MSF Paediatric Days

PAEDIATRIC VACCINATION: ANYTHING BUT CHILD’S PLAY

Marja.Hyvarinen — Fri, 19 Apr 2024 17:06:43 +0000

PAEDIATRIC VACCINATION: ANYTHING BUT CHILD’S PLAY

Marja.Hyvarinen Fri, 04/19/2024 - 19:06

Photo: MSF medical staff, Corinne Peters and Stefanos Tsallas holding signs advocating for broader use of the pneumonia vaccine at a lower price. © MSF/Sophia Apostolia.

It is unsurprising that the adage ‘prevention is better than cure’ has become a tenet of modern healthcare. Vaccines are arguably the most cost-effective preventative healthcare tools. They are weakened, inactive, deconstructed or mimicked forms of diseases that are introduced to the body to trigger an immune response thus producing antibodies. Subsequently, the body can easily fight off future attacks from the actual disease. Simply put, vaccines are the immune system’s training wheels.

The first of its kind, the smallpox vaccine was a herculean evolution in the global health landscape. By 1980 we had completely eradicated a virus that had killed more than 300 million people in the span of a single century. Today, 25 diseases are classed as vaccine preventable. Diseases such as polio and measles, that would be otherwise devastating to children’s health, are well on their way to worldwide elimination.

Vaccines have saved more lives than any other medical invention. They are the most successful form of public health intervention. “Vaccination not only reduces morbidity and mortality rates amongst populations, but it is also one of the most cost-effective public health measures that exists,” states Catherine Bachy, a Vaccine-preventable-diseases referent with MSF, “By investing in one cheap vaccine, we can avoid a lot of extra costs from having to treat a sick child or even losing her.”

Moreover, many vaccines provide an easy path to herd immunity. This refers to the protection from infection that a community obtains when a large subset of its population is immune to a disease. Consequently, the spread of the disease becomes unlikely, thus greatly minimizing disease emergence, recurrence and persistence as well as protecting those who may be unable to get vaccinated due to various health conditions.

An estimated 4 million deaths are prevented by childhood vaccination each year. Inversely, approximately 29% of deaths among children between the age of 1 and 5 were due to vaccine preventable diseases. In spite of this, millions of children still do not obtain this life-saving intervention, owing to the multiple barriers that hinder vaccine-uptake. These barriers can range from individual obstacles such as uncertainty about the safety and effectiveness of vaccines, to systemic obstacles such as age restrictions on catch-up vaccinations. Catherine Bachy boils the solution down to a single approach – access.

“Community engagement is vital to directing MSF’s approach to access. A community’s acceptance can make or break health interventions. If well executed, it encourages patient awareness, fosters trust and ultimately increases vaccine uptake,” says Catherine Bachy, “It starts with identifying patient needs and understanding what is acceptable to them. Following this, you have to adopt an approach that is suited to their needs and lifestyle such as conducting vaccination exercises in easily accessible areas and at a favourable time,” she explains.

Photo: Routine vaccination campaign for nomadic communities in N'Djamena. View of a contact meeting between MSF and the leaders of the nomadic camps. © MSF/Johnny Vianney Bissakonou

The MSF Access Campaign was founded on the principle of eliminating barriers to healthcare. For 25 years the campaign has been advocating for quality vaccines, diagnostics and medicines that are: consistently available, affordable, suited to patients’ needs, and adapted to the places they live in.

Victorine De Milliano, Vaccine Policy Advisor for the MSF Access Campaign, is especially troubled by the inadequate policies on catch-up vaccinations for individuals who are missing some or all doses of vaccines listed in their national immunisation programmes.

“Current national and global policies make it difficult to catch-up on vaccinations. For example, the support provided by Gavi, the vaccine alliance, which is the main procurement body for vaccines for many of the countries where MSF works, generally does not span beyond the age of 1, although they have recently announced a temporary age increase until the age of 5,” she explains. As such, she strongly advocates for the institution of permanent policy changes within Gavi and national bodies to ensure all children are reached in a sustainable manner.

Catherine Bachy believes that creating a culture of immunisation will aid in initial and catch-up vaccination efforts. “We should incorporate vaccination into every health activity. This comes down to checking the eligibility for vaccination of anybody that comes into a health structure thus determining whether they require catch up vaccines and administering them if they do.”

Conflict, poverty, and institutional deficiencies are present in many humanitarian settings. These, according to Catherine Bachy, often discourage health-seeking behaviours. Moreover, they often create a vicious cocktail that culminates in incredibly fragile health systems. Communities dependent on inadequate health systems are more likely to experience the adverse and long-term consequences of low immunization coverage. As a result, many rely on external bodies like MSF for vaccine compliance.

“There are many children who miss out on their basic childhood vaccination, especially in humanitarian settings, simply because the government cannot or will not reach these areas,” Victorine De Milliano explains, “More must be done to ensure these children are reached, including allowing humanitarian organizations the freedom to operate as well as allowing for agile and tailored approaches, partnerships and rapid and unhindered access to vaccines in fast changing environments.”

The suppression and eventual eradication of diseases hinges on the utilisation of proactive and reactive measures. Reactive vaccination strategies are a vital outbreak response tool that have been used to curb highly virulent diseases such as measles and cholera. However, they can easily overshadow routine programmes.

MSF vaccine advisor, Primitive Gakima explains that one of the reasons childhood vaccinations are not accessed earlier in emergency situations is because the focus is on reactive vaccinations which solve seemingly more urgent issues. “Routine immunization is not prioritized. Instead, more attention is given to campaigns which are reactive and Supplementary Immunization Activities.”

“We need to uphold routine childhood vaccination as a part of primary healthcare. This includes training health personnel to seize every opportunity presented to them including when conducting reactive campaigns,” she adds.

Photo: A child receives a measles vaccination in Cecca 16 health center Wamba in the Democratic Republic of Congo © MSF / Juliette Muller

2021 saw the lowest level of immunisation against DTP 3 (Diphtheria-Tetanus-Pertussis) since 2008 at 81 percent global coverage. This was concerning as the regimen is used as an indicator to assess how well countries are doing in the provision of routine childhood vaccinations.

This lack of proper immunisation coverage has furthered the spread of vaccine-preventable diseases. Measles outbreaks have become more frequent. In 2022 alone, 136,000 people (mostly among children) died from the disease. Low-income countries continue to bear the brunt of limited coverage. A united and concerted effort by local, regional, and global health partners is needed to prevent, monitor, detect and respond to outbreaks of vaccine preventable diseases.

“We really need all hands on deck to ensure all these children are reached. And not just the children of today but also the children of tomorrow, and all the days after this. This means real changes in the way we are approaching vaccination in humanitarian settings.  Every child must have access to vaccines and immunization must be based on needs.” Victorine De Milliano concludes.

The 2024 edition of the Paediatric Days conference will be held on 3rd and 4th May in Nairobi, Kenya. Experts from WHO, GAVI, UNICEF, MSF, including Catherine Bachy and Victorine De Milliano, will discuss how to maximise catch-up vaccination opportunities in the post-COVID 19 era. The session will highlight the recent increases in epidemics of vaccine-preventable diseases, while analysing potential new vaccination strategies in humanitarian settings. Register here to join the discussion.

The diseases the world forgot about

Marja.Hyvarinen — Tue, 06 Dec 2022 11:18:26 +0000

The diseases the world forgot about

They are called neglected diseases. A list of 20 conditions that each year affect millions of people. What these diseases have in common is that they hit the poorest populations the hardest - and that not enough is done to address them.

Photo: A year and a half old, Wijdan, is hospitalised in Ad Dahi hospital due to high fever. MSF responds to treat patients with tropical neglected diseases such as malaria and dengue in the area.
©MSF/Majd Aljunaid, Yemen

Marja.Hyvarinen Tue, 12/06/2022 - 12:18

Leishmaniasis, sleeping sickness, bilharzia. Do these names ring a bell? They all have something in common, as three of the 20 conditions defined as neglected tropical diseases by the World Health Organization (WHO).

These diseases are mainly prevalent in tropical and subtropical areas in some 150 countries. While rare in Sweden, they have a devastating impact around the world. More than 1.7 billion people fall ill with a neglected tropical disease each year, and of these, hundreds of thousands of people die. Many of those who survive are physically and mentally scarred for life.

“Most often, these illnesses affect the poorest people,” says Dr Gabriel Alcoba, a specialist in tropical medicine and child health with Médecins Sans Frontières/Doctors Without Borders (MSF). “Those who are already sick or live in very remote areas where the road to healthcare can be long and fraught with danger.”

Dr Alcoba leads the MSF working group on neglected tropical diseases. He has extensive experience caring for patients with the diagnoses on the WHO list, particularly those affected by parasitic disease kala azar (visceral leishmaniasis) or snakebite envenoming.

“We call them neglected because [their prevalence]is underestimated, there are no effective or easy-to-use diagnostic methods and the drugs are often old and expensive, and have severe side effects,” he says. “There is little risk of these diseases being passed on to high-income countries and causing a global outbreak. Therefore, not enough research has been directed at them.”

Photo: A 13 year old patient is treated for a snakebite at Paoua Hospital, northwestern Central
African Republic, supported by MSF.
©Alexis Huguet, Central African Republic

Do not have to search for them

But these diseases affect many of the patients who MSF works with, especially those living in areas that are remote or underserved in terms of health services.

“We work with all the diseases on the list, from the most common to the rarest,” says Dr Alcoba “We don't have to look for them.”

Dr Alcoba stresses that neglected tropical diseases cause great harm from a public health perspective, not least if you look at disability-adjusted life years (DALYs). Several of the diseases can, in the most severe cases, leave patients with deformed limbs, and treatment for these diseases may involve an amputation or other surgical interventions.

“Most patients treated by MSF for neglected tropical diseases are children, teenagers, and young adults. The psychological strain of these conditions is also great; nightmares are common among young patients, and many don't want to go to school for fear of being teased.”

In some countries, tropical illnesses are a substantial burden of disease.

“Along the border between Sudan and Ethiopia, kala azar is one of the common causes of persistent fever, leading to almost as many deaths as tuberculosis and malaria," says Dr Alcoba.

Photo: A six-year-old noma patient from Borno state sits inside the female
ward in the noma hospital with her mother and siblings.
© IDENIZ/Claire Jeantet & Fabrice Caterini, Nigeria

Almost no vaccines available

Medical products to diagnose and treat kala azar, as with many other diseases on the list, are not adequate and can present huge challenges for patients.

“The drugs are toxic and can affect the kidneys and heart. Some of them can even cause deafness," says Dr Alcoba.

There is no vaccine to protect against kala azar. In fact, of the 20 diagnoses on the neglected tropical diseases list, only one – rabies – can currently be vaccinated against, and people still require treatment with antibodies if they are infected. One vaccine has also been licensed for use against dengue.

Like rabies, many neglected tropical diseases are zoonoses, which are diseases transmissible from animals to humans. The infectious agents vary: most of them are parasites, but others are viruses, bacteria, fungi and snake venom.

The environment plays a big role in who is affected by neglected tropical diseases. Perhaps you live in an environment with animals close to you. Or you work barefoot in the fields, which increases your risk of being bitten by a snake or infected insect. Or maybe there is only contaminated water available for you to use for drinking or bathing.

“When I worked in Agok in northern South Sudan, many of our patients were internally displaced people who lived in tents by the river,” says Dr Alcoba. “When Agok was hit by floods many of the displaced people were bitten by venomous snakes, which made their way into the huts or tents at night.”

Photo: MSF medical team during morning rounds in Kala azar-HIV ward in Rajendra
Memorial Research Institute(RMRI) Hospital in Patna, Bihar
©Javeed Shah, India

Outbreak of rabies

Conflict, poverty, and climate change are contributing to the spread of some tropical diseases. After the floods in Pakistan this year, there have been reports of more people being bitten by snakes. Dengue fever has emerged in new areas around the globe, in a context of global warming and increased travel.

“There is currently a rabies outbreak in Yemen,” says Julien Potet, policy advisor on neglected tropical diseases at MSF. “Years of war have seen the vaccination of dogs collapse and MSF is now seeing more and more patients bitten by stray dogs that likely have rabies.”

Potet has worked for 11 years to put pressure on governments and pharmaceutical companies to pay more attention to tropical diseases.

“It can be difficult to live a normal life and have a job if you fall ill,” he says. “In many countries, people with neglected tropical diseases face stigma and social isolation, but also a huge financial toll. MSF’s care is always free, but in many places, patients have to pay for at least part of the treatment.”

Forced to borrow money

This can lead to what researchers call "catastrophic health expenditure", which is a measure of the burden of healthcare expenditure on a household’s available resources.

“Patients are often forced to borrow money or sell animals or property to pay for their treatment,” says Potet. “There have been studies on how snakebite poisoning has caused entire families to fall back into poverty, even in middle-income countries. The diseases can also have a major impact on livestock herds and are therefore a threat to people who rely on animal agriculture.”

As the COVID-19 pandemic swept across the world, many donors withdrew funding for tropical disease response. One example is the UK, which diverted resources towards the domestic COVID-19 response.

“Several projects focused on schistosomiasis and kala azar in East and West Africa were forced to suddenly shut down during COVID-19”, says Dr Alcoba. “With the energy crisis and the troubled global economic situation, health budgets have shrunk, and funding has not returned to pre-pandemic levels.”

Arsenic treatment

Dr Alcoba and Potet agree that more attention needs to be paid to neglected tropical diseases as a matter of urgency.

“It is not that they are unpreventable or untreatable, says Potet. “If sufficient investment is made over a significant period of time, it will pay off. The most striking example is the development of an effective treatment for sleeping sickness by the Drugs for Neglected Diseases initiative (DNDi).”

It was in 2018 that the DNDi, which MSF co-founded at the turn of the millennium, launched an oral treatment for sleeping sickness. Previously, patients with sleeping sickness had to endure painful injections of a medication containing arsenic.

“Sleeping sickness cases have decreased significantly since 2018. So, there's no reason to think this wouldn't be possible for other diseases,” says Potet.

Photo: © MSF/Arlette Blanco, Honduras

The most forgotten

Last year, the WHO launched an ambitious roadmap to reduce illnesses and deaths caused by neglected tropical diseases, with one of the targets being to reduce the number of people needing care for these diseases by 90 percent by 2030.

But there are some diseases that are so neglected that they are not even on the list of forgotten diseases. One of them is noma.

“It's a bacterial infection that starts in the gums and spreads to the cheeks,” says Dr Acoba. “Today, noma mainly affects malnourished children in low-income countries, but the disease existed in both the concentration camps of World War II and in Russian prisons in Siberia. So, it can occur anywhere under the right, or rather wrong, conditions."

Noma affects around 140,000 children every year and patients usually need surgical treatment and psychological support, which MSF provides at a specialised hospital in Sokoto in north-western Nigeria.

“We have seen how stigmatised these patients are, they are shut out of society,” says Dr Alcoba. “If people can access treatment quickly, the damage to the face doesn't have to be severe. We've been working hard to get noma included on the WHO list, bringing in ministers from Nigeria, Burkina Faso, and Switzerland. We are also working with the NoNoma Federation, which is a collection of organisations working on the disease.”

There are indications that noma will be included on the WHO’s list in 2023. Both Dr Alcoba and Potet stress that perhaps the most important role MSF can play is to continue to shine a light on these diseases through sharing our experiences and assisting patients to share theirs, especially in contexts where there is little media attention or few other organisations responding.

“We must continue to put pressure on the WHO, pharmaceutical companies, and other stakeholders,” says Dr Alcoba. “The people affected by these diseases often have no voice in society. They must be able to share their stories. It is both unacceptable and unethical for these diseases to be forgotten."

Fact box: Neglected Tropical Diseases according to WHO

Buruli ulcer: Skin infection caused by a mycobacterium, related to the TB bacterium, that breaks down skin, soft tissue, and bone tissue.
Chagas disease: Life-threatening parasitic infection transmitted by insects called “kissing bugs”, blood transfusions or from mother to child during pregnancy.
Dengue fever: Caused by a virus transmitted by mosquitoes. Symptoms are flu-like and sometimes develop into a severe form with a high mortality rate.
Dracunculiasis (guinea worm): Spread by small crayfish living in fresh water. Leads to intense itching, vomiting, fever, diarrhoea, and dizziness.
Echinococcus infection: Caused by tapeworms, which take hold in the liver or lungs where they form cysts containing larvae.
Human African trypanosomiasis (sleeping sickness): Caused by a parasite transmitted by tsetse flies. Affects the central nervous system and if left untreated, sleeping sickness is fatal.
Filariasis (elephantiasis): Caused by roundworms attacking the lymphatic vessels. In the worst cases, skin and tissues can thicken to the point where parts of the body assume extreme proportions.
Foodborne trematodes: Flounder worms transmitted to humans via fish, shellfish or vegetables and can cause severe damage to the liver and lungs.
Leishmaniasis: Parasitic disease transmitted by sand flies. The visceral form, kala azar, affects the internal organs and the immune system, while the cutaneous form affects the skin and causes ulcers and scarring.
Leprosy: Caused by a bacterium similar to the TB bacterium. Spread through the air and can lead to deforming skin lesions.
Mycetoma: Caused by fungi. The disease usually affects the feet, hands, and legs, resulting in swollen tissue.
Snakebite envenoming: Bites from venomous snakes require the right antidote in time, otherwise they can lead to death or require amputation.
Onchocerciasis (river blindness): Caused by roundworms that create lumps under the skin, usually around the shoulders and hips.
Rabies: Caused by lyssavirus secreted in the saliva of sick animals. Humans usually contract rabies from dogs and the disease is almost always fatal once symptoms appear.
Schistosomiasis (bilharzia): Caused by intestinal worms whose larvae invade the skin and mucous membranes, which can affect the internal organs.
Scabies: Caused by a skin parasite that makes holes in the outer layers of the skin and lays its eggs there. Causes severe itching.
Soil borne helminths: Intestinal worms spread by soil infected by human faeces. Leads mainly to diarrhoea and weight loss.
Taeniasis and cysticercosis: Caused by the swine tapeworm Taenia. Taeniasis is a mild intestinal infection while cysticercosis can lead to severe neurological symptoms.
Trachoma: Infection of the conjunctiva of the eye caused by the bacterium Chlamydia trachomatis. The most common infectious cause of blindness in the world.
Yaws: Infects skin, bones and joints and is caused by the bacterium Treponema pallidum pertenue.

This article was originally published in Swedish "Sjukdomarna som (den rika) världen glömde" on MSF Sweden/Läkare Utan Gränser website.

Text Sanna Gustafsson.

Prevention is better than cure

Marja.Hyvarinen — Mon, 28 Nov 2022 12:26:46 +0000

Prevention is better than cure

Malaria is one of the leading cause of child mortality in sub-Saharan Africa with mortality numbers increasing in the past few years. Seasonal or year-round, MSF is fighting the disease with a focus on enhancing prevention methods.

Photo: Eliza Lupenza, MSF’s entomologist in Nduta camp and her colleague Fulgence Irakoze, vector control supervisor, test a mosquito trap to make sure it is functioning before installing them in people’s houses in different zones of the camp the next day.
© MSF/Cynthia D'Cruz, Tanzania

Marja.Hyvarinen Mon, 11/28/2022 - 13:26

Malaria, a disease spread by plasmodium parasite carrying mosquitoes, causes an often-severe infection to the body. The symptoms caused by malaria, include fever, inflammation, and breathing difficulties. It can affect any part of the body, from the brain to the liver or lead to coma or death if left untreated.

“We can see malaria across all ages in most populations where MSF works. The people who are most at risk for having malaria, especially severe cases of malaria, are children” says Kemi Ogundipe, MSF Paediatric Advisor and member of MSF's international Paediatric Working Group.

Kemi Ogundipe has worked in MSF projects all over the world and has seen firsthand the effect malaria has on populations, especially children.

The severity of malaria rises the younger the patient is, studies show that 77% (2021) of all malaria mortalities were children under five. The symptoms are usually more pronounced in children under five and more severe, often fatal, in children under two. Malaria often causes side effects, some that outlast the infection.

“Typically, there are other things that come along. For younger children, malaria can cause anemia and they will need blood transfusions. When malaria is not fatal, patients can have a hard time recovering fully and may experience some lingering problems, such as seizures, learning difficulties and delays in overall development”.

Every year malaria is the number one cause of fatalities in children under five years old in sub-Saharan Africa. There are effective medications, but the patients and their families might not always have access to them or do not seek treatment until it is too late.

Liliana Palacios, nurse and health advisor in MSF operations department continues:

“One of the challenges to assure early detection and opportune treatment is the access to services, as most of the time they are centralised and families might have difficulties accessing them, because of economic reasons or because the treatment is simply too far to reach”.

Photo: Hadi is three years old. Here he undertakes a blood test at MSF's mobile clinic for malaria in Al Shantefah, north Yemen. During malaria season, MSF runs mobile clinics specifically for malaria on a weekly basis. Often people in the rural areas of north Yemen can't afford the cost of transportation to the closest hospital, which may be two hours away.
Ehab Zawati/MSF, Yemen

This is one of the key reasons why both Kemi Ogundipe and Liliana Palacios feel strongly about developing effective and widespread malaria prevention tactics and medications.

“We have made some amazing strides in what we can do to treat the patients who have been infected by malaria. The medication is effective, and we are now able to support the patients better when they are sick. But if we were able to prevent malaria from even occurring, we would take a huge burden off the patient and off the community at large”, says Kemi Ogundipe.

Kemi Ogundipe highlights that there are already some prevention mechanisms that have been proven to work extremely well. For example, in the last 20 years, Sri Lanka has been able to eradicate malaria completely. “We have chemoprophylaxis for areas where malaria only occurs for a few months of the year. It prevents children being infected during the risk period with up to 74% efficiency. We also have bed nets, water treatments and sprays... Imagine if you combined all these things, you would avoid malaria occurring in a lot of populations”.

The science on effective malaria prevention tools is continuously developing, still much more conversation, innovation and investment are needed.

“For example, we can see that there is real lack of more effective preventive measures in place – possession and correct use of mosquito nets, for instance, is not always present or promoted efficiently,” says Liliana Palacios. “If we could work in anticipating, facilitating or promoting the early consultation and the application of complementary measures of vector control we could contribute to reduce the number of patients or deaths related to the disease.”

Photo: MSF teams are conducting different vector control activities to reduce the spread of malaria in Nduta refugee camp and in neighbouring villages. In this photo, MSF teams are carrying out larviciding, which involves spraying a non-toxic chemical called Bactivec, to kill mosquito larvae in swamps and stagnant water.
© MSF/Cynthia D'Cruz, Tanzania

Kemi Ogundipe adds: “There is still a lot unknown in terms of prevention and we are limiting our impact, if we only focus on receiving and treating a child or an adult that is sick from malaria. The investment and the conversation should be on prevention if the goal is to avoid children dying of malaria”.

Today we can see that malaria infection numbers are increasing globally partly due to climate change. The disease is now appearing in areas where it has not been met before, as the changing climate is offering more hospitable places for the malaria parasite to live.

Added risks appear also in combination with other diseases as malaria tends to be more fatal when combined with other illnesses. Kemi Ogundipe says that humanitarian medical community was anticipating COVID-19 pandemic to make malaria even more serious of a problem. Luckily, that did not happen in many of the countries where malaria prevention program had been completed.

Kemi Ogundipe: “This shows that if we could avoid malaria completely and put more focus on prevention, we would be more prepared and capable fighting diseases like COVID-19”.

Malaria: Prevention is better than cure will be one of the main sessions during the MSF Paediatric Days 2022.

The MSF Paediatric Days team thanks Kemi Ogundipe and Liliana Palacios for their contribution to this article.

Fatal first days

Marja.Hyvarinen — Mon, 31 Oct 2022 17:01:59 +0000

Fatal first days Marja.Hyvarinen Mon, 10/31/2022 - 18:01

Photo: © MSF / Seydou Camara, 2017

Which are the riskiest days in life? Half of the deaths among children under the age of five occur in the first 28 days after birth. In many places where MSF works, high-tech solutions for the care of newborns are lacking, but a lot can be achieved with relatively simple efforts.

"Nasreen sits on the edge of the bed and holds the small chin and the mask with one hand, the manual resuscitator with the other and stares at the chest. It is day three of the boy's life, and he has fought like a lion to survive, having been born 8-10 weeks early, weighing only 1.6Kgs. Nasreen has been helping him breathe for more than six hours. The hope that the boy will be able to continue breathing on his own is small, but alive. She continues a little, a little while longer.”

This is an excerpt of paediatrician Sanna Sjöberg’s blog post on MSF's website. She and her colleague Nasreen know all too well the challenges that the little boy and other children born prematurely face in Afghanistan, where neonatal mortality is one of the highest in the world.

Half of the patients

In the small town of Khost, located in the eastern part of the country right on the border with Pakistan, MSF runs a large maternal and newborn health hospital.

“When women do not have the opportunity to seek medical care during pregnancy or childbirth, they are at risk of serious conditions with no possibility for diagnosis or treatment. This in turn increases the risk of the babies of these women being born prematurely or with complications,” says Paediatric Advisor Kemi Ogundipe.

She is part of the MSF International Paediatric Working Group, which was created in 2008.

“In most countries where we work, children make up more than half of the patients we see and we have realized that we need to take a focused approach to the paediatric healthcare we provide,” says Kemi Ogundipe.

Midwives are important

Over the past 50 years, the under-five mortality rate has fallen significantly on a global scale. This development can be explained mainly by the improved availability of vaccinations against diseases such as diphtheria, tetanus, whooping cough, measles, rubella, and mumps.

It is also because the methods for preventing and treating malaria have improved, access to clean water has increased and more children receive treatment against dehydration and malnutrition.

“Unfortunately, the death toll among the very smallest has not decreased to the same extent. Newborns account for almost half of all deaths among children under the age of five,” says Kemi Ogundipe.

The main reasons why babies fall sick, or die, are complications resulting from premature births or asphyxia, which means that the baby suffers from a lack of oxygen and insufficient blood circulation. In case of asphyxia, the delivery must be quick and is often managed with forceps, vacuum-assisted delivery or caesarean section.

Kemi Ogundipe emphasises the importance of women receiving regular health checks during pregnancy so that risk factors can be detected early, and problems prevented, something that does not always happen in humanitarian or low resource settings. Well-trained health workers are crucial in the management of premature births and asphyxia. A large part of what the Paediatric working group does is therefore about education.

Premature or sick babies often need help breathing, getting nutrients, and staying warm. In many of the places where MSF works, access to high-tech medical care as in high income countries is not available.

But even if technology is important, much can be done with basic techniques. This is underlined by Mats Blennow, chief physician specialised in neonatology, who has worked for MSF in Jordan and Nigeria.

Photo: A mother keeps her baby on her chest, with the 'kangaroo' method in Castor Maternity, Bangui.

© MSF/ Marco Scardovi, 2020

Healthy skin contact

“Skin-to-skin contact with the mother is crucial for the health of the newborn, as it helps regulate the baby’s temperature and heart rate, helps promote breastfeeding and milk production and helps the baby to stay calm and decrease stress. In Sweden, over the past 30 years we have increasingly invested in family-centred care, assuring that mothers, fathers, caretakers and babies can be together, in the same room, 24/7. In the past, mother and baby were separated and there could be six to seven babies in the same room.

Similarly, it is possible to implement simple strategies in the places where MSF works, where skin to skin has become an important part of care for newborns through kangaroo mother care (KMC). KMC uses locally acquired materials to create a wrap that can safely and securely allow babies to have continuous skin-to-skin contact with their mother, father, or another primary caregiver for over 20 hours every day. This stabilises the baby's breathing and heart rhythm and makes them less susceptible to infection. The method is specifically indicated for low birthweight babies, the World Health Organization (WHO) recommends this for all children below 2 kilograms.

“A large research study was recently released in which KMC was used with premature babies in Ghana, India, Malawi, Nigeria, and Tanzania. The study showed that the newborns had a higher rate of survival,” says Mats Blennow.

Particularly susceptible to infection

The design of the wards for newborns is also important to reduce the risk of transmission of infections, Kemi Ogundipe points out.

“Newborns are extra vulnerable to bacterial infections in the blood, brain, and skin due to their immature immune system. Premature babies are also particularly sensitive to infections in the gut. Babies need to be kept in a closed environment where they are in contact with as few people as possible.

“It is also important to make sure that the wards are cleaned properly, that the staff maintains good hygiene and that there is proper access to clean water.” The importance of these efforts became particularly clear to MSF five years ago when a neonatal unit in Bangui, the capital of Central African Republic, suffered a severe outbreak of sepsis and antibiotic resistant Klebsiella pneumoniae was identified.

“After the outbreak, we introduced warning systems where babies with fever are closely monitored to detect cases of resistant bacteria. We have also ensured that there is more space to isolate patients, that the beds are not put too close together to avoid the spread of infections. All mothers are also given continuous access to clean water to wash their hands and given clean gowns to place over their clothes,” says Kemi Ogundipe.

In recent years, some more advanced care solutions for newborns have become available in low resource settings. One example is Continuous Positive Airway Pressure (CPAP), a non-invasive treatment that uses air pressure to maintain an open airway, decreasing the risk of apnea and maintaining appropriate oxygen levels in their blood. For two years, CPAP has been used, at the MSF hospital in Khost.

“But the machines themselves are not the whole solution. What is often lacking in low resource settings are the resources. There must be enough staff to care for the patient and they must know how to use the equipment in a safe manner,” says Mats Blennow.

“Otherwise, you risk worsening the situation, or solving a problem only to create a new one. There are many home-made versions of machines that rather impair the baby's breathing ability, and if too high a concentration of oxygen, is given in the inhaled air, this can make babies blind.”

“Since there has not been enough research dedicated to the care of newborns in humanitarian crises, I can rarely use what is presented at other conferences that I participate in as a paediatrician. Many of the medical practices are still adapted to the settings in high resource countries”

Photo: A doctor is examining 26 days-old, who is suffering from respiratory distress in Khamer hospital, Amran governorate, Yemen.

© MSF / Agnes Varraine-Leca, 2019

Mortality has gone down

Kemi Ogundipe spends a large part of her working time in hospitals and clinics around the world teaching, how to use CPAP or how to calculate the right quantity of fluid and nutrition to newborns so that they don't get too much at once – which can be very dangerous.

She is happy that the investments made by MSF in the care of newborns have yielded results. Encouraging results, indeed.

“In many of our newborn wards, the mortality rate was around 20 percent a few years ago. Last year, it had dropped to seven percent,” she says.

More research is needed

She and the others in the working group are also involved in the Paediatric Days conference organised by MSF. There, the organisation's employees and other actors gather to present new research and find new ways to collaborate around children's healthcare in humanitarian crises.

“Since there has not been enough research dedicated to the care of newborns in humanitarian crises, I can rarely use what is presented at other conferences that I participate in as a paediatrician. Many of the medical practices are still adapted to the settings in high resource countries,” says Kemi Ogundipe.

Mats Blennow and Kemi Ogundipe agree that it will take more effort to ensure that newborns everywhere in the world have a better chance of survival.

“Being a newborn is not an illness. If babies are kept warm, nourished, and protected from infections, they often become healthy people and then you have made enormous gains in the form of expected life years,” says Mats Blennow.

This article was originally published in Direkt magazine 1/2022. Text Sanna Gustafsson.

The MSF Paediatric Days are held on November 29-30 and December 1, 2022. Under the umbrella of family-centred care, the main session on 29th November will focus on newborn care. The session will introduce the concept of zero mother-baby separation and explore to what extent this concept is applied in MSF, the main barriers and challenges, and how can we overcome these by adapting the concept to fit the reality of MSF projects. 

Nurses important in the fight against antibiotic resistance

Elise D — Thu, 16 Sep 2021 14:02:00 +0000

Nurses important in the fight against antibiotic resistance Elise D Thu, 09/16/2021 - 16:02

Every year, 200.000 children die from sepsis caused by resistant bacteria. It is a serious threat to global public health. Nurses are often the first to identify signs of Sepsis and potential outbreaks, writes paediatric nurse Lindsay Bryson in this opinion piece published in Swedish magazine Vårdfokus.

Photo: Paediatric nurse Lindsay Bryson has worked in Thad for MSF.
© Photo by Médecins Sans Frontières.

“I have worked as a nurse for 23 years, predominantly in humanitarian contexts, in countries such as Ethiopia, Haiti and the Central African Republic. For me, it is the perfect professional role - I get the opportunity to develop on a daily basis, both in terms of my medical knowledge and in treating patients in the best way. When I started working for Médecins Sans Frontières (MSF) in 2003, my biggest interest was to understand a new scope of public health and emergency care within a humanitarian context. Over the years, I have worked as a nurse, a Project Medical Referent (PMR) and Medical Coordinator and I have been challenged in ways I never expected.

People are often unaware that nurses make up the majority of heath care professionals globally. Nurses play an important role in ensuring the quality of care in humanitarian programs in contexts facing armed conflicts, natural disasters, or nutritional crises. Nurses ensure that there are functioning clinics in remote, difficult to access settings, nurses coordinate mass vaccination campaigns, nurses engage with communities to understand their needs, nurses work with health promotion and nurses develop guidelines to support the implementation of nursing care.

In humanitarian crises, children are almost always the hardest hit, and they make up 60 percent of MSF patients worldwide. Children are by nature vulnerable and are often the first victims when there is a shortage of food and/or water. Young children can lose weight quickly and malnutrition is much more dangerous for them than for adults. Therefore, quick access to care is extremely important. MSF started the Paediatric Days in 2015, as an opportunity for our staff and other global health actors to present research and learn about new ways to improve paediatric care in humanitarian contexts.

MSF’s Sweden Innovation Unit based in Stockholm, where I currently work, has organized a Hack-a-thon aligned with Paediatric Days in 2019, where we gathered experts to find new - and sometimes unexpected - solutions to the challenges we face in our projects around the world.

This year, one of the main topics presented at Paediatric Days was antibiotic resistance (ABR) in children. Resistant bacteria are a serious threat to global public health. Estimates show that over 200,000 newborn children die each year from sepsis causes by resistant bacteria. When it is no longer possible to use the first choice of antibiotics, more expensive alternatives must be used. This often leads to longer treatments and hospital stays, which in turn leads to an increased risk of the patient suffering from hospital acquired infections.

Frontline healthcare professionals around the world must be trained in responding to outbreaks of resistant bacteria, but also in how antibiotic resistance can be prevented and managed. Nurses play a crucial role in the fight against antibiotic resistance. In many countries where MSF works this is about ensuring the correct prescription, preparation, and delivery of antibiotics and ensuring that appropriate infection control measures are in place. Nurses are often the first to see signs of outbreaks of resistant bacteria in a ward. Nurses also ensure proper hand hygiene and proper working methods in the care of patients. They ensure that surfaces are cleaned and disinfected and that proper precautions are taken to reduce the spread of resistant bacteria.

Our strength lies in our work as a team, where nurses, doctors, microbiologists, pharmacists, epidemiologists, water and sanitation experts and logisticians work together to meet the systematic challenges of ABR in MSF settings. I have learned a lot during my 23 years as a nurse – and a lot has changed. The important role of the nurse is receiving increasing attention. More and more often, I see nurses in leadership roles, who push for improved care that puts the patient at the centre. I am glad to see this, and I feel hopeful about nurses’ opportunities to tackle current and future global health challenges.”

Lindsay Bryson, paediatric nurse, and medical advisor at MSF’s Sweden Innovation Unit.

This article was originally published as an opinion piece in Vårdfokus on the 30th of June 2021.

Children are not the face of covid-19 but will certainly not be spared

MarinaBP — Tue, 08 Jun 2021 14:27:28 +0000

Children are not the face of covid-19 but will certainly not be spared

Photo: COVID-19 health promotion activity with children in a school in Al-Ramadin, a Palestinian village located southwest of Hebron (West Bank)

© MSF, 2020

Children have been more severely affected by the indirect impact of the pandemic than by the virus infection itself.  The COVID-19 pandemic has impacted child health through increases in poverty, loss of education, food insecurity, violence as well as increased strain on health systems and reduction in access to health services. These collateral effects of the pandemic have stricken most in resources limited settings where increase in child mortality is a major concern. There is a risk that these collateral effects will be further exacerbated when hundreds of millions of COVID-19 vaccine doses will be rolled out in the latter part of this year in low-income countries. The amount of healthcare workers needed to deliver those vaccines may push away services that we already see are damaged and children will be paying the price for this.

Liliana Palacios, who answers our questions, is a nurse with a master's in Public Health and Structures Management. She currently works as a Health Advisor for MSF Spain, giving support to projects in RDC, RCA and Cameroon. She is also part of the team that developed the “Collateral damage of COVID-19 on child health" session for the MSF Paediatric Days 2021. Liliana reflects on the outcomes of the session and considers the Paediatric Days conference an open space to share and learn.

MarinaBP Tue, 06/08/2021 - 16:27

Can you explain what the objective of the “Collateral damage of COVID-19 on child health" session was?

The session focused on highlighting the impact of the collateral effects of the pandemic on child health and mortality in MSF settings. We wanted to share experiences on how the teams providing paediatric services faced the situation and overcame (or not) the challenges. For that, we carried out a survey among MSF field staff and recorded video testimonies. We were also interested in hearing experiences and stories on this matter, so we invited experts from other organizations and from MSF to participate in the session.

Which child services and programs have been more severely affected by the COVID-19 pandemic?

From the beginning of the pandemic, we clearly saw that vaccination and nutrition programs were heavily impacted. At the same time, other basic non-medical services for children have also been affected: access to education, protection against domestic violence, etc.

The health staff also had to be relocated to meet the needs arising from the pandemic. In this type of humanitarian context there is already a limited medical staff, hence by diverting part of the human resources to cover the response to COVID-19, the risk of not meeting basic needs in paediatric programs increased.

The pandemic also impacted the “physical spaces” of other areas such as paediatrics as the increase in demand for beds and isolation units to treat COVID-19 have been prioritized.

Photo: An MSF staff member vaccinates a child during a mobile clinic at the health centre in Sebeya, a town close to the Eritrean border in the northern Ethiopian region of Tigray.

© Igor Barbero/MSF, 2021

What are the main recommendations outlined during this session to prevent child morbidity and mortality growth?

The first recommendation is simple, we must maintain the preventive and curative paediatric regular services. Part of the human, material and strategic resources that usually exist for these preventive programs have been reduced and we will see the consequences in the near future. For example, we might see some epidemic outbreaks soon because of the children who have not been vaccinated against rubella or measles. By reducing or closing outpatient clinics, the number of diagnoses (for example the diagnosis of severe malaria) may increase in the future.

Secondly, we should develop new approaches and implement practical tools needed in the field (for example: “Family MUAC” (Mid-Upper-Arm Circumference) nutrition programmes, digital learning opportunities, increased community engagement, etc.)

Lastly, we need to further advocate for children's rights in this pandemic. They are not the ones dying of COVID-19 but will certainly be the ones that are most impacted.

Regardless of the negative impact the COVID-19 pandemic has and will have on children, have there actually been any positive externalities in paediatric projects on the field?

Community health care activities, which have become a key part in addressing COVID-19, have reminded us of the efficiency of this system and should continue to be highly implemented and integrated in MSF operational strategies.

This situation reminded us that we need to be flexible and innovative to provide proper technical support to the field.

Photo: MSF team in Anzoátegui (Venezuela) carries out health sessions directly in the communities of vulnerable populations. In the COVID-19 context, team goes door-to-door to carry out malaria screening and treatment, mosquito net donations, de-worming, vaccinations, and prevention and health promotion activities.

© MSF

Can you give a concrete example of good field practice or a successful intervention strategy that was presented during the MSF Paediatric Days? What could we learn from it and could it be implemented in other MSF projects?

The “Family MUAC” project in White Nile (Soudan) has shown good results in other field projects and is a way of ensuring community participation in a more active way. MUAC trains mothers and other caregivers to identify early signs of malnutrition in their children using colour-coded paper bracelets to measure the mid-upper-arm circumference.

To implement this model in Sudan, we used MSF’s previous experience in Congo in 2019. We started executing it in Congo due to the difficulties the population faces to access local health services (because of long geographical distances and violent conflicts). The goal was to enable early detection of malnutrition and reduce admissions of severe malnutrition. It should be noted that the “Family MUAC strategy” is not an invention of MSF: other humanitarian organizations such as ALIMA, UNICEF or Action Against Hunger also have similar programs.

With the COVID-19 current situation, this kind of project works very well. It helps reducing the contact between the health staff with the patients. By moving this task to mothers (or other family members), the cases are detected earlier, leading to less hospitalizations; and families are empowered to manage their children's health. I do think it shows very well how our field programs can be adjusted to keep assuring the main outputs in those places where services for children are very relevant.

Photo: Once community volunteers have been trained, they go door-to-door to meet the mothers individually and hold awareness-raising and training sessions on how to use the MUAC (Mid-Upper Arm Circumference) tape. They also give nutritional guidance. A grandmother in Niger looking at the MUAC tape a community volunteer just gave her.

© MSF

As a medical professional, why do you feel it is important to participate in conferences such as the MSF Paediatric Days?

Because it is an opportunity to share experiences, learn and debate with other people, which in turn will helps us improve our activities. Listening to other colleagues inspires me and helps me improve my work. The online format has broken down many barriers and connectivity has made it possible to have a wider audience.

The Paediatric Days team thanks Liliana Palacios for her contribution to this article.

BACK TO BASICS: DELIVERING ESSENTIAL CARE FOR THE HEALTHY DEVELOPMENT OF NEWBORNS

MarinaBP — Tue, 13 Apr 2021 16:04:13 +0000

BACK TO BASICS: DELIVERING ESSENTIAL CARE FOR THE HEALTHY DEVELOPMENT OF NEWBORNS

MarinaBP Tue, 04/13/2021 - 18:04

Melissa Hozjan is a paediatric and neonatal nurse who joined MSF in 2011. After working in field assignments, first as a nurse supervisor and later as a medical team leader, since 2018 she is the Paediatric Nursing Advisor of MSF Sydney Medical Unit. Her primary role is to support nurses caring for children from birth in MSF projects.

Photo: Melissa Hozjan during one on her field missions/ MSF

Florencia Romero received her Paediatric training in Buenos Aires (Argentina). Since 2006, she has participated on several MSF field missions located in Liberia, Zimbabwe, Perú or Zambia. Florencia has worked in and with all types of contexts and settings, providing direct care as a Paediatrician: supervision and training of local colleagues or designing, coordinating and managing medical programmes. She is currently in Geneva, where she holds the position of Staff Health Unit Manager.

Photo: Florencia working as a Paediatrician, supporting the Cholera emergency in Lusaka, 2010

Florencia and Melissa are both members of the Paediatric Days Content Committee. They answer some questions about neonatal essential care, which will be the focus of our first session on April 15, 2021.

Can you briefly explain what the essential neonatal care is?

Melissa Hozjan: Essential new-born care aims to minimize the risk of illness and maximize a new-born’s growth and development. It includes providing warmth, evaluating breathing, initiating breastfeeding and preventing infection. This requires the support of trained healthcare staff. Many of the neonates we see hospitalised could have been prevented with the provision of essential neonatal care.

Why is this topic so important for MSF?

Melissa Hozjan: Under 5 mortality is highest in the neonatal period, the first 28 days of life. The care received in the neonatal period has impacts beyond the first month of life. For example, we are seeing high rates of malnutrition in children under 6 months, which are directly related to breastfeeding practices. These children are being cared for in our nutrition programs by healthcare workers who may not have experience or training in supporting breastfeeding.

Some topics like Kangaroo Mother Care (KMC) or breastfeeding were discussed back in the first edition of the MSF Paedriatic Days (Stockholm/2016). Do you see some progress in the field regarding essential neonatal care?

Melissa Hozjan: While there have been improvements globally, we continue to see high rates of neonatal mortality in countries where we work. Where MSF is involved in maternity, we can ensure essential care is provided however this can be complicated by the short stays in the postnatal period, making it challenging to ensure successful breastfeeding is established.

About breastfeeding: What are the main benefits?

Florencia Romero: The short-term and long-term benefits to both mother and baby are well established. Some of the main benefits for the baby: breastfeeding protects the baby against infections, ensures adequate nutrition through the constant adapting of the milk, according to the baby’s growth and needs, it protects and prevents the development of allergies and other chronic conditions, it contributes to the neurodevelopment of the baby and to mother-baby bonding.

According to your experience in the field, can you explain why it’s sometimes difficult or impossible for some mothers to breastfeed?

Melissa Hozjan: There are many factors to consider: the health of the mother, both physical and mental, family, culture and community influence and support, the impact of context and traditional practices, and many factors we may not fully understand however we need to consider and respect each woman’s unique circumstances for her and her baby and adapt our support.

How can the community´s role impact (positively or negatively) the implementation of breastfeeding?

Florencia Romero: Within communities and within families we can always find those who can help women overcome challenges to breastfeeding. Strong female figures within families can also both strongly encourage or discourage women to breastfeed. Religious and community leaders, both female and male, can play very important and supportive roles to the implementation of breastfeeding activities.

What kind of post-natal care MSF provides that helps to develop the mother-baby dyad?

Florencia Romero: Depending on the setting of the MSF project, location and context, post-natal care can be provided in an out-patient clinic or through outreach, community – activities (thorough mobile clinics for example). Post-natal care is offered, within the first week after delivery, to detect early post-delivery complications and to help initiate of breastfeeding. A follow-up visit at 6 weeks after delivery is also planned, to detect late complications post-delivery complications, to ensure initiation/continuation of PMTCT activities (Prevention of Mother To Child Transmission of HIV), to support initiation/continuation of breastfeeding and vaccination of the baby.

Could you share with us a personal experience of successful implementation of essential neonatal care?

Florencia Romero: In Haiti, after the emergency phase following the earthquake, MSF was running a very busy maternity with an outpatient clinic offering Sexual and Reproductive Health services, including post-natal care. Essential new-born care was present as a continuum of care between the maternity and the outpatient clinic.

The Paediatric Days team thanks Florencia Romero and Melissa Hozjan for their contribution to this article.

THE COMMUNITY AS A PILLAR: PROVIDING ACCESS TO HEALTH CARE IN ISOLATED OR INSECURE CONTEXTS

Elise D — Sat, 03 Apr 2021 15:44:07 +0000

THE COMMUNITY AS A PILLAR: PROVIDING ACCESS TO HEALTH CARE IN ISOLATED OR INSECURE CONTEXTS Elise D Sat, 04/03/2021 - 17:44

Photo: Community health workers at MSF's base in Kumba, South-West Cameroon receiving training on how to provide first aid to injured patients before referral/MSF (2020)

Michel Quéré, who answers our questions, graduated as a Medical Doctor from the Medical Faculty of Brest (France), with a master’s degree in public health from the Tropical Medicine Institute of Antwerp (Belgium). His professional path with Médecins Sans Frontières began in 1984. For 25 years, he was part of several field missions in the North of Benin, Chad and Democratic Republic of Congo. Since 2009, Dr. Quéré is based at the MSF headquarters in Switzerland, firstly working a Medical Advisor and now as a Community Health Advisor. He will be speaking during the panel discussion focusing on community health approaches during the MSF Paediatric Days 2021 (April 15th).

What are the “Community Based Models of Care”?

We can start with the decentralized health model of care, which consists of providing health care outside of health care establishments and therefore being closer to the patients in order to ensure greater accessibility of both curative and preventive medical activity. In this decentralized health model of care, there are two different kinds of interventions:

- Community health-based interventions, that are basically medical and educational health activities implemented within a community by community health workers who are trained, enabling them to be closer to the target populations.

- Decentralized interventions, that are a range of primary health care activities performed by qualified personnel employed by MSF and/or by the Ministry of Health, who are then deployed within the community.

Why are the Community based models of care so important for MSF?

Access to health care is of prime importance, especially for the most vulnerable populations, who are isolated geographically or are living in insecure contexts. Therefore, decentralizing health care and focusing on access in the community is a simple, adaptable and efficient strategy allowing these populations to access health care, whilst also empowering them.

MSF cannot limit itself to providing care in hospitals and the support brought by mobile clinics and smaller health facilities also has its limitations. In order to provide health access at earlier stages (and therefore avoid complications), decentralizing care to the community level is very efficient due to its geographical proximity, acceptance, and availability 7 days out of 7.

Lastly, in more and more contexts marked by high insecurity, patients struggle to reach smaller health facilities: the community model of care then plays an essential role.

And in addition, the preventive and promotional component of the community model of care is fundamental.

Could you give some examples of community-based programs currently implemented by MSF?

We have classic programs (also implemented by the Ministry of Health and several NGOs) which are “Integrated Management of Childhood Illness at the Community level” (PCIMEC) which undergoes an integrated approach by volunteers to assess and classify signs and symptoms of pneumonia, diarrhoea and malaria in children under five years of age, as well as providing nutritional screenings.

We have this program in Magaria (Niger) with 278 Community Health Workers (CHW) and it can be adapted to different contexts. A few examples of MSF programmes:

- In Agock, South Sudan, community-based malaria care for all ages;

- In Ngala and Rann in Nigeria, in Djibo in Burkina Faso and in Kolofata in Cameroon, community-based care of malaria and diarrhea;

- In Ngala and Gambaru (Nigeria), community health care has been developed, whereas it is usually dedicated to rural areas and isolated villages;

- In the DRC, in the Nizi and Angumu camps, apart from care of malaria and diarrhoea we have also established care for the moderately malnourished as well as family planning activities.

In addition, we are working on community-based interventions such as:

- The "parenting MUAC" program, empowering parents to screen their children for malnutrition;

- Mental health support, including sexual and reproduction health activities.

Photo: Violet Mesape, community health nurse, is receiving patients in a village in South-West Cameroon. This baby has symptoms of malaria/MSF (2020)

How is the COVID-19 health emergency affecting this kind of health service:

The demand of decentralized health care, whether it is expected to increase, remain steady or decrease?

The priority has been to maintain the community-based case management program in a safe manner. It is essential that the CHW do not put themselves in danger and continue with consultations whilst minimizing the risks, thus reinforcing hygiene measures, distancing, protection with masks and even, in some projects, a “no-touch policy” (e.g., not doing the rapid malaria test).

Ultimately, there was no decrease in demand for community care and this reduced the burden on smaller health facilities and thus reduces the risk of COVID-19 contamination.

Regarding the existing community packages (implemented before COVID-19), will it be possible to adapt them with limited resources available?

It is possible to maintain them due to their low cost and effectiveness, but it is necessary to maintain minimum funding in terms of supervision costs and drug supply.

What are the main challenges in the implementation of community care packages?

Among the numerous challenges there are a few key ones like:

- Adapting health care to isolated villages;

- Assuring supply without interruption;

- Maintaining a good quality of care, with a real challenge particularly regarding the management of acute respiratory infections and the over-prescription of antibiotics;

- Adapting to the highly variable literacy level of the CHW;

- The complex task of data collection and the need to simplify all documentation;

- Retention of CHW.

There is also a challenge linked to the optimization of the community care package. How far to push this package, without overwhelming the CHW and replacing the current health care system?

Which strategies are put in place to ensure the quality of care at community level, as it is a non-professional medical setting?

The quality of the training is a key factor, it has to be done by using simple modules, simple tools and an adapted pedagogy. The second key point is ensuring good quality supervision of the trainings. Our experience has shown that for malaria care, diarrhoea, the introduction of “Sayana press”, as well as for the implementation of a "MUAC parenting" program, our strategies and mechanisms have been successful. However, maintaining a constant quality of care remains a real challenge, particularly regarding the management of acute respiratory infections and the over-prescription of antibiotics.

The Paediatric Days team thanks Michel Quéré for his contribution to this article.

WHEN PAEDIATRIC PATIENTS DON'T RESPOND TO ANTIBIOTICS: DEALING WITH ANTIBIOTIC RESISTANCE IN SOUTH SUDAN

Elise D — Tue, 30 Mar 2021 11:27:07 +0000

WHEN PAEDIATRIC PATIENTS DON'T RESPOND TO ANTIBIOTICS: DEALING WITH ANTIBIOTIC RESISTANCE IN SOUTH SUDAN Elise D Tue, 03/30/2021 - 13:27

Photo: Dr. Hilaire Pato Mukobelva, MSF paediatrician, at the Hospital in Bentiu POC (South Sudan)/ MSF

Dr. Hilaire Pato Mukobelwa, who answers our questions, is an experienced paediatrician who has been working in the Democratic Republic of Congo, in Rwanda, in Cameroon, in Niger or in Afghanistan. Part of Médecins Sans Frontières medical staff since January 2017, Dr. Hilaire currently holds the position of Hospital Clinical Lead in Bentiu POC (South Sudan). Prior to the Paediatric Days event (April 15 and 16, 2021), he shares his first-hand testimony coping with ABR in humanitarian settings.

Can you briefly explain what ABR is?

Antibiotic Resistance (ABR) is the ability of microbes, especially bacteria, to survive to medicines used against them. Eg. In general Salmonella (a bacteria that caused typhoid fever) used to be sensitive to ciprofloxacin but since few years there is a significant increase of cases that not respond to this drug due to wildly or abuse use of this drug in some low-income countries.

What about Infection prevention and control (IPC) and the antibiotic stewardship program?

IPC is an approach and most practical solution designed to prevent harm caused by infection to patients and health workers. This is the place all public health measures in hospital are necessary: eg. Hand washing before touching each patient …

The antibiotic stewardship program is more focused on rational use of antibiotics.

The main concerns are that first, we have to see if the clinical reasoning to reach the diagnosis is correct. And second, we have to see if the prescribed drugs correspond to the diagnosis. The aim of these two approaches is to minimize side effects of antibiotics, minimize resistance, minimize toxicity, optimize clinical outcomes and the last goal is to reduce the costs.

As a paediatrician with experience in humanitarian settings, could you explain why is this a serious problem for MSF? And why particularly in paediatrics?

This topic is very important and at the same time challenging for all Health workers. The Antibiotic resistance is increasing at alarming rates in low-income countries especially for children and even new-borns. For example, during my mission in Afghanistan as a paediatrician, I have seen many children with severe sepsis including malnourished and new-borns who could not respond to usual antibiotics such as Ampicillin, Gentamycin, Ceftriaxone…The direct consequence was a very high mortality rate. The more we will rationally prescribe antibiotics to our patients, the better we will prevent resistances and save lives.

How is MSF approaching the challenges of ABR?

MSF works hard on:

- Infection prevention and control;

- Antibiotic stewardship;

- Diagnostic tools and surveillance.

How the different tools (SIPCA, Point prevalence survey) are being implemented in the Bentiu project?

Regarding the Stepwise IPC Approach (SIPCA), this involves WatSan (Water & Sanitation) and the logistic team during an assessment. The observation goes directly to dashboard [kobo collect] it is done twice a year where we check the level of IPC.

And on the Point Prevalence Survey (PPS), the first one was done in February 2019, the second in February 2020. The Global Point Prevalence Survey (GPPS) provides a tool for a one-day snapshot looking at the number of antimicrobials being used, whether there is documentation about their use and whether their use is compliant with locally approved or other endorsed guidelines.

Could you give real example of what happens in the field when microbiology is not possible?

It is very challenging to work on ABR while there is no microbiology. As mentioned above, clinical reasoning and rational use of antibiotics based on guidelines or some evidence-based medicine updates are the only possibilities to prevent resistance in the field when microbiology is not available. This is the reason to having AMR (antimicrobial resistance) Committee to evaluate regularly trough a PPS/SIPCA how things are going.

In practice we review all the medication and medical charts of all inpatients on antimicrobials on a day. The results will be communicated to the entire team and strategies are taken to improve in the future.

Is the COVID-19 health emergency affecting the implementation of stewardship activities?

Absolutely, we were planning a PPS in February 2021 unfortunately due the surge of Covid-19 it has been postponed. However, the Committee is in place. The better would be to have it at least twice a year.

The Paediatric Days team thanks Hilaire Pato Mukobelwa for his contribution to this article.

Treating children with chronic diseases in Hawija, Iraq

Elise D — Mon, 26 Aug 2019 09:03:18 +0000

Treating children with chronic diseases in Hawija, Iraq

Photo: A nurse during a consultation with a patient affected by a chronic disease, in Hawija Primary Healthcare Centre supported by MSF/MSF

Elise D Mon, 08/26/2019 - 11:03

“Seven percent of our current patients are children under 18 years old. The three main diseases we treat among children are epilepsy, diabetes mellitus type 1 and asthma.

For each patient referred to us, MSF double-checks the diagnosis; sometimes this requires a referral to the hospital for specialised diagnostic testing.

After the diagnosis is confirmed, we make a treatment plan and provide the medication required. Sometimes we also diagnose and treat acute and long-term complications such as hypertension, blindness and chronic infections.

One of the most common chronic diseases in children is diabetes mellitus type I, a chronic condition in which the pancreas produces little or no insulin, a hormone needed for glucose to enter cells to produce energy.

With diabetes, it’s very important for patients to understand the reasons why their blood sugar levels change so much. This helps them deal with the disease, understand the long-term need for a special diet, and understand the reason for injecting themselves with insulin regularly. But this process isn’t always easy, especially with children.

With diabetes in children, a high level of self-discipline is required at a young age. It imposes a need to pay attention to what they can or can’t eat, for instance, and a different lifestyle. They have more responsibilities for their self-care than other children, and they have to realise that they’ll be dealing with this disease for a lifetime. This can be hard to accept at such a young age.

Sadly, we see severe complications at a young age, for example impaired vision or even blindness. These can be avoided through good health education, proper follow-up and adapting their treatment plan.

I have also seen chronic ulcers on the feet and cardiovascular diseases in this young group of patients.

Children in our clinics tell us that they often feel shy about injecting insulin when they are at school. We have seen cases where parents take their children out of school because they are afraid that the child might be stigmatised or might suffer one of the acute complications of diabetes, such as hypoglycaemia – a severe acute side effect of treatment with insulin. Mild hypoglycaemia shows symptoms like sweating, shaking, dizziness and confusion. Severe hypoglycemia may lead to coma, brain damage and death.

It breaks my heart to see these children taken out of school, as the lack of education could create additional problems for them.

Adapting the lifestyle of a child with diabetes means adapting the lifestyle of the whole family. Meals have to be prepared differently and food must be eaten regularly. Sweets and sugared drinks should be avoided. Families here in Iraq generally live and eat together, so it can be difficult for them to change the diet of a single person in the family.

A big challenge with chronic diseases in general, and with diabetes especially, is that patients often do not understand the danger of the disease, as the long-term complications are not evident at first. The complications often do not start to appear for 10 or 20 years. This can make it very difficult to convince a person that she or he needs to take their medication or stick to their diet plan – particularly when some families are still facing the aftermath of the conflict. They may have lost loved ones or be struggling to get back to normal. Many households lack incomes because of unemployment. For the children, who depend on their parents and wider family, patient education needs to be carried out not just for the child but for the whole family.

Even though children with chronic diseases don’t seem, on first sight, to be that sick, neglecting their health education on lifestyle changes and the proper treatment of chronic diseases may result in severe life-threatening complications at a young age.

Severe complications include cardiovascular disease, as there is a high risk of heart attacks at a young age; cerebrovascular disease, as there is a particular risk of strokes at a young age; diabetic nephropathy, or renal failure, which makes dialysis necessary; severe infections, especially in the feet, which can no longer be treated by antibiotics and could lead to amputation of the feet or legs. All of these could have a big impact on the patient and their family.

Chronic diseases are conditions which normally have a long duration and may have lifelong consequences. In addition, patients often don’t feel unwell and, for this reason, they may deviate from the agreed treatment plan.

This is why we provide not only treatment and medications in our clinics, but also psychosocial support and health education. They are all part of our holistic approach to chronic disease management. Mental health counsellors support the patients through their medical process, while health education sessions are a fundamental tool for raising awareness about the importance of taking treatment regularly and having a healthy lifestyle.”

Photo: Hawija Primary Healthcare Centre supported by MSF, an MSF health promoter runs an education session about non-communicable diseases in the waiting room./MSF

MSF started activities in Hawija in 2009 and is currently responding to the lack of healthcare services in the district. MSF teams currently work in Hawija and Abassi primary health centres, where they provide treatment for non-communicable diseases, health promotion sessions and mental healthcare. MSF also supports the district’s main referral hospital with maternity care, emergency care, laboratory activities and infection prevention and control measures.

In 2018, MSF provided consultations and treatment to more than 2,900 patients living with chronic diseases in Hawija and Abassi.