P³ | #8 Spring - Summer 2019

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COLOPHON Responsible Publisher Bruno Gryseels Editor-in-Chief Roeland Scholtalbers

Editorial Coordination Ildikó Bokros Editorial Committee Roeland Scholtalbers Nico Van Aerde Eline Van Meervenne Catie Young Maria Zolfo

Layout Toech Reclamestudio

Photography Astrid Bultijnck, Enric Català, Jessica Hilltout *P³ - ITM’s essence captured in one letter Our innovative and interdisciplinary research focuses on Pathogens (Department of Biomedical Sciences), Patients (Department of Clinical Sciences) and Populations (Department of Public Health). ITM researchers improve our understanding of tropical diseases, and develop better methods for their diagnosis, treatment and prevention. Others study the organisation and management of health care and disease control in regions where means are limited, but needs are huge. We also focus on the health of animals and the diseases they spread to humans.

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Contact communicatie@itg.be +32 (0)3 247 07 29



Dear Reader, For almost 25 years, Director Bruno Gryseels put his stamp on the Institute of Tropical Medicine. This summer, he will pass the torch to his successor Marc-Alain Widdowson. In an extensive interview with P3, Bruno looks back on a quarter of a century of tropical medicine. One thing is certain, the Institute and the world changed significantly over the years. This Spring edition takes a closer look at an ambitious leprosy study in the Comoros and Madagascar. ITM scientists, together with local and international partners, research new solutions to protect people against this forgotten disease that is still prevalent in these countries. This edition also sheds light on the special relationship between the artist Philip Aguirre y Otegui and ITM. And talks about how, 20 years on, a second member of the Nacoulma family from Burkina Faso is specialising in public health at the Institute. Delve into a bit of history in an article on malaria around the North Sea and learn what’s new in travel advice. Enjoy the photos of our latest scientific colloquium in Phnom Penh and find out more about scientific podcasts thanks to a science journalist from Indonesia. Finally, P3 introduces two new professors, one from Germany and one from Spain, both of whom have recently joined ITM. We hope you will enjoy reading this edition of P3! Yours sincerely, The Editorial Committee

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THE LIST: DEWI’S 4 FAVOURITE PODCASTS ITM AND I: PHILIP AGUIRRE Y OTEGUI © The contents of this publication may not be reproduced in whole or in part without the express consent of the publisher. Images in this report were taken with full understanding, participation and permission of the people portrayed. The images truthfully represent the depicted situation and are used to improve public understanding of our work.

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During Open Monument Day 2018 we welcomed 1803 people - a new record for this event. Together with our 20 enthusiastic volunteers they really made the day! It was a pleasure to guide the guests through our hallways, rooms and garden on that lovely sunny Sunday.

MAKING LEPROSY A DISEASE OF THE PAST Colonies of severely deformed blind patients, often missing limbs, quarantine, exile, contagion, discrimination and shame - leprosy or Hansen’s disease has these connotations. Although the World Health Organization (WHO) declared its elimination in 2000, the stigma and pain lives on with the disease continuing to be a significant public health threat in some parts of the world.

ITM and its partners are continuing their vigil to sustain elimination efforts with the start of a clinical trial that aims to screen over 140,000 persons on the islands of Comoros and Madagascar and will attempt to change the landscape of leprosy in these most-affected countries. P³ talks with epidemiologist Dr Epco Hasker and Head of Mycobacteriology Prof Bouke de Jong about leprosy in the world today, the WHO’s current global leprosy strategy and their research. CATIE YOUNG

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You are embarking on a four-year journey to better understand how to protect people from leprosy. Why in this part of the world and why now? BOUKE: Around three years ago our longterm partner, the Damien Foundation contacted us. They have a highly dedicated and amazing team of people working towards leprosy reduction on the Comoros Islands. They requested our help because they had a conundrum in their treatment of leprosy. They couldn’t understand why the disease was so highly endemic in their part of the world, although they were strictly following the WHO leprosy control guidelines. EPCO: Before joining ITM, I worked on tuberculosis and leprosy, so when the Damien Foundation asked me to contribute to a study on leprosy on the Comoros I was immediately very interested. Bouke and I first visited the Comoros in April 2016. The islands are beautiful with palm tree lined beaches where the Indian Ocean is always close at hand. Unfortunately they have also been politically unstable and remain impoverished and despite the best efforts of our partners, leprosy continues. During door-todoor surveys in 2017, we found 2% of the population of four villages to be suffering from leprosy, which is enormous particularly as in the rest of the world it has been ‘eliminated as a public health problem’. The WHO declared back in 2000 that worldwide the prevalence of leprosy had now been lowered to 1 in 10,000 people and that the disease had therefore been ‘eliminated’. However this does not apply to individual countries, the Comoros even today has 5-10 times the WHO elimination rate.

BOUKE: And that’s where the difficulty lies. This prevalence below 1 in 10,000 people may be true within the global population of 7.7 billion people but victory has been cried too soon for the pockets where it is still endemic. Unfortunately this declaration has meant that after 2000 funding for control programmes has decreased; training on diagnosis and treatment of the disease for doctors and health care workers has diminished; laboratory testing has been deemed unnecessary. EPCO: Yes, I believe this success was mainly a result of treating the backlog of existing cases with a one-year treatment and not a life-long one. Once released from treatment you are no longer a leprosy patient, so the numbers were greatly reduced but the numbers of new leprosy patients found each year did not go down as much. On top of this leprosy also still holds a lot of stigma, so households will often hide the disease. We can’t forget either that in such impoverished communities contact with health care professionals is not a part of their lives. These are the main factors that allow continued transmission. So, despite best efforts using the WHO recommended guideline, the number of new patients arising each year has not gone down much and has remained stable over the past five years. It’s no wonder that when I asked the staff of the Damien Foundation ‘in a perfect world, what could most help you in your fight against the disease?’ they responded ‘doing mass screenings of the population’.

© photos by Johanna de Tessières, Damien Foundation

Leprosy still holds a lot of stigma, so households will often hide the disease.

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BOUKE: With this message in mind from the front line of the disease, we designed a clinical study for the islands that will allow us to screen hopefully some 140,000 people in order to research who will benefit most from the preventative effects of rifampicin – an antibiotic with many years of proven efficacy in leprosy treatment. Rifampicin can be used as a ‘post exposure prophylaxis’ or PEP for short. Currently this method – meaning we treat those who have been exposed to contagious people – is seen as the most effective way to stop the chain of infection. We want to find out whether the effect of prophylaxis is confined to a person’s household or a broader social context. Another reason for our focus, is the WHO’s call for more research into systematically tracing household contacts and finding the optimal way to administer PEP. This is for all-important cost effectiveness reasons. This is where our clinical study comes in.

Could you please tell us more about your study? EPCO: A preceding study we are doing, funded by R2Stop, investigates why leprosy remains a persistent health problem on the Comoro island of Anjouan. In order to broaden this study and to include the other Comoro islands and Madagascar, we looked to the EDCTP*. We are very grateful for their funding, to which the Leprosy Research Initiative also generously contributed. This made the PEOPLE** trial a reality. Thanks to their help we can now study what is the most optimal approach to preventing leprosy in endemic areas. BOUKE: As per the PEOPLE trial: our hypothesis lies in the premise that PEP works better when given to household contacts as well as to neighbourhood contacts. Alongside this it is generally assumed that transmission of Mycobacterium leprae, the bacterium causing the disease, is sustained by people who carry high numbers of the bacteria but show no symptoms.

So what we want to prove is that we can effectively interrupt infection by giving PEP to people without symptoms but testing positive in a fingerstick blood test for antibodies against M. leprae – indicating infection with the bacterium. In addition, we will be using DNA fingerprinting of M. leprae from the same patient samples and social network to identify such highly infectious people and to additionally outline the transmission networks. This is reflected in the four arms of the study. In all arms, with participant consent, we will provide annual door-to-door screening, we’ll identify leprosy patients and treat them, and then each village will be offered one of four different approaches. Arm one is our control arm. We will continue as usual – treating the leprosy patients without preventive treatment of the household contacts who had been examined as leprosy-free. Arm two – we treat the leprosy patients and then give members of the same households preventive treatment. In arm three, every person living in a radius of 100 metres around a confirmed leprosy patient will be given PEP. In arm four, we give PEP to every member of the same household, plus to persons living in a 100 metre radius who test positive in the fingerstick blood tests. Importantly, within each of the arms we will be assessing the social acceptability of the screening as well as performing costing of the different approaches. You have many partners in this project – can you tell us about some of the capacities that will be built and what the future holds? story 9 # Cover # Dossier

BOUKE: The PEOPLE team is made up of an impressive group of seven local southern partners and northern contributors. On the endemic islands, we have representatives who have been dedicated to leprosy patients for many decades. We are also pleased that there will be a SouthSouth capacity building aspect with the very well rehearsed Damien Foundation team on Anjouan being able to share their knowledge and experience with our other southern partners, Fondation Raoul Follereau, in Madagascar. Thanks goes to all those involved so far for their endearing commitment.

EPCO: Indeed we are very grateful for the partnerships – both local and international and the prospect of our work together. We also have an excellent scientific advisory committee. Everything is geared toward assuring that the study is relevant to the greater good of helping people with leprosy in other continents. * EDCTP: European & Developing Countries Clinical Trials Partnership ** PEOPLE: Post ExpOsure Prophylaxis in the Comoros and Madagascar


Institute of Tropical Medicine Antwerp (Belgium) Damien Foundation (Belgium, Comoros) Centre d’Infectiologie Charles Mérieux (Madagascar) Fondation Raoul Follereau (France, Madagascar) L’Institut National de la Santé et de la Recherche Médicale (France) Leiden University Medical Center (The Netherlands) Genoscreen (France) Fiocruz (Brazil)

LEPROSY » Leprosy is caused by bacillus Mycobacterium leprae – M. leprae. » Most individuals (95%) have sufficient immunity to directly kill the bacteria without developing an infection. » In those in which it survives, M.leprae multiplies slowly with an average incubation time of five years, symptoms may occur in one year but can also take up to 20 to arise. » Leprosy is curable with multidrug therapy. » As a chronic disease people die with leprosy not because of it.

» People’s limbs don’t just ‘drop off ’ because of the disease – people lose all sensation in areas where the bacillus thrives – namely certain nerve endings. This total numbness means patients cut and bruise themselves without noticing and superinfections with other bacteria set in easily. Limbs then need to be amputated because of infection of the bones. » Up to 1996 leprosy patients in Japan were still quarantined and highly stigmatised until laws were repealed stopping the practice, most countries closed their leprosy colonies in the 1960’s.

“I AM STILL WORKING ON MY FIRST 100-DAY ACTION PLAN” Outgoing Director Bruno Gryseels on the transition of ITM to a science-driven institute

P³ readers need no introduction to Professor Gryseels, who has been the Director of ITM since 1995. After 24 years of service, he retires at the end of June. P³ talked to him about his life before and at ITM – and of course about his expectations for the future for the Institute. Tell us about your life prior to ITM and about your family. I come from a very large family of 11 children: I have eight brothers and two sisters. Nowadays that sounds unusual, but at the time, the average household often had five or six children. My father was a biology teacher at a local Catholic school and one of the first in his Pajottenland village to continue studying after completing secondary school. Almost all his children followed suit and went to university, three of us even obtained a doctoral degree, as did two of my own daughters. My third daughter obtained two masters. The accessibility and quality of education in post-war Flanders has powered unimaginable intellectual progress in just a few generations. We also experienced the Flemish emancipation during the sixties and seventies in a very conscious way. I did well in elementary and secondary school; read and even wrote political articles for the local youth magazine. I also enjoyed maths and physics and wanted to become an engineer or a writer. Why drew you to medicine? In the end I decided to follow my interest in science and remain socially engaged. I was convinced that medicine would pro-

vide me with this ideal combination, but that proved to be rather disappointing from both aspects. After completing my medical studies at Ghent University in 1979, I decided to register for a postgraduate course in tropical medicine at ITM. This experience was, without a doubt, an eye-opener. Apart from clocking long hours behind the microscope, immersed in the astonishing world of parasites, I unexpectedly discovered the concepts of public health and prioritisation in medicine, the idea that when tackling a disease, however serious, you cannot ignore the limited resources. The enthusiastic stories about working in exotic and adventurous conditions were decisive: I was dead set on working in the tropics. What happened next? ITM pathology Professor Gigase carried out research on schistosomiasis. The control of this worm disease, transmitted by fresh-water snails, was predominantly the domain of biologists. As new drugs suitable for mass treatment programmes came onto the market, Prof Gigase was looking for a young doctor to carry out initial field experiments. Immediately after my tropical studies, in August 1979, I started work at his Unit of Tropical Pathology at ITM. To gain experience I was sent to the Parasitology Laboratory at the University of Kinshasa in 1980-1981, which was managed by ITM in those days. Believe it or not, Professor Muyembe, who is still the director of INRB (Institut National de Recherche Biomédicale) in Kinshasa today and a very close partner and friend of ITM, was already then Dean of the Faculty of Medicine. My work consisted of diagnostics, ed-

ucation, participation in the detection of sleeping sickness and epidemiological research into parasitic diseases. I set up new schistosomiasis control programmes and regularly worked in the jungle of Maniema in Eastern Congo where open mining was associated with extreme infection and disease rates. After my DRC experience, another project of Professor Gigase took me to Burundi as an ABOS (now DGD, short for Belgian Directorate-General for Development and Humanitarian Aid) employee. I stayed for five years; even my two eldest daughters were born there. Both are now researchers, respectively in tropical medicine and biology. I became head of the national research and control programme for schistosomiasis and intestinal parasites at the Ministry of Health. Although young and inexperienced, I managed 40 experienced technicians; in those days such shameful and paternalistic situations were still common. I took a scientific approach to the programme which subsequently became an important pilot exercise for the

World Health Organization (WHO), and I obtained my first research grant. With this money I bought my first Apple II computer with 36 KB memory and even managed to write the BASIC programmes for it. Spare time was dedicated to my family, nature and lots of books. We had no TV, telephone, fax, let alone internet. The result was that I managed to read just about the complete world literature from the Greeks to the present. I also got acquainted with institutional politics, which are very important in the Belgian context. The relationship between ITM and DGD was far from perfect in those days. ABOS suspected ITM of wanting to finance its research projects with development money, not entirely unjustified, all things considered. I took on the role of the loyal ABOS development worker and even signed my research papers with the DGD affiliation. It did not make me popular with ITM’s previous director. The result was that the promised return to the Antwerp base never materialised.

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How did your tropical mission end? As the door of ITM was closed for me in 1985, I received an offer to become research lecturer at the Laboratory of Parasitology and Tropical Medicine at Leiden University. I had worked closely with this laboratory in Kinshasa and Burundi under the mentorship of Anton Polderman. In close consultation with my wife I thought hard and deep about a career as a development worker versus a scientific career. The latter meant losing two thirds of my salary. But Leiden gave me the opportunity to further develop my research in an academic environment, to undertake a doctorate and to set up a team of researchers younger than myself. Together we started new projects in the field and worked in Senegal, Mali, Morocco, Egypt, Congo and some other countries. Our funding came mostly from the early European framework programmes, and we collaborated with teams from France, Germany, England, Denmark, Italy. With the naïve courage of the ignorant I became a young, thirty-something consultant for international organisations such as the WHO, the World Bank and GTZ (former name of the German Development Agency) for control programmes in China, Egypt and Brazil. Meanwhile, daily life continued and our third daughter was born. She later followed in the artistic footsteps of my wife. Despite the many clichés about Holland and the Dutch, we had a good time there for ten years and learned a lot. In 1995 you became the seventh director of ITM. How did that come about? Professor Eyckmans retired in 1995. Peter Piot, tipped as his obvious successor, had taken a sabbatical. He went to the WHO in

Geneva where he set up UNAIDS and became its first director. A few internal candidates were keen to take on the position but relationships within the institute were not all that harmonious. The Board of Governors published a vacancy. I was not even 40 but naively decided to apply. The Board of Governors was rather less involved then and left it to the Academic Council to interview and rank the candidates. Apparently, I brought a good story, and perhaps my profile as an external candidate with an internal past also played a role.

ITM has the potential to turn academic excellence and scientific innovation into significant added value. What was ITM like when you took over? In 1995 ITM had only 200 staff and the budget was a quarter of what it is now. There was no clear mission, structure or strategy for the future. Cooperation with ABOS was difficult and fragmented; each grant or project was individually negotiated. We had no fixed core funding from the Flemish Ministry of Education. Except for a small reference in the Decree on the Universities, there was no law or contract that governed our role, position or funding. There was no research allowance and the medical services were virtually bankrupt. I took office on 1 July 1995; in October I submitted a diagnosis and an action plan to the Board of Governors, who approved its implementation in December. I sometimes think that 24 years later I am still working on that initial “100-day action plan”. That is

Bruno Gryseels as a student at ITM, 1978-79 (front middle in cardigan and white shirt) not surprising either: in today’s world stagnation is not an option and reforms are a constant necessity. My priority was to lay down the societal mandates of ITM in terms of content and legislation. That was no mean feat: with the fourth state reform of 1993, the responsibility for education, research, health care and development cooperation had only just been transferred from the federal to the regional authorities; many uncertainties remained about who should finance what. How did you proceed? First and foremost, with well-founded, objective projects and a good relationship with the various government administrations, rather than through political lobbying; and secondly thanks to getting the timing right on broader developments. In 1998, after a lot of scandals, ABOS was thoroughly reformed. BTC (now Enabel) was created for the implementation of bilateral cooperation, the NGOs and the universities were brought under Dutch and French-language “umbrellas”. We succeeded in obtaining a separate frame-

work agreement because we are a specialised institute with no counterpart in French-speaking Belgium. We started with 3 million euros per year for a programme of institutional and individual capacity-strengthening in the South. Currently we are on our fourth framework agreement with a budget of 15 million euros per year, completely dedicated to scientific capacity-building for disease control and health care. Apparently, we did not do too badly. We had been looking for a better statute at the Flemish Ministry of Education ever since 1996. In 1999, once again for “politically sensitive” reasons, the Vlerick Business School in Ghent needed urgent regulation. As a result, we were defined by a new category: “Public Utility Institutions for Post-initial Education, Research and Services” operating on a post-university level. A separate decree governed legal approvals and assignments, five-year management agreements and structural funding. “Bien étonné de se retrouver ensemble,” you could say. We still are a separate category from the business schools and we operate as autonomous foundations. The research subsidy took a bit lon-


ger and only became official in 2007, after years of hammering on our equivalency with universities. From 2020 it will even get in line with the subsidy for education, a logical consequence, but administratively and politically not immediately obvious. We were also able to convince the federal Ministry of Public Health and Social Security that we are indispensable as a reference centre for tropical diseases and travel medicine. After an “experimental� 3-year phase, we were acknowledged and subsidised, ever since 1998, as the only such centre in Belgium. The HIV/AIDS care reference laboratory and centre were added later. It would be very difficult to maintain our expert services for travellers, expatriates and migrants without this recognition and these subsidies. The establishment of these distinct but strongly interwoven mandates and

Bruno Gryseels in DR Congo, 1980

funding was and remains the basis for ITM’s existence and its operations. In the meantime, we have also become a partner institution of the Flemish Departments of Welfare and International Cooperation. We are proud of this societal support but must keep earning it. This means that we must constantly prove our added value in everything we do. Our position is quite exceptional in Europe and implies that we must permanently question and improve ourselves and adjust to environments that change faster than ever. The second part of my 100-day action plan focused therefore on internal operations and particularly on the quality of the scientific work. What has changed inside ITM in the last 24 years? When I took over, there were many professors and even administrators with a colonial or neo-colonial past or mentality. Appointments were mainly based on personal relationships instead of on a strategic vision: there were nine veterinary professors but only three in public health. The few assistants had a lot of field experience but often no PhD, let alone academic prospects. Publishing articles was discouraged because the results in the field were considered to be much more important. Nevertheless, ITM has carried out great pioneering work in basic health care and stood at the cradle of the Primary Health Care concept. Most of that work has never been published and if it was published it often was by coincidence. This is regrettable, because in global health, the struggle for basic health care as a universal human right goes on until today. HIV/AIDS was an overwhelming priority at the time but re-

Bruno (left) and his brother Guido Gryseels (right) in DR Congo, 1980

ceived few resources as it was considered a “dirty disease� and its pioneers built their own empire with external funds. The Department of Clinical Sciences did not exist and doctors in the medical services also took on academic tasks. Our courses were famous all over the world, but our master’s degrees were not legally recognised. The concepts of horizontal health systems and vertical disease control programmes seeped into education and created two separate and opposing course curricula. The structure of the institute was rather fragmented. The 100-day action plan established five scientific departments: Microbiology, Parasitology, Animal Health, Public Health and, for the first time, Clinical Sciences. A rotating system of department heads formed a management committee, together with the director and the general manager. Homeric discussions ensued, both about the broad policy lines

and executive details. Nevertheless, many colleagues rose to the challenges. Our academic unit saw the set-up of a new Master in Disease Control, which later merged with the Master in Public Health. The medical services were separated operationally and financially and became more professional. The departments drafted strategic research programmes spurred on by an external Scientific Advisory Council. The allocation of full-time professors (ZAP) and other personnel was based on a more rational footing. The framework agreement with DGD was considerably expanded and built on a project cycle management. All department heads, including ZAPs, took on line management responsibilities in HR, safety and well-being. A quality system was implemented in fits and starts and we invested heavily in buildings and infrastructure including Campus Rochus and Campus Mortelmans, L3 laboratories, 17

student accommodations and the Karibu restaurant. All decisions, including controversial ones, were thoroughly substantiated, discussed and submitted to the Board of Governors. The year 2010 marked a new chapter with the ITM2020+ vision, which reinforced the previous reforms for the 21st century. It included the following changes: the five thematic departments merged into three disciplinary departments according to the P3 concept: pathogens, patients, populations; departments became more autonomous and set up their own line management; the introduction of the “Switching the Poles” concept in our southern operations; a strategic generation turnover; administrative professionalisation; a new institutional mission statement and everything that entails. Today’s ITM is incomparable with that of 1995. That is not my achievement but that

of a whole generation of scientists, staff and administrators. Throughout the transformation to a goal-oriented, structured and professional organisation, we have managed to maintain and even strengthen the fundamental values of ITM. This was accompanied by a lasting commitment to our partners in the South, who can now take over the helm in their own country. We will increasingly have to draw our raison d’être and added value from our academic and scientific quality and integrity. In hindsight, what could you have done better, or differently? I had a strong vision and knew how to translate this into strategic, operational and financial plans but did not always succeed in rallying people behind this vision. I believed that when you are right, or think so, people will eventually follow. I learned the hard way that change is always difficult for a great majority, even if they under-

Prof Bruno Gryseels addresses Ms Dubois at the inauguration of the Dubois building in 1996. Left from Gryseels are former Directors Prof Luc Eyckmans and Prof Pieter-Gustaaf Janssens

stand the rationale. Probably I should have reached out more often for external assistance in change management and sought personal coaching from early on. That might also have saved me a lot of sleepless nights and personal upsets, because I do not have a tough elephant skin. An unfinished component is the adjustment of administrative services to the new ITM. We have a very strong and committed middle management, but the structures and processes are not yet optimally geared to the current needs of the departments. We are a very versatile and specialised organisation, with many exceptional needs in an increasingly regulated environment, where small-scale has both advantages and disadvantages. However, we are certainly heading in the right direction. What kind of ITM are you leaving behind? In my view, ITM has the potential to turn academic excellence and scientific innovation into significant added value, especially for the poor and vulnerable communities in a globalised world. We deliver first-rate science that makes a real difference for patients, communities and governments. Recent articles in top journals about subjects such as Ebola and sleeping sickness are witness to this. Without our education, our partnerships and our medical services, Flanders and Belgium would not be able to pull such weight in the international health arena. There is so much more to do. Tropical medicine remains a fascinating research subject, revealing fundamental mechanisms of humans, pathogens and vectors. Cost efficiency in health care is part of our DNA and is also one of the biggest societal challenges of the 21st century in the west.

Our knowledge and experience are indispensable for tackling climate change, infectious diseases and antibiotic resistance that threaten the whole world. I am proud that all employees of the ITM are ready to work on this future together. What will the new director need to do? There are far more resources than ever available for disease control in developing countries, especially through targeted international funds and large philanthropic organisations. That is a very good thing, but on the other hand, a real “global health” industry has emerged in which scientific integrity and equal partnership give way to rhetoric and financial pressures. ITM has chosen not to take part in this. The South’s call for decoloniality is growing louder. I hope that with the support of governments and the public we can preserve our independence so that we do not continue to work from, but for the South. On the other hand, we must unequivocally enter the competition for scientific funds and talent, deploy resources even more efficiently and continue to exploit our interdisciplinary potential. There is certainly enough work left there for my successor. ITM has built up a truly unique combination of excellence, relevance and integrity in its niche. It is not only for the Director, but for the entire ITM staff to continue to cherish our identity. To know more about ITM’s Switching the Poles programme, visit switchingthepoles.itg.be 19

MASTER OF PUBLIC HEALTH a Nacoulma family tradition Walking in the international medical career shoes of a revered relative is a special feeling. This is no exception for Dr Noël Nacoulma who is currently doing his Master of Public Health at the Institute. He is enjoying the Antwerp halls and teachings even more as he follows a family tradition of becoming a medical doctor and now, like his paternal uncle before him, also studying public health at ITM. CATIE YOUNG

“I was very happy to be accepted to the 2018-2019 Master in Public Health at ITM. This is my second application – my first was in 2014 but it was sadly refused. Following encouragement from contacts at UNICEF I applied again and to my delight was accepted!” A trained general practitioner, a husband to a pharmacist and a proud father of two boys, you could say Nacoulma has medicine in his blood with the majority of his family working in the public health sector. The family, originating from the rural village of Tanghin about 20 km from Ouagadougou in Burkina Faso, includes doctors, nurses, public health officials and pharmacists. “Since I was a child I always wanted to be a medical doctor. During secondary school I lived with my father’s elder brother, Innocent Nacoulma, who is a trauma surgeon. I have always marvelled at his endurance when it came to work and the studies he continued to follow, despite his heavy workload. Due to his excellent example, I was even more confirmed in my choice to study medicine for the next step in my education.” Finishing his medical studies in 2008, Nacoulma then worked directly for the public health system in Burkina Faso. He started his career as head doctor in the district health centre of Gourcy and then in Seguenega as chief medic, both in the North

of the country, and also in the district of Boulmiougou in the capital Ouagadougou. “In the Northern districts I had a very rich and varied experience: as emergency surgeon; assisting the implementation of free medical treatment for children under five years and working with pregnant women - this was with the NGO ‘Terre des Hommes’. Outside of this I also worked on setting up a digital consultation registry for the PCIME clinic (clinic for integrated management of childhood illnesses).” To reinforce his career in public health Nacoulma is now following in his other paternal uncle’s, Daniel’s footsteps. Also a medical doctor, his uncle graduated from the same ITM master programme in 1999 and went on to work for UNICEF in the

Democratic Republic of the Congo and also led the implementation of the sharedcost care system in the district of Houndé outside of Ouagadougou. Having seen the positive effects that studying at ITM brought for his uncle Daniel, the younger Nacoulma was immediately attracted. “From my uncle’s experience, I knew a lot about the Institute and I am very grateful to be studying here as it is a renowned school in the public health field and one that is greatly respected for its quality of education in Burkina Faso.” To finish, Nacoulma shares with obvious pride the fact that his uncle Daniel’s daughter, living now in Morocco, is also studying medicine. Who knows, maybe another Nacoulma will continue the tradition?

Daniel Nacoulma as a student at ITM in 1998-99, top row, fifth from right

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PHOTO STORY ITM COLLOQUIUM 2018 Since 1959, the Colloquium has been ITM’s yearly flagship scientific conference, funded by the Belgian Development Cooperation. Every other year the Colloquium takes place in a partner country of ITM. In 2018, ITM teamed up with its partner organisations in Cambodia to hold the 59th edition jointly, in Phnom Penh. This edition took on one of the defining global health challenges of our times: antibiotic resistance.

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MALARIA AROUND THE NORTH SEA – HISTORY IN A NUTSHELL These days, we are quick to associate malaria with warm and tropical climates. However, until the 1950s this disease was quite common in our regions. Especially in the polders, you ran a very real risk of contracting malaria. The Anopheles mosquito, which can carry malaria, breeds quite happily in stagnant water. Popularly the disease was known as ‘swamp fever’ because people thought malaria (from Italian - mal’ aria, meaning bad air) was caused by the strong-smelling air of wetlands. For centuries the disease accounted for a substantial number of casualties in Western Europe.

nals. The puddles that remained between the dykes became the perfect habitat for malaria mosquitoes. Furthermore, crusaders and pilgrims returning from their journeys to distant lands brought back various diseases, including malaria.

ELINE VAN MEERVENNE Spraying in a school

The Plasmodium parasite, responsible for malaria, travelled from its origins in Africa via human hosts to Europe. It spends its life partly in humans and in the Anopheles mosquito, which at the time had settled in the vast marshland around the North Sea. These wetlands, with their mix of stagnant salt and fresh water, were an ideal breeding ground for these mosquitoes. The settlements of our ancestors offered them shelter during the long cold weather spells. High death rates, in Western Europe’s coastal areas during the 4th and 5th century AD, point to outbreaks of malaria. From the 11th century onwards, people began building dykes and digging ditches and ca-

Photo Noord-Hollands Archief

Between 1500 and 1750 ‘swamp fever’ reached its peak in Western Europe with a large-scale outbreak, due to an increase in maritime activities. The construction of waterways meant that seawater could flow inland and mix with fresh water. Lakes were artificially drained leaving ponds and puddles behind and, creating ideal conditions for the mosquito population to flourish, subsequently increased the malaria risk. Extensive shipping meant the disease could travel and outbreaks suddenly occurred in regions where this disease had never been seen.

Until the 19th century, people were not familiar with the cause and diagnosis of swamp fever. As there was no effective treatment, alternative remedies were often used. Only in 1880, Charles Laveran, a French doctor, discovered a single-cell parasite in the blood of malaria patients. In 1897, Ronald Ross, a British physicist, discovered the link between the parasite and the female Anopheles mosquito. The puzzle fell into place and it became clear that malaria was transmitted through the mosquitoes that lived in wetlands. Malaria was already receding though before its cause and how it spreads was discovered. Large-scale swamp drainages were undertaken to get rid of the ‘damaging’ marsh air. When constructing new dykes and canals, stagnant water was contained where possible. The malaria mosquitoes saw their breeding grounds disappear. In

Photo Geheugen van Nederland

House in the Netherlands where malaria was a common illness last century - The open rain barrels were also a breeding ground for mosquitoes Photo Noord-Hollands Archief

addition, quinine was found to be an effective treatment. Many other factors may have caused a reduction in the malaria burden: industrialisation, more people moving to urban areas, land-use change (less swamps) and better hygienic conditions (tubed sewage systems, closed house constructions, separation of human and animal habitation). Most effective against the disease, however, was the heavy use of DDT, a chemical insecticide, in Europe. Thanks to eradication campaigns and social factors, Belgium became malaria free in the 1950s. Today, most Europeans get infected with malaria while on a long journey in the South. Very rarely, sometimes inexplicably, cases of malaria occur in countries such as Germany, Italy and even Belgium, in people who have not even travelled to areas where malaria is endemic. Greece experienced a local outbreak with about 40 confirmed cases in 2011. Since the malaria mosquito is still present in Europe, it could be assumed that we might have to deal with the disease once again. Because of the complex connection, however, between the Plasmodium parasite, the malaria mosquito, cultural and economic prosperity, predictions are difficult to make. # Rewind 25

TRAVELLING SOON? Read what’s new!

Our doctors in the travel clinic see more than 24,000 travellers every year. We highlight four diseases that require particular attention.

TICK-BORNE ENCEPHALITIS Status: on the rise in Europe Tick-borne encephalitis is a viral disease of the central nervous system. Symptoms come usually in two phases starting with a mild flu-like syndrome. In the second phase neurological symptoms can appear and in some instances neurological damage remains.



Check with the travel clinic or your doctor – but you should consider vaccination if you’re planning an active outdoor stay in Central and Eastern Europe in spring, summer or autumn.

There are two types of vaccination schedules against rabies: preventive vaccination and vaccination after possible exposure (after an animal bite or scratch). Preventive vaccination is recommended for those going to areas with rabies among dogs and who: travel frequently or for longer periods; travel to remote places without immediate medical services; do higher risk activities (such as biking, working with animals).

Vaccination Three doses: day 0 / month 1 to 3 after the first vaccine / month 5 to 12 after second vaccine, first booster after 3 years, next booster after 5 to 10 years. RABIES Status: a simplified vaccination schedule Rabies is a contagious and fatal viral disease transmitted through the saliva mammals (e.g. dogs) causing madness and convulsions or apathy. Once signs and symptoms appear it is more than often fatal. Where In Belgium and in most European countries, rabies does not circulate anymore amongst dogs, but it can still be present in bats. In most non-Western countries dogs can also transmit rabies. Prevention Keep your distance from animals and don’t touch dead animals.

After a bite Wash the wound thoroughly with soap and seek medical advice as soon as possible. ‘post-exposure’ vaccinations are recommended and the doctor will decide which vaccination schedule is appropriate (short or long) and whether or not you need immunoglobulins. Immunoglobulins or antibodies are sometimes injected around the wound to neutralise any of the virus immediately. People who have had preventive vaccination will need a shorter post-exposure procedure, without immunoglobulins. Vaccination The WHO introduced new guidelines for rabies in April 2018 changing preventive vaccination from three vaccinations to a schedule of two vaccinations administered on days 0 and 7. The new regime is based upon research at ITM and the Belgian Defence amongst others; our Institute has been applying the new regime since May 2018.




Status: updated recommendations

Status: Belgian travellers still affected

Yellow fever is a deadly virus transmitted by mosquitoes that bite during the day. It occurs only in certain countries in South America and Africa. There are no medicines to treat yellow fever, but there is a very effective and well-tolerated vaccine.

Malaria is caused by a parasite, which is transmitted by the anopheles mosquito. The disease is characterised by episodes of fever that can seem similar to an ordinary flu. Malaria is treatable but if treatment is not started rapidly, the disease can be deadly.

Who You should get vaccinated if you are travelling to and from the endemic regions in South America and Africa. In Belgium, the vaccine is only available in an official yellow fever vaccination center. Vaccinations The WHO declared in June 2016 that the certificate of vaccination against yellow fever is valid for life. However, it is unsure whether a single vaccination offers lifelong protection to everyone. For a list of the people recommended for yellow fever boosters please see: www.itg.be/E/Article/yellow-fever-vaccination.

Who Malaria is found in the tropics and in a number of sub-tropical regions. The risk depends on the country and region visited, but can vary according to the season, and the type of accommodation at night. There is no malaria vaccination for travellers but you can prevent and treat it - with prevention being the best medicine. Prevention Malaria prevention has several approaches: awareness, mosquito bite prevention from dusk till dawn, and preventive tablets that are available via prescription only when staying in a region with a high risk. In case of fever during or up to three months after the journey, one needs to be tested within 24 hours.

TIP! Prepare yourself about eight weeks in advance. Full details of how best to protect yourself: www.itg.be/E/travel-health/how-to-travel-and-stay-healthy


HOLA, WIE GEHT’S? A German and a Spanish professor settle in Antwerp # Portrait 29

When professors retire, a wealth of expertise goes out the door. But it also creates the opportunity to bring in fresh blood and refocus on the challenges of the future. P3 introduces Ruth Müller and José Peñalvo, the German and Spanish scientists who aim at bringing research on entomology and non-communicable diseases (NCDs) to the next level. ROELAND SCHOLTALBERS One, Ruth Müller, is a biologist and the new professor of Medical Entomology in the Department of Biomedical Sciences. The other, José Peñalvo, is an epidemiologist who recently joined the Department of Public Health as ITM’s first professor of NCDs. Ruth grew up in a German village on the border with Poland; José is a Madrileño in heart and soul. But the two have more in common than what divides them. Both in their early forties, they have strong academic credentials and are eager to leave a mark. The new professors have clear ideas about their added value and the opportunities to strengthen ITM’s research portfolio. Ruth studies the link between mosquito-borne disease risks and global changes using eco-bio-social approaches, develops eco-friendly vector control tools and contributes to the development of integrative prevention and control strategies. She also works on native and invasive mosquitoes in Europe, particularly in Germany and Italy, and in Asia. José takes a life-course approach to health

promotion, using big data to analyse the long-term effects that biological, physical, and social exposures may have on the onset and development of NCDs. His career led him via Spain, Finland, the United States, and Germany to Antwerp. SETTLING IN AND LINKING UP When we sit down in José’s office overlooking the convent garden of ITM’s Campus Rochus, he talks about his first weeks in Antwerp. “A specific focus on NCDs is new at the Institute and reflects the growing importance of these diseases across the globe. The burden of cardiometabolic diseases and cancer is increasing steadily in low- and middle-income countries in Africa, Asia and Latin America, but the specific risk factors underlying these conditions in these areas are not yet fully understood. Effective strategies addressing the multi-morbidity nature of NCDs are currently lacking.” Even if the NCD burden is often greater than that of infectious diseases, the lack of sound data makes it more difficult to tackle them. In the eyes of José, ITM has a lot to gain in applying epidemiological methods to big datasets to understand the current burden of NCDs and modelling future outcomes to inform the design of public health interventions. “Data modelling provides vital information before the intervention, but can also be used to make predictions on outcomes. For example, there is a lot of attention on diabetes and hypertension, because they cause the highest burden of disease now. But what

about the future? Cardiovascular disease and mental health might become a bigger burden. Mental health issues also affect otherwise healthy individuals, including young people with a life ahead of them. Managing these aspects will be increasingly important and data can help. Mental health might provide interesting links with other work at ITM too, because patients with infectious diseases are at a higher risk of mental problems.”

Much more effort should be made in the prevention of disease to curb the current burden of NCDs globally. Prof José Peñalvo

Because of its large impact on NCD prevention, José also aims to build up ITM’s expertise on lifestyle in general and nutrition in particular, a topic he has worked on extensively during his time in the US, from where he focused mainly on Spain, Colombia, Mexico, and underserved communities in US. “The word prevention is crucial in this context. A lot of my work has focused on finding the major determinants of NCD onset to inform meaningful prevention strategies and I believe this research will be important at ITM too. Plenty of attention goes towards disease control and treatment, and rightly so, but much more effort should be made in the prevention of disease to curb the current burden of NCDs globally.”

JOSÉ L PEÑALVO – PROFESSOR NON-COMMUNICABLE DISEASES, ITM » Adjunct Professor in Epidemiology, Friedman School of Nutrition Science and Policy at Tufts University in Boston (2017-current) » Associate Director Epidemiology, Real-World Evidence, Merck, Darmstadt (2017-2018) » Assistant Professor in Epidemiology, Friedman School of Nutrition Science and Policy at Tufts University in Boston. (2014-2017) » Epidemiology Lead at the Spanish National Center for Cardiovascular Research in Madrid (2008-2014) » BSc in Pharmacy (University Complutense of Madrid), PhD (University of Helsinki) and postdoctoral training (John Hopkins University, Baltimore) in Epidemiology

# Portrait 31

José is exploring how his expertise can be most useful to strengthen the research portfolio of the Department of Public Health and ITM as a whole. “I am in the middle of conversations with various ITM teams to see how my quantitative work can link up with their more qualitative approach. I am excited to see there are plenty of opportunities where both sides can strengthen each other.” NEW PERSPECTIVES Ruth Müller’s office is a few blocks away in Campus Mortelmans. Unlike José, who is setting up a new unit, Ruth is leading an established team with plenty of projects in Belgium and the tropics. “ITM has amazing expertise on vector control, both regarding invasive species in Belgium and mosquitoes in tropical settings. My predecessor Prof Marc Coosemans was a global expert on insecticide-treated bed nets, while I bring expertise on other control methods. I look forward to linking up more with the Unit of Virology, for example, in order to gain a deeper understanding of the ecology of arboviral diseases.”

We need research into new tools that can complement proven control methods such as insecticide-treated bed nets. Prof Ruth Müller

In 2018, ITM researchers found proof that the Asian tiger mosquito no longer exclusively arrives in Belgium via shipped goods, but also via populations in border areas of neighbouring countries, like Germany. “I want to bring Belgian and German experts to the table to look at the problem of invasive mosquitoes together. There is plenty we can learn from each other,” says Ruth. Vector control is a dynamic field with plenty of new developments. In her transalpine adventure Ruth oversees the contained study of genetically modified mosquitoes. “We know that we need integrated methods of vector control to reduce mosquito populations to the extent that we can eliminate diseases as a public health problem. That requires research into new tools that can complement prov-

en concepts such as insecticide-treated bed nets. I will continue my work on genetically modified mosquitoes, for example.” Through genetic modification either mosquito populations can be reduced or mosquitoes can be prevented from passing on disease. “To be able to intensify experiments in the area of vector control, we currently explore opportunities to create a new insectary,” says Ruth. Ruth is also passionate about the climate. In her early career she travelled as far as the Arctic to study the environmental risk of increased UV radiation due to ozone depletion and oceans warming due to climate change. Ruth also has an ongoing collaboration with the National Health Research Institute in Nepal. She will continue her ongoing studies on the Aedes mosquitoes at different altitudes in mountainous Nepal. “We look at the link between climate and mosquito-borne disease risks in the environment and in society to develop specific vector control strategies and communication tools. That requires an interdisciplinary eco-bio-social approach and a ‘One Health’ perspective.”

RUTH MÜLLER – PROFESSOR MEDICAL ENTOMOLOGY, ITM » Head of Department Environmental Toxicology and Medical Entomology and head of BSL 1 laboratories at the Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt (2015-2018) » Principal investigator and chief manager of Contained Release Facilities of Genetically Modified Mosquitoes at Polo d’Innovazione di Genomica, Genetica e Biologia (PoloGGB), Perugia and Terni (2017-ongoing) » Diploma in Biology, Freie Universität Berlin; Dr. rer. nat. at the AlfredWegener Institute and University of Bremen

# Portrait 33

THE LIST Dewi’s four favourite podcasts In October 2018, science journalist Dewi Safitri landed in Antwerp for three weeks as one of ITM’s three journalists-inresidence 2018. During her stay at ITM, she immersed herself in dengue research

and interviewed our scientists. Once back home, she wrote a long read on dengue for CNN Indonesia. ELINE VAN MEERVENNE

ITM’s journalist-in-residence programme allows journalists from Africa, Asia and Latin America to take a deep dive into their subject(s) of choice in the realm of tropical diseases and other topical issues in international health. The initiative is part of ITM’s capacity building programme in developing countries, financed by the Belgian Directorate-General for Development. As a true ‘news junkie’, Dewi is addicted to news websites and papers, but also to podcasts. A podcast is an episodic series of digital audio (or video) files, which users can download and listen to, most often on their mobile device. The rise of the podcast started about ten years ago. These audio stories à la carte draw the attention of more and more people every year. Dewi listed her four favourite podcasts for P³, with an emphasis on science and one outlier. 1. LIFE SCIENTIFIC The Life Scientific is presented by astrophysicist Jim Alkhalili on BBC Radio 4. The podcast is about scientists and their scientific journey. I think this podcast is great because you get a glimpse of what is inside the head of great minds. They talk about their ups and downs and their human experiences. I love the way these scientists make it sound like their life is not that different from the rest of us, mortals. Amazing people, amazing minds. www.bbc.co.uk/programmes/b015sqc7/ episodes/downloads 2. INFINITY MONKEY CAGE Infinity Monkey Cage is hosted by the renowned astrophysicist Prof Brian Cox and

comedian Robin Ince on BBC Radio 4. They delve into entertaining issues that intersect with science. It’s hilarious and noisy. And more than once, it tested my limits of English. Whilst Prof Cox is a ‘serious’ scientist, Ince is a legit comedian. The topics they choose are somewhat funny, too. Like the episode “Serendipity” that tells the secret of great scientific breakthroughs which are complete accidents. www.bbc.co.uk/programmes/b00snr0w/ episodes/downloads 3. STARTALK Startalk is with astrophysicist Neil deGrasse-Tyson. DeGrasse-Tyson talks about space, science, and popular culture, and he is assisted by various comedians and celebrity co-hosts and often invites guests. Neil deGrasse-Tyson is probably the most famous person for communicating space knowledge these days. He has 13 million followers on Twitter – that’s celeb level. www.startalkradio.net 4. CALIPHATE Caliphate on the New York Times podcast is written and presented by Rukmini Callimachi, a New York Times war correspondent. It’s a non-science podcast but just proves that journalism is vital in this day and age. Especially to help the world understand one of the greatest (disaster) stories of our time: the rise and fall of ISIS. www.nytimes.com/interactive/2018/podcasts/caliphate-isis-rukmini-callimachi. html

# The List 35

Photo by C Jeroen Hanselaer

ITM & I PHILIP AGUIRRE Y OTEGUI Artist Philip Aguirre y Otegui created sculptures that adorned the garden of ITM during the Ecce Homo exhibition (2017-2018). I am writing to you from Kinshasa. Médecins Sans Frontières (MSF) invited me to visit and get acquainted with their HIV-initiatives. A few days before my departure, ITM asked me to write a few lines. The timing could not have been better. I have known the Institute for a long time as a leading body in the medical and scientific field. The splendour of its buildings has always fascinated me. As an artist I have often had the opportunity to visit Africa, in particular Senegal, Cameroon and now the Democratic Republic of the Congo. As a traveller, I am not only an ITM customer for vaccinations, but I have been treated several times for minor ailments that incurred during those trips. The expertise of the attending doctors helped me enormously. As a layman, I kept a close watch on developments since the outbreak of the HIV epidemic and on the role of ITM in research and control of the disease. In Kinshasa I came face to face with the harsh reality of HIV and the havoc it wreaks on peo-

ple’s lives. Together with MSF, I visited the hospitals that treat HIV patients, many of whom also have tuberculosis. The treatment is free; the staff is highly motivated and tries to offer personal guidance. I was able to talk to several patients and listen to their testimonies. The medical problems can basically be resolved, but the prejudices patients face in society are worse and far more difficult to solve. They often get stigmatised and become social outcasts. We also spoke to local NGOs of people living with HIV who try to combat these prejudices. These are very brave initiatives. My respect for the work of ITM in the field of HIV, tuberculosis and malaria has certainly increased after my experience in Congo. From November 2017 to February 2018 I received permission to install sculptures in the garden of ITM for the Ecce Homo exhibition. It was a unique event for me personally and as an artist both on an architectural level and in the context of ITM’s activities. www.eccehomoantwerpen.com www.philipaguirre.be

# ITM & I 37


Antwerp Urban Trail

23 Apr

ITM-CeMIS Migration and Health Seminar

28 Apr

Antwerp 10 Miles

9-10 Oct Connecting the dots 60th ITM Colloquium 22 Nov

Flemish Science Day

YOUR THOUGHTS COUNT! If you have questions, remarks or suggestions or to place orders for paper copies of P³, please contact communicatie@itg.be


Read P3 online at www.itg.be/magazine


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