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MadarounfaOutpatientCentreAnne Yzebe, Niger, 2005four inpatient facilities and the rest in outpatientcare. In the three southernmost departmentsof Maradi, two decentralised paediatricunits were also opened and medicines wereprovided to a dozen government health centres,to facilitate free outpatient and referral healthcare for all under 5 children. Between July andOctober 2005, MSF distributed over 4,000 tons(129,487 rations) of blended, enriched flour andcooking oil to families of 53,031 at risk or moderatelymalnourished children aged less than 5years old. In Zinder region, MSF would go on toadmit over 21,000 severely malnourished childrenin the last five months of the year, usingthe same simplified outpatient system as inMaradi.Programme designChildren between 65 and 110 cm of height wereadmitted on the basis of mid-upper arm circumference(MUAC) < 110 mm, weight-forheight(W/H) < -3 Z scores (ZS) of the NCHSstandard or the presence of bilateral oedema.Children in the same height range with aweight for height between –2 and –3 ZS accompaniedby severe pathology were also admitted.Children between 60 to 65 cm height and above6 months of age were admitted on the basis ofweight-for-height or oedema criteria only.All admissions received systematic amoxicillinfor 5 days, single doses of albendazole,folic acid and vitamin A according to weight,and measles immunisation. Those identified aspositive for falciparum malaria by rapid bloodtest received artemesin-based combinationtherapy (ACT). Specific treatments were givenfor respiratory, gastrointestinal or cutaneousdiseases according to standardised protocols.All complicated cases presenting with anorexia,severe pathology or moderate to severe bilateraloedema were immediately referred to a SC.Uncomplicated cases were consulted andweighed weekly and sent home with furtherspecific treatments, 1000 kcal/day of a RUTF(two 92g packages of Plumpy’nut daily) and asof March 2005, a family protection ration of 5 kgof blended, enriched flour (Unimix) and 1 litreof cooking oil. Returning outpatients withanorexia, severe pathology, appearance of moderateto severe oedema, abrupt or progressiveweight loss or failure to gain weight after 4weeks in the programme, were referred to a SC.Children reaching exit criteria (W/H > -2 ZS for2 consecutive weeks, mid upper arm circumference> 110 mm, no oedema and absence ofongoing infection) were sent home with a dischargeration of 50 kg of millet, 25 kg of cowFigure 1 Weekly admissions to Maradi programme during 2005Weekly addmissions Maradi Region 2005Médecins Sans Frontiéres, NigerMaradi SC + 7 OCopened 2001-2004Dakoro SC + 6 OCopened weeks 16-17Aguié SC + 3 OCopened weeks 25-26peas and 10 litres of cooking oil.All six SCs had planned capacities of up to250 children, with actual patient counts reachingover 300/day in some centres during thepeak part of the year when 100 patients/daywere being admitted. Along with standardfeeding centre facilities, SCs had well staffedintensive care units of up to 50 beds to handlecritical cases referred from outpatient care.These units were equipped with oxygen, a miniblood bank, broad spectrum parenteral and oralantibiotics and the ability to monitor a largenumber of children receiving tube feeding (F-100 milk) or rehydration (Resomal solution).Stabilised patients were referred back to outpatientcare unless they had already reached dischargecriteria (W/H > -2 ZS for 3 consecutivedays, mid upper arm circumference > 110 mm,no oedema and absence of ongoing infection) inwhich case they were discharged directly homewith a one-month discharge ration.ResultsMSF admitted 43,529 malnourished childreninto its programmes in Maradi and Tahouaregion between January 1st and December 31st2005 (see figure 1). Almost 20,000 were admittedin a ten week period (weeks 30 to 40) inAugust and September 2005. As in previousyears, 95% of admitted children were under 85cm in height. Moderately malnourished childrenbetween –2 and –3 ZS with severe pathologyrepresented 6.4% of admissions, and kwashiorkoronly 2.8%. These results are typical forcountries in the Sahel, with chronic high rates ofwasting striking weaning age children less than24 months old, reaching dramatic levels duringhunger gap periods and epidemic proportionsduring bad years.Detailed results are given here for all 37,483patients treated and discharged from programmesin Maradi region, including the SCs inMaradi, Aguié, Tiberi and Dakoro and 18 associatedOCs in the six rural departments(Madarounfa, Guidan Roumdji, Aguié,Tessaoua, Mayahi and Dakoro) opened for atleast part of the year (see table 1). Results from2005 are compared with results for the sameregion between the years 2001-2004 when therewas one SC in Maradi and seven outpatientcentres in the three heavily populated, agriculturaldepartments of southern Maradi, whichalso accounted for 75% of the admissions in2005 (see figure 2). Geographical expansion wasnot the determining factor explaining the dramaticincrease in the number of admissions toMSF programmes in Maradi over previousyears.Out of the 39,353 admissions in Maradiregion in 2005, only 0.8% was readmissions(relapse within 3 months of previous discharge).A total of 25,688 (65.3%) were admitteddirectly into outpatient care and of these, 1,996(7.8%) were subsequently referred to a SC atsome point during the course of treatment. OCsTiberi SC + 2 OCopened week 36OC= Outpatient centreDakora SC closedAguié SC to SCF10 OC to SCF & ACFweek 48SC= Stabilisation centre3
<strong>Field</strong> Articleaccounted for 31,246 (83.4%) of 37,483 total discharges(see table 2). Overall programme curerate was 91.4%, mortality rate 3.2%, default rate4.7% and 0.7% were transferred out of MSF programmes.These results are superior to those obtainedin 2004 when cure rates were 83.5%, defaultrates 10.3% and mortality rates 6.0%.Readmission rates also dropped from 1.6% in2004 to 0.8% in 2005. The better results in 2005,despite much larger patient numbers, wasprobably due to early diagnosis and greaterparticipation in the programme, encouraged bythe introduction of protection and dischargerations in March 2005 amidst widespreadhousehold food insecurity. Although childrendischarged from outpatient care have longerdurations of stay and lower daily weight gainsthan those treated as inpatients, they still spendless than a month (29.1 days) in the programmeand their daily weight gain (10.5 g/kg/d) iswell above recognised benchmarks. It could beargued that spreading the total weight gainover a longer period of time within the patient’susual family environment may be a factorexplaining the low rate of relapse (0.8%) followingcure.DiscussionNiger faced an epidemic of acute malnutritionin 2005 primarily affecting young children lessthan 24 months of age in the southern areas ofMaradi and Zinder provinces during thehunger gap period between June and October.This epidemic occurred on top of chronicallyhigh rates of wasting and mortality amongstyoung children.In Niger, most rural families are highlydependent on market food purchases for a largepart of their dietary intake . In 2005, milletprices in Maradi reached up to 28,000 CFA for a100 kg bag in July compared to 8,000 CFAreceived by farmers at the time of the previousharvest in 2004. There is a striking correlationbetween the market price of millet in Maradi in2005 and the number of admissions of wastedchildren into MSF programmes five weeks later(see figure 3).MSF’s experience in Niger has importantimplications for medical practice in countrieswith high endemic rates of childhood malnutritionand large numbers of children requiringtreatment.• The results of MSF’s outpatient programmedescribed here, combined with results froman increasing number of similar programmes elsewhere, suggests that the vastmajority of severely wasted children can becured with simplified weekly surveillanceand ready to use therapeutic foods forhome consumption.• In Niger since 2001, tens of thousands ofmothers and fathers have been makingsustained efforts to bring their wastedchildren to MSF feeding programmeswhere, in over whelming numbers, theypersist in attending each week until completecure of their child has been achieved.All reason and evidence suggests that facedwith an effective, accessible and easy to useremedy, parents are willing to go to greatlengths to save the lives of their children.• The new paradigm of outpatient care usingnutrient dense therapeutic foods makesnonsense of the argument that the treatmentof malnutrition is a desirable but impossibleobjective for resource poor countries.Therapeutic foods can be produced andmade widely available where the need isgreatest. Acute childhood malnutrition,highly prevalent and frequently lethal, isalso eminently treatable.For further information, contact MiltonTectonidis,email: milton.tectonidis@paris.msf.org orIsabelle Defourny,email: isabelle.defourny@paris.msf.orgTable 1 Programme indicators for Maradi programme, 2005Weeks SC openAdmissions OC (n)Admissions SC (n)Total admissions (n)Proportion directadmissions to OC (%)Maradi Aguié Tibiri Dakoro Total MaradiregionWeeks 01-527,92613,61221,538Weeks 25-48 Weeks 36-52 Weeks 16-481,9824,2776,2592,2564,2396,4951,5013,5605,06113,66525,68839,35363.2% 68.3% 65.3% 70.3% 65.3%Figure 2100%90%80%70%60%50%40%30%20%34,86,853,3Discharges by Category (%) Maradi2001 – 200529,36,663,916,87,475,810,3 4,73,26,083,591,4% Defaulted% Died% CuredCuredn(%)15,968(90.8%)6,340(90.7%)7,139(91.7%)4,800(93.6%)34,247(91.4%)10%0%2001 2002 2003 2004 2005DiedDefaultedTransferredn(%)n(%)n(%)Total Discharges (n)707(4%)875(5%)37(0.2%)17,587190(2.7%)279(4%)180(2.6%)6,989140(1.8%)494(6.3%)8(0.1%)7,781181(3.5%)114(2.2%)31(0.6%)5,126Deaths in SC (n) 627 144 82 127 980Discharges from SC (n)Movements fromSC to OC (n)In hospital mortality (%)Movements OC to SC (n)3,3794,9577.5%6251,175 7339501,4575.5%2,302 1,0832.7%6.2%645 3643621,218(3.2%)1,762(4.7%)256(0.7%)37,4836,2379,7996.1%1,996Table 22002200320042005Figure 3Discharge profile per year for MaradiregionTotal discharge from SCand OCn5,3076,3559,52437,483Discharge from OC only3,871Comparison between the evolution ofweekly millet market prices in Maradi(FEWS/SIMA) and weekly admissions ofmalnourished children in Maradi (MSF)n3,5577,10431,246Direct admissions toOC (n)13,6124,2774,239 3,560 25,68830002500OC to SC/Directadmission OC (%)Average length of stayOC (days)Average length of staySC (days)Average weight gainOC (g/kg/d)Average weight gain SC(g/kg/d)4.6% 15.1% 8.6% 10.2% 7.8%29.113SC=Stabilisation centre OC=Outpatient centre31.9 28.526.511.729.116.4 16.1 13.910.6 10.4 10.2 10.410.518.9 19.1 14.3 14.217.3Weekly price100kg (CFA)2500200015001000500Price of milletin Maradi(francs CFA)MSF Maradi FeedingProgramme WeeklyAdmissions0W1 W15 W30 W452000150010005000weekly admissions4
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