disease control policy is quite clear and make legislative revisions of vector control provisions while taking care to homogenize the coding (public health code, general local authorities code, rural code).
■ Formalize the strategy (objectives to be achieved, result indicators, indicators of means and methods applied) and define ways and means of implementing control measures in the plans; the important point being to involve all the actors together, in particular the mayors whose statutory duties include civil engineering actions.
■ Develop cooperation schemes with the different actors (département councils, mayors, associations and so on) using suitable legal tools (EIDs in metropolitan France, GIPs in overseas départements and territories.
■ Specify the role and duties of these EIDs and GIPs in the multi-year con-tracts of objectives and means concluded with the director-general of the ARS and, where necessary, delegate management powers to those who request it.

Table 7 – Chronology of specific texts on vector control and mosquito destruction

Table 7 – Chronology of specific texts on vector control and mosquito destruction

Table 7 (continuation) – Chronology of specific texts on vector control and mosquito destruction

Table 7 (continuation) – Chronology of specific texts on vector control and mosquito destruction

Notes

1 In this chapter, references to the CD-ROM concern question 3: “How is governance organized?”.

Table des illustrations

Titre Table 2 – Structure and means
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-1.jpg
Fichier image/jpeg, 148k
Titre Table 3 – Vector control organisation
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-2.jpg
Fichier image/jpeg, 144k
Titre Table 4 – Vector control organisation
Légende Note * The Ministry of Health reimburses the département with the whole of its salarial expenditure by means of the General decentralization endowment (DGD).
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-3.jpg
Fichier image/jpeg, 208k
Titre Table 5 – General organization
Légende Note * This service consists of 32 agents.
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-4.jpg
Fichier image/jpeg, 108k
Titre Table 6 – General organization
Légende Note * The vector control service is composed of 23 agents. Moreover, the sanitation engineer who is in charge of the health-environment service devotes 10 % of his time to it.
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-5.jpg
Fichier image/jpeg, 72k
Titre Table 7 – Chronology of specific texts on vector control and mosquito destruction
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-6.jpg
Fichier image/jpeg, 320k
Titre Table 7 (continuation) – Chronology of specific texts on vector control and mosquito destruction
URL http://books.openedition.org/irdeditions/docannexe/image/1267/img-7.jpg
Fichier image/jpeg, 318k

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