Sharing knowhow and joining forces towards Health for All
Contribution to the Annual Report 2013 of the MMI Network

We called her Chantal...

We called her Chantal...

We called her Chantal – her parents had not thought of a name yet, as they weren’t sure she would make it. In fact her twin brother already died a couple of months ago. Chantal probably was about 2 years old, but her bodyweight was only 5,050 g – not much more than a newborn! And too much of this weight was concentrated in her legs: both presented pitting oedema. We found Chantal in a small village in Burkina Faso near Leo on the border to Ghana. With only 10.4 cm of mid-upper-arm-circumference (MUAC) she was diagnosed with complicated severe acute malnutrition (SAM) and brought to the district hospital. Unable to drink on her own, a feeding tube was placed through her nose in her stomach and treatment started immediately. During the first two days Chantal received a special malnutrition formula feeding every 2 hours – day and night, but nevertheless her weight decreased further…..

The 2012 Sahel food crisis compounded food insecurity and malnutrition in Burkina Faso, one of the poorest countries in the world, ranking 181 out of 187 countries on UNDP's Human Development Index (2011). The most recent emergency food security assessment found 1.7 million people at-risk of food insecurity, and nationwide more than 10% of children under age 5 years showing weight for age more than two standard deviations below the median for the international reference population.  Of those malnourished children, 20% fulfil WHO criteria for severe acute malnutrition.

The situation is further complicated by the fact that some people consider malnutrition a curse or a punishment so the child may be called a snake or a monkey and nobody wants to be in touch with him. But malnutrition is also a sign of poverty, which is considered shameful, so the poor child may be hidden by the family and not brought to a nutrition center – until it is too late.


Emergency project against severe acute malnutrition

By mandate of the national health authorities and in order to strengthen the implementation of their malnutrition programme, the European Community Humanitarian Office called for projects that would tackle this important emergency. Working in Burkina Faso continuously for over 10 years, Medicus Mundi Italia (MMI) was in a position to offer help and together with Lay Volunteers International Association  (LVIA) designed a pilot project. In May 2012 we started in two districts in the North-Western region and since March 2013 the project was extended to cover the whole region (5 districts totalling 21,700 km2 ) with a population of 1,415,000 people. Five Doctors, 12 nutritionists one nurse from MMI and LVIA supported by logistic staff, care for a population of 245,000 children aged 6-59 months of whom 13,400 are estimated to suffer from SAM every year. We expect to find 90% of those patients by three screening campaigns and aim to treat at least 80% of those identified. Our 1-year goals are:

  • Strengthening of the local health system in the management of SAM and reducing SAM-related stigma, by supporting the regional hospital and the five district hospitals with logistics, equipment and staff.
  • Equipment and training for almost 2000 community health agents or nurses – based in 170 health posts throughout the region -  in the detection (by MUAC measurement) and treatment of malnutrition
  • Organization and implementation of three region-wide door-by-door MUAC screening campaigns (to identify all the children that never went to a community health centre) with the help of the trained health work force.
  • Free procurement of ready to use therapeutic food (donated by UNICEF) for moderately malnourished children and free treatment of those affected by SAM (including transport to the hospital, medical treatment, hospitalization fee, meal for accompanying person)
  • Support for the collection, transmission and analysis of data on malnutrition. The target is a cure rate of >85% for the outpatients and > 75% of the inpatients, with a mortality rate < 10% for inpatients and < 3% for outpatients while no more than 10% should be lost to follow up.

Directly linked is a project for the production of fortified therapeutic food to prevent SAM. In four villages women are trained to produce a MiSoLa-type of supplementary food which is based on locally available ingredients.

 

The results:

As of December 2013 we trained 1700 community health workers and 350 nurses.

  • During the first ten months from March to December 2013 in two rounds 257,748 and 267,526 children were screened respectively, and on the basis of a MUAC < 115 mm 1819 and  1971 children were diagnosed with SAM and referred for treatment. In addition during the first ten months the health centers identified additional 5298 patients suffering from SAM among those visiting the centers for various reasons.
  • The total diagnosed was thus 9,088, and 8,818 (97.0%) of them started treatment. Of the children with SAM, 1,513 (17.1%) had complications (mostly oedema or loss of appetite) severe enough to be treated on an inpatient basis. (In a third campaign in January 2014 among 273,476 children screened, 1662 were identified as suffering from SAM; data on outcome not available yet).
  • Cure rate (defined as achieving 85% of the target weight) was 85.7% for the outpatients and 92.6% for inpatients while unfortunately 43 outpatients and 56 inpatients died (death rate 0.7% and 6.3%).
  • Drop out rate (missing three consecutive appointments for outpatients – while being actively searched ) was 13.7 and 1.1% respectively.
  • Children with moderate malnutrition (defined by MUAC <125 and ≥115mm) were supplied with a lipid-based ready-to-use food supplement. 20 tons of this fortified flour were produced by the four production sites created by the project.

 

Conclusions

Door by door malnutrition screening through MUAC by trained health care workers is very efficient in identifying children with SAM, allowing to discover also patients that would not show up at a Health Care Center by their own.  Furthermore, despite cultural obstacles, almost all parents of the patients identified, accepted treatment. Last but not least, treatment proved effective as shown by a extremely low mortality rate.  We hope that the MUAC-screening is now implemented as a health post- routine. However, hygiene, clean water, logistics and culture remain obstacles for a durable malnutrition management. It is questionable how in-hospital care for malnourished children will continue once families will be asked to pay for all the related costs.All together our results show that with strong input much can be done to fight malnutrition even in the poorest and most hit regions of sub-Saharan Africa.

...and Chantal? Yes, after the first critical days her weight gradually increased, she started to drink and improved slowly but steadily. Oedema disappeared and after 17 days she went home – walking her first steps ever!

A contribution by G. Cattaneo, V. Pietra and R.F. Schumacher for the ECHO-LVIA-MMI (European Community Humanitarian Office, Lay Volunteers International Association, Medicus Mundi Italia) project team and S. Barro, M. Kagone and R. Kargougou for the team of the Direction Régional Santé du Centre-Ouest du Burkina Faso. Special thanks to all the community health workers and the personnel of the Community Health Centers and District Hospitals of Koudougou, Leo, Nanoro, Reo and Sapouy in the Central-Western Region of Burkina Faso.

Contribution to the Annual Report 2013 of the MMI Network
More information: www.medicusmundi.it

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