MSF - Operational Centre Brussels - MEdical Department
OCB MEDICAL ACTIVITY REPORT 2012
MSF-OCB - Belgium - Brazil - Denmark - Hong Kong - Italy - Luxembourg Norway - South Africa - Sweden
MSF - Operational Centre Brussels - MEdical Department
OCB MEDICAL ACTIVITY REPORT 2012
MSF-OCB - Belgium - Brazil - Denmark - Hong Kong - Italy - Luxembourg Norway - South Africa - Sweden
OCB Medical Activity Report 2012
MSF-OCB
94 Rue Dupré
B-1090 Bruxelles
Belgium
Technical support & coordination
Luxembourg Operational Research (LuxOR)
MSF-Luxembourg
68 Rue de Gasperich
Luxembourg
Compilation and editing
Sokhieng Au
Rafael Van den Bergh
Further information and reprints
Dr. Rony Zachariah
E-mail: rony.zachariah@brussels.msf.org
Tel: + 352 332515
Fax: + 352 335133
MSF MEdical Department OCB
CONTRIBUTORS
Photographs © Halimatou Amadou, Jodi Bieber, Peter Casaer, P.K. Lee, Robin Meldrum, Andre Quillien, Sami Siva and Sven Torfinn
Maps generated using StatPlanet v3.0
MEDICAL ACTIVITY REPORT 2012
Contributors
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Introduction Bertrand Draguez Biomedical Equipment Vincent Maure Emergency Medicine Pola Valles Emergency
Unit Rosa Crestani & Marie-Christine Ferir Epidemiology/Epicentre Fabienne Nackers Evaluation Unit Boris
Stringer Health Informatics Armand Sprecher, Marcel Manzi & Rafael Van den Bergh Health promotion and socioanthropology Yasmine Al Kourdi HIV/Tuberculosis Dmytro Donchuk, Eric Goemaere & Helen Bygrave Infection
Control Sarah Daho Intensive Care Pola Valles Laboratory Pascale Chaillet Malaria Jorgen Stassijns Medical
Structures-Inpatient Department Nadja De Groote Mental Health Nathalie Severy Nutrition Pascale Delchevalerie
Operational Research and Documentation Rafael Van den Bergh & Rony Zachariah Paediatric Care Isabel Zuniga
Pharmacy Caroline Beetz, Marjolein De Bruycker & Ramon Spatini Bernardo Sexual and Reproductive Health
Eva De Plecker Surgical Activities Miguel Trelles Vaccination Catherine Bachy Water, Hygiene and Sanitation
Peter Maes Compilation and editing Rafael Van den Bergh & Sokhieng Au Editing Rony Zachariah & Tony Reid
Coordination Rony Zachariah
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MSF MEdical Department OCB
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Contents
01.Introduction
02.Executive Summary
03.List of Abbreviations
04.A Year In Snapshots
05.medical data
06. Biomedical Equipment 07.Emergency Medicine 08.Emergency Unit 09.Epidemiology/Epicentre 10.Evaluation Unit 11. Health Informatics 12. Health promotion and socio-anthropology 13.HIV/Tuberculosis
14.Infection Control 15.Intensive Care 16.Laboratory 17.Malaria 18.Medical Structures-Inpatient Department 19.Mental Health 20.Nutrition 21.Operational Research and Documentation 22.Paediatric Care 23. Pharmacy 24. Sexual and Reproductive Health 25. Surgical Activities 26.Vaccination 27.Water, Hygiene and Sanitation 28.Annex – tables and figures
pages
MEDICAL ACTIVITY REPORT 2012
Contents
6
MSF MEdical Department OCB
Introduction
The Medical Department of MSF-Operational Centre Brussels is responsible for guiding and
supporting its medical activities in the field. As such, the Medical Department is at the heart
of MSF’s identity as a medical humanitarian organisation.
I am pleased to present the fifth edition of the OCB Medical Activity Report. With this publication, we highlight the activities of the 22 technical domains of the Medical Department, with
the objectives of 1) providing a platform for the accountability of the medical department and
highlighting its important role in the OCB operations, 2) maintaining a memory document of
the activities and lessons learned over time, 3) enhancing self reflection and critical review of
the department and its activities, and 4) demonstrating the scope and depth of our medical
activities to our partners and donors around the world.
I wish to thank all members of the Medical Department for their hard work over the past year,
and for their support in compiling this report. Any feedback on the content or presentation of
the report is most welcome, and should be sent to rafael.van.den.bergh@brussels.msf.org
and rony.zachariah@brussels.msf.org.
Finally, my sincere gratitude goes out to all OCB staff around the world, both at headquarters
and in the field, and to all partners for their continued support to MSF activities.
7
With compliments
Dr Bertrand Draguez
Director – Medical Department
Médecins Sans Frontières –
Operational Centre Brussels (OCB)
Brussels
Belgium
MEDICAL ACTIVITY REPORT 2012
01. Introduction
Tel: + 32 24 74 74 74
MSF MEdical Department OCB
Executive
Summary
1. Overview of OCB activities
In 2012, Médecins Sans Frontières – Operational Centre Brussels
(OCB) was active in 28 missions, with 73 projects reporting medical
activities. Overall, 2,045,318 consultations in the outpatient department
(OPD) were performed and 135,259 admissions to the inpatient
department (IPD) were registered. Large-scale emergency interventions
focused on refugee care (in Mali, Mauritania and South Sudan) and
cholera outbreaks (Guinea, Haiti, Sierra Leone). Geographically, subSaharan Africa continued to be the main region of intervention, though
important activities were also performed in North Africa, Asia and the
Middle East (fig. 1).
Care was provided for:
111,199 HIV patients on antiretroviral therapy (ART), of which 29,925 new cases
277,086 confirmed malaria cases
55,354 with severe acute malnutrition
47,908 deliveries
15,813 new surgical cases
More than 370,000 individuals vaccinated for measles during outbreaks
9
219,146 emergency department (ED) consultations
02. Executive Summary
Figure 1: Global OCB sections and missions, 2012
OCB Mission
OCB Mission & Section
MEDICAL ACTIVITY REPORT 2012
OCB Section
2. Year in Review
The past year brought a clear reduction of
the medical activities of OCB, with reduced
numbers in virtually every domain (mental
health, nutrition, OPD consultations, sexual
and reproductive health (SRH), surgery, TB
care, vaccination, etc.), except for malaria
(stabilised versus 2011), hospital admissions
(slightly increased since 2011) and HIV care
(increased ART initiations since 2011). These
decreases were usually the consequence of
programme closures/handovers, including
particularly large projects such as Lashkar-
10
Gah (Helmand), Afghanistan.
novel data management tool MINOS was
rolled out further, and by the end of the year
accounted for 18% of all OPD data and 11%
of all IPD data. Additionally, a series of new
standardised databases for different medical
activities (obstetric, neonatal, ED, and sexual
violence care) were successfully piloted and/
or implemented. Analyses based on these
novel tools are available in the relevant sections of this report. Concomitantly, the use of
routine data to generate evidence for the
guidance of operational decisions was expanded, for example with the analysis of
3. Challenges and prospects
The reorientation of OCB operations to larger, more specialised projects has strong implications for the Medical Department. While
this narrower but more focused medical
portfolio within OCB may lead to an improved
quality of care, resulting from the higher degree of specialisation and innovation allowed
in such projects, it is not without consequences. Investment in a limited number of
large projects may carry higher risks than
managing a larger number of smaller projects, as closure of one such large project
due to for example security issues would
lead to a considerable loss of activities and
missed vaccination opportunities to steer
came an increased depth: projects which
OCB vaccination programmes, and the de-
were not closed tended to expand – this was
velopment of a set of standard Health Pro-
noted in particular for SRH, where all overall
motion indicators which will be implemented
A general trend for 2013 promises to be an
numbers were reduced but individual pro-
over the course of 2013. This is mirrored by
increased focus on transversal or integrated
jects often increased and/or refocused their
the increased uptake of Operational Re-
approaches. This should include better inte-
SRH activities. Higher levels of specialisation
search (OR) in different topics, such as Water
gration of HIV and TB care into non-vertical
were noted, e.g. in surgery (where more
and Sanitation (WatSan), Laboratory (antibi-
programmes, a holistic approach to hospital
high-level orthopaedic interventions and spe-
otic resistance) and Mental Health & Health
management, better integration of vaccina-
cialised fistula surgeries were performed), TB
Promotion (where initiatives were launched in
tion activities in nutrition and HIV pro-
care (where higher numbers of multi-drug
2012 and will be formalised in 2013). How-
grammes, a comprehensive approach on the
resistant TB cases were noted despite an
ever, much work remains to be done on the
nutritional management of infants younger
overall decrease in TB patients in care),
“data culture” in OCB, where data manage-
than six months, and an emphasis on ration-
emergency medicine (where fewer ED con-
ment is sometimes considered an imposition
al drug use as a cross-cutting health chal-
sultations were conducted, but the South
from headquarters on the field, rather than an
lenge. Such transversal approaches will re-
Africa Triage Score system was rolled out
intrinsic component of programme evalua-
quire close interactions both within the
successfully). However, some topics, such
tion and improvement.
Medical Department and between the Medi-
reduction in overall numbers mirrored by
higher degrees of specialisation. An increased degree of innovation and doing
“more with less” was also noted. Examples
are the “light approach” to HIV care implemented in a number of vertical HIV programmes, which succeeded in increasing
ART initiation by 25% despite the negative
funding climate for HIV, and the use of maternity waiting homes in obstetric care pro02. Executive Summary
tion, considerable progress was made. The
With a reduced volume of medical activities
as nutrition and vaccination, did not see their
MEDICAL ACTIVITY REPORT 2012
At the level of data monitoring and evalua-
grammes to increase institutional delivery
rates (already noted in 2011 and analysed in
more detail in 2012).
An increased focus on training was also not-
expertise. Further discussions on this strategy need to be held.
cal and Operations Departments.
ed, including specific training on biomedical
In addition, an enhanced emphasis on evi-
equipment, emergency medicine, intensive
dence-based approaches is foreseen during
care, aspects of WatSan, and higher levels of
2013. Examples include: close monitoring of
on-the-job training for e.g. infection control
specific data in the ED and the intensive care
and data management. A specific course for
unit (both relatively new services within OCB),
the training of hospital management teams
continuation of thorough missed-vaccination
has also been developed and will be rolled
opportunities analyses, compilation of a full
out in 2013. The first MSF-organised OR
inventory of OCB hospital-based activities,
training course was finalised in 2012, and
and an increased uptake of OR in areas such
showed high success rates and outputs,
as Health Promotion, Mental Health, WatSan
leading to official accreditation of the joint
and emergency interventions. These devel-
Union/MSF course by the World Health Or-
opments will need to be backed up by com-
ganisation (WHO).
prehensive, standardised and efficient data
management tools.
MSF MEdical Department OCB
OR: Operational Research
ORS: Oral Rehydration Solution
OT: Operating Theatre
PCR: Polymerase Chain Reaction
PCV: Pneumococcal Vaccine
PEPFAR: President’s Emergency Plan For AIDS
Relief
PFA: Psychological First Aid
PHC: Primary Health Care
PHU: Primary Health care Unit
PLW: Pregnant and Lactating Women
PLWHA: People Living With HIV/AIDS
PMTCT: Prevention of Mother-To-Child
Transmission
PNC: Postnatal Care
POC: Point Of Care
PPD: Preparation for Primary Departure
PSP: Populations in Precarious Situations (course)
PTB: Pulmonary Tuberculosis
PUC: Pool d’Urgence Congo
RDT: Rapid Diagnostic Test
REPEPI: Responding to Epidemics (course)
RIC: Remaining In Care
RIF: Resistance to Rifampicin
RUSF: Ready to Use Supplementary Food
SAGE: Surgery/orthopaedics, Anaesthesia/
reanimation, Gynaecology/obstetrics, Emergency/
intensive care
SAM: Severe Acute Malnutrition
SAMU: Southern Africa Medical Unit
SATS: South African Triage Score
SEU: Stockholm Evaluation Unit
SGBV: Sexual and Gender-Based Violence
SFC: Supplementary Feeding Centre
SOP: Standard Operating Procedure
SRH: Sexual and Reproductive Health
STI: Sexually Transmitted Infections
SV: Sexual Violence
TB: Tuberculosis
TDF: Tenofovir
TFP: Therapeutic Feeding Programme
TPR: Termination of Pregnancy on Request
UNICEF: United Nations Children’s Fund
VHF: Viral Haemorrhagic Fever
WaSH: Water, Sanitation, and Hygiene
WatSan: Water and Sanitation
WFP: World Food Program
WHO: World Health Organisation
WHS: Water, Hygiene and Sanitation
03. list of abbreviation
ICU: Intensive Care Unit
IDP: Internally Displaced Persons
ILS: Immediate Life Support
IM: Intramuscular
IML: Immediate Life Support
IPD: Inpatient Department
IPT: Isoniazid Preventive Therapy
ITC: International Technical Coordination
ITFC: Inpatient Therapeutic Feeding Centre
IV: Intravenous
KAP: Knowledge, Attitude and Practice
KPI: Key Performance Ïndicators
KZN: KwaZulu Natal
LCC: Logistics Coordinator Course
LN: Long-lasting insecticide-treated Nets
LRTI: Lower Respiratory Tract Infection
LTFU: Loss To Follow-Up
LUXOR: Luxembourg Operational Research
MAM: Moderate Acute Malnutrition
MCC: Medical Coordinator Course
MCI: Mass Casualty Incident
MDR: Multi-Drug Resistant
MedCo: Medical Coordinator
MFP: Medical Focal Person
MFH: Modular Field Hospital
MH: Mental Health
MHS: Management of Health Services
MINOS: Medical Information Network for
Operational Support
MIO: Mobile Implementation Officer
MoH: Ministry of Health
MRAC: Musée Royal d’Afrique Centrale
MSF: Médecins Sans Frontières
MUAC: Mid-Upper Arm Circumference
MWH: Maternity Waiting Home
NA: Not Applicable
ND: No Data
NDRA: National Drug Regulatory Authorities
NGO: Non-Governmental Organisation
NICD/NHLS: National Institute of Communicable
Diseases/National Health Institute
NTP: National Tuberculosis Programme
OCA: Operational Centre Amsterdam
OCBA: Operational Centre Barcelona
OCB: Operational Centre Brussels
OCG: Operational Centre Geneva
OCP: Operational Centre Paris
OD: Operating Department
OPD: Outpatient Department
MEDICAL ACTIVITY REPORT 2012
ACF: Action Contre la Faim
AIDS: Acquired Immune Deficiency Syndrome
ALSO: Advanced Life Support in Obstetrics
ANC: Antenatal Care
ART: Antiretroviral Therapy
ATFC: Ambulatory Therapeutic Feeding Centre
BCG: Bacille Calmette-Guérin (TB vaccination)
BEmONC: Basic Emergency Obstetric and Neonatal
Care
BIRT: Business Intelligence Reporting Tool
BLoC: Basic Logistics Courses
BraMU: Brazilian Medical Unit
CDC: Centres for Disease Control
CEmONC: Comprehensive Emergency Obstetric
and Neonatal Care
CFR: Case Fatality Rate
CMAM: Community Management of severe Acute
Malnutrition
d4T: Stavudine
DBS: Dried Blood Spot
DFID: Department for International Development
(UK)
DPC: Directorate of Disease Prevention and Control
DPT: Diphtheria-Pertussis-Tetanus vaccine
DR-TB: Drug Resistant Tuberculosis
DRC: Democratic Republic of Congo
DST: Drug Susceptibility Testing
E-Unit: Emergency Unit
EAC: Enhanced Adherence Counselling
ED: Emergency Department
EML: Essential Medicine Llist
EPI: Expanded Programmes of Immunisation
Eprep: Emergency Preparedness
EPTB: Extrapulmonary Tuberculosis
ERB: Ethics Review Board
Explo: Exploratory Mission
FDA: Food and Drug Administration
FP: Family Planning
GAM: Global Acute Malnutrition
GAS: Gynaecology, Anaesthesia, Surgery
GDP: Good Distribution Practices
GRC: Gondama Referral Centre
HAT: Human African Trypanosomiasis
HIV: Human Immunodeficiency Virus
HP: Health Promotion
HQ: Headquarters
HR: Human Resources
HTC: HIV Testing and Counselling
IC: Infection Control
11
List of Abbreviations
MSF MEdical Department OCB
a year in snapshots
Biomedical equipment
- To address the increasing demands in terms of
biomedical equipment, a staff reorganisation
was done, including reinforcement of the team
with two Mobile Implementation Officers (MIO).
- A biomedical support system was developed
to assist missions with complex equipment, in
particular hospital projects.
- An extensive biomedical training course was
organised for the first time for national staff
working with biomedical equipment – this
course will be repeated over the next years.
12
Evaluation Unit
Emergency Medicine
- Emergency medical care continued to play a
major role in OCB: it was provided in 15 projects across eight countries.
- Three evaluations were conducted in 2012; additionally, two from 2011 were finalised and two
were planned for 2013.
- A total of 219,146 emergency department (ED)
consultations were performed during 2012; the
ED of Timergara, Pakistan had the highest case
load (76,310 consultations).
- Collaboration between the four evaluation entities within MSF (Paris, Athens, Vienna, and
Stockholm) was formalised, and joint activities
on training, evaluations and dissemination were
conducted.
- The South African Triage Scale (SATS) system,
introduced in 2011, was in place in eight ED of
OCB by the end of 2012.
- New trainings were introduced on Immediate
Life Support (ILS) and Basic Assessment and
Support of Seriously Ill Patients in Developing
Healthcare Systems (BASIC DHS).
Emergency Unit
- In 2012, the E-Unit was active in 18 countries
and was involved in 32 emergency interventions, exploratory missions (Explos) and/or
emergency preparedness interventions (Eprep).
04. A Year in Snapshots
- In order to ensure better dissemination of study
results to the OCB Operations and Medical Departments, several meetings were organised in
the offices of OCB during which Epicentre epidemiologists presented the results of their recent studies. These meetings appeared useful
and well appreciated.
- After the pilot phase of two years, the project
has continued as the Stockholm Evaluation
Unit (SEU).
- A standardised tool for monitoring of ED activity was designed and implemented in six projects.
- The largest interventions in terms of medical
needs and HR/logistics/financial requirements
were the refugee interventions in Maban (South
Sudan), Mali and Mauritania, and the cholera
intervention in Sierra Leone.
- Increased human resources support at headquarters was required for the Syria and Maban,
South Sudan interventions. At the field level, 15
field emergency coordinators were active and
more than 350 departures for emergency missions were noted.
Epidemiology/Epicentre
MEDICAL ACTIVITY REPORT 2012
- The latest version of the HIV data collection
tool, FUCHIA, was developed and released.
- Epicentre conducted six field interventions in
collaboration with OCB: Haiti, the Horn of Africa, Sierra Leone, South Sudan (twice) and Zimbabwe.
- Clinical and operational research was conducted on vaccine preventable diseases (rotavirus,
pneumococcal infections and measles), nutrition, HIV/Tuberculosis, malaria and novel laboratory developments.
- The international pool of evaluators now consists of 200 potential candidates. However, not
enough work is available for this pool and their
full-time availability is thus not ensured.
- All evaluations in 2012 were conducted by consultants with an MSF background. This model
will be continued: investment in the evaluator
pool will be reduced in favour of using external
evaluators on a consultancy basis and pairing
them with internal MSF evaluators.
Health Informatics
- The two OCB main routine data tools were the
Epicentre outpatient department/inpatient department/gynaecology/obstetrics (OPD/IPD/
GynObs) data collection tools and the new data
collection software MINOS – these formed the
basis of most analyses presented in this report.
- The Epicentre outpatient department/inpatient
department/gynaecology/obstetrics data collection tools were used in 12 out of 14 missions
where their use was indicated.
- The new data collection software MINOS was
expanded in projects in Pakistan and South
Sudan (including the Maban refugee emergency), and introduced in DRC, Egypt and Somaliland.
- Overall, 61% of all OPD patients and 81% of all
IPD patients were reported on using the Epicentre tools. For MINOS, these proportions
came to 18% and 11% respectively.
- Human resources turnover remains a challenge to the collection of good quality data –
this was noted in particular during the implementation of MINOS in the Maban refugee
emergency (South Sudan).
- A combined request for Typology and annual
sectional data was sent out to the field – in general, the process went well, but some vertical
projects and projects in transition between
data tools experienced problems in supplying
the data on time.
Health Promotion and
Socio-Anthropology
- Health promotion activities were provided in 32
projects, including three emergency interventions and 29 regular projects.
- Collaboration with other MSF sections was initiated through a contact group, which allowed
the sections to share experiences, practices,
and tools while developing a common approach.
- An HIV/TB Patient and Community Support
advisor has been recruited to support field
capitalisation efforts and promote innovative
patient support approaches. This person will
be part of the Southern Africa Medical Unit
(SAMU) and will be directly responsible for all
health promotion activities in vertical HIV/TB
projects.
- Standard HP indicators have been developed
and disseminated but not yet implemented in
all projects.
HIV/Tuberculosis
- OCB has handled the negative funding climate
for HIV/TB quite well, by adopting more focused strategies and by implementing more
ambitious targets in several of its vertical programmes.
- At the end of the year, OCB was supporting 18
vertical integrated HIV/TB projects in 10 countries. Very favourable results were obtained
with the “light approach” programmes in Zimbabwe and Malawi.
- In case finding activities for HIV, 27,183 patients
were tested for HIV and 4.9% tested positive.
- A total of 27,396 HIV patients were newly registered in OCB-supported clinics during the year,
and 5,960 TB patients were taken in care.
- A total of 29,925 adults and children were initiated on antiretroviral therapy (ART) – a sharp
increase compared to 2011, as a result of the
universal implementation of the higher CD4
count thresholds and introduction of Prevention of Mother-To-Child Transmission (PMTCT)
B+ in several projects.
- The majority of OCB projects were using Tenofovir-based ART regimens as first line treatment, except for Malawi, Mozambique and
DRC.
- Among adults on ART, retention in care ranged
between 64% and 95%, with a target of 85%.
This target may be adjusted to 90% following
the rapid implementation of community-based
chronic care strategies.
- Prevention of malaria was not always sufficiently or correctly implemented during emergencies and in some routine activities.
- As a consequence of the decreasing malaria
burden, there is a need to improve the diagnostic tools (such as RDT) and protocols for differential diagnosis of malaria, to improve the management of fever in children.
Infection Control
Medical Structures-Inpatient
Department
- A major achievement at the level of infection
control was the opening of the orthopaedic internal fixation programmes in Tabarre (Haiti)
and Kunduz (Afghanistan). The highest standards of hygiene were achieved there, showing
that such standards can be attained even in
resource-poor settings.
- OCB has been increasingly involved in secondary healthcare: in 2012, a75 million were dedicated to running IPD structures in 16 different
countries, including in emergency contexts,
numbering a total of 2,088 beds and catered
for by approximately 5,794 staff.
- Infection control is more and more integrated
into all programmes, with an infection control
officer and infection control committee present
in most health structures.
- A multidisciplinary infection control working
group has been created at OCB to allow a holistic approach to infection control.
Intensive Care
- The focus of OCB is to achieve a good standard of care in basic level Intensive Care Units
(ICU).
- The two ICUs reporting data in 2012 (Kunduz,
Afghanistan and Tabarre, Haiti) saw a total of
506 admissions over the course of the year.
- In 2012 OCB provided inpatient care in 30
health facilities, including in four during emergency interventions.
- Compiling an inventory of all hospitals in OCB
was more challenging than anticipated, but has
now been performed. Data is being actively
shared with OCP and OCBA.
- The Gondama Referral Centre (GRC) in Bo, Sierra Leone, and the hospital in Masisi, DRC
were the largest remaining hospitals by the end
of 2012 in terms of admissions, staff and bed
numbers.
- Due to project closures, only two hospitals with
sizeable paediatric populations remain: the
GRC in Sierra Leone and Guidan Roumdji in
Niger.
- The high level, technically advanced ICUs in
OCB have suffered from the level of complexity
they bring, in particular at the level of recruiting
and retaining sufficiently trained staff.
- A course for the training of Hospital Management Teams has been developed, and will be
provided over the course of 2013.
- Better documentation and analysis of ICU performance and outcomes are required to improve the ICU activities in OCB.
Mental Health
Laboratory
- At the end of 2012, 35 laboratories provided lab
support in 34 projects: the major areas receiving laboratory support were HIV/TB care, blood
transfusion and hospital services.
- More automated solutions for support of advanced laboratories, such as mobile network
connectivity options, are urgently required.
- A major laboratory-based operational research
study on antibiotic resistance in Lashkar-Gah
(Helmand), Afghanistan was ongoing, and results are expected by 2013.
Malaria
- 476,056 Rapid Diagnostic Tests (RDT) were
performed, with high positivity rates (i.e. high
malaria endemicity) in projects in South Sudan,
Mauritania, Niger, Sierra Leone and DRC.
- During 2012, OCB provided mental health (MH)
activities in 24 regular projects across 15 countries and in an additional five emergency interventions.
- The portfolio of MH interventions was reduced
for ongoing projects, as a result of the closure
of seven projects/MH components. New MH
projects mainly developed as additional components of projects in countries with pre-existing activities.
- New projects with a strong MH component
were the Maban refugee intervention in South
Sudan (with a focus on the therapeutic feeding
programme, activities at the main clinic and
health posts, and awareness activities in the
community) and Egypt (comprehensive medical and MH care for migrants in Cairo).
- Contacts were made with external partners to
develop an Operational Research portfolio on
MH.
- 22 nutritional projects across 13 countries were
managed by OCB; no new projects were
opened (except for the emergency projects in
Mali, Mauritania and Maban (South Sudan) and
two major ones were handed over (in Sierra
Leone and Niger).
- 55,354 patients with severe acute malnutrition
were admitted to Intensive or Ambulatory Therapeutic Feeding Centres and 298 patients with
moderate acute malnutrition were admitted to
Supplementary Feeding Centres, representing
the lowest levels since 2008.
- 3,831 patients benefited from selective feeding
(in one single project), and 612 patients received specific targeted nutritional support –
also representing a sharp decline since the
previous years.
- No General Food Distributions were done in
2012.
- For the projects providing outcome data, two
out of 15 achieved the target cure rate of >80%,
while eight remained below 70%. Low cure
rates were typically linked to high defaulter
rates, even in refugee settings such as Maban
(South Sudan) and Mauritania. In Mauritania,
these defaulter rates were reduced significantly
by interacting with the community.
- The Kamrangirchar project in Bangladesh has
developed into a focus project for Operational
Research (OR) into nutrition and nutritional approaches in Asia in particular. The first publications based on the research conducted in
Bangladesh were released in 2012.
Operational Research
and Documentation
13
-In vertical HIV programmes reporting on
PMTCT, 92% of all women attending antenatal
care (ANC) were tested for HIV, 87% received a
full PMTCT intervention and transmission rates
were limited to 3%.
- Injectable artesunate was rolled out as new
treatment for severe malaria – its implementation seems feasible in the field.
Nutrition
- 2012 saw the completion of the first MSF-led
OR course in Luxembourg (initiated in 2011),
and the launching of two new courses managed by MSF in Europe and in Africa. Excellent
outcomes were achieved for these courses,
with 88% of the participants meeting all their
milestones, and a 12-month and 24-month
publication success rate of 77% and 93% respectively.
- 81 OCB-related peer-reviewed papers were
published, the main topics being HIV (14%),
health programme monitoring and management (12%), TB (11%), HIV/TB co-infection
(11%), and Operational Research (11%). The
MSF courses were a driving force behind the
strong increase in publications in 2012.
- 72 study protocols were developed over the
course of 2012, 48 of which in the context of
the OR courses.
- The first OR Day was organised at OCB. It was
considered a great success in terms of enhancing the credibility and perceived value of
OR in MSF, and will henceforth become a yearly event.
-Several studies have influenced policy and
practice. One OR study, on the reduction of
maternal mortality in Burundi and Sierra Leone,
received massive press attention, featuring in
an international documentary leading to discussion with the European Commission Development Cooperation Directorate.
04. A Year in Snapshots
- A total of 495 patients were initiated on treatment for multidrug-resistant TB (MDR-TB)
across ten different OCB projects.
- The numbers of malaria cases stabilised versus
2011, at 277,086 confirmed malaria cases
treated by OCB; 90% of these cases were
treated in four missions only: DRC, Niger,
South Sudan and Sierra Leone.
MEDICAL ACTIVITY REPORT 2012
- TB treatment outcomes were variable: only two
projects achieved the target treatment success
rate of >85% for smear-positive pulmonary TB.
Death rates exceeding the 10% threshold were
observed in three projects, and treatment interruption rates >10% in another two. Only one
project had a >85% treatment success rate
among smear-negative pulmonary TB and extrapulmonary TB cases.
- A document outlining the vision, goal, strategies and outputs of the Union-MSF OR group
was written up and will be published over the
course of 2013.
Paediatric Care
- 673,274 (37%) of all outpatient consultations
and 35,435 (48%) of all hospital admissions in
OCB were for children under five.
- The leading causes of morbidity for paediatric
outpatients were similar to the previous years:
respiratory tract infections (39%), malaria (18%),
non-bloody diarrhoea (16%), skin infections
(5%) and eye diseases (4%); for paediatric inpatients, the major morbidities were severe malaria (33%), lower respiratory tract infections
(17%), neonatal pathologies (10%) and nonbloody diarrhoea (9%).
- The leading causes of paediatric inpatient mortality were severe malaria (27%), neonatal pathologies (26%), lower respiratory tract infections (12%), septicaemia (5%) and non-bloody
diarrhoea (3%).
- Neonatal pathologies as a proportion of under
five IPD morbidities increased from 5% in 2011
to 10% in 2012, primarily due to better reporting: for the first time in 2012, neonatal diagnoses were systematically included in the Epicentre IPD tools.
14
- In emergency obstetrical programmes, there is
a need to think about neonatal services from
the outset, since 10- 20% of babies may need
inpatient care.
- Concerning tuberculosis (TB), a total of 333
cases (0.1% of all morbidity) were suspected in
under five children, showing that little measurable improvement has been made in case detection and/or reporting of TB at the health
centre level.
Pharmacy
MEDICAL ACTIVITY REPORT 2012
04. A Year in Snapshots
- The emergencies in Syria and South Sudan
and the increased activities in countries with
import constraints such as Ukraine, Afghanistan, Pakistan and India continued to represent
significant challenges to the medical supply
chain.
- Major changes occurred at supply level with
the move of the MSF Supply site from Merchtem to Neder-Over-Heembeek, the start of
the new Supply Unit under a unique Supply &
Logistics Support Director, contributing to the
restructuring of MSF Supply departments, and
the creation of a Supply Chain director position.
- Fifteen products were validated by MSF pharmacists.
- Two batch recalls and seven quality alerts concerning OCB projects were issued during 2012
- An evaluation of the local pharmaceutical market was conducted in 12 countries: 14 manufacturers were approved in six countries, and
69 wholesalers were approved.
- Total expenditure for medical procurement was
22.1 Ma, with an additional 1.6 Ma for therapeutic food.
- Collection of data on local purchases and donations has improved slightly, but still needs to
be strengthened and implemented by all missions. However, collection of stock management indicators with reporting on losses was
far from successful and will remain a major
challenge.
Sexual and Reproductive Health
- Sexual and Reproductive Health (SRH) saw a
reduction in its activities across the board,
mainly due to project closures/handovers and
reorientations. In 2012, 40 projects provided
SRH components – the projects which remained tended to expand their SRH activities.
- Antenatal care was offered in 24 projects and
169,672 antenatal consultations were performed – adequate antenatal care coverage
(four visits during pregnancy) remained low.
- Deliveries were conducted in 27 projects, all of
which offered emergency obstetric care and 16
provided Caesarean sections and blood transfusion. 47,908 deliveries were performed, 5,411
of which by Caesarean section.
- Postnatal care was offered in 23 projects and
18,985 postnatal consultations were conducted.
- Family planning was offered in 27 projects and
47,662 family planning consultations were conducted.
- Termination of pregnancy on request was offered in 13 projects and was provided for 1,636
women.
- Management of obstetric fistula included two
fistula campaigns (in Masisi, DRC and Gogrial,
South Sudan) and the long-term project in Gitega, Burundi, offering holistic care for fistula patients. Overall, 551 surgical fistula repair interventions were provided.
- Care for survivors of sexual violence was offered in 22 projects, though only 16 projects
reported cases of sexual violence: 2,909 cases
were seen.
- An SRH in emergencies toolkit has been developed to accommodate for the increasing implementation of SRH activities in emergencies.
Surgical Activities
- Surgery in OCB focused on providing 1) essential, life-saving surgery, with low-tech requirements; 2) high-standard orthopaedic care in
selected projects; and 3) specialized surgical
care to women with obstetric fistula in various
locations.
-Operating department data coverage and
quality continued to be high.
- 22 OCB projects offered surgical care; for 19 of
these OCB was directly responsible for all aspects of surgical care.
- 15,813 new surgical cases were seen.
- The operating department admitted 20,443
surgical cases; 89% of which were emergency
cases.
Vaccination
- 27 OCB projects provided data on vaccination
activities; this represents an underestimation,
as some projects with vaccination activities did
not manage to provide vaccination data.
- A total of 343,678 routine vaccinations were
administered in OCB projects during 2012, representing a 12.4% decrease since 2011. This
decrease is distributed equally between routine
and post-exposure vaccinations.
- Vaccination activities are mainly offered in outpatient departments and at antenatal consultations; vaccination in nutrition activities and in
vertical HIV projects was not reported at all in
2012.
- Tetanus continued to be the most administered
antigen (31%) in routine activities, followed by
polio (26%) and the diphtheria-pertussisteta­nus or pentavalent (diphtheria-pertus­­sistetanus- Hepatitis B-Haemophilus influenzae
type B) vaccine (19%).
- The vaccination follow-up in OCB programmes
is poor: drop-out rates in the pentavalent vaccine from the first to third dose among children
were 38%, while drop-out rates for tetanus
vaccination among pregnant women between
the first and the third dose was 78%.
- More than 370,000 vaccinations for measles
were conducted, mainly during major outbreaks in DRC and South Sudan.
- Results of six evaluations indicated that missed
vaccination opportunities varied between 15%
and 48% in children and between 14% and
30% in women of childbearing age.
Water, Hygiene and Sanitation
- Scanning for Water, Hygiene and Sanitation
(WHS) challenges was done systematically,
and WHS was involved in almost all ongoing
projects.
- A focus was placed on providing expert WHS
support to established missions, while the
WHS needs in complex emergencies were
managed by polyvalent technical staff with
technical support from headquarters.
- Specific WHS interventions focused on borehole rehabilitation in Niger, water source detection in South Sudan, WHS infrastructure installation in the refugee camps in Maban (South
Sudan) and Mauritania, and outbreaks of viral
haemorrhagic fever in DRC and Uganda.
- Three WHS-associated studies were published
during 2012, and at least nine WHS study protocols were developed.
MSF MEdical Department OCB
Medical
DATA
1. Overview
An analysis is provided of general outpatient and inpatient department (OPD/IPD) data in OCB, as these
topics are not covered explicitly in the subsequent sections of this report. For the analysis here, only
projects implementing the Epicentre data tools were included, as the other data collection systems in
place (Typology, customised project databases, etc.) do not allow refinement of the programme activity
data. In the future, data collected through MINOS (cf. Health Informatics section, §2.2.) will also be
included in this section.
2. Data analysis
and Maternity and Intensive Therapeutic
58,855 inpatient admissions were reported
Feeding Centre (ITFC) admissions, repre-
(compared to 66,717 in 2011).
2.1. Typology –
overall activities
senting a modest increase of 4% compared
Based on the 2012 Typology data collection,
covering all OCB projects, 2,045,318 outpatient consultations were conducted, includ-
2.2. Epicentre
data tool analysis
2.2.1. OPD consultations
The 2012 distribution of OPD consultations
by country and as a proportion of the total
OPD consultations is indicated in figure 1.
ing consultations in the OPD (1,816,100),
The use of the Epicentre data tools is dis-
The highest proportion of OPD consultations
antenatal and postnatal consultations, family
cussed elsewhere in this report (cf. Health In-
reported through the Epicentre tools were in
planning consultations, Emergency Depart-
formatics section,§2.1.). A global summary of
Afghanistan (24%), followed by Niger (22%)
ment (ED) visits, etc., representing a de-
all data collected using the Epicentre tools is
and DRC (17%).
crease of 5% compared to 2011. In parallel,
presented in table 1 (annex): a total of
135,259 hospital admissions were regis-
1,095,373 outpatient consultations were reg-
2.2.2. IPD admissions
tered, including admissions to the IPD proper
istered (compared to 1,309,649 in 2011) and
The 2012 distribution of IPD admissions by
15
to 2011.
country as a proportion of the total IPD admissions is indicated in figure 2. The highest
Figure 1: Distribution of OCB OPD consultations by country in 2012
proportion of IPD admissions was observed
in Afghanistan (36%) followed by Niger
Sierra Leone 5%
(22%), DRC (15%) and Sierra Leone (15%).
North Sudan 3%
Afghanistan 24%
The proportion of adverse outcomes among
all exits is shown by country for 2012 (fig. 3).
For most countries, the proportion of discharges with medical agreement met the tar-
Niger 22%
get of > 85%, except in India and Afghanistan where it was respectively 82% and
80%.
The proportion of discharges without medi-
Mali 0%
cal agreement was under the acceptable
threshold of 10% in all the countries except
Kenya 11%
DRC 17%
India (15.1%) and in Afghanistan (13.5%),
though it was reduced by 50% in India and
by 9% in Afghanistan since 2011. The mor-
Haiti 6%
Ethiopia 3%
tality rate was higher than the acceptable
threshold of 5% in three countries: Sierra
Leone (8.0%), Afghanistan (6.4%) and Niger
(5.2%).
MEDICAL ACTIVITY REPORT 2012
India 5%
DRC: Democratic Republic of Congo
05. medical data
Bangladesh 4%
Figure 2: Distribution of OCB IPD admissions by country, 2012
Somaliland 1%
Sierra Leone 15%
North Sudan 1%
Afghanistan 36%
Niger 21%
Mali 0%
India 3%
Haiti 7%
DRC 15%
Ethiopia 1%
DRC: Democratic Republic of Congo
Figure 3: Proportion of adverse IPD outcomes (inpatient deaths, discharges without
medical agreement and defaulters) among all inpatients exits, by country, 2012
% Defaulters
% Deaths
05. medical data
MEDICAL ACTIVITY REPORT 2012
So
m
al
ila
on
Le
Si
er
ra
Su
th
or
nd
e
n
da
er
ig
N
Countries
DRC: Democratic Republic of Congo
N
i
al
M
a
di
In
ti
ai
H
ia
op
hi
Et
DR
ta
is
an
Af
gh
C
Accepted threshold ≤ 5%
n
Proportion adverse outcomes
16
% Discharges
100
90
80
70
60
50
40
30
20
10
0
MSF MEdical Department OCB
Biomedical
Equipment
1. Overview
With the substantial increases in the use of advanced medical equipment in OCB projects, the need
for technical support has concomitantly increased. Fortunately, to address this need, OCB reinforced the
Logistics back office in 2012 with two Biomedical Mobile Implementation Officers (MIOs). With the
organisational changes over recent years in all MSF sections, field support for biomedical equipment has
increased to currently include:
Operational Centre referents: a biomedical referent in OCB and all other centres (part-time in OCBA)
Supply centres: a biomedical engineer in MSF Supply and MSF Logistique
MIOs: two in OCB, three in OCP, one in OCG, and one likely to be added to OCA in 2013
Biomedical expats: one in Afghanistan (OCB)
The OCB Logistics department recruited two
MIOs to reinforce the support for biomedical
equipment. Coordinated by the Biomedical
referent (of the Medical Department), their
priorities are determined in collaboration between the Operations Department and the
documentation, and guidelines for all
equipment.
- Ensure that preventive maintenance is undertaken as recommended.
- Implement MSF standard tools (both softand hardware).
- Record and file all performed maintenances.
Logistics back office coordinator. These
A correct implementation of this system re-
MIOs are key in efforts to create and strength-
quires two initial field visits with a six months
en a biomedical equipment support system
interval to allow time for ordered materials to
for all missions with substantial complex
arrive, and annual follow-up visits.
medical equipment, with hospital projects as
the first priority. This support “system” is in-
2.2. Field visits
tended to:
A number of field visits providing technical
- Assure all users are familiar with the use
support were performed by the referent in
The two MIOs visited:
-The Gondama Referral Centre (GRC) in
Bo, Sierra Leone.
- The health structures of the Kabezi, Kirundo and Gitega projects in Burundi.
- The health structures of the Kabul, Kunduz
and Lashkar-Gah (Helmand) projects in Afghanistan.
- Burao hospital in Somaliland.
- The health structures of the Gogrial, Pibor
and Maban (Doro) projects in South Sudan.
3. Training and
human resources
Previously, a small biomedical module was
provided in the Preparation for Primary De-
and daily maintenance of their equipment,
2012 to the health structures of:
and provide training as needed.
- The AIDS project in Kinshasa, DRC – tech-
Courses (BLoC). In 2012, a more extensive
nical training for mission staff was also pro-
biomedical training course was developed.
vided.
Extending over five days, the training was in-
- Recruit and train technicians.
- Ensure correct installation of equipment.
- Manage the equipment inventory.
-Maintain stocks with sufficient backup
equipment, spare parts and consumables,
while ensuring that orders are completed.
- Kabezi and Gitega projects in Burundi.
-Martissant, Tabarre and the projects of
OCA/OCG/OCP in Haiti.
17
2.1. Technical support
- Maintain a library with manuals, supporting
parture (PPD) course and the Basic Logistics
tended mainly for national staff, but was designed for all technicians and supervisors
working with biomedical equipment in the
field. As a collaboration between OCA/OCB/
OCG, the course was provided three times in
both French and English during 2012. It has
proved to be successful, and the model will
06. Biomedical Equipment
2. Programme activities
be repeated in 2013.
MEDICAL ACTIVITY REPORT 2012
-
-
-
-
4. Looking back and ahead
Lessons learned for 2012
Due to the complexity of biomedical equipment in MSF projects, full support could not be provided in all cases, due to the lack of speciallytrained engineers equipped with the necessary, often expensive, parts and tools. Such complex medical equipment includes multiparameter
monitors, ultrasound machines, x-ray machines and other advanced laboratory equipment. In the case of x-ray machines and some
advanced laboratory equipment, transport to Europe for repairs is unfeasible, and local solutions must thus be sought. Results of such
local or regional interventions have been variable, and a systematic solution to this challenge has not yet been formulated. In particular,
several new x-ray machines have been installed over the last few years, many of which encountered problems that proved difficult and
time-consuming to resolve.
Prospects for 2013
The referent will focus field visits on HIV/TB projects to assess the current situation and investigate technical support from local companies.
The goal is to improve the provisioning of technical support in such missions.
Together with MSF Supply, the possibility of negotiating more advantageous contracts when purchasing equipment that needs
local support will be explored. For example purchase and service contracts with the “mother” company in Europe on equipment
that will be supported by local companies will be examined.
The implementation of Biomedical MIOs will hopefully significantly improve the existing biomedical equipment support after
MEDICAL ACTIVITY REPORT 2012
06. Biomedical Equipment
18
the first year. Results will be assessed after one year and future strategies will be developed accordingly.
MSF MEdical Department OCB
Emergency Medicine
1. Overview
The Emergency Department (ED) provides health care for outpatients requiring immediate assistance,
whether for a life-threatening condition (emergency) or a non-life threatening condition (urgency).
The services provided in the ED include initial triage, evaluation, diagnosis, stabilization, treatment
and observation of patients demanding immediate care. In most cases the department is integrated
into a hospital and has an essential relationship with other services in the health facility, such as surgery,
imaging and hospitalization. The department should operate 24 hours a day, seven days a week.
During 2012, ED activities continued to play an important role in OCB projects, as MSF continued to be
increasingly involved in secondary and tertiary level care settings. New EDs were opened during 2012 in
Haiti, Pakistan and Somalia.
Freestanding units are confronted with many
2.1 Activities at project
and mission level
other services needed for the continuity of
challenges, as they are not supported by the
patient care. Their staff needs to be well-
vided in 15 OCB projects across eight differ-
defined referral system needs to be in place.
2.3.1. Data collection
During 2012, ED data was collected with different tools, varying by country. By the end of
the year, six projects were using the stand-
ent countries: Afghanistan, Democratic Re-
In contrast, hospital-based EDs usually have
ardized individual-based data register devel-
public of Congo (DRC), Haiti, India, Pakistan,
a complete backup system, which includes
oped specially for the emergency depart-
Sierra Leone, Somalia and South Sudan (not
an operating theatre and hospitalization
ments (cf. Health Informatics section, §2.3.).
including emergency care given by the Emer-
wards, where quality care can be continued.
The use of this tool permits each project to
gency Pool projects).
In 2012, OCB had 13 projects with such a
better understand, monitor and evaluate its
setting. There are important differences be-
activities, while facilitating an overall com-
tween these EDs, as some receive general
parison of ED activities between different
emergencies where a wide range of patholo-
projects and countries. Most of the remaining
gies and patients are treated, while others
projects collected ED data with the standard
are specialized centres, such as the paediat-
MSF aggregated data tool, the Epicentre
ric emergency centre in Gondama Referral
tools (cf. Health Informatics section, §2.1.).
sultations were performed in regular projects
during the reported period (table 1, Annex).
The ED in Timurgara (Pakistan) had the highest patient caseload (76,310 consultations).
Centre (GRC) in Bo, Sierra Leone, or the
2.2. ED Structures
In most OCB projects with ED activities, the
ED is integrated into a hospital (hospitalbased Emergency Departments). By the end
trauma centres in Kunduz (Afghanistan) and
Tabarre (Haiti). The Tabarre centre also treats
other surgical emergencies.
ED indicators on the use of services and
quality of care, together with surveillance of
specific epidemiological markers, were incorporated into the logical frameworks of spe07. emergency medicine
A total of 219,146 emergency medicine con-
cific projects.
of 2012 only two EDs - Martissant in Haiti
and Karachi in Pakistan - were operating as
freestanding EDs.
Table 2: OCB emergency departments using the SATS system – priority category proportions during 2012
Country
Project ED
High acuity proportion
Percentage of red cases
Percentage of orange cases
Sierra Leone
Somalia
Kabul
Afghanistan
Kunduz
Martissant
Haiti
Tabarre
Karachi
Pakistan
Timergara
GRC - Bo
Burao
13.3
13.8
12.2
29.3
33.0
23.8
61.9
22.5
3.2
1.7
2.0
3.2
2.1
5.0
34.6
5.6
10.1
12.1
10.1
26.1
30.9
18.9
27.2
16.9
Percentage of yellow cases
39.9
47.3
42.0
61.9
63.1
36.7
25.6
41.4
Percentage of green cases
44.3
38.4
45.9
8.8
3.6
39.1
12.6
36.1
ED: emergency department; GRC: Gondama Referral Centre
MEDICAL ACTIVITY REPORT 2012
In 2012, emergency medical care was pro-
qualified to stabilize severe cases, and a well-
2.3. Specific activities
19
2. Programme activities
2.3.2. Triage
In 2011 the South African Triage Scale (SATS)
system was adopted by OCB and implemented for the first time in Timergara (Pakistan); by the end of 2012 this triage system
was already in place in eight OCB EDs. The
main objective of triage implementation is to
The GRC in Sierra Leone has the highest
as the medical coordinator course (MCC),
proportion of severe patients; 86% of pa-
management of health services (MHS), and
tients seen in this ED are children under five
the medical coordinators week. Specific
years of age.
training on mass casualty incidents (MCI) tri-
3. Human resources
and training
allow early identification of the sickest pa-
The ongoing challenges around human re-
tients, reduce patient mortality, and decrease
source capacity for emergency medicine
waiting times, thereby improving overall sat-
continued to be tackled through close col-
isfaction and quality of care.
laboration with the pool managers and re-
The SATS system permits the categorization
of patients into different priority groups (table
2): the red category indicates the most severe cases and the green category indicates
cruiters. Emergency medicine doctors are
clearly identified as a separate pool and the
profile for emergency medicine nurses is now
fully established.
patients that have no signs of emergency or
Emergency care in MSF continued to be pro-
priority and therefore are not urgent cases.
moted through internal training courses such
age was offered, and management and planning was provided successfully to several
groups. In collaboration with the Italian Resuscitation Council, a training workshop on
Immediate Life Support (ILS) adapted to field
needs was run in Haiti shortly before the
opening of Tabarre hospital. To respond to
the need for specific training in the management of severe patients, the Basic Assessment and Support of Seriously Ill Patients in
Developing Healthcare Systems (BASIC
DHS, cf. Intensive Care section, §3.) training
also took place in Haiti during 2012.
4. Looking back and ahead
Lessons learned for 2012
- To better understand and improve our emergency medicine activities, better monitoring and evaluation of these activities needs
to take place through the implementation of effective surveillance systems.
20
- Measures to ensure greater standardisation of care in our emergency departments need to continue in order to improve
the quality of care delivered.
Prospects for 2013
- The implementation of the data collection tool in the EDs will be further monitored and supported.
- The care provided in new EDs will be further standardised, and current recommendations for the running of these projects
will be assessed and revised where necessary.
- The OCB Toyota Land cruiser ambulance will be launched and its adequacy under field conditions (urban and rural settings)
will be evaluated.
- Expatriate staff will continue to be followed up by the emergency medicine referent.
- Relevant emergency care trainings will be included in the HQ training list and the international guidelines will be rendered
MEDICAL ACTIVITY REPORT 2012
07. emergency medicine
accessible and useful to field teams in differing contexts.
- The MSF catalogue will be updated for emergency care drugs and equipment.
MSF MEdical Department OCB
Emergency Unit 1. Overview
The emergency unit (E-Unit) oversees the direct management of emergency projects and supports
emergency interventions managed by the operational cells. In 2012, the E-Unit was active in
18 countries and was involved in 32 emergency interventions, exploratory missions (Explos) and/or
emergency preparedness interventions (Eprep). Of these, 18 were direct emergency interventions/
Explos and 14 involved support to cells in charge of emergency management, or human resources
(HR) support for regular projects in conflict contexts. Four Eprep activities were conducted during
the year.
Major interventions in 2012 were assistance to refugees in South Sudan, the Sahel intervention
(Mali and Mauritania) following the conflict in Mali, the malaria outbreak in DRC, the Syria intervention
and the cholera outbreak in Sierra Leone. Several of these are discussed in more detail below.
2.1. Emergency activities
in 2012
Managed by the E-Unit
Reason for intervention
Comments
Brazil
Illegal Haitian migrants
In collaboration with the Brazil office
Over the course of 2012, 32 interventions (di-
Philippines
Floods
Exploratory/short intervention
rect and support) were performed by the E-
Syria-Lebanon-Turkey
Conflict
Unit (table 1). These included management
Libya
Conflict
Handed over in February
of disease outbreaks, care for internally dis-
Mauritania
Refugees + nutrition
placed persons (IDP) due to conflicts and
Mali
Conflict + nutrition
natural disasters, care for refugees/migrants,
South Sudan
Measles
care for war wounded, and several nutritional
South Sudan
Refugees
emergencies related to IDP and refugees.
Sierra Leone
Cholera I
Sierra Leone
Cholera II
DRC
Malaria
Uganda
VHF – Marburg
Somalia
Nutrition - measles - cholera- IDP
Mogadishu and Guriel
2.2.1. Refugee intervention
in South Sudan
Support to cell
Malawi
Floods
Expertise
In November 2011, an intervention to assist
Guinea
Cholera
Tech support
refugees fleeing the Blue Nile State in Sudan
Uganda
VHF – Ebola I
Tech support & HR to OCBA
was initiated in Maban county, South Sudan:
DRC
VHF – Ebola II
Tech support & PUC-HR to OCBA
OCB worked in three refugee camps (Doro,
Brazil
Evaluation of emergencies
Tech support
Zimbabwe
Typhoid fever
Tech support
Belgium
Migrants
Support
Brazil
Emergency study/assessment
Tech support
Batil, and Jamam) in the region. The E-Unit
was involved in this intervention from May
2012 onward, to manage the new influx of
refugees at Batil camp and to complete the
set-up of activities at Doro camp. Comprehensive packages were provided in Batil and
Doro camps. The activities in Jamam camp
were handed over to OCA in June 2012 and
in Batil camp on the first of December. Mobile
clinics were set up from the beginning of
2012 to cover the new influx at the border
sites, performing a total of 3,620 consultations in 2012.
Eprep
South Sudan
War wounded
Sierra Leone
Cholera
Mali
War wounded and cholera
Mauritania
War wounded and cholera
DRC: Democratic Republic of Congo; Eprep: emergency preparedness; HR: human resources;
IDP: internally displaced persons; OCBA: Operational Centre Barcelona; PUC: Pool d’Urgences Congo;
VHF: viral haemorrhagic fever
08. emergency unit
2.2. Major emergency
response activities in 2012
21
Table 1: Emergency activities managed by the E-Unit (direct, support and Eprep),
November 2011 to October 2012
MEDICAL ACTIVITY REPORT 2012
2. Programme activities
Medical care, sexual and reproductive health
refugees (between 40,000 and 50,000 dur-
and antenatal care (ANC), a nutritional pro-
ing 2012).
gramme, a mass measles vaccination for children, a mental health component, and health
promotion activities were carried out at all
22
08. emergency unit
nou, with a total of 7,851 consultations
during the year.
- A nutritional survey in November to assess
the status of the children and their vaccina-
three sites. A total of 197,605 medical consul-
The intervention concerned four of the five
tations were performed at the three sites, the
districts of this region. The team worked in
majority at Doro camp. The top causes of
Ministry of Health (MoH) structures, opening
morbidity in the three camps were lower res-
(or re-opening) four Inpatient Therapeutic
piratory tract infections, malaria and diar-
Feeding Centres (ITFC, locally termed URE-
rhoea. 1,436 deliveries were performed, the
NI) and 16 Ambulatory Therapeutic Feeding
vast majority (83 %) at Doro, due to the lack of
Centres (ATFC, locally termed URENAS). The
time in building relationships with traditional
intervention treated in total 1,653 children
birth attendants at the other two camps be-
under five years of age, with a default rate of
fore those projects were handed over to
nearly 25%. The high rate of the defaulters
OCA. 12,061 ANC consultations were per-
was mainly due to the semi-nomadic nature
formed overall, and a total of 5,665 patients
of the populations treated. The intervention
were admitted to the malnutrition programme.
included several activities: the logistical set-
During the year, across several campaigns,
up of the areas for treating the malnourished,
83,613 measles vaccinations were provided
training and incentives for the MoH staff, and
to children between six months and 15 years
provisioning of medical and non-medical
Approximately 16,500 children were vacci-
of age. The Expanded Programme of Immu-
items for the activities. The activities were
nated for measles, and the intervention sup-
nisation (EPI – including BCG, tetanus, and
handed over to the MoH at the end of the
ported the routine MoH immunisation pro-
polio) was also offered in Doro camp, and in
year, as a nutritional crisis did not materialise
gramme with the standard vaccines. Health
Batil at the end of the year.
during the dry season.
promotion (HP) was very difficult to imple-
2.2.2. Sahel intervention
(Mali & Mauritania)
MEDICAL ACTIVITY REPORT 2012
2.2.2.1. Assaba nutritional intervention
(Mauritania)
- Support to the health centre in Bassikou-
Explos were conducted in Mauritania and
Mali following the food crisis first noted in
early 2012. A nutritional intervention was
mounted in the Assaba region of Mauritania
and in the Mopti region of Mali; these interventions were predominantly preparedness
measures in view of the worsening food crisis, rather than a full response to an existing
nutritional crisis.
2.2.2.2. Mbera refugee camp intervention
(Mauritania)
tion coverage (approximately 13% global
acute malnutrition (GAM) and less than
70% of measles coverage).
The three ATFC and the ITFC admitted a total
of 3,877 patients - an additional 297 cases
were enrolled at the ATFC of Fassala. Overall,
37% recovered fully, while a high default rate
of 48% was observed, due mainly to the
movements of the population and misunderstandings on the services offered. Several interventions were undertaken to improve the
default rate, and by the end of the year it had
been reduced to 20%.
ment, mainly due to a lack of qualified personnel during most of the year. Only nutritional screening and active research of
OCB initiated activities in Fassala village (the
defaulters was possible. A focus will need to
entry point for the refugees from Mali) on
be placed on improving the HP component
March 5th 2012, followed by activities in Mbera
in 2013.
camp itself. These activities included:
- Primary health care in the camp and in the
surrounding villages (five outpatient departments, ATFC’s and health posts for preventive activities: three in the camp and two in
the villages of Fassala and Mbera). In Fas-
MSF is continuing the above activities in
2013, and indeed, the arrival of new refugees
(approximately 70,000) in the camp in January has increased the need for more aid and
consequently for more HR.
A full medical intervention in Mali was pre-
sala, 17,243 consultations were performed
cipitated by the geopolitical events in the
during the year, while the three OPD’s of
country, when radical Islamist groups took
Mbera performed 60,207 consultations.
In response to the food crisis, a nutritional pro-
control of the north of the country after the
Respiratory tract infections and diarrhoea
gramme (supporting MoH structures) was im-
separatist MNLA Tuareg movement ousted
were the main pathologies for the outpa-
plemented in Mopti; during six months in 2012
the national army from the region (declaration
tient consultations; malaria was present for
there were 1,451 new admissions. The recov-
of the State of Azawad in April 2012). In the
only half of the year (seasonal from June to
ery rate was approximately 70%, with a de-
internal turmoil that followed, the Malian
November).
faulter rate of more than 25%. This was mainly
president was overthrown by another faction,
-Secondary health care in the camp of
and a transitional government was installed
Mbera (one hospital with an inpatient de-
in the south. These conflicts led OCB to in-
partment (IPD), maternity, and ITFC). The
tervene in the north in the Douentza district
IPD received 1,286 admissions, with a
(support to Gao hospital for a few weeks)
90.7% recovery rate. The maternity pro-
due to the deterioration of the health system,
vided 2,161 primary ANC consultations ,
degradation of the population’s nutrition and
1,426 follow-up consultations, and 465
health status and general problems of ac-
deliveries. OCB assisted in another 225
cess to health care.
deliveries in the Fassala health post and
Simultaneously, refugees fleeing the conflict
146 in the Bassikounou health centre.
2.2.2.3. Mali nutritional intervention
due to movement of the population, lack of a
decentralised system, and lack of access in
several areas because of flooding during the
rainy season. The average weight gain remained on target (7g/kg/day), as did the average length stay in the programme (36 days).
The main causes for morbidity at registration
at the ATFC were malaria (36.7%), respiratory tract infections (18.2%), and diarrhoea
(18.8%). Similarly, the main reasons for ad-
started to arrive in Mauritania; OCB inter-
- Planning for the opening of an emergency
mission to the ITFC were malaria (35.2%),
vened in the camp of Mbera in March to pro-
surgical unit in Bassikounou (completed in
diarrhoea (28.2%) and respiratory tract infec-
vide health care and nutritional support for
January 2013).
tions (19%).
Figure 1: Cholera cases in the Western Area of Sierra Leone, week 1-39, 2012 (MoH data)
Cases
CFR
Number of cases
1400
4,0
1200
5
1459
4,4
4,5
1200
1140
1240
4
1117
955
1000
800
3,5
903
3
757
2,2
660
2,5
621
600
1,6
400
1,2
189
200
1
2
3
4
5
6
7
8
9
1,5
1,0
0,6
25 45
11
0
1,3
2
476
1,3
1
0,5
0,4
0,2
Case Fatality Rate (CFR)
1600
0,5
0,3
0
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
Epidemiological weeks
2.2.2.4. Mali North intervention (conflict)
Figure 2: Case Fatality Rate at MSF Cholera Treatment Centres in Freetown-Sierra Leone, 2012
800
OCB activities were focused in the Douentza
700
OPD consultations were performed, where
28% of patients were children under five
years of age, and the main pathology seen
was malaria. The IPD, which had 12 beds,
2,6
500
400
1,6
258
300
2,5
422
1,6
1,5
200
100
3,0
602
428
2,0 2,0
1,5
271
0,6
78
1,0
0,4
0,2
0,4
99
0
0,5
0,0
wk28
wk29
wk30
wk31
wk32
wk33
wk34
wk35
wk36
wk37
wk38
Epidemiological weeks
had a total of 111 admissions with a mortality
rate of 3%. There were 240 primary antenatal
3,5
655
653
600
4,0
CFR
Even in those areas, the cases were sporadic
ted to the outbreak response. UNICEF and
and spread apart, well within the capacities
WHO were tangentially involved, but did not
of the primary health care units (PHUs). Thus
contribute concretely. In week 33, the presi-
the intervention in Port Loko was limited to a
dent declared a National Emergency, and the
donation of Eprep stock, and a short training
UK’s Department for International Develop-
on cholera preparedness for the District
ment (DFID) released two million GBP in week
2.2.3. Cholera intervention – Sierra Leone
Health Management Team.
34. This led to a much larger involvement from
Sierra Leone has had at least 10 document-
MSF was on the alert for the second cholera
consultations and 196 follow-ups, 38 postnatal consultations, 11 family planning consultations, and 96 deliveries with 94 live
births. Nutrition activities, which started late
in the year, saw 52 admissions.
ed cholera outbreaks since the seventh
world pandemic hit the African continent in
the 1970s. Outbreaks often occur during the
heavy rains (from May to October), which
cause flooding and contamination of water
sources. The disease is endemic in the border between Guinea and Sierra Leone, where
the coastal swamp guarantees a good environment for the survival of the Vibrio cholera
during non-epidemic periods.
The first signs of a diarrheal disease outbreak
in the country appeared in Freetown during
the latter half of 2011. A cholera outbreak
was officially declared for Port Loko and
Kambia Districts on February 27th 2012. An
OCB emergency team arrived in the country
on week eight to perform an assessment and
intervene if needed. The assessment of Port
Loko revealed a gross overestimation of the
number of cholera cases. The true cholera
outbreak declared in 2012, and was active in
the Cholera Task Force meetings at the Freetown level. The first suspected cases of cholera in Freetown were detected in week 25,
and V. cholera was confirmed by the MoH
Central Laboratory in week 28. Over the
course of the intervention (week 28-39), MSF
treated 47% of all the reported cases of cholera in the Western Area. At the peak of the
outbreak, during weeks 31-35, 56.6% of all
the patients were being treated at MSF structures (fig. 1).
The case fatality rate (CFR) followed the usual
trend in a cholera intervention. It was high at
the beginning because the local staff were inexperienced and were probably overwhelmed
by the number of cases. The CFR gradually
dropped to acceptable levels, only to increase
again slightly (two deaths) at the end of the
intervention (fig. 2).
23
last three months of the year. In total, 4,760
Cases
811
different actors, and the creation of more task
forces (Cholera Coordination Command Centre, Presidential Task Force on Cholera). There
was a widespread call for funds from the government, the WHO and several NGOs, based
on what has turned out to be an overestimation of the predicted number of cases.
MSF remained the sole non-governmental
actor in case management in Freetown until
the arrival of Save the Children in week 36,
who concentrated on Oral Rehydration Solution (ORS) points and supporting Connaught
Hospital. With the release in funds, other water, sanitation, and hygiene (WaSH) actors
08. emergency unit
three first level health structures) during the
3,3
758
joined ACF in community WaSH activities
(bucket chlorination, HP, distribution of
household water treatment kits). Outside of
Freetown, many NGOs started becoming involved in case management, health promotion and WaSH activities, though the degrees
of operationality varied. The presence of
cases were probably concentrated in com-
During the first month of the Freetown out-
these other actors in almost all the districts
munities along the coast and the border with
break, the MoH, MSF and Action Contre la
led OCB to concentrate its activities in Free-
Kambia.
Faim (ACF) were the only actors fully commit-
town and Bo.
MEDICAL ACTIVITY REPORT 2012
area (one second level health structure and
3,8
Case Fatality Rate (CFR)
900
hospital (mainly with medicines and HR),
Number of cases
In 2012, after one month supporting the Gao
The nationwide response was initially coordinated by the Directorate of Disease Prevention and Control (DPC)-led Cholera Task
Force, but coordination was passed in week
34 to the Cholera Coordination Command
Centre, chaired jointly by the DPC and WHO.
UNICEF provided the majority of the case
management supplies outside of MSF structures, which they distributed through the
MoH’s Central Medical Stores.
2.3. Emergency preparedness
Eprep training was performed throughout the
year in several countries, most notably in India. Additionally, an “assessment training”
was done for the regional network in Asia
(Hong Kong). The E-Unit continued to support the ongoing Eprep training in South
Lebanon.
In South Sudan, following possible scenarios
of conflict, the E-Unit completed an Eprep for
war wounded in Juba. In Sierra Leone after
the cholera intervention, an Eprep team was
left to cover the needs in the region. In Mali
and Mauritania, Epreps were done to cover
the possible scenarios of war wounded and
cholera.
3. Human resources
and training
- The VHF full kit is ready to be sent on re-
The E-Unit has three permanent emergency
- An IT kit was finalised, and will be pro-
coordinators and three permanent support
staff (HR, logistics/supply and finance). Increased support was required in 2012 for the
Syria and South Sudan interventions (emergency coordinator and HR/Finance support).
The number of field emergency coordinators
(medical and non-medical) remained at
around 15 throughout the year .
There were more than 350 departures under
quest.
duced. Two units are in stock.
- A hospital electricity kit was finalised, produced, and is in stock.
- An energy kit was finalised, production is
ongoing, and it will be in stock by the end
of 2013.
- The development of the boat kit is ongoing
and is to be finalised in 2013.
E-Unit interventions (from the first of January
- The mobile surgery/anaesthesia kit list is
to the end of October). The main issue during
completed, but must still be checked and
2012 was the lack of experienced staff for
HR allocated to work on the production of
the Sahel interventions (only non-European
a prototype. It is to be finalised in 2013.
passports were allowed for security reasons).
- The mobile HP Kit was finalised, produc-
Another issue was the high turnover in the
tion is ongoing, and will soon be in stock in
intervention in Maban (fatigue and sickness
the emergency unit.
during the first two months of the Batil intervention).
4. New developments
and innovations
New developments in 2012 included:
- A telecom kit was finalised, but not yet
produced.
- The simplification of the protocols to accommodate the low level of the local staff
in the Sahel has been completed for hygiene and women’s health.
- External trainings were conducted of Medical Focal Persons (MFP) by a Mobile Implementation Officer (MIO) for paediatric
issues during the Sahel intervention, and
24
the use of the E-learning was implemented
for nutrition training.
5. Looking back and ahead
Lessons learned for 2012
A number of specific lessons were drawn from field interventions:
- The Eprep training and implementation support continued to show its added value in the field for emergency interventions.
An added value is also clear in countries where a conflict scenario is highly possible (as in South Sudan).
- The organisation and centralisation of documentation, planned the previous year, was not realised – the optimal way forward
will be further considered in 2013.
08. emergency unit
- In order to continue to improve security, training and improvement of the tools of the emergency field coordinators is required.
- Operational research is possible during emergencies (as was done in Maban), but it must be taken into account that this requires time.
Thus, operational research is good for innovation, but not for the emergency intervention in itself.
- The intervention in Maban was started late by the E-Unit. More discussion is needed within the emergency cell and by
the direction to understand how to better prepare for these kinds of needs.
- Concerning communication, there was a good follow up by the communication officers during emergencies throughout the year
MEDICAL ACTIVITY REPORT 2012
and there was valuable flexibility from both sides on media needs and a general capability to cover this. However, the capacity
of the E-Unit capacity to provide data, testimonies and operation updates for communication needs to be improved.
Prospects for 2013
- The training/support for Eprep will be continued, in particular in contexts where emergency scenarios may be anticipated.
- The collaborations with external specialists (Orthopaedist International Association, Renal Disaster Relief Task Force,
Handicap International, Disaster Epidemiology Centre) will be continued and contacts have been made with the International
Spinal Cord Society.
- The ongoing training for the installation of the modular field hospital (MFH) will be continued. Scenarios for use of the MFH
and logistic adaptation of the supplies (priorities and simplification of delivery) still need to be finalised.
- The mobile surgery/anaesthesia kit will be finalised.
- The development of protocols for burn care within the Medical Department will be followed up and the possibility
for a kit for burn care in emergency interventions will be examined.
- The collaboration with the Pool d’Urgence Congo (PUC) will be continued.
- Continue the close interaction with the Rio Office (Brazil) in terms of HR (2 positions open for Emergency coordination in Rio)
and support of the general overview on emergency assessment.
- The level of 10-15 mobile team members will be maintained throughout 2013.
- The preparation of the E-coordinators on security and risk analysis management will be continued.
- HR will identify an African expat for a coordination position and mentor/prepare them.
- Better mapping possibilities will be evaluated and put in place in emergencies .
- Proper media briefing and media training to all the E-Unit staff need to be provided.
- New satellite devices and technologies (e.g. geolocalisation) are being explored.
- The contents of the emergency stock need to be reassessed with the revision of scenarios and protocols.
- An assessment of new modes of emergency transport needs to be performed.
- New telecom devices such as the telecom kit will be deployed, and research will be conducted in this area.
25
- An assessment with the technical department of new kinds of shelters (e.g., Delta Wood) will be performed.
- The “Emergency Boat” will be finalised.
MEDICAL ACTIVITY REPORT 2012
08. emergency unit
- The development of Extranet MSF Supply for the Emergency Pool will be continued.
MSF MEdical Department OCB
Epidemiology
Epicentre
1. Overview
Epicentre epidemiological studies aim at providing MSF with practical evidence to improve its
interventions and medical care in general. Results may also be used to support advocacy in the
scientific community or with local and national authorities. The Epicentre scientific team is composed of
epidemiologists and statisticians. Two epidemiologists are integrated into the OCB medical department
(in the Operational Research and Disease Control Units), in order to enhance communication, facilitate
new ideas to emerge and allow research projects to be implemented.
2. Activities
2.1. Research in emergency
settings
Epicentre epidemiologists participated in
several OCB field interventions in 2012 (table
26
1). The compilation of the medical data that
tion. The Department of Clinical Research
pact of a pneumococcal vaccine (PCV) mass
focuses specifically on HIV/AIDS, tuberculo-
vaccination (target population: birth to 14
sis, malaria and neglected diseases. During
years) with administration of reduced dosag-
2012, OCB collaborated in a number of
es among infants. This strategy is expected
these research activities.
to achieve a rapid reduction in transmission
2.2.1. Vaccine preventable diseases
09. Epidemiology/Epicentre
gencies and settings where routine vaccina-
started in 2011 for all of the MSF projects lo-
In early 2010, a surveillance system was put
tion is failing. In 2012, a trial site was identi-
cated in the Horn of Africa continued until
in place in Niger in the Maradi region and in
fied in southwestern Uganda. The study
week 10 in 2012. These data were updated
Niamey, in order to assess the burden of ro-
planning has been progressing well, with the
and shared with all Operational Centres on a
tavirus and to provide a profile of diarrhoeal
objective of implementing this trial by the end
weekly basis. In March 2012, Epicentre col-
disease in children less than five years of age.
of 2013.
lected and analysed spatial data to guide the
During the two first years of surveillance (up
until March 2012), 10,600 children were in-
In 2011, Epicentre continued its ongoing col-
OCB response to an outbreak of typhoid fever ongoing in Harare, Zimbabwe. In July,
cluded in the study and 30% were found to
Epicentre investigated and mapped a chol-
be positive for rotavirus. The G2P[4] geno-
era outbreak in Freetown, Sierra Leone. Also,
type was predominant during the first year
Epicentre supported OCB interventions in
and there was a complete switch to G12P[8]
Batil refugee camp, South Sudan, by con-
during the second year. Publications are in
ducting a nutrition and retrospective mortality
preparation. The surveillance is now ongoing
survey, and reinforcing the surveillance sys-
in a subgroup of sentinel sites, with a more
tem in place during the hepatitis E outbreak.
important focus on the links between rotavirus and malnutrition. These data provide an
2.2. Summary of other
research conducted in 2012
important baseline prior to introduction of a
The key research areas for the Department of
The deployment of new and under-utilized
Epidemiology and Population Health (within
vaccines in crisis settings is recognized as a
Epicentre) are vaccine-preventable diseases,
top priority for MSF. In this vein, MSF plans to
diarrhoeal diseases, mental health, and nutri-
conduct a trial aimed at investigating the im-
laboration with OCB in responding to measles outbreaks against the backdrop of a
changing epidemiological profile for measles.
A publication on the lessons and challenges
for measles control from the unexpected
2010 large outbreak in Malawi was accepted
for publication in 2012 (Minetti et al, Emerg
Infect Dis, 2013).
2.2.2. Nutrition
Several scientific studies investigating the
rotavirus vaccine.
preventive distribution of Ready-to-Use Supplementary food (RUSF) to children in Niger,
as well as on the intra-household use and
acceptability of RUSF, were completed and
published this year (Grellety et al, PLoS One,
2012; Cohuet et al, Appetite 2012).
Epicentre conducted a secondary analysis of
Table 1: Epicentre/OCB field interventions in 2012
MEDICAL ACTIVITY REPORT 2012
and disease burden, critical for acute emer-
Country/project
Intervention
Topic
Horn of Africa
Surveillance system and weekly data compilation
of all sections
Complex emergency
Zimbabwe
Outbreak investigation: mapping
Typhoid
Haiti
Harmonization of the intersection surveillance system
Cholera
Sierra Leone
Outbreak investigation: mapping
Cholera
South Sudan
Survey
Nutrition and mortality
South Sudan
Outbreak investigation and case-cohort study
Hepatitis E
204 MSF nutritional surveys, including 39
surveys from OCB. The aim was to describe
the relationship between different indices of
prevalence of global and severe acute malnutrition (including mid-upper-arm circumference and weight-for-height). The final report
was sent to the Nutrition Working Group for
review in October 2012 and further work is
planned for 2013.
sis and the final report are expected in 2013.
2.4. Niger research base
During 2012, OCB continued to support the
Epicentre research base in Niger. The studies
patients treated in MSF HIV programmes.
The study examining the field efficacy of
in progress included an ambitious project
The database came from various MSF Afri-
ACTs (artesunate-amodiaquine, dihydroarte-
conducted in partnership with the World
can and Asian HIV/AIDS projects, including
misinin-piperaquine and artemether-lume-
Food Program (WFP), aimed at comparing
those from OCB. An article is in preparation.
fantrine combination therapies) for the treat-
different food distribution strategies to pre-
ment of uncomplicated malaria in children
vent malnutrition. Other studies focused on i)
aged 6 to 59 months entered in a pilot phase
the burden of rotavirus (cf. §2.2.1.), ii) the
in Maradi (Niger) in 2012. Inclusions will start
transcultural validation of a screening tool for
in 2013 and will last for one year.
mental health distress in children from 3 to 6
Mbongolwane (Eshowe, Uthungulu District,
The protocol of a trial aiming to compare the
year-old, iii) support to epidemiologic and
Kwazulu Natal, South Africa). In 2012, the
efficacy of artesunate amodiaquine and ar-
laboratory surveillance (including meningitis
study protocol was submitted to local and
tesunate lumefantrine fixed combinations in
and influenza), iv) a preliminary study on the
international ethics committees. The study
malnourished children was delayed in 2012
molecular resistance and potential use of
will start in 2013, as soon as official authori-
but progress is expected in 2013.
ACT (sulfadoxine-pyrimethamine) for sea-
Epicentre plans to conduct a populationbased study to assess the HIV prevalence
and incidence, and the programme coverage
in support of the scaling-up OCB project in
sations are obtained, and will last approxi-
sonal malaria chemoprevention in children,
mately three months. When repeated over
2.2.5. Miscellaneous
time, such a study allows the monitoring of
The laboratory working group, with the sup-
the dynamics of an HIV epidemic under real
port of Epicentre, is developing a study pro-
conditions.
tocol for a laboratory-based phase 2 evalua-
Supported by Epicentre, an MSF intersec-
tion of a handheld creatinin analyzer (Nova
tional study to evaluate the performance of
new and currently used rapid diagnostic
tests for HIV in five African countries started
StatSensor® XpressTM Creatinine), which
seems suitable for MSF settings. This evaluation is planned in collaboration with the Uni-
as well as v) the field efficacy of ACTs (artesunate-amodiaquine, dihydroartemisinin-piperaquine and artemether-lumefantrine combination therapies) for the treatment of
uncomplicated malaria in children aged 6 to
59 months.
2.5. Miscellaneous
Members of Epicentre were involved in pre-
in 2011. One OCB (Conakry, Guinea) site
versity Medical Center, Utrecht, Netherlands.
was included in this multicentric study. The
The results of the evaluation of a rapid test for
inclusions were finished in 2012 in three
the diagnosis of cholera in the absence of a
sites, including the Guinea site where all pos-
gold standard have been published (Page et
itive and negative specimens showed con-
al, PLoS One, 2012) as well as results on the
cordant results. The study is ongoing in two
early prediction of treatment efficacy in sec-
other sites. Final results are expected for
ond-stage Gambiense human African trypa-
2013.
nosomiasis (Priotto et al, PLoS Negl Trop Dis,
Finally, the yearly “FUCHIA bulletins” were re-
2012).
in Precarious Situations (PSP) courses and
2.3. FUCHIA updates
courses which were attended by staff from all
leased, providing a standardised descriptive
analysis of HIV-infected patient outcomes for
all OCB HIV projects, both by project and
The last FUCHIA version (1.7.1) was finally
globally.
released in November 2012. This version incorporates the developments decided on in
2.2.4. Malaria
2011. It includes the Prevention of Mother-
The study on the time required for three ma-
To-Child Transmission (PMTCT) report in line
laria rapid diagnostic tests (RDTs) to become
negative after successful treatment in children under five years of age was completed
in the site of Kazo, Mbarara district, Uganda
(high malaria transmission, 212 patients recruited as per protocol). Results were presented in May 2012. In the site of Kakiika
with the World Health Organisation (WHO)
recommendations, and an updated user
guide in English and French. The FUCHIA
helpdesk continued to provide regular technical support to all projects where a FUCHIA
monitoring system was implemented during
2011.
senting and participating in internal (including
working groups) and international meetings
on the different themes discussed in §2.2
27
analyses on the tuberculosis outcomes of
will be completed in early 2013. Data analy-
and 2.1.
3. Training
During 2012, Epicentre ran two Populations
two Responding to Epidemics (REPEPI)
MSF sections including OCB. The PSP
course that took place in Frascati, Rome,
was run by OCB. In 2012, Epicentre started
reviewing the content of the PSP, taking into
account the recommendations of the global
PSP evaluation of 2011. OCB staff also attended a “Training of Trainers “ organized by
Epicentre in Paris. OCB ran a “Responding
to emergencies” course for OCB regional
staff in Manila, the Philippines. Finally, Epicentre provided support to the “WatSan in
emergencies” training organised by OCB in
09. Epidemiology/Epicentre
In 2012, Epicentre conducted multi-centric
(low malaria transmission), the recruitment
Brussels and during the Nutrition and Vaccination training (“Nut-Vacci”).
MEDICAL ACTIVITY REPORT 2012
2.2.3. HIV
4. Looking back and ahead
Lessons learned for 2012
One of the main challenges in 2012 was to ensure better dissemination of study results to the OCB Operations and Medical
departments. Towards that objective, several meetings were organised in the offices of OCB during which Epicentre epidemiologists
presented the results of their recent studies on rotavirus, nutrition, measles, typhoid fever as well as on a new framework for use of
vaccination during emergencies. These meetings appeared useful and well appreciated. In 2012, Epicentre also extended its collaboration
with OCB to the field of HIV/AIDS research.
Prospects for 2013
In 2013, Epicentre aims to continue to organise meetings within OCB in order to ensure the dissemination of recent study results
to the Medical and Operations departments. Epicentre also plans to organize two PSP courses with a reviewed content based
on the recommendations of the 2011 evaluation. And, as usual, Epicentre will concentrate efforts to improve its interaction,
MEDICAL ACTIVITY REPORT 2012
09. Epidemiology/Epicentre
28
communication and collaboration with OCB partners both in the field and at headquarters.
MSF MEdical Department OCB
Evaluation
Unit
1. Overview
The Stockholm Evaluation Unit (SEU) was established as a pilot project in 2010 with the objective to
institutionalise evaluations within OCB and standardise the evaluation process. Following the pilot phase,
the project has continued in 2012 as the SEU, under the direct responsibility of MSF Sweden. The unit aims
to provide a credible capacity to manage evaluations on behalf of OCB and other sections and to contribute
to developing a methodology that can help to measure the medical humanitarian impact of MSF. More
than twenty evaluations and reviews were completed by the SEU and they are available throughout the
movement alongside those managed by other sections. Together, they provide a useful source of information
which can help inform future decisions and choices.
During 2012, the SEU managed three evaluations or reviews as well as supporting two
others (one for the international office), finalising two from 2011 and planning two for
2013. The three direct evaluations performed
in 2012 were : 1) a planned evaluation on behalf of a donor; 2) a review of a training initiative; and 3) a routine evaluation of a largescale
emergency
intervention
(table
1,
Annex).
formalised their collaboration with a view to
since there are only a few evaluations be-
share findings, amplify learning, and avoid
ing carried out. As a consequence, many
duplications and inefficiencies. The group
members of the pool are not available
worked together on a number of initiatives
when needed.
including training, the inter-sectional evaluation day and evaluations on request of the
international platforms.
4. Human resources
and training
-The international pool of evaluators has
been further reinforced during the year
3. Innovations
and collaborations
with a course held in April for 20 new pool
In 2012 the four evaluation entities within
different profiles. However, at any one
MSF (Paris, Athens, Vienna, and Stockholm)
time, only a few members are at work,
members. The international pool consists
of more than 200 potential candidates with
- All evaluations carried out in 2012 were
carried out by consultants with an MSF
background. Despite slightly higher financial costs, the use of consultants has
proved itself to be more efficient and effective in the long run.
29
2. Programme activities
- Despite planning additional capacity within
the unit in 2012, the plan did not develop
due to the last-minute withdrawal of the
candidate chosen for the position of Evaluation Officer.
5. Looking back and ahead
- Following the high workload of 2011 and the subsequent (reported) lack of quality, expectations were reduced for 2012:
only four to six reviews or evaluations were planned. However, this lower target was still not met, in part due to the number of requests
which was slightly lower than expected, and in part because of challenges associated with workload bottlenecks due
to the annual planning cycle.
- The (perceived lack of) usefulness of the evaluations remained one of the major challenges for the unit. The process invariably
10. Evaluation unit
Lessons learned for 2012
failed to produce the expected “new” information, leaving stakeholders feeling that the process had not delivered results. Despite this,
In the majority of cases, recommendations were either implemented or reflected changes already made. In the small number of cases
where they were not, recommendations provided a useful orientation for discussion and debate.
MEDICAL ACTIVITY REPORT 2012
the process itself still proved to be useful, offering a formal moment of reflection and providing a tool for incremental learning.
Prospects for 2013
- With between eight to ten evaluations and reviews proposed for the coming year, the output of 2013 will likely pick up again after
the relatively limited outputs of 2012. Also, the issue of the planning cycle will be overcome, with an additional focus on planning activities
for the coming 18 months and beyond.
- The SEU will continue to invest in and support the intersectional training course for evaluators, with a view to developing a basic level
of skills and knowledge for all those involved in commissioning and using evaluations as part of operational management.
- Investment in the evaluator pool will be reduced in favour of using “external” evaluators on a consultancy basis and pairing
them with “internal” MSF evaluators. The use of external consultants should help improve the objectivity of the evaluation
process and reduce the potential bias in recommendations and results.
- Increased collaboration will be explored with other units of OCB, in order to capitalise on experience and expertise as well as amplify
the learning process and maintain efficiency. International collaboration will be further developed and strengthened,
and renewing the collaborations with other operational centres will be a priority.
- Streamlining systems for sharing and dissemination will be a continued priority, with an additional focus on the follow-up and use
of results and recommendations. Broader, long-term learning initiatives will also be developed.
- ”Making evaluations work for us” will be the focus for 2013, particularly with regards to methodology and approach. There is a need
MEDICAL ACTIVITY REPORT 2012
10. Evaluation unit
30
to look beyond the evaluation of output towards a more robust measurement of the impact on the medical humanitarian intervention.
MSF MEdical Department OCB
Health
Informatics
1. Overview
Improving the data management process at field level remained a core activity. Unfortunately, even though
the policy of briefings at OCB headquarters (HQ) changed during 2012, some epidemiologists went to the
field without passing by HQ. However, some countries (Burundi, DRC) have been visited by the OCB Data
Officer to support and train the field staff with the goal of improving the overall data quality.
Within OCB, two main tools exist for the standardised monitoring and reporting of general medical
programme data. The most frequently used is the Epicentre tool for data involving outpatient and inpatient
departments and gynaecology/obstetrics services (OPD/IPD/Gynobs tools). More recently, the Medical
Information Network for Operational Support (MINOS) was introduced – this is a system designed in-house
for the collection, storage, transmission, analysis, and reporting of medical service data. This system
currently handles the data generated by the most common MSF services: OPD, IPD, sexual and
reproductive health services, and therapeutic feeding centres.
The Epicentre tools were used in 12 missions, which represents 86% of the missions which were supposed
to implement the tools (14). MINOS was expanded from two missions to five, and eight projects reported
their 2012 data through MINOS during the annual data collection. For all other missions/projects, the annual
data was collected through the International Typology data request, which was again synchronised with all
other medical data requests to the field.
2. OCB routine data tools
2.1. Epicentre tools
Of the 73 OCB projects reporting medical
The use of the Epitools remained relatively
data, eight were using MINOS as main data
stable, with 12 out of 14 missions (86%)
reporting tool by the end of 2012 and 21
which were supposed to implement the
were using the Epicentre tools (fig. 1). The
Epitools actually using them, vs. the 88% in
projects using neither of the two were mainly
2011. Their use was well accepted in the
vertical projects (HIV/Tuberculosis (TB), sexu-
field.
ventions – refugee care in Maban (South
Sudan) and Mali – also used MINOS and the
Epicentre tools. Among the 1,816,100 general OPD consultations (i.e. disregarding
ante- and postnatal care and family planning
consultations), 61% were reported through
Over the course of 2012, the recurrent chal-
Other
21%
MINOS
19%
Epitools
60%
lenge of the Epicentre tools of their inability to
aggregate data across different tools was finally addressed: a sum-up tool was generatEpitools
ed which can aggregate OPD/IPD/GynObs
Figure 1: Main data tools per OCB project,
end 2012 (n=73)
the Epicentre tools and 18% through MINOS
MINOS
Figure 3: OCB data reporting tool for IPD admissions,
2012 (n=73,210)
Other
8%
Epitools
29%
(fig. 2). Following approximately the same
Other
MINOS
11%
trend, among the 73,210 general IPD admissions (i.e. disregarding admissions to inpatient therapeutic feeding centres (ITFC) and
maternity admissions), 81% were reported
through the Epicentre tools and 11% through
MINOS (fig. 3).
Other
60%
MINOS
11%
Epitools
MINOS
Other
11. health informatics
ventions; two of the major emergency inter-
Figure 2: OCB data reporting tool for OPD
consultations, 2012 (n=1,816,100)
Epitools
81%
Epitools
MINOS
Other
MEDICAL ACTIVITY REPORT 2012
al violence, etc.) and minor emergency inter-
31
Emergencies, vertical projects and smaller-sized projects tended to collect and report data through
customised databases. Additionally, a number of dedicated databases on specific activities (sexual violence,
neonatology, etc.) were implemented in a number of projects.
data across up to 20 different datasets, which
guage for the user interface. This will also al-
face; develop a fuller change management
will save a large amount of manual work of
low for the expansion of MINOS into other
strategy; and increase resources devoted
aggregation. Additionally, the quality of the
francophone countries in 2013.
to the project. These recommendations
Epicentre tools was further improved by al-
One of the limitations of MINOS often cited in
lowing them to collect the data for years of 53
weeks, which was previously impossible.
NOS data (cf. §2.2.), provided the basis for
tools have provided graphical and tabular
Dedicated databases for the monitoring of
most of the data analyses presented in this
display of several indicators simultaneously,
vertical HIV/TB projects and specific activi-
Medical Activity Report, most notably the
which has been of great value to the field. To
ties such as mental health, nutrition, surgery,
sections on Malaria, Medical Structures,
add this capacity to MINOS, the business in-
etc. are discussed in the relevant sections. Of
Paediatric Care, Sexual and Reproductive
telligence reporting tool (BIRT) was integrat-
note, several new databases collecting data
Health and Vaccination.
ed into the software. This will allow simulta-
at the individual level and designed at HQ
neous display of a previously defined
were introduced/piloted over the course of
selection of indicators. Report formats have
2012:
been designed for therapeutic feeding pro-
- A database on sexual and gender-based
grammes, antenatal care, and ambulatory
violence, implemented in Masisi and Nian-
As stated above, MINOS handles the aggre-
primary care. This capacity is now a part of
gara (DRC), Nasr City (Egypt), and Kibera
gated data of most standard MSF services.
version 2.0 of the software - though a fuller
(Kenya).
For these services, MINOS produces and
range of report formats will be needed for this
displays the standard project monitoring and
capacity to be fully exploited.
epidemiologic surveillance indicators. These
- A neonatal database, implemented in Ahmad Shah Baba, Lashkar-Gah and Khost
indicators show the use of MSF medical ser-
2.2.4. Evaluation
(Afghanistan); Masisi (DRC); Dakoro and
vices by the beneficiaries, the quality of those
During 2012, an invited external evaluation of
services, and the trends of the occurrence of
MINOS was carried out by the Centres for
Referral Centre (GRC) in Bo (Sierra Leone).
diseases of operational interest. The scope
Disease Control (CDC) Public Health Infor-
of MINOS is the production of these indica-
matics Fellowship Program. After several tel-
tors.
econferences and reviewing available docu-
Project data requires exportation from field da-
mentation
tabases, transmission to the capital and HQ,
conducted a site visit over the course of one
and importation into the HQ databases. Auto-
week to interview staff at OCB HQ. The eval-
mation of this manual process has been post-
uators’ conclusions were that: poned to allow concentration of developer re-
- MINOS has great potential as a key sys-
sources on higher priority tasks. Nevertheless,
tem in the emerging information system
the process is simple enough that field data
enterprise within OCB. It also has the po-
are made quickly available to HQ and mission
tential to be a major force in the field of
coordination staff.
public health and disaster informatics.
2.2.2. Implementation
At the beginning of 2012, MINOS was only
implemented in one project in Pakistan and
in two projects in South Sudan. A Mobile Implementation Officer (MIO) was engaged to
facilitate MINOS implementation in the field.
Over the course of the year, MINOS was expanded in South Sudan and Pakistan to
on
MINOS
two
evaluators
Guidan Roumdji (Niger); and the Gondama
- An Emergency Room database (cf. Emergency Medicine section, §2.3.1.), piloted
in Kunduz (Afghanistan), Martissant and
Tabarre (Haiti), Karachi (Pakistan), the GRC
(Sierra Leone), and Burao (Somaliland).
2.4. Typology
All routine programme data not reported
through the Epicentre tools, MINOS or a
dedicated database were collected directly in
the annual Typology data compilation. The
Typology represents an initiative by the MSF
International Office that collects a set of inter-
- It however needs more investment in its
sectionally agreed indicators, aggregated per
development and field implementation to
year. In OCB, a number of important pro-
drive its use, and clearly demonstrate its
gramme indicators are integrated into the an-
operational and organisational value.
nual Typology data collection, in order to
- The use of good quality information (that
streamline the process and not overburden
MINOS can provide) by OCB and the MSF
the field with multiple data requests. For
movement supports its culture of open-
most missions this process went smoothly –
ness and accountability.
however, some vertical projects (notably the
cover the remaining projects. MINOS was
- Balancing the varying demands of stake-
also initiated in Somaliland, Egypt, and DRC.
holders and delivering value across the
OCB represents the next phase in the life-
MEDICAL ACTIVITY REPORT 2012
2.3. Other data tools
how this indicator might be displayed. Past
2.2.1. MINOS background
32
at a time - allowing the user great flexibility in
for 2013.
The Epicentre tools, supplemented with MI-
2.2. MINOS
11. health informatics
2012 was its design to deliver one indicator
have been incorporated into the planning
2.2.3. New developments
cycle of MINOS, and institutional support
A necessary expansion for MINOS imple-
is necessary for its success.
mentation in DRC was adding the ability to
- Recommendations were to: add software
select either French or English as the lan-
testing capacity; improve the user inter-
HIV projects) and missions which underwent
a transition of data system over the course of
the year experienced some difficulties in supplying complete data. As a consequence,
minor differences may occur between different versions of the annual data.
3. Looking back and ahead
Lessons learned for 2012
- The implementation of the Epicentre tools has been well accepted in the field, but the quality of data needs still to be improved.
Field staff need to be encouraged to improve quality of data collection and, in particular, to use these data to monitor their
respective projects. Data management should not be perceived as an exercise in sending data to HQ.
- The overhaul of the Epicentre tools in 2012 answered to the needs expressed in the field, allowing aggregation of data from
multiple tools of a single project and collection of data for the years with 53 weeks.
- The installation of MINOS in the emergency intervention in Maban (South Sudan) was not without complications. The high rate of turnover
in this project rapidly replaced the experienced users who were trained at implementation, and newcomers did not have experience with
this novel tool, nor was there a sufficient handover. The ensuing burden of learning a new tool added to the already high workload on the
team in the field. It may thus be better to postpone deployment to emergency contexts until the expanded use in more routine missions
has created a “MINOS culture”.
- Turnover as a cause of loss of competence is not limited to emergency projects. The implementation procedures used in 2012 focused
on the training of data managers and a limited set of supervisors. In a couple of contexts, the departure of these individuals caused a
significant decline in the ability of the mission to make use of MINOS. Future implementation will need to target a broader user base as
well as assuring a local mechanism of training that ensures continuity of competence.
- The transition between data management tools is easiest at the change of calendar years. The end of 2012 was no exception,
with both DRC and Afghanistan requesting MINOS implementation at that time. This problem can be avoided in the future
by better planning and facilitating mid-year transitions - e.g. by allowing for the migration of data collected earlier in the year.
- A number of bugs in MINOS were reported over 2012. This is an understandable consequence of having to deploy software before
it had been fully tested. The discovery of bugs and the need for testing has been taking into account in the planning for 2013.
- The quality of data depends on the good links between the medical department, the medical polyvalents, the medical coordinators and
the staff in the field. When everybody in the network understands the importance of data for project monitoring, data collection will
33
become easier and the quality of the collected data is likely to improve. This will continue to be our challenge in the future.
Prospects for 2013
- In 2013, emphasis will continue to be placed on the use of the Epicentre tools in settings where MINOS is not available.
Briefings of new medical polyvalents, expatriates going to the field, and during trainings and field visits will be conducted as usual.
- Discussions will be held on the possibility for regional data collection trainings of epidemiologists and database technicians
in the field, to understand what the data quality problems are and how to solve them.
- MINOS has been selected as one of the ten projects in OCB to be organised and supported by standardised project
management methodology. This will involve the creation of a steering committee and more precise planning.
- In 2013 a data integration officer will be added to the MINOS team. This person will be charged with:
- Software testing and bug description.
- Creation of standardized BIRT reports in collaboration with subject matter experts in the medical department and operations managers.
- Integration of past data collected with legacy software into MINOS.
- Set up and fine-tuning of an anomaly detection system to provide data validation on entry and proactive detection of epidemics.
- Field implementation of MINOS will be continued: Afghanistan is the first mission scheduled for 2013. From there, additional missions will
be added, starting with those whose medical services are best matched to the current capabilities of MINOS.
11. health informatics
- Project management, overseeing the timely advance on MINOS deliverables.
- As experience with the Maban project in South Sudan illustrated, having a well informed and trained user base is critical for good system
course began in 2012, but will need to expand. Additionally, other components of change management will need
to be added: user guides, self-training videos, and a more robust communication programme.
- The most important feature to be added to MINOS is the handling of individual data. Some service types require indicators that cannot be
calculated on the basis of aggregated data, e.g. those with longitudinal patient follow-up such as HIV/TB. Work on developing this
capacity is scheduled for 2013, and it is hoped that it will be ready by the end of the year.
- At the level of specific databases, the development and use of data collection and monitoring tools in emergencies and conflict settings
will be explored, with the goal of improving both the routine data monitoring and operational research in this domain.
MEDICAL ACTIVITY REPORT 2012
acceptance and performance. The integration of MINOS into training programmes such as the Management of Health Systems (MHS)
MSF MEdical Department OCB
Health Promotion and
Socio-Anthropology
1. Overview
Health Promotion (HP) activities continued to be well integrated into both existing and new projects as
well as emergency interventions. 2012 was a busy year that saw several changes in the work load
distribution. Both the position of support to the referent and the Mobile Implementation Officer (MIO) for
HIV/tuberculosis (TB) Patient and Community Support have been discontinued. On the other hand, a
new position of HIV/TB Patient and Community Support advisor was created within the Southern
Africa Medical Unit (SAMU). This position integrates HP and mental health into one global support
position (including the educational, social and counselling aspects). The advisor is part of the SAMU
unit based in Brussels. In this report, all HP issues related to vertical HIV/TB projects will be presented
in the HIV/TB section.
Collaboration with other MSF sections (OCBA, OCG) was initiated through a contact group, which
allowed the sections to share experiences, practices, and tools while developing a common approach.
A “hygiene promotion forum”, composed of different agencies dealing with HP, has also been used to
promote collaboration and further contacts.
12. Health Promotion and socio-Anthropology
34
2. Programme Activities
2.1. Health Promotion
activities at a project
level - example
In 2012, HP activities were conducted in 32
4. Research and developments
4.1. Qualitative surveys
projects across 17 missions - not including
To better understand the socio-cultural con-
vertical HIV/TB projects, which are reported
texts in which OCB operates, and better sup-
The typical workload for the HP/anthropolo-
elsewhere (cf. HIV/TB section, §2.9.). These
port OCB medical activities, qualitative socio-
gy component of an OCB mission is demon-
projects included emergency interventions
anthropological
strated in table 1. In this project, performing
(three projects; table 2, Annex) and regular
conducted as part of HP activities. Addition-
more than 75,000 outpatient consultations
projects (29 projects; table 3, Annex).
ally, two comprehensive evaluations of the HP
28,446 individuals were reached by HP/anthropological activities. Most of these were
activities focusing on Maternal and Child
Health and classical HP among the patients
of Timergara project. Other, more specific
activities were also conducted (such as support to the blood bank), but to a much lesser
extent (table 1).
3. Training and
Human Resources
Number of participants
N (%)
Maternal Child Health 16,296 (57%)
Hygiene Promotion
10,642 (37%)
Seasonal Diseases
1,446 (5%)
Blood Bank
62 (0.2%)
Total
28,446
were
routinely
are available upon request.
- DRC - Masisi: satisfaction survey on the
The number of trainings including an HP or
medical care provided to the HIV patients
socio-anthropology topic has remained con-
in Masisi Hospital.
stant from last year:
- DRC - Kinshasa coordination: satisfaction
-Water and Sanitation (WatSan) week in
emergencies: module “Health promotion in
WatSan and emergency”
Table 1: Health promotion activities in Timergara,
Pakistan, 2012
surveys
component have been conducted. All reports
and admitting more than 2,500 inpatients,
Health education
session
MEDICAL ACTIVITY REPORT 2012
2.2 Health Promotion general
overview
-Reproductive
“Health
Health
promotion
regarding their medical care.
-Egypt - Abu Elian: Knowledge, Attitude
module
and Practice (KAP) survey on health-seek-
reproductive
ing behaviour of women and children un-
training:
and
survey for MSF staff and their beneficiaries
health”
der five.
- Management of Health Services course:
-Bangladesh - Kamrangirchar: survey on
module on “Medical anthropology and
barriers to accessing SRH services for
health promotion in OCB”
adolescent and young women (15 to 24).
- Health Promotion level I training in Brussels:
ten day training, open to all sections.
- Health Promotion level II training in Brussels: one week training, open to all sections.
4.2. New/revised policies
and protocols
During 2012, the HP unit was involved in the
development of several guidelines and protocols:
-Revisions and updates of all HP documents and tools available by medical topic. The Health Promotion Tool Kit is now
available on USB key.
- Ongoing work on HP messages per topic
(sexual and reproductive health, nutrition,
etc.).
5. Looking back and ahead
Lessons learned for 2012
An HIV/TB Patient and Community Support advisor has been recruited for two years. He will respond to the need for capitalization of field
experiences and promotion of innovative patient support approaches, development of training and mentoring on patient support, general
and direct field support, and promotion of operational research on patient support. The advisor is part of the SAMU and fully in charge of all
vertical HIV/TB projects.
All existing health promotion materials and documents have been re-organized and gathered in an “HP tool kit” created to replace
the previous two DVDs. This toolkit is now available on USB key, by FTP site, and on a Health Promotion platform on Tukul
(workspace accessible upon request).
HP participation to the Fifth Emergency Environmental Health Forum held in London provided a good opportunity to create networks and
become integrated within the hygiene promotion forum. Participatory activities of this kind are key to developing more interactions with other
actors active in the field of HP.
Some contacts and exchange with other MSF sections, including OCG and OCBA, led to the creation of a Health Promotion
and Anthropology “contact group”. A first meeting was held and further collaboration is anticipated.
part of the centralized MSF medical database (MINOS), thus aiding in the standardisation of HP data collection.
35
Standard HP indicators have been developed and disseminated but not yet implemented in all projects. Ideally these indicators should be
Prospects for 2013
Efforts to integrate HP activities into different areas of intervention should be maintained, with a special focus on qualitative research and
links with other programme components. Qualitative data will continue to be collected routinely on a large scale, and a formal collaboration
the Populations in Precarious Situations (PSP) training, and the intersectional workshop on HP and Anthropology.
MEDICAL ACTIVITY REPORT 2012
Efforts to maintain links with other section should also be continued through the Contact Group, the integration of HP in
12. Health Promotion and socio-Anthropology
with the Operational Research and Analysis and Advocacy Unit will take place in 2013 with two missions: South Sudan and Egypt.
MSF MEdical Department OCB
HIV/AIDS
and Tuberculosis
1. Overview
The 2012 scientific environment around HIV and tuberculosis (TB) has been dynamic, with high-level political
declarations in line with “the end of AIDS in sight”. Strategies focused on reducing HIV incidence using
large-scale “treatment as prevention” combined with other prevention methods have been highlighted as
key future interventions.
National policies in high burden countries have tried to adapt to more ambitious World Health Organisation
(WHO) targets, in large part by increasing the CD4 count initiation threshold to 350 cells/µl and moving out
of option A towards B or B + (universal antiretroviral therapy (ART) for all pregnant women regardless of CD4
count) for the prevention of mother-to-child transmission (PMTCT). This progress has continued despite
absence of new international funding, with the cancellation of the Global Fund Round 11 and PEPFAR
(President’s Emergency Plan For AIDS Relief) reducing its funding levels this year.
36
OCB has managed to navigate this financial ”storm”, which included changes to its internal HIV/TB
allocated budget portfolio, adopting more focused strategies and implementing more ambitious
targets in several of its vertical programmes (e.g. B + in Malawi and CD4 350 in all other sites).
OCB operations have expanded geographically by adopting a “light approach” in several new districts,
using supportive rather than substitutive approaches. These strategies have resulted in an ART initiation
increase of 25%, including a 20% increase in paediatric initiations. This was accompanied by an increased
pace of stavudine phase-out (d4T), switching to a tenofovir (TDF)-containing first line regimen.
However, the large investment in vertical programme came at a cost: little progress was made in
implementation of the HIV minimal package in non-vertical projects, despite a strong OCB commitment
to do so. Regarding TB, integration of HIV/TB activities progressed in several countries, and widespread
implementation of the new molecular test for TB, Xpert MTB/Rif, came with detection of drug-resistant TB
(DR-TB) everywhere and raised DR-TB treatment questions across a number of OCB projects.
2. Programme activities
13. HIV/AIDS and Tuberculosis
2.1.1. HIV
At the end of 2012, OCB was supporting 17
vertical integrated HIV/TB projects in the following 10 countries: India (Mumbai), Guinea
(Conakry), DRC (Kinshasa), Mozambique
No. of countries
2.1. Introduction
MEDICAL ACTIVITY REPORT 2012
roll-out of rapid molecular testing for TB and
Figure 1: Number of countries with HIV projects
supported by OCB 2004-2012
20
18
16
14
12
10
8
6
4
2
0
15
17
19
drug resistance (Xpert MTB/RIF) across a
number of projects. A new vertical TB project
18
14
was launched in the Jebel Awilia area in Khar12
10
10
10
Nsanje, Chikwawa), South Africa (Khayelit-
toum with the highest burden of TB, the project will be supporting TB-related activities in
five health facilities of the area, focusing on
2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
(Mavalane, Tete), Kenya (Kibera), Zimbabwe
(Buhera, Gutu, Chikomba), Malawi (Thyolo,
toum, Sudan. Located in the area of Khar-
TB case detection, treatment of drug sensitive TB, and patient and community support.
DR-TB projects in Donetsk, Ukraine and Dire
2.1.2. TB
Dawa, Ethiopia launched curative activities,
Lesotho
In 2012, OCB continued TB-related activities
initiating their first cohorts in June and De-
(Roma), and Ukraine (Donetsk). The focus
in ten vertical TB or HIV/TB projects in India,
cember 2012 respectively.
continued to be on countries with the highest
Guinea,
Mozambique,
The speed and scale of integration of TB care
HIV burden in Southern Africa (fig. 1). The
South Africa and Malawi. In addition, in 11
in non-vertical projects in settings with a high
very favourable quantitative and qualitative
non-vertical projects in settings with a high
burden of disease was, however, variable.
results of the “light approach” programmes in
burden of TB, OCB teams were involved in
Considerable progress was observed in a
Zimbabwe (Gutu and Chikomba) and Malawi
delivering different components of TB care. In
number of projects (Chhattisgarh and Mon in
(Nsanje and Chikwawa) continued to demon-
vertical projects with a high burden of drug-
India, Kamrangirchar in Bangladesh, and
strate the added value of MSF’s support to
resistant tuberculosis (DR-TB), the focus has
Imey in Ethiopia), while other projects were
kick-start HIV activities and decentralise the
been on improved DR-TB case finding and
rather slow in integrating the minimum pack-
provision of ART in new districts.
diagnosis, which was advanced by further
age of TB care into their activities.
sha,
KwaZulu-Natal,
Musina),
Ukraine,
Ehiopia,
2.2.2 TB case finding
The proportion of children among newly reg-
In 2012, 17 projects reported their TB case-
2.2.1 HIV testing
finding data (table 1). A total of 5,960 TB pa-
istered TB cases declined in 2012 to 10%
(14% in 2011). This is likely due to lack of
reporting from several nutritional projects in
Over the last year, HIV testing and counsel-
tients were registered in OCB-supported pro-
ling (HTC) has been increasingly supported
grammes during the year, about 9% of whom
by partners (e.g. Ministries of Health and
were retreatment cases. The decrease com-
other international NGOs) resulting in an
pared to 2011 data is due to several factors:
overall sharp decline of the facility-based
discontinuation of reporting drug sensitive TB
Only 29 children, in contact with active TB
testing strategy (fig. 2). As a result, only five of
(DS-TB) cases from Khayelitsha project
cases, were reported to have been offered
the ten OCB vertical projects are supporting
(which reported 1,509 cases in 2011, and
isoniazid preventive therapy (IPT) in 2012 (67
HTC (Guinea, Kibera, KwaZulu-Natal (KZN),
narrowed its focus on DR-TB cases since)
in 2011), which is less than 0.5% of the total
Musina and Lesotho). The projects in Kibera
and Tete (reported 396 cases in 2011), and
number of new TB patients registered during
and Guinea continue to support facility-
missing data from DRC, Niger and Sierra Le-
the year, suggesting that tracing and follow-
based testing, while Musina, KZN, and Leso-
one projects (seven projects reported 1,379
ing up of child contacts needs to be more
tho have moved towards a community-
cases in 2011). Despite the overall drop in TB
systematically addressed and/or reported in
based testing strategy. The project in KZN,
cases, six projects reported increases in the
all projects with TB activities.
South Africa, implemented a novel approach
number of TB patients registered, including a
in community-based testing in 2012, using
significant increase in Chhattisgarh (India)
mobile and door-to-door testing strategies.
project from 71 to 199 cases, Bangladesh
In 2012, 75,624 patients were tested, with
(from 5 to 27), and KZN (from 502 to 950).
12% found to be positive. Additional new
Two projects started registering TB cases in
In 2012, 27,396 patients were newly regis-
testing strategies, such as oral self-testing,
2012 – Mon (India) with 180 registered cases,
tered in HIV care and treatment in OCB-sup-
will be introduced in some projects in 2013.
and Nsanje (Malawi) with 622 cases. The
ported clinics (fig. 3). This decrease since
At the programme level, considerable em-
largest TB cohorts were reported in South
2011 may be linked to data recording prob-
phasis has been placed on ensuring that all
Africa, Zimbabwe, and Malawi.
lems, as it does not match the observed in-
TB patients are tested for HIV and that all
Increased access to molecular testing (Xpert
pregnant women presenting for antenatal
MTB/RIF) in 2012 prompted a change in re-
care are tested as part of overall PMTCT ac-
porting, and instead of reporting smear posi-
tivities. In 2012 64% of all TB patients and
tive and smear negative pulmonary TB (PTB)
92% of all pregnant women were tested for
cases, projects in 2012 reported “confirmed
HIV in MSF supported programmes.
pulmonary TB cases” which included smear
and Xpert positive. Among new TB cases,
TB (EPTB) cases, although slightly increased
75650
in 2012, continues to be lower than expected
75624
in most projects. This further prompts the
need for thorough clinical examination of patients with TB symptoms together with ac-
2007
2008
2009
2010
2011
2.3. Patient enrolment 2012
2.3.1. Pre-ART enrolments
crease in ART initiation (cf. §2.3.2.). Data reveal that pre-ART retention remains weak but
a number of projects have begun to implement some additional strategies, such as isoniazid preventive therapy, which may support
pre–ART retention (South Africa, Lesotho,
Kenya and Malawi).
2012
curate interpretation of their X-ray images.
Figure 3: Number of newly registered HIV patients
in OCB programmes by year of entry, 2005-2012
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
39352
28919
37011
29871 30931
34640
25905
27396
2005 2006 2007 2008 2009 2010 2011 2012
Table 1: Tuberculosis case detection in OCB projects, 2008-2012
2008 (23 projects
reporting)
2009* (14 projects
reporting)
2010 (21 projects
reporting)
2011 (22 projects
reporting)
2012* (17 projects
reporting)
Total number of TB cases registered
10,848
4,198
8,741
8,255**
5,960
i. New cases
8,859
3,713
7,641
6,869
5,423
Smear-positive pulmonary
43%
35%
35%
34%
41%***
Smear-negative pulmonary
36%
40%
43%
45%
35%
Extra-pulmonary
21%
25%
22%
22%
24%
ii. Retreatment cases (% of total)
2,006 (18%)
495 (12%)
1,100 (13%)
884 (11%)
560 (9%)
Data were not available from all OCB projects with a TB component in 2009 and 2012;
**
One project was able to provide a total (n=502) but not a breakdown by new and retreatment cases;
***
Confirmed PTB (sputum smear or Xpert MTB/RIF positive cases)
*
13. HIV/AIDS and Tuberculosis
However, the proportion of extra-pulmonary
96981
74185
previous years.
MEDICAL ACTIVITY REPORT 2012
cases was 41%.
163178
161192
paediatric TB cases had been diagnosed in
the average proportion of confirmed PTB
Figure 2: HIV testing supported in OCB projects,
2004-2012
180000
160000
140000
120000
100000
80000
60000
40000
20000
0
Niger and Sierra Leone, where most new
37
2.2. Testing for HIV and TB
2.3.2. ART enrolments
A total of 29,925 adults and children were
initiated on ART in 2012 compared to 22,570
in 2011 (fig. 4). This is to a large extent due to
the implementation of B+, the universal implementation of the higher initiation threshold
Africa. Malawi significantly increased the
the WHO 2010 guidelines recommending
number of adults initiated on ART in 2012
initiation of all HIV positive infants under the
due to the implementation of PMTCT B+,
age of two years on ART regardless of CD4
while the expansion in new adjacent districts
counts. In 2012, the South African projects,
showed rapid results, mostly in Nsanje and
in line with their national guidelines, moved to
Gutu (fig. 5).
initiate all children under the age of five. It is
of 350 cells/µl, and the successful decen-
The majority of projects in 2012 were able to
tralisation to more clinics in the new projects
initiate all new patients on the less toxic TDF-
of KZN, Gutu, Chikomba, and Nsanje.
based first line regimen, except for Malawi
(only pregnant women and individuals with
negative side effects were eligible for TDF in
Figure 4: ART initiations (adults and children)
in OCB projects, 2005-2012
tries are likely to move towards a TDF-based
first line regimen in 2013. For those projects
29925
30000
20000
15404
mendation in 2013 based on evidence that
earlier ART treatment in these children will
help to prevent long term respiratory, cardiologic and neurological problems.
2012), Mozambique, and DRC. These coun-
35000
25000
likely that this will become a general recom-
22570
21492
20018 20443
17318
17159
Figure 6: Paediatric ART initiations in OCB projects,
2005-2012
using the electronic data management sys-
3500
tem FUCHIA, the percentage of patients re-
2500
maining on a d4T-based regimen represent-
2000
10000
ed 12.4% of the cohort, a reduction of 20%
1500
5000
from 2011.
15000
2949 3021
3000
2386
2558 2621
2422
1962 1930
1000
500
0
0
2005 2006 2007 2008 2009 2010 2011 2012
2005 2006 2007 2008 2009 2010 2011 2012
2.3.2.2 Paediatric ART Initiations
In 2012, a total of 2,422 children were initi-
2.3.2.1 Adult ART initiations
ated on ART in OCB-supported pro-
The greatest proportion of adult ART enrol-
grammes, an increase since 2011 (fig. 6 & 7).
ments in OCB programmes still remains in
All OCB supported projects have access to
Malawi, Mozambique, Zimbabwe, and South
early infant diagnosis and have implemented
The increase in paediatric ART initiations
does not reflect the adult threshold initiation,
as more aggressive PMTCT strategies are
supposed to reduce the number of infected
children. It is rather a result of the successful
decentralisation of paediatric ART initiation in
Figure 5: Adult ART initiations by OCB projects, 2011 vs. 2012
38
Mavalane, KZN, Conakry, and Kinshasa as
well as the project expansion in Nsanje, in
10000
which a substantial number of children were
2011
2012
9000
8000
enrolled. All OCB projects have by now
switched children away from the more toxic
7000
d4T-based first line regimen and all projects
6000
apart from Malawi are able to provide a more
5000
robust lopinavir/ritonavir-based first line regi-
4000
men for PMTCT-exposed positive children.
3000
South Africa as an exception provides a lopi-
2000
navir/ritonavir-based first line regimen for all
1000
children under three.
sk
ne
t
Do
M
um
ba
i
in
a
us
m
ba
M
C
Ki
hi
ko
ha
sa
m
Ki
ns
a
be
ra
u
ut
Ro
on
G
ak
ry
sh
a
Kh
M
C
KZ
N
bi
ur
am
N
ay
el
it
nd
a
e
sa
nj
ne
lo
al
a
yo
av
Th
M
2.4. HIV and TB outcomes 2012
2.4.1 ART outcomes
Figure 7: Paediatric ART initiations in OCB projects, 2011 vs. 2012
2.4.1.1 Adult ART outcomes
800
700
The current target for combined death and
2011
2012
600
loss to follow-up (LTFU) is set at less than 15%
at 12 months. This equates to a “remaining in
500
care” (RIC) indicator of >85% at 12 months.
400
For projects reporting cohort outcomes, retention in care at 12 months ranged from 64%
300
in the Mumbai project to 95% in the Gutu pro-
200
ject in Zimbabwe (fig. 8).
100
In most of these projects, the rapid imple-
0
ba
i
um
M
ne
ts
k
a
in
us
M
Do
Kh
ay
e
lit
sh
a
a
m
Ro
ba
m
ko
C
hi
be
ra
Ki
sa
Ki
ns
ha
y
N
ak
r
on
C
u
KZ
ut
G
nd
a
bi
ne
av
M
ur
am
M
al
a
nj
sa
N
yo
lo
e
mentation of community-based chronic care
Th
MEDICAL ACTIVITY REPORT 2012
13. HIV/AIDS and Tuberculosis
0
strategies based on the community groups/
clubs model (cf. §2.9.) are likely to improve
Figure 8: Adult Retention In Care at 12 months, for patients initiated in 2011 in OCB projects
100
90%. Musina project is an exception; be-
90
76
73
71
70
60
50
40
30
20
10
due to the timely (within 2 days) defaulter
ra
e
Ki
be
M
av
C
on
ak
al
an
ry
N
Ro
m
KZ
a
sa
Ki
ns
ha
el
its
h
G
ut
u
cal community partners at the clinics. The
a
0
tracing system that is performed by their lo-
ay
rates in the Zimbabwean projects are likely
77
70
a
bile patients. The amazingly high retention
79
80
Kh
specific counselling package for these mo-
86
bi
nd
given an official transfer letter as part of the
87
lo
documented as being LTFU will have been
89
M
ur
am
bwean migrant farm workers, many of those
95
yo
cause it is a cross border project for Zimba-
% Retention in Care at 12 months
increase in the 12 months RIC objective to
Th
long term retention even more, permitting an
high death rate in the Mumbai project is likely
because its cohort is a particularly vulnerable
second line cohort and often co-infected
with TB or MDR-TB, while Kinshasa’s high
mortality is due to the enrolment of mostly
40
35
Death
LTFU
0
30
26
has been decentralized to the primary care
5
TB treatment outcomes for patients with
drug-sensitive (DS) TB were available for
4,010 patients registered during 2011 from
eight projects. In five additional projects, TB
patients, once diagnosed, were referred to
the respective National TB Programmes
(NTP) for management without any further
22
4
22
12
9
9
8
sa
ur
Ki
M
am
ns
bi
um
ha
ba
i
a
nd
ha
its
el
39
M
Kh
M
C
ay
Ki
on
Ro
ak
m
a
ry
N
be
us
KZ
ra
in
e
a
0
fully, will continue to improve retention rates.
2.4.2. TB outcomes
13
2
23
13
M
HIV care nearer to their homes which, hope-
10
34
15
vertical programmes, MSF paediatric ART
tings. This means children are able to access
27
20
10
level and is initiated by nurses in most set-
5
2
an
that of adults (fig. 10 & 11). In most of the
7
al
Paediatric RIC at 12 months is higher than
3
25
av
% Dead and LFU
very advanced AIDS cases (fig. 9).
2.4.1.2 Paediatric ART outcomes
Figure 9: Adult death and LTFU at 12 months for patients initiated in 2011 in OCB projects
Figure 10: Paediatric Retention In Care at 12 months for patients initiated in 2011 in OCB projects
120
100
97
100
91
87
85
85
83
77
81
80
65
60
47
40
20
MSF support or involvement. Among prona
13. HIV/AIDS and Tuberculosis
M
us
i
a
er
Ki
b
e
an
av
al
as
M
C
Ki
n
sh
on
a
kr
a
y
N
KZ
m
ur
a
M
Kh
a
ye
l
bi
its
Ro
Th
success rate of >85% was achieved in Imey
nd
a
ha
m
lo
yo
ut
G
itive TB cases in 2012, the target treatment
a
0
u
(89%) and Thyolo (87%). Only one other project, Roma (80%), was close to achieving this
target treatment success rate (fig. 12). Death
rates exceeding the 10% target were observed in Murambinda (12%), Roma (15%),
and Nsanje (11%). Treatment interruption
Figure 11: Paediatric death and LTFU at 12 months for patients initiated in 2011 in OCB projects
60
0
Death
50
LTFU
40
rates exceeding 10% were observed in
6
30
53
tended to be higher for patients with smear-
8
ha
ns
Ki
ur
M
sa
a
am
bi
ak
on
C
el
ay
Kh
nd
ry
ha
its
ne
6
3
2
2
lo
10
yo
11
Th
11
5
a
13
la
av
a
a
KZ
N
M
Murambinda and Kibera. Mortality rates
15
0
er
were observed in Chhattisgarh, Conakry,
0
6
15
a
Treatment interruption rates exceeding 10%
10
in
Kibera with 79% (fig. 14).
8
0
29
us
Imey had a success rate ≥ 85%, followed by
20
M
new smear-negative and EPTB cases, only
Ro
m
13). Among projects that had more than 20
Ki
b
Nsanje (16%) and Chhattisgarh (44%) (fig.
MEDICAL ACTIVITY REPORT 2012
jects that had more than 20 new smear-pos-
negative and EPTB, due most likely to delays
in diagnosis and initiation of TB treatment.
Mortality rates exceeded 20% in Murambinda, Roma, Thyolo and Nsanje. The introduction of Xpert MTB/RIF in Thyolo in 2012
should reduce the diagnostic delay in many
smear-negative cases and thereby help to
decrease the unacceptably high mortality
rate. Among retreatment TB cases, treatment success rates were highest in Imey
(100%), Roma (89%) and Kibera (82%).
2.5. Drug-resistant TB
Figure 15: MDR-TB treatment initiations
per OCB project, 2012
In 2012, a total of 502 patients were initiated
on treatment for multidrug-resistant TB
(MDR-TB) across 11 different OCB projects:
Failure
Mumbai (32), Maputo (34, referred to NTP),
Murambinda
3%
Murambinda (19), Dire Dawa (7), Mon (4),
Thyolo (3), Chattisgarh (2) and Nsanje (2) (fig.
15). These figures differ slightly from the
overall reported ones in the OCB typology,
Nsanje
0%
continuous scale up of molecular drug sus-
50
ceptibility testing (DST); in 2012 Xpert MTB/
40
RIF was introduced in five additional sites. In
30
the majority of cases, OCB provided signifi-
20
cant support in MDR-TB case management.
10
As a result of this significant scale-up of in-
0
volvement in MDR-TB, OCB will be obliged
e
nj
sa
yo
Th
Ki
be
m
Ro
N
C
am
bi
Im
nd
ey
ry
ak
on
ga
tis
at
M
2.6. HIV/TB statistics
Figure 13: Treatment outcomes in OCB projects in 2012: sputum smear-negative PTB
Death
to invest more in DR-TB management, preferably in collaboration with NTPs.
ur
hh
lo
registered DR-TB cases may be due to the
60
ra
Ukraine. A further increase in numbers of
70
a
80
a
a start of one new vertical DR-TB project in
rh
MDR-TB treatment initiations is mainly due to
90
C
40
The significant increase in the number of
Succes rate
In 2012, 14 projects out of 17 reported ac-
Completed
100
cess to HTC for patients with suspected and
90
confirmed TB. Despite the reported access
80
to HTC, only 64% of all registered TB pa-
70
tients were tested for HIV in seven OCB pro-
60
jects. Among those tested, 77% were HIV
50
positive. Across all projects that reported HIV
40
positive patients, five OCB projects reported
30
use of cotrimoxazole for co-infected patients
20
with an overall rate of coverage of 77%.
10
Two OCB projects, Thyolo and Nsanje, both
je
N
sa
n
lo
Th
yo
ra
a
m
be
Ki
bi
m
M
C
proportions of co-infected patients on ART
were 94% and 79% respectively. Isoniazid
Figure 14: Treatment outcomes in OCB projects in 2012: EPTB
Death
Interrupted
in Malawi, submitted data on ART enrolment
of registered TB/HIV co-infected patients;
ur
a
Ro
nd
a
ey
Im
ak
r
on
C
hh
at
ti
sg
a
rh
y
0
preventive therapy (IPT) to prevent active TB
Completed
100
in HIV-infected individuals was offered to 545
90
patients in two projects reporting this activity
80
(Roma and Mumbai) – slightly more than in
70
2011 when 535 people living with HIV/AIDS
60
(PLWHA) were offered IPT in three projects
50
(Kibera, Mumbai, and Roma).
40
2.7. PMTCT
30
20
PMTCT is fully reported in the sexual and re-
10
productive health section of this report.
e
N
sa
nj
lo
yo
Th
ra
a
m
Ki
be
am
bi
ur
M
Ro
a
nd
ey
Im
ry
ak
on
C
hh
at
tis
ga
rh
0
C
13. HIV/AIDS and Tuberculosis
Donetsk
38%
Khayelitsha
35%
100
Interrupted
MEDICAL ACTIVITY REPORT 2012
Chhattisgarh
0%
Thyolo1%
Mumbai
7%
Mon 1%
due to slight differences in definition.
Death
Mavalane
7%
Donetsk (189), Khayelitsha (174), KZN (40),
Figure 12: Treatment outcomes in OCB projects in 2012: sputum smear-positive PTB
Interrupted
KwaZulu Natal
8%
PMTCT is supported in six countries (Kenya,
Lesotho, Malawi, Mozambique, South Africa,
and Zimbabwe) and integrated in one mater-
in adolescents, feasible ways of making HIV
countries that will require substantial labora-
nal and child health programme in Burundi.
services “adolescent friendly”, and the need
tory support and supervision.
In vertical HIV programmes that are reporting
to develop a comprehensive counselling
on PMTCT, 92% of women presenting for
package covering issues of adherence, dis-
antenatal care (ANC) were tested for HIV. Of
closure and sexuality education.
2.11. TB infection
control activities
Finally, 2012 has seen the adaptation of com-
Implementation of TB infection control at field
munity models of care, such as the commu-
level aims to ensure the implementation of
nity ART groups from Mozambique and the
simple and sustainable measures. Support
adherence clubs from Khayelitsha, for roll-out
from the infection control specialist within the
2.8. Integration of HIV,
TB and DR-TB into non-vertical
HIV programmes
in new settings. Both programmes have
Southern Africa Medical Unit (SAMU) has
shown high rates of retention (97%). The
been given to several HIV/TB projects
Thyolo project in Malawi implemented com-
(Khayelitsha, KZN, Mavalane, Dire Dawa,
munity ART groups formed in collaboration
Thyolo, Nsanje, Chikwawa, Donetsk and
Although integration of HIV, TB, and MDR-TB
with the network of people living with HIV,
Mumbai) as well as to OCG projects (Shis-
in non-vertical programmes remains weak in
while KZN has piloted adherence clubs. Fur-
elweni, Bishkek and Osh). A new TB infection
OCB, some progress has been made in
ther context-adapted roll-out of these com-
control guidance document entitled “Assess-
2012. In the two hospital-based programmes
munity-based ART delivery strategies is
ing natural ventilation in resource-limited set-
in Masisi and Niangara (DRC), 53 and 108
planned for 2013.
tings” has been developed for project use.
weeks) showed a transmission rate of 3%.
patients respectively were initiated on ART in
2012. The primary health care projects in India (Chhattisgarh and Nagaland) where the
HIV prevalence is very low (<0.5%) have provided HIV testing and counselling and linkages to HIV care. In addition, both projects
have supported training and development of
the capacity to diagnose and treat DR-TB
and to ensure that the correct drug treatment
is initiated.
2.10. Laboratory
support in HIV/TB
Xpert MTB/RIF (also known as “GeneXpert”)
has been introduced at five additional sites
during 2012 (Gutu, Roma, Thyolo, Nsanje
and Dire Dawa, Ethiopia), making a total of
12 OCB sites that now have access to this
new TB molecular diagnostic tool. Increases
in microbiological detection of Mycobacteri-
3. Monitoring and Evaluation
and Operational Research
Four projects continue to use the electronic
HIV data management tool FUCHIA. Mozambique has moved to using the electronic
register exclusively while Zimbabwe is employing a tiered approach using FUCHIA, eregister, and a paper-based system for their
smaller clinics. Many national programmes
are beginning to introduce their own elec-
HIV testing and treatment options offered by
um tuberculosis and rifampicin resistance
MSF or through linking to other actors should
were evident in all projects upon introduction
be considered in all projects, but in particular
of this new assay. Pima Point-of-Care CD4
in those with a prevalence greater than 1%.
analyzers were introduced in Guinea and
In addition, MSF should ensure access to TB
Mozambique, resulting in a total of 30 instru-
Operational research (OR) is discussed fully
diagnostics that can identify drug-resistant
ments being implemented and more than
in the operational research section of the re-
strains of TB (e.g. Xpert MTB/RIF).
8,000 tests being performed. Challenges
port. OR topics in HIV/TB were targeted to-
faced during the introduction of these new
wards the HIV/TB advocacy agenda and
tools included high error rates, ensuring ad-
highlighted points around TB/HIV integration,
equate supervision, and quality control when
the need for viral load monitoring, and the
Patient and community support interventions
placed in decentralized sites.
use of clinical retinal screening in the diagno-
in 2012 have focused on the roll-out of HIV
The implementation of the HIV viral load lab-
2.9. Patient and
community support
viral load testing, development of specific
strategies for adolescents, and adaptation of
the community ART group model to different
country contexts.
oratory in Thyolo, Malawi, enabled a gradual
roll-out of viral load testing in the district, with
more than 3,000 tests performed by the end
of 2012. In Zimbabwe, referral of Dried Blood
With the roll-out of routine viral load testing in
Spot samples prepared by nurses at the de-
Kenya, Zimbabwe, and Malawi and its ongo-
centralized sites and sent to a private labora-
ing implementation in South Africa, an en-
tory in South Africa facilitated roll out of rou-
hanced adherence counselling (EAC) pack-
tine viral load testing, with more than 2,000
age has been developed for those patients
samples a month now being processed. All
with high viral loads. Early analysis of re-sup-
laboratories in the region have been enrolled
pression rates following this counselling inter-
in a quality control assurance program, either
vention show that between 60-80% of pa-
locally or in South Africa with the National In-
tients are able to re-suppress their viral loads.
stitute of Communicable Diseases/National
A workshop on adolescents and young
adults held in July 2012 highlighted the need
Health Institute (NHLS) proficiency testing
programme.
to incorporate adapted testing strategies to
2013 will be a challenging year, with the im-
identify the high burden of undiagnosed HIV
plementation of viral load platforms in several
tronic monitoring and evaluation systems
41
rates post-delivery (PCRs taken before 10
which may need to be integrated into MSF
programmes.
sis of disseminated TB.
4. HIV/TB trainings
Four basic and four advanced clinical HIV/TB
trainings and one DR-TB workshop were
supported by the SAMU training unit. A twoweek HIV/TB programmatic course attended
by 24 intersectional participants was also
held for the first time in Cape Town in March
13. HIV/AIDS and Tuberculosis
PMTCT intervention and the transmission
2012. In addition to these trainings, SAMU
hosted a regional workshop on the management of adolescents with HIV, to share experiences both internally within MSF and with
external experts. 2012 saw the launch of the
development of tools to support a mentorship approach for HIV/TB support within our
projects; this approach will be further developed in 2013.
MEDICAL ACTIVITY REPORT 2012
those testing positive, 87% received a full
5. Looking back and ahead
Lessons learned for 2012
- Despite a difficult international funding environment and OCB budget constraints along with a move towards a less toxic but
more expensive first line regimen, more patients were initiated on ART compared to 2011. This reflects better treatment efficiency
resulting from a mix of early initiation, decentralization, task shifting and integration with ANC and TB services.
- HIV-related mortality for patients in care is in continuous decline, mostly in children where some reliable monitoring and
evaluation systems (Khayelitsha, KZN, Gutu) report for the first time zero deaths at 12 months on treatment.
- Altogether, vertical transmission continues to decline with increased coverage and better efficiency in our PMTCT programmes.
- OCB adolescent-focused programmes have shown slow progress in 2012, despite being one of the major focuses of the Operations
Department. Failure to contain a still-alarming incidence rate in the young female age groups should convince MSF to become more
innovative and consider the implementation of biomedical prevention interventions as soon as scientifically validated.
- As previously described, the main failure of 2012 has been the minimal commitment to integrate HIV activities within OCB’s
non-vertical projects.
- In 2012, OCB managed to maintain the overall level of involvement in TB control, keeping the number of patients registered for
TB care in OCB projects stable. Moreover, involvement of OCB in care for DR-TB is on the rise, with numbers of patients initiated
in 2012 double of those in 2011. However, the neglected area remains the tracing and follow-up of child contacts of TB cases.
Integration of TB in non-vertical projects in settings with a significant TB burden remained a challenge in 2012, as little progress
was achieved compared to 2011.
Prospects for 2013
Challenges ahead for 2013 within the vertical projects will focus on the extremes of the HIV cascade:
42
- Extending community based testing and linkage to care activities in order to improve coverage. The relative disengagement
from testing in 2012 needs to be reconsidered in that light.
- Increasing the ART initiation threshold (CD4 500) in projects already having high coverage at a CD4 count threshold of 350.
- Improving long-term retention in care with further community-based chronic care initiatives moving towards the concept of
patient self-management, and phasing in viral load using different resource-saving strategies (point of care, Dried Blood Spots,
viral load pooling).
Regarding TB:
- A high mortality related to smear-negative and EPTB is observed in settings with a high burden of HIV, highlighting the need
to improve early TB case detection and diagnosis in HIV positive individuals. A number of OCB projects will start implementing
the new “Determine TB LAM” test for early detection of HIV-associated TB in severely immunosuppressed patients.
MEDICAL ACTIVITY REPORT 2012
13. HIV/AIDS and Tuberculosis
- High rates of treatment interruption in DR-TB, and the low level of DR-TB/HIV integration, need to be more aggressively addressed
with more attention to patient support and advocacy activities.
- Integration of basic components of TB care into non-vertical OCB projects will remain a focus in 2013, and the implementation
of the basic package of TB care will be reinforced.
- The 2012 FDA prequalification of Bedaquiline as well as the anticipated prequalification of Delamanid may mean a new era of less toxic
and more feasible DR-TB treatment.
MSF MEdical Department OCB
Infection
Control 1. Overview
Over the course of 2012, the scope of Infection Control (IC) activities continued to expand from health
structures providing surgical care to other structures involved with general medical care. With OCB’s
growing involvement in hospitals, in providing a higher level of surgical care (for example internal fixation
for orthopaedic-trauma), and in intensive care units, along with increasingly difficult work contexts
(in relation to conflict, low education levels of local staff, challenging supply processes, or climate
conditions), the challenges around IC have become more complex. A case by case review followed
by a tailored approach is required.
More and more projects are applying basic recommendations on hygiene, such as: providing uniforms
for all staff, using hydro-alcoholic solution for hand hygiene improvement, better cleaning and disinfection
procedures and materials, and/or high quality sterilization and laundry services. IC is now also better
represented in OCB with an Infection Control Committee as well as an infection control officer in most health
structures. There is also a higher level of interest in the development of new techniques and procedures,
especially regarding sterilization.
lated issues were provided to numerous OCB
projects (in Haiti, Pakistan, Afghanistan, India,
Burundi, Ethiopia, DRC, South Sudan, Malawi, Lesotho, Somaliland and Sierra Leone).
Chhattisgarh. This included assessment of
the level of IC and compliance to standard
precautions in the health facilities and auxiliary services (sterilization and laundry), as
well as the implementation of IC measures
by training and coaching of staff, defining
Field visits were conducted by two IC Mobile
the roles of medical, logistical and WatSan
Implementation Officers (MIO). These includ-
staff in IC and the establishment of an In-
ed missions for:
fection Control Committee.
- The set up and implementation of operating theatres (OTs) and/or delivery rooms
3. Training & human resources
and auxiliary services (sterilization, laundry,
In 2012, a MIO with a specific OT profile was
cleaning services) in Tabarre (Haiti), Khost
(Afghanistan), Kibera (Kenya) and Karachi
(Pakistan). The IC MIO provided support
for the organization of IC activities (including training and coaching of staff, definition
of the roles of medical, logistical and Water
& Sanitation (WatSan) staff and the estab-
-The Basic Logistics Course (BLoC) in
Brussels (three times),
- The Gynaecology, Anaesthesia and Surgery (GAS) week in Hong Kong, the Sexual
and Reproductive Health course (once),
- The WatSan operational support course
(once),
- The Biomed training (twice).
4. Developments and innovation
-Participation in defining the IC requirements for:
recruited to reinforce the set up of surgical
- Internal fixation.
activities. A second MIO remains involved
- Sputum induction.
with general IC assessment and implementation. The MIOs play a pivotal role in providing
on-the-job and field-based training and technical support.
14. infection control
Direct technical support and advice on IC-re-
(Somaliland), and in India, Nagaland and
- Finalisation of the “sterilisation and laundry” guideline.
- Creation of training materials to help the
implementation of standard precautions,
sterilisation, and isolation set up.
lishment of an Infection Control Commit-
In terms of training, IC sessions were provid-
tee) and advice on infrastructure.
ed at the following courses:
- Update of the briefing CD.
-The assessment and implementation of
-The Management of Health Services
- Finalisation of the recommendations for bi-
hygienic measures in Martissant (Haiti),
(MHS) courses in Brussels (twice) and in
omedical device management by medical
Kaboul and Kunduz (Afghanistan), Burao
Nairobi (once),
staff (oxygen concentrator, suction pump).
MEDICAL ACTIVITY REPORT 2012
2. Programme activities
43
The major achievements of the previous year were the openings of the internal fixation programmes
in Tabarre, Haiti and Kunduz, Afghanistan. MSF invested in a European standard of hygiene with high
filtration ventilation, industrial laundry services, cleaning trolleys, and an intensive care unit equipped with
ventilators. These two missions, along with the experience of the Lubutu, DRC programme, demonstrate
that the highest level of hygiene is challenging but possible even in low-resource settings. These successes,
along with an intensive investment in field IC implementation missions and in briefing/training from
headquarters, benefited IC globally by improving awareness on IC issues and solutions.
-Update of the different infection control
protocols:
- OT dress code.
- Treatment of reusable medical devices.
- Personal protective equipment.
- Participation in the planning and design of
- Introduction of new protective material:
health facilities, especially the laundry and
- OT protective glasses
mortuary chapter.
- Surgical astronaut cap for internal fixation
- Finalisation of the monitoring tools to as-
- Beard mask
sess adherence to standard precautions in
each department.
5. Looking back and ahead
Lessons learned for 2012
- The introduction of internal fixation as a surgical procedure within our trauma and orthopaedic projects required clarification
from an IC perspective in conjunction with clarification of other issues around infrastructure, HR requirements, surgical protocols, and
microbiological testing capacities. A guidance document on internal fixation requirements was developed.
- The recruitment of an IC officer in many projects has contributed to a spectacular improvement in the quality of care through
better hygiene management, particularly in the internal fixation and Lassa fever projects.
- Despite greater awareness of the importance of IC in order to achieve an acceptable standard of care in OCB projects,
stimulating an appropriate level of investment in various areas remains a challenge, in particular for:
- The set up of support services of high quality, especially laundry and kitchen facilities.
- The implementation of additional precautions to curb the transmission of highly contagious diseases, with an adequate isolation set up
(including anteroom, private latrines and showers).
- The planning and design of infrastructure with higher quality materials and including all essential units.
- There is a need to provide guidance on laundry set up, including the selection of a washing machine/dryer and the infrastructure
adaptation. A small multidisciplinary working group has been created with the electricity and WatSan referent.
44
- An OCB IC support group including all OCB referents linked to IC (epidemiology, WatSan, construction, health promotion,
sterilization) has been created. It provides a platform for sharing information to achieve a multidisciplinary approach at the level
of headquarters and in the field.
- The standard autoclave used across our projects does not offer enough capacity to meet the sterilization needs of trauma- and
orthopaedic-related surgery. Alternative autoclaves have been identified but need field-testing. They may ensure a better sterilization
quality and traceability but are more complex to install and maintain.
- There is an urgent need to develop and implement a standard protocol on wound and burn care in OCB. An OCB Wound Care working
group has been created, but with the immense workload, an additional contractual position needs to be recruited.
- The management of biomedical devices has improved with the clarification of maintenance protocols, the first biomed international
trainings, and the recruitment of two biomedical MIOs (cf. Biomedical Equipment section, §2.1.). These interactions have been reinforced
with improved support to the field.
14. infection control
Prospects for 2013
- Close interactions with the Operations Department and Ministries of Health will be maintained and/or strengthened to promote early
and committed investment and correct set-up in basic hygienic measures (standard precautions), maintaining an IC committee,
or recruiting an IC officer. Special attention should be given to sterilization, laundry, hospital kitchens, cleaning services and maintenance
of biomedical devices.
- The IC checklists will be implemented as an indicator and monitoring tool within all OCB projects.
MEDICAL ACTIVITY REPORT 2012
- An operational research portfolio will be developed in the area of IC, using the IC checklist.
- A suitable opportunity to test and implement an alternative autoclave needs to be identified.
- Nursing care needs to be improved by developing nursing care protocols in collaboration with the new Hospital Manager
and pursuing the update of the Nursing Care guidelines.
- An OCB Wound Care guideline will be created, with the introduction of new dressings materials.
- Specifications and adapted requirements will be defined for laundry set up within the laundry working group, and field
and cell awareness will be raised on the need to consult these guidelines when planning and designing a laundry.
MSF MEdical Department OCB
Intensive
Care
1. Overview
An Intensive Care Unit (ICU) is concerned with providing an increased level of medical care and
observation to patients in a critical or unstable condition. It often requires additional technology and
medical material than a standard hospital ward or care facility and is the most human resourcedependent form of care, requiring a high nurse/patient ratio in order to ensure sufficient surveillance
of patients and reactivity to critical events. Depending on existing needs, some ICUs may cater to a
specific medical specialty or type of patient (e.g. neonatal, paediatric, cardiac or trauma care units).
Taking into account the different contexts and needs where MSF works, four levels of care have been
defined for ICUs within MSF. This depends on the requirements for human resources, logistics and
auxiliary services. A level 0 ICU is the most basic and level 3 is the most technical level of ICU.
Our current strategy aims to achieve good standards of care in basic ICU units.
In some projects, a very high level of technically advanced care is provided (e.g. mechanical
ventilation). However, experiences during 2012 have highlighted the challenges these projects
confront due to this high level of technology. MSF is still building its capacity towards these units
and further assessment of the quality delivered and the impact on morbidity and mortality is required.
2.1. Activities at project
and mission level
During 2012, intensive care medical activities
were provided in three OCB projects in Sierra
Leone, Afghanistan, and Haiti. Specific data
on intensive care was received from two pro-
Table 1: ICU activities in Kunduz and Tabarre Intensive Care Units, 2012
Kunduz (Afghanistan)
Tabarre (Haiti)
Total admissions
314
192
Proportion children under five
3.9%
2.9%
Mortality rate
7.2%
7.5%
Referral rate
10.3%
3.9%
Bed occupancy rate
76.1% (4 beds)
33.1% (7 beds)
Average length of stay
3.7 days
4.3 days
45
2. Programme activities
Tabarre. This ICU has a capacity of seven
In collaboration with the paediatric team,
beds. While invasive mechanical ventilation
standards are being developed to ensure the
has yet not been implemented, non-invasive
provision of quality care and treatment for se-
2.2.1 Afghanistan
ventilation is available. The priority in this set-
verely ill children (making up a significant pro-
ting has been to ensure the basic knowledge
portion of the project’s beneficiaries), such as
OCB provides intensive care in Kunduz pro-
of national staff before upgrading the unit.
the implementation of early warning score
ject, a trauma centre in the north of Afghani-
The achievements in terms of quality and
systems and the development of manage-
stan, which had four beds in 2012. The Kun-
standards of care have been very high,
ment tools for conditions such as shock and
duz ICU is the most complex unit run by
thanks to the hard work of all national and
severe malaria.
OCB because it provides invasive ventilation,
international staff.
2.2 Country specific activities
a major challenge for all staff and support
personnel involved. Since the project’s start,
the international staff’s main aim has been to
train national staff and ensure the provision of
quality care. The achievements so far are impressive, but the unit still needs regular supervision of daily activities.
2.2.2 Haiti
2.2.3 Sierra Leone
3. Human resources
and training
International doctors and nurses special-
The Gondama Referral Centre (GRC) in Bo
ized in intensive care medicine have been
district provides paediatric and obstetric
recruited as a response to the needs in the
health care. The capacity of the ICU is 30
field. The main challenge around human re-
beds. This centre delivers a more basic de-
source capacity for intensive care relates to
gree of care than the prior two centres, cor-
the skills of national staff. Doctors and
responding to an ICU level 1. The patholo-
nurses in charge of ICU patients should
Since February 2012, OCB has been running
gies seen here differ from the other units, as
have specific knowledge, attitude, and
a hospital for acute trauma and surgical pa-
infectious diseases are the main cause of
skills related to the physiology of the criti-
thologies in a container-based structure in
critical illness.
cally-ill patient, the specific clinical man-
MEDICAL ACTIVITY REPORT 2012
(table 1).
15. intensive care
jects, which had a total of 506 admissions
agement strategies, and the life-saving
critical patients by helping them to recognize
procedures required.
these severe cases early, thus reducing the
The development of the Basic Assessment
and Support of Seriously Ill Patients in Developing Healthcare Systems (BASIC DHS, cf.
Emergency Medicine section, §3.) training
was a response to this need as it tackles the
issue of non-specialized doctors in charge of
time between recognition of the critical illness
and the required interventions such as oxygen therapy and basic airway management,
volume therapy and transfusion, surgery, antibiotic therapy, and/or management of lifethreatening disorders.
4. Looking back and ahead
Lessons learned for 2012
- To better understand and improve intensive care activities, improved monitoring and evaluation of these activities needs to take place
through the implementation of effective surveillance systems.
- A need for more specific documentation was identified: guidelines and standardization for the management of intensive care patients,
and protocols for the treatment of specific critical illnesses are required.
- A balance needs to be found between the expectations for intensive care activities and the required preconditions and field realities.
Prospects for 2013
- Implementation of the data collection tool in ICUs will be monitored.
- The strategy for intensive care standards will be presented, and collaborations with other medical units will be developed
46
in order to disseminate tools to reach these standards.
- Expatriate staff will continue to be followed up by the intensive care referent.
MEDICAL ACTIVITY REPORT 2012
15. intensive care
- The BASIC DHS training will be continued for national staff working in ICUs.
MSF MEdical Department OCB
LABORATORY
1. Overview
2012 saw the introduction of new laboratory activities, along with the expansion of existing tools
and activities. For example, the use of an automated tuberculosis (TB) diagnostic test, the Xpert
MTB/RIF, was expanded to additional projects, Dried Blood Spot (DBS) viral load testing in
Malawi and Zimbabwe was gradually rolled out, and the UNITAID Memorandum of
Understanding (for funding of HIV diagnostics) was signed at the end of the year.
2. Programme activities
The quality of OCB laboratories was recog-
- Preliminary results of the viral load pooling
nized this year, when the viral load laboratory
study in Malawi showed satisfactory re-
2.1. Laboratory activities at
a country and project level
in Thyolo, Malawi obtained a certificate of
sults with significant cost savings; final re-
excellence in quality control from the Centres
sults will be published in 2013. One oral
for Disease Control (CDC), and the Buhera,
presentation on the roll-out of the Xpert
Zimbabwe laboratory obtained two stars in
MTB/RIF diagnostic tool in MSF and three
the World Health Organisation (WHO) ac-
posters on CD4 and viral load were pre-
creditation process.
sented at the African Society of Laboratory
bwe, South Africa, Malawi, Lesotho, and Afghanistan. Four laboratories were closed (in
DRC, Ethiopia, Malawi, and Mozambique)
(table 1, Annex).
2.2 Use of a reference
laboratory
Medicine in Cape Town.
4. Operational Research
and developments
- Excellent results were obtained in a study
in Buhera, Zimbabwe, evaluating the usefulness of CD4 stabilization tubes for CD4
OCB continued to work with the Institute of
testing; consequently, these tubes have
Tropical Medicine in Antwerp, Belgium, which
replaced the standard EDTA tubes. This
served as an HIV reference laboratory. Addi-
substitution allows longer CD4 storage
tionally, OCB continued collaborations with
time at room temperature, a key feature for
the National Institute of Communicable Dis-
decentralized laboratory sites.
eases/National Health Institute (NICD/NHLS)
and Global Laboratories in South Africa.
- In Malawi, final results of a study on finger
prick DBS viral load validation with the Nu-
3. Quality control
cliSENS platform proved promising and
OCB laboratories continued to be enrolled in
district is planned in 2013. In contrast, a
the Proficiency Testing Programme of the
roll-out of the diagnostic technique in the
Zimbabwean study on finger DBS valida-
- The number of sites implementing Xpert
MTB/RIF in OCB increased from seven
laboratories in 2011 to 12 in 2012, representing an increase of 71%. Similarly, an
expansion in the number of PIMA POC
47
activities were introduced in Ethiopia, Zimba-
CD4 was seen in 2012 with a total of 30
instruments deployed in five countries
(Guinea, DRC, Mozambique, South Africa
and Lesotho).
- An operational research study was initiated
in Afghanistan on antibiotic resistance in
the population attending the Lashkar-Gah
hospital in Helmand. This study represents
a major initiative to understand the scope
of the problem of antibiotic resistance in
MSF contexts, and results are expected in
2013.
NICD/NHLS. With the implementation of the
tion with the Roche Taqman platform yield-
PIMA Point-Of-Care (POC) CD4 machine,
ed very disappointing results, mainly a
there was an increase in the number of sites,
poor specificity which led to a higher rate
mainly clinics, using this device. OCB contin-
of false positives. A way to overcome this
During 2012, two expatriate and three na-
ued to participate in proficiency testing to
problem is to raise the cut-off used to de-
tional staff attended the laboratory training
ensure that laboratories monitored their qual-
termine virological failure, or finding ways
organized by MSF Austria.
ity regularly and staff remained motivated.
to remove proviral DNA when using whole
5. Training
16. Laboratory
33 missions in 20 countries. New laboratory
blood.
MEDICAL ACTIVITY REPORT 2012
Laboratory activities were supported in over
6. Looking back and ahead
Lessons learned for 2012
- The introduction of new diagnostic tools in OCB represents new challenges in terms of quality control and monitoring. Although
the rate of inconclusive results with Xpert MTB/RIF decreased considerably in 2012, it still remains relatively high. A similar trend
of invalid results is observed with the PIMA POC CD4; monitoring a high number of sites implementing new technologies is time-consuming (cf. Biomedical Equipment section, §2.1.) and more automated solutions such as mobile network connectivity options are urgently
required.
- A wide range of emerging operational research topics represent both promising areas for innovation in OCB laboratory activities
and an added work load in terms of laboratory support.
Prospects for 2013
2013 will be the year:
- Of viral load implementation in OCB projects. Five countries (Malawi, Zimbabwe, Mozambique, Lesotho and South Africa)
will be introducing and scaling up lab-based viral load testing as well as POC viral load as part of a UNITAID-funded initiative.
- Of the use of molecular biology to identify Plasmodium falciparum resistance in Cambodia, in collaboration with the Pasteur Institute
in Phnom Penh (cf. Malaria section, §2.3.).
MEDICAL ACTIVITY REPORT 2012
16. Laboratory
48
- Of microbiology implementation in one of the OCB Trauma Centres in Afghanistan.
MSF MEdical Department OCB
Malaria
1. Overview
After some years of decrease, the total number of confirmed malaria cases treated by OCB in 2012
remained stable. However, malaria continued to be a leading cause of morbidity and mortality in OCB
projects, and some missions, such as South Sudan and Niger, observed a substantial increase in cases
from 2011.
We continued the roll-out of the new treatment for severe malaria, injectable artesunate. Monitoring of
results thus far has shown that this treatment is effective and safe, and that its implementation is feasible.
A new malaria project was opened in Kirundo, Burundi, with an initial focus on the correct management of
severe malaria. The malaria project on artemisin resistance/tolerance in Cambodia has been approved and
preparations are ongoing for a start in 2013.
OCB, together with other MSF sections, intervened for a malaria emergency in DRC. This intervention
highlighted again the challenges for timely detection and adequate response, including prevention.
2. Programme activities
Figure 1: Total and confirmed malaria cases in OCB projects, 2004-2012
700000
2.1. Malarial cases
pared to 2011.
Approximately 6% (17,752 cases) were se-
49
was 277,086 (fig. 1), a slight increase com-
500000
400000
300000
200000
vere cases of malaria. DRC, Sierra Leone,
100000
and Niger represented the missions with the
0
highest burden of severe malaria. More than
2004
2005
2006
2007
9 out of 10 malaria cases were treated in just
four missions (fig. 2), and one of those, DRC,
represents 40% of the cases.
250000
tection with the implementation of malaria
care and intervention. For South Sudan,
OCB launched a new refugee project (cf.
3%
2010
2011
2012
2011
2010
2012
200000
150000
100000
50000
Figure 2: Confirmed malaria cases
9%
Confirmed malaria cases
in DRC, this was mainly due to increased de-
2009
Figure 3: Malaria trends in OCB-missions, 2010-2012
A considerable increase was seen in missions such as DRC and South Sudan (fig. 3):
2008
Year
0
4%
40%
DRC
Niger
Sierra Leone
South Sudan
17. MALARIA
firmed malaria cases treated in OCB projects
600000
Number of malaria cases
During the year, the total number of con-
Total cases
Confirmed cases
Niger
18%
26%
South Sudan
Emergency Unit section, §2.2.1.), which ex-
Sierra Leone
plains in part the increase; however, an im-
Mauritania
pressive increase in malaria cases (141%) is
Other missions
also observed for existing projects. In the
Guidan Roumdji project (Niger), the number
of cases increased by 72% compared to
2011.
2.2. Diagnostics
In 2012, 476,056 Rapid Diagnostic Tests
(RDT) were performed during OPD consultations. A high proportion of positive RDT – indicating a high malaria endemicity – was
seen in projects such as Pibor, South Sudan
(60%); Mauritania (78%); Guidan Roumdji,
MEDICAL ACTIVITY REPORT 2012
DRC
Niger (59%); Bo, Sierra Leone (59%); and all
Figure 4: Evolution of the proportion of confirmed malaria cases, 2007-2012
projects in DRC.
increasing over the years, up to 98% in 2012,
indicating that the MSF-policy of systematic
parasitological confirmation of all malaria cases is well implemented (fig. 4).
2.3. Case management – artemisinin-combination therapy
Resistance/tolerance to artemisinin has now
100,0
Proportion confirmed malaria cases
The proportion of confirmed malaria has been
98,0
96,0
94,0
92,0
90,0
88,0
86,0
84,0
2004
2005
2006
2007
2008
2009
2010
2011
2012
been documented in four countries in the
Mekong-region, including Cambodia. A new
Rectal Artesunate remains one of the most
project focusing on artemisinin resistance/
effective and safe pre-referral treatments for
tolerance in Preah Vihear province, Cambo-
use at peripheral healthcare levels and more
dia was approved. The objective is to con-
OCB missions began using this drug in 2012.
tribute to the elimination of resistant/tolerant
Plasmodium falciparum malaria. Preparations are ongoing to implement a targeted
screening and treatment strategy, using PCR
as a diagnostic tool and Dihydro-artemisinin/
Piperaquine as treatment. The network of Village Malaria Workers will be reinforced, and a
collaboration with the private sector will be
considered. The project will be launched in
50
2013.
2.4. Case management –
severe malaria
After publication of the AQUAMAT-study
(showing the superiority of Artesunate IV/IM
over Quinine IV in the management of severe
malaria in African children), the MSF policy is
to recommend Artesunate IV/IM as the treatment of choice for severe malaria. Implementation started at the end of 2011, and
throughout 2012 OCB projects gradually replaced artemether with injectable artesunate.
By the end of 2012, all projects with a high
malaria burden were using artesunate, except South Sudan and the emergency interventions in Mali and Mauritania.
Around 1,400 patients in 19 MSF-projects
17. MALARIA
(all sections) have been monitored specifically and the results so far are very promising: the average treatment duration is short
(75% of the patients can switch to oral treatment after 24 hours), clinical outcomes are
good (93% cure rate) and very few problems
MEDICAL ACTIVITY REPORT 2012
have been reported concerning the preparation of the drug. These results demonstrate
the feasibility of implementing artesunate.
Furthermore, a package of documents for its
practical use, the quantification of needs and
a FAQ-sheet have been developed.
3. Re-positioning of
OCB malaria activities
With the opening of a vertical malaria project
in Cambodia focused on the elimination of
At the end of 2012, OCB finally launched a
resistant/tolerant Pf-malaria, OCB is en-
malaria project in Kirundo province, Burundi,
gaged for the first time in malaria-elimination
that will focus during a first phase on the cor-
activities in general and resistant/tolerant
rect management of severe malaria at all lev-
malaria in particular. Additionally, in Burundi,
els, from the community to the hospital.
which has been defined as a project by
2.5. Community management
of malaria
After the closure of the project in Sierra Leo-
choice with a focus on malaria, OCB has the
opportunity to implement innovative malaria
control activities.
ne, OCB no longer has community projects
4. Operational Research
for malaria. However, the new malaria project
A study to evaluate patient adherence to
in Cambodia will have a considerable com-
fixed-dose combination Artesunate/Amodi-
munity component, using a network of Vil-
aquine was performed in Sierra Leone, with
lage Malaria Workers and Mobile Migrant
results still pending.
Workers for the detection of cases and for
mass screening.
With MSF being one of the first implementers
of injectable artesunate in Africa, it was
2.6. Outbreaks
agreed among all MSF sections to document
Confronted with an emergency malaria situa-
oped to monitor the profile of patients receiv-
tion in different regions in DRC, OCB organized a number of short-term interventions in
the Maniema, Equateur and Oriental provinces. The focus of the intervention was on
case management: more than 70,000 cases
of simple malaria and 2,100 cases of severe
malaria were treated in mobile clinics, health
centres and hospitals, and a considerable
number of transfusions were done. Together
with other MSF sections, an intersectional
advocacy report is being prepared.
2.7. Prevention
Vector control (through distribution of longlasting insecticide-treated nets (LN) and Indoor Residual Spraying (IRS)) is an essential
and effective component of any malaria control programme. However, the MSF Malaria
policy is not always implemented correctly in
our existing projects or during emergencies.
this experience. A specific tool was develing the treatment, the duration of treatment,
the route of administration, treatment outcomes and problems related to treatment
preparation or administration. So far, about
1,400 patients have been monitored.
In Burundi, a baseline survey was done, evaluating mortality, malaria health seeking behaviour and coverage of preventive tools
such as LN.
5. Looking back and ahead
Lessons learned for 2012
- Adherence to ACT (Fixed Dose Combination) and monitoring of this adherence needs to be strengthened.
- The emergency intervention in DRC has highlighted some issues: malaria surveillance, timely detection and adequate response
to malaria outbreaks remain a challenge in most of the outbreak-prone areas where we were working in 2012.
- Prevention of malaria (through provision of LN) was not always sufficiently or correctly implemented, during emergencies as well
as in some routine activities.
- In line with the decreasing malaria burden, the proportion of non-malaria fevers has increased. There is, therefore, a need to improve
the diagnostic tools (such as RDT) and protocols for differential diagnosis of malaria and to improve the management of fever in children.
Prospects for 2013
- A pan pLDH-test will hopefully be validated in 2013.
- In the malaria project in Cambodia, PCR and a test for detecting G6PD-deficiency will be evaluated.
- We will evaluate the performance of RDT, microscopy and PCR for the diagnosis of malaria in neonates.
- Further roll out of artesunate IV/IM will continue in 2013. Specific monitoring of the use of artesunate in pregnant women,
malnourished children and at peripheral levels is planned.
- The use of rectal artesunate as a pre-referral treatment should be reinforced.
- An evaluation of the community component of the malaria project in Sierra Leone is planned. Community management of
malaria – using Village Malaria Workers and Mobile Migrant Workers - will be a key-component of the project in Cambodia.
- An adapted strategy for the prevention of malaria in pregnancy needs to be developed, taking into account factors such as
- The intersectional guideline for malaria outbreaks will be finalized. Surveillance, timely detection and adequate response in case
51
epidemiological context and/or efficacy of sulfadoxine-pyrimethamine.
of outbreaks need to be reinforced. Vector control, through the distribution of LN, should be a key component of each intervention.
Based on the experience in DRC, the best strategy for these high-endemic malaria contexts needs to be evaluated.
- Resistance to artemisinin, emerging in the Greater Mekong Region, has not been documented yet in Africa. In regard to this,
the efficacy of current first line ACT should be monitored.
- A new preventive strategy, the Seasonal Malaria Chemoprophylaxis, is planned in Niger, and might be considered for South Sudan.
- The prevention of malaria through distribution of LN (to pregnant women at antenatal care (ANC) or during emergencies) needs to be
MEDICAL ACTIVITY REPORT 2012
17. MALARIA
strengthened.
MSF MEdical Department OCB
Medical Structures – Inpatient Department
1. Overview
Secondary health care and/or hospital capacity allows for the provision of medical care for complicated
cases that are referred from peripheral structures. This has an important impact on acute mortality.
Since 2005, OCB has been more and more involved in secondary healthcare, a shift in strategy that
places the organization in new terrain. In 2012, €75 million were dedicated to running Inpatient
Department (IPD) structures in 16 different countries, including in emergency contexts, numbering a
total of 2,088 beds and catered for by approximately 5,794 staff.
In these structures, a variety of activities coexist, requiring a specific management approach. Hospital
management is “the ability to organize human resources, technology, supplies and finances to ensure
provision of quality patient care within a structure” (World Health Organisation (WHO)). For OCB, there
is a need to standardise the multi-disciplinary support approach to running these health facilities.
Different criteria are used to classify secondary health care structures, depending on their specific
characteristics. In OCB four types of secondary health care structures are recognized:
- General Hospital - seven: Lashkar-Gah and Ahmad Shah Baba (Afghanistan); Lubutu, Masisi and
Niangara (DRC); Nagaland (India); and Burao (Somaliland)
52
- Service or Disease Specific Activities - twelve: Khost and Kunduz (Afghanistan); Gitega, Kabezi
and Kirundu (Burundi); AIDS Kinshasa (DRC); Tabarre (Haiti); Dakoro and Guidan Roumdji (Niger);
Timergara (Pakistan); Gondama Referral Centre in Bo (Sierra Leone); and Khayelitsha (South Africa)
- Hospital Based Activities - seven: Imey (Ethiopia); Martissant (Haiti); Dargai (Pakistan); Galgaduud
(Somalia); Gogrial and Pibor (South Sudan); and Shaeria (Sudan)
- Emergencies - four: Mali; Mauritania; South Sudan (Maban region) ;and Syria
18. medical structures – inpatient department
About half of these health facilities are managed exclusively by OCB. Nearly half (47%) of the 30
facilities are located in “default” settings (location chosen by the exigency of an acute crisis).
2. Programme activities
2.1. Activities at project
and mission level
In 2012 OCB provided inpatient care in 30
health facilities, including during emergency
interventions (fig. 1).
- One in-depth feasibility study was
performed for the opening of a paediatric
hospital in Juba, South Sudan. Following
this analysis, OCB decided not to start
this project.
MEDICAL ACTIVITY REPORT 2012
- Three structures were opened: Khost
(Afghanistan), Kirundu (Burundi) and
Tabarre (Haiti).
- Five structures were closed/handed over
during 2012: Lashkar-Gah (Helmand,
Afghanistan), Lubutu (DRC), Dakoro
(Niger), Dargai (Pakistan) and Galgaduud,
Somalia.
- After the 2012 Annual Review of Operations, the decision was taken to close/
Figure 1: OCB medical structures offering IPD
services, 2012
hand-over five more structures in
Emergency
13%
2013/2014: Kabezi (Burundi), Niangara
(DRC), Imey (Ethiopia), Nagaland (India)
and Khayelitsha, South Africa.
- The emergency pool intervened in four
Continued
43%
To be
closed
17%
countries where IPD structures and/or
surgery was implemented to answer
health needs: Mali, Mauritania, South
Sudan and Syria (cf. Emergency Unit
section).
- Thus, excluding the emergency projects,
16 health facilities with IPD bed capacity
(3 of which new projects) will remain at
the end of 2013.
Closed
17%
New
10%
2.3.1 Paediatrics
The GRC (Bo) and Masisi are in the top five for
number of beds and staff and total number of
– Dakoro and Kirundu were excluded from
this analysis due to missing data (fig. 2). Staff
size at each site ranged from 300 to 600 (fig.
3, no data for Galgaduud, Somalia). The
Lashkar-Gah hospital in Helmand, Afghanistan saw the largest number of consulta-
At the end of 2012, the GRC in Sierra Leone
admissions among all OCB IPD structures.
and the hospital in Guidan Roumdji were the
The two trauma centres managed by MSF
two remaining structures with high volumes
(Tabarre, Haiti and Kunduz, Afghanistan) do
of paediatric (under 5 years of age) patients
not have more than 120 beds or the highest
– 7,601 and 10,166 respectively. Two pro-
number of yearly admissions, but they do
jects admitting an important number of chil-
have a high number of staff because of their
dren were closed this year, Lashkar-Gah and
high level of specialisation.
Dakoro. There was a substantial improve-
tions, at 18,231 (including deliveries) in 2012
Ahmad Shah Baba (district hospital in Kabul,
ment in the data collection for neonatal care
(fig. 4, no data for Lubutu, DRC). Lashkar-
Afghanistan) has a high number of admissions
this year; data was collected in nine OCB
Gah, which was one of the largest hospitals
for deliveries (9,245 or an average of 770 per
structures (cf. Paediatric Care section, §2.2.).
in terms of numbers of beds, staff and ad-
month), which in 2012 represented 84% of
In addition, this year saw an important invest-
missions, was handed over to OCA in 2012.
the total admissions to this hospital. Guidan
ment in terms of providing care to this subset
Roumdji in Niger, a project focusing on paedi-
of the paediatric population (fig. 5).
Figure 2: Top five OCB medical structures offering
IPD services – number of beds, 2012
Lubutu; 144
GRC (Bo); 220
atric care and malnutrition, follows Lashkar-
Knowing the proportion of under-five patients
Gah as the IPD structure that has absorbed
which is malnourished remains a challenge.
the highest number of overall admissions in
The existing data collection system does not
2012 and half of all paediatric admissions in
permit an analysis of the proportion of chil-
OCB. It averaged slightly less than 1300 ad-
dren coming in with acute illness who are
missions per month, of which 66% were in the
also undernourished. This data is vital be-
paediatric ward, which has about 60 beds.
cause the case management (in terms of
drug and fluids) is different from that for a
2.3. Paediatrics, deliveries
and surgery
normally nourished child, and nutritional
treatment is crucial for their convalescence.
According to the data collected for the 2012
Burco; 149
Helmand; 170
2.3.2 Under-five mortality
(including neonates)
typology exercise (cf. Health Informatics section, §2.4.) there were:
Masisi; 150
N
Figure 3: Top five OCB medical structures offering
IPD services – size of staff, 2012
Masisi; 310
Helmand; 592
The highest percentage of mortality in under-
%
fives occurred in the projects of Kabezi (Bu-
Total IPD admissions
135,280
Admissions (without
deliveries and ITFC)
73,210
54.1%
Paediatric < 5 admissions
35,435
26.0%
Neonate admissions
2,779
2.1%
Maternity admissions
52,595
38.9%
Paediatric < 5 mortality
2,174
6.2%
Neonatal mortality
419
15.1%
rundi) and Lashkar-Gah (Afghanistan). Neonates represent all under-five mortality in
Kabezi and Khost, as no other paediatric
cases were admitted to these IPDs (fig. 6).
Cf. Paediatrics section for an in-depth analysis of these trends.
2.3.3. Deliveries
Although the Khost project opened quite re-
IPD: inpatient department;
ITFC: inpatient therapeutic feeding centre
Tabarre;
312
cently, it already saw a high number of deliv-
GRC (Bo); 381
Figure 5: Paediatric admissions to OCB medical structures offering IPD services, 2012
Kunduz; 356
Figure 4: Top five OCB medical structures offering
IPD services – number of admissions, 2012
20000
18000
Paediatric (<5), excl. neonates
16000
Masisi; 9976
Neonates
ITFC admissions
IPD >5
14000
Helmand; 18231
53
On average, hospitals had a size of 167 beds
18. medical structures – inpatient department
2.2. Hospital Size
(excluding emergencies)
12000
10000
Ahmad
Shah
Baba;
10898
6000
4000
2000
i
ez
l
ria
og
G
Ka
b
t
sa
n
ar
tis
M
ab
an
M
co
Bu
r
Ba
b
a
ra
ga
Sh
ah
ad
M
as
isi
Da
ko
ro
an
d
H
el
m
RC
G
N
ia
n
Ah
m
Guidan Roumdji;
15050
G
GRC (Bo); 12024
ui
da
n
Ro
u
m
dj
i
(B
o)
0
MEDICAL ACTIVITY REPORT 2012
8000
3. Developments and innovation
Figure 6: Mortality for children under-five admitted to OCB IDPs, by project, 2012
16.0%
To reinforce hospital management in the field,
Threshold
Mortality rate
OCB has chosen to invest in human resourc-
14.0%
es at headquarters, thereby permitting a
12.0%
transversal and multidisciplinary approach.
10.0%
The positions opened include:
- A hospital management coordinator
8.0%
based in the Operations Department
(January 2012)
6.0%
- A hospital logistician based in the logistics
4.0%
back office (November 2012)
2.0%
- Transition from part-time to full-time
technical hospital management referent in
0.0%
Khost
Tabarre
AIDS Kinshasa
Dargai
Kunduz
Shaeria
Nagaland
Imey
Pibor
Kabezi
Gogrial
Martissant
Maban
Burco
Ahmad Shah Baba
Dakoro
Niangara
Masisi
Helmand
GRC (Bo)
Guidan Roumdji
the medical department (recruitment
ongoing)
To monitor priorities and guide the way forward, the Operations middle managers, together with the hospital management coordinator formed a steering group that is
accountable to the Board of Directors.
eries (more than 1,000 per month). In Ahmad
Shah Baba (Afghanistan), Masisi (DRC), and
Burao (Somaliland), the number of monthly
deliveries is also quite high (more than 300/
month). The projects of Kabezi and GRC exclusively treat obstetric cases with complica-
54
tions and do not manage normal deliveries.
2.3.4. Surgery
Kunduz and Tabarre are the two trauma centres run by OCB; they are important in terms
of surgical activities, level of care (internal fixation), and hygiene standards. Gitega focuses exclusively on fistula care. All other projects have an operating department where
MSF focuses on necessary, life saving surgery, including c-sections. These activities
are discussed in more detail in the Surgical
18. medical structures – inpatient department
Activities section.
4.Training and human
resources
Because the past year was spent in large
part on the set-up of this new hospital management approach, there was little investment in human resources for trainings. The
first Hospital Management Team Training is
planned for November 2013; it will focus on
the hospital management team in MSF contexts.
5. Looking back and ahead
Lessons learned for 2012
- In 2012, one of the objectives was to get a global overview and inventory of the situation within OCB (staff ratios, cost, workload, etc.).
This was more challenging than anticipated, because the existing reporting system and data collection has been developed in terms of a
project approach. It proved challenging to find and centralize information and data specific to hospitals (number of beds, staff, budget,
medical data, etc.).
- A pilot hospital platform was set-up for the upgrade of the GRC in Sierra Leone and is still ongoing. The objective is to provide
MEDICAL ACTIVITY REPORT 2012
a transversal technical approach (a representative per department) to support operations. The GRC committee was held on a bi-weekly
basis throughout the year. It has been (and still is) challenging to find appropriate solutions for a running 220-bed facility, taking into
account the urgency (challenges related to Lassa fever endemicity).
- Contacts and regular platforms (every three months) were created with OCP and OCBA; sharing of information, tools and data
is ongoing.
- In order to consolidate knowledge, ensure quality health care, and maintain capacity, the number of hospitals in OCB is not increasing
(following the motion of the board). Within the remaining hospitals, focus will be placed on building internal capacity, expertise and
standards through capitalisation, training, and rotating a pool of experienced human resources.
Prospects for 2013
- 2013 started with a hospital steering committee (Operations middle managers), which should re-enforce OCB accountability, monitoring,
guidance and support for hospital activities, as well as ensure stronger hospital management in the field and at the level of headquarters
with recommendations, tools and trainings.
- In collaboration with the training unit, a comprehensive competency-based curriculum for training a Hospital Management Team
in MSF contexts is being developed. This training should start at the end of 2013. Parallel with this, a toolkit and guidelines are being
MEDICAL ACTIVITY REPORT 2012
18. medical structures – inpatient department
55
developed with the goal of clarifying concepts and approaches for improving managerial competencies.
MSF MEdical Department OCB
Mental
Health
1. Overview
Compared to the previous year, in 2012 Mental Health (MH) activities were much less integrated into
the medical activities during emergency interventions. While MH is usually particularly implicated in violence/
conflicts, displacement of populations, and natural disasters, activities this year were more limited, as
security issues did not permit the missions of expatriates to implement MH activities onsite (e.g. in
Mauritania, Mali or Syria). MH interventions in emergencies were integrated mainly into the medical
activities in three camps in South Sudan; these activities focused predominantly on nutrition.
56
As seven projects/MH components were closed, the portfolio of MH interventions was reduced for ongoing
projects. New MH projects developed in large part as additional components to projects in countries with
pre-existing activities. For example, in Pakistan, MH expanded into a second project, integrated in the
outpatient department (OPD) in an urban slum of Karachi; in Afghanistan, MH was integrated into the OPD
in Lashkar-Gah, Helmand (and handed over to OCA) and an assessment conducted in Kunduz has led to
planned MH activities for the victims of trauma in 2013; and in Egypt, a sexual violence component was
added to the vertical MH programme in Egypt, focusing on migrants.
Some activities which were planned for 2012 were ultimately cancelled due to changed circumstances.
These included MH for victims of violence in Bahrain and a rehabilitation centre for victims of torture in Libya.
Because MSF cannot maintain a constant presence in an increasing number of contexts, in some cases
professionals were identified and trained outside of their country of origin (e.g. Bahrain and Syria) to serve
MH needs. This type of intervention is efficacious on condition that it is accompanied by follow-up through
remote control clinical supervision and technical support.
19. mental health
The integration of psychiatric care in MH activities continued in 2012, both directly by MSF (Egypt, India,
South Sudan, and Kenya) and through a referral system (Afghanistan, Pakistan Ukraine, and Libya).
Databases and patient files were accordingly implemented in several projects. To increase technical support,
a part time consultant psychiatrist was recruited mid-year. New fields of intervention were discussed at the
operational level over the course of 2012: hepatitis C treatment (MH would be involved due to the possible
psychiatric effects of the drugs) and rehabilitation for victims of torture (where analysis of the feasibility of a
possible project has started).
In early 2012, the position of “HIV/TB community and patient support advisor” was created to reinforce the
support to HIV-TB projects (South Africa, Guinea, Malawi, DRC, Zimbabwe, Kenya, Mozambique, Ethiopia,
and North Sudan), with regular collaboration with the MH and Health Promotion advisors. The position is linked
to the Southern Africa Medical Unit (SAMU), but based in Brussels to allow exchange with the other technical
advisors. It is anticipated that this position will permit a holistic approach to care that includes emotional,
educational and social aspects and will facilitate the development of strategies at the community level.
2. Programme activities
During 2012, OCB provided non-emergency
MH activities in 25 projects across 15 coun-
MEDICAL ACTIVITY REPORT 2012
tries. At the beginning of 2012, 18 projects in
13 missions included an integrated MH component, in addition to the HIV/TB programmes (table 1, Annex). Additionally, MH
activities were included in five emergency interventions (table 2, Annex).
Despite a general reduction of MH activities
by the end of the year, the diversification of
contexts has permitted the continuation of a
wide variety of activities, including individual
2.1 South Sudan (Doro Camp)
consultations, awareness activities, psycho-
Since the end of 2011, 46,000 refugees have
education, Psychological First Aid (PFA),
fled to the refugee camp of Doro, Maban
training of medical staff and other identified
County, to escape ongoing violence in the
professionals as teachers, and community
Blue Nile state of North Sudan (cf. Emergen-
mobilisation as support in the implementa-
cy Unit section, §2.2.1.). A vast majority have
tion of group activities to restore collective
endured traumatic experiences during their
coping mechanisms. Below, two specific
displacement (lost family members, bomb-
noteworthy contexts with an MH focus are
ing, destruction of villages, and general ex-
discussed.
perience of violence) on their way to the
camp. At Doro, many were still living under
stressful conditions, facing food shortages,
team of seven community workers from dif-
rial, meeting of experts/centres for reha-
lack of basic non-food items, and in some
ferent communities raised awareness about
bilitation of torture, participation in the con-
cases, lacking water or sanitation. MH activi-
MH and SV among migrant groups. During
cept note, organization of training for the
ties began in mid-August. A team of five psy-
2012, the number of patients increased reg-
field team).
chosocial workers and seven home visitors
ularly, with a total of 348 patients this year.
was recruited, trained and continually super-
Half were followed by both a psychologist
vised by a clinical psychologist expatriate.
and a psychiatrist. The majority came from
4. Training and
human resources
MH activities were focused along three axes
Eritrea, Sudan (North and South), Ethiopia
During 2012 a number of different MSF train-
of intervention:
and Somalia. The most common diagnoses
ings included an MH component:
the physical health but also the mental status of caregivers can be affected, making it
difficult for them to find resources to stimulate their child. This lack of psycho-stimulation can have adverse consequences for
the child’s development and MH, especially
when combined with malnutrition. In Doro,
the team started daily group sessions on
mother and child psycho-stimulation, group
order and chronic anxiety disorders. Most
migrants had experienced violence in their
port to survivors of SV.
-The Management of Health Services
Egypt: 62% of MH patients reported direct
(MHS) training: MH policy and integration
physical violence (among them 34% report-
and role of the medical staff.
ed spontaneously, at the initial session, tor-
- The Populations in Precarious Situations
ture/ill treatment). The medical component
(PSP) course – co-facilitation of the emer-
will therefore be reinforced next year.
gency module, and evening sessions on
3. Technical guidance
Over the course of 2012, a number of activi-
counselling sessions.
ties were undertaken in relation to the devel-
teams were trained for identification of MH
midwifes: a module on psychological sup-
country of origin, during their journey, or in
discussions with mothers, and individual
- In the main clinic and health posts: medical
- The SRH training course for nurses and
opment/revision of MH tools and guidelines,
including:
disorders and an MH team provided indi-
- Finalisation of the “manual of training in
vidual counselling sessions, group ses-
MH for primary health care professionals”
sions for PFA and psycho-education, and
and the start of its translation into French
group discussions. Psychiatric care was
(intersectional).
MH.
The following external trainings were also
provided:
- Institute of Tropical Medicine – Master of
Public Health: mental health within humanitarian interventions.
- Training for surgeons with the University of
Verona: stress management.
- University clinic Saint Luc: mental health
interventions within MSF (HUMA course).
added in the main clinic at the end of 2012.
-Start of the guideline for specific ap-
- In the community: MH awareness and PFA
proaches and techniques to working with
OCB continued to collaborate with OCA in
children and teenagers (intersectional).
the organisation and running of a two week
were promoted, severe cases were identified, and home visits were performed
when necessary. Special attention was devoted to awareness and care of Sexual
and Gender-Based Violence (SGBV).
2.2 Cairo
This project aimed to provide comprehensive
medical and MH care to documented and
undocumented migrants in Cairo. Cairo is
estimated to have between one and four mil-
- Development of protocols and tools related to psychiatric care.
-Development of practical and standardized tools for screening MH disorders and
for evaluating the outcome of psychiatric
support.
- Review of the chapter on postpartum MH
disorders in the Sexual and Reproductive
Health (SRH) guideline.
MH training course in the Netherlands for
field psychologists and counsellors (national
and international staff). Seven OCB candidates participated and there was an increasing involvement from other sections for the
training modules. The possibility of running
the same decentralised course in French is
being considered between the sections.
In terms of human resources, 25 psychologists/psychiatrists were deployed to the field,
lion undocumented migrants, who suffer
- Participation in the review of a SV pocket
among whom seven were on their first mis-
from barriers to care, stigmatisation, and
guideline (chapter about psychological
sion. This represents a decrease of expatri-
harsh living conditions. The MH clinic opened
support and psychotropics).
ate positions, due mainly to nationalisation of
in February 2012, with a specific sexual violence (SV) component added in April.
A team of national clinical psychologists,
psychiatrists and nurses was recruited to
provide comprehensive MH care at the clinic.
A private psychiatric hospital was identified in
case of the need for hospitalization. A social
worker was also added to link the patient
with existing social services, provide support
to the administrative procedures, and rein-
- “MH key messages” for the Health Promotion manual.
57
malnutrition. During a food crisis, not only
chronic psychosis, post-traumatic stress dis-
some positions and closure of certain projects.
19. mental health
care practices and MH have an impact on
-Standardization of MH job profiles and
competencies for MH professionals.
- Compilation of MH documents translated
into Arabic.
- Participation in developing the patient support guideline for MDR-TB (will be finalized
in 2013).
force the mutual referrals with the other ac-
- Development of MSF expertise about care
tors working with migrants. In addition, a
for victims of torture (compilation of mate-
MEDICAL ACTIVITY REPORT 2012
- In the therapeutic feeding programme: child
were depression (moderate and severe),
5. Looking back and ahead
Lessons learned for 2012
Psychiatric care is still too often excluded from humanitarian care, even though such a gap in treatment not only has an impact on
the dimension of health, but can also have a negative affect on social integration and access to health care. OCB has already made
considerable efforts to integrate psychiatric care into overall medical care through MH interventions; such efforts should continue, particularly in emergencies but also through the training of general practitioners, if needed, in regular projects.
Prospects for 2013
- The MH databases must be reviewed and data analysis improved in order to adapt better the MH strategies, but also to better document
MH activities. Operational research could also be developed in the field of MH, for example on outcome measurements for beneficiaries
of MH interventions. Towards this end, in collaboration with the Operational Research Unit, MH made connections with external contacts
to provide technical support on this topic.
- More human resources need to be allocated towards the implementation and supervision of MH activities. Many of the current positions
of expatriate psychologists are not devoted full-time to psychology (e.g., the shared position of Field Coordinator and psychologist);
others are mobile positions between projects or temporary short-term positions, neither of which permit sufficient support for the MH
MEDICAL ACTIVITY REPORT 2012
19. mental health
58
professionals in the field. Ongoing training and supervision are mandatory to ensure quality MH care.
MSF MEdical Department OCB
Nutrition
1. Overview
In the context of nutrition, 2012 was characterised by a political crisis in the Sahel region of Africa,
accompanied by a food/nutritional crisis. In this context, OCB intervened in Mali, Mauritania and Niger. In
addition, OCB also responded to the humanitarian crisis in South Sudan by providing medical care in the
refugee camps in the region (cf. Emergency Unit section, §2.2.1.). An innovative approach, based on
Mid-Upper Arm Circumference (MUAC)-for-height as admission criterion for therapeutic feeding centres,
was introduced for management of acute malnutrition in children over five years of age in the refugee
camps.
For the regular programmes, the total numbers of beneficiaries was the lowest since 2008: the number of
patients treated for Severe Acute Malnutrition (SAM) was lower than in 2010 and 2011, and in particular
the number of patients with Moderate Acute Malnutrition (MAM) decreased dramatically. Additionally, this
year there were no selective feeding distributions and decreased nutritional support to ill patients.
As forecast previously (cf. Medical Activity Report 2010), the new project in the Kamrangirchar slum
setting in Dhaka, Bangladesh has developed into a focus project for operational research into nutrition in
general and nutritional approaches in Asia in particular. The first research publications from Bangladesh
were released in 2012.
2.1. Activities at project
and mission level
During 2012, OCB conducted 22 nutritional
projects across 13 countries (table 1). Most
Table 1: OCB nutritional projects in 2012
Type of programme
Countries and projects
Nutrition main activity/emergencies
DRC (Refugee Goma); Mauritania (Mbera Malian
refugees, Assaba); Mali (Mopti, Douenza); South
Sudan (Maban)
Nutrition integrated into medical activities
Afghanistan (Lashkar-Gah, Kabul); Bangladesh
(Kamrangirchar); DRC (Masisi, Niangara, Lubutu);
Ethiopia (Imey); India (Chhattisgarh); Niger (Dakoro,
Guidan Roumdji); Sierra Leone (Bo); Somalia (Guriel);
North Sudan (Darfur); South Sudan (Pibor, Gogrial)
Nutrition integrated into HIV programmes
DRC (Kinshasa); Guinea (Conakry, Gueckedou);
Kenya (Nairobi); India (Mumbai)
of the regular nutritional programmes were
integrated programmes. Except for the
emergency programmes in Mauritania, Mali
and South Sudan, no new programmes were
opened and two major ones were success-
59
2. Programme activities
DRC: Democratic Republic of Congo
fully handed over to the Ministry of Health
months of age are now treated in the MSF
lance through the nutrition international
2.2.1.1. Mauritania
working group as well as a platform to share
data and discuss strategies. All sections
Since January 2012, the southern region of
combined treated 142,251 SAM children in
Hodh El Chargui received an influx of Malian
seven countries compared to 124,990 (five
refugees due to the conflict in northern Mali
countries) in 2011. Comparing within coun-
(cf. Emergency Unit section, §2.2.2.). In
tries, Niger increased its number of benefi-
March, nutritional activities started in the
ciaries by 21% (and by 3% compared to
camps (screening, ambulatory therapeutic
2.2. Nutritional Emergencies
2010, considered a “bad year”), Chad in-
feeding centres (ATFC) and an inpatient ther-
creased by 82% (but decreased by 23%
apeutic feeding centre (ITFC)). Nutritional
2.2.1. Sahel
compared to 2010), and Mali increased by
surveys in June and November revealed high
7%. Burkina and Nigeria were much less af-
levels of global acute malnutrition (GAM) (re-
fected than 2011, with decreases of 62% for
spectively 20% and 17%) and SAM (5.9% &
both countries. However, with the exception
4.6%) with no improvement between the two
of Niger, comparisons are not straightforward
surveys despite food distribution and the
as the number of projects differs within coun-
presence of a nutrition programme.
hospital) and to the national NGO BEFEN in
Dakoro, Niger. Lashkar-Gah hospital (Helmand) with its therapeutic feeding programme in Afghanistan was handed over to
OCA.
From December 2011, alerts on a possible
food crisis in the Sahel were raised. The international community and concerned governments set up action plans to mitigate the
shock (general food distribution, targeted
food distribution, subsidised cereal banks,
etc.). MSF set up an intersectional surveil-
tries.
In the Assaba region, which was affected by
food insecurity, support to MoH health struc-
20. nutrition
intensive care cases and infants under six
MEDICAL ACTIVITY REPORT 2012
(MoH) in Bo, Sierra Leone (only malnourished
tures in five districts started for the management of SAM, with the secondary objective of
surveillance of the situation in preparation for
rapid response in case of a crisis, which for-
Table 2: Number of OCB nutritional programmes in 2012
Type of programme
No. of centres
No. of patients admitted
ITFC
20 total
18 integrated in hospital care
1 unknown
1 day-care
9,100
ATFC
67 total
66 integrated in hospital/HC
1 unknown
46,254
SFC + Selective Feeding (PLW)
4
298 + 3,831
Specific targeted nutritional
support (sick patients)
4
612
tunately did not materialise. The proximity
with the communities was a challenge in this
context, impairing the efficacy of surveillance.
2.2.1.2. Mali
OCB intervened in the conflict area (Mopti –
Douentza) with support to primary health
care (PHC), including the treatment of SAM
ATFC: ambulatory therapeutic feeding centre; ITFC: intensive therapeutic feeding centre;
NA: not available; PLW: pregnant and lactating women; SFC: supplementary feeding centre
(cf. Emergency Unit section, §2.2.2.).
2.3. Nutrition Programmes
60
2.2.1.3. Niger
The typical setup of OCB nutritional activities
(1,790) compared to 4% in 2011; the decrease is due to the handover of the Dakoro
Niger registered more patients in nutrition pro-
consists of one ITFC for severe/complicated
grammes than in 2009 and 2011. Admissions
cases, several satellite ATFCs for uncompli-
to the ATFCs were lower than in 2010 in the
cated cases, and sometimes several Supple-
first semester and similar in the second. How-
mentary Feeding Centres (SFC) for moderate
ever, the increase in ITFC admissions was
cases. In addition, selective feeding (adapted
dramatic, with a four to six fold increase from
to the target population) is provided to vul-
August to October, probably due to the over-
nerable groups such as children under two
lap of the malaria season with the malnutrition
years of age or pregnant and lactating wom-
Cure rates in TFP ranged from 8.4% in
peak and the cessation of NGO support to
en (PLW), and specific targeted nutritional
Chhattisgarh (India) to 85.5% in Sudan (table
Maradi hospital, draining people to Guidan
support is provided for patients in vertical
4). Globally, most of the integrated projects
Roumdji hospital.
projects, such as HIV/tuberculosis (TB) pro-
performed slightly less well than last year;
grammes. An overview of all OCB nutrition
only Sierra Leone stayed stable (with 83.7%
activities is presented in table 2.
compared to 83.3% the prior year). An 80%
2.2.2. South Sudan
Nutritional interventions were done in the
refugee camps in the Maban region. In the
camps, particularly in Batil, the health status
of the population was poor and the prevalence of malnutrition was high (GAM: 39.8%,
SAM: 13.4%), even when measured by
MUAC and oedema only (27.7% and 10%
respectively). Children over five years of age,
adolescents and adults (especially the elderly) were also affected and were included in
the programme from September. Once included, this segment of the population represented 33.4% of the admissions. The prob-
20. nutrition
represented 3.4% of the total beneficiaries
Overall, OCB treated 60,095 patients in
2012, compared to 96,193 patients in 2011
(table 3). This represents the lowest number
of patients treated since 2008. Except in one
HIV project (Kenya), MAM was not treated
and organized selective distributions did not
occur. In the contexts where these programmes were pertinent (e.g. Niger, refugees
in South-Sudan and Mauritania), these needs
were covered by the World Food Program
(WFP) and other NGOs.
project in Niger in September. There are still
large variations between projects: the top
three projects are Bangladesh with 35.7% of
infants, Sierra Leone with 26% (due to restriction of target population of the programme), and Afghanistan with 10%.
cure rate was set as the target. Only two out
of 15 (13.3%) programmes achieved this target (compared to 28.6% in 2011), while eight
out of 15 (53.3%) even remained below 70%.
Low cure rates were typically a consequence
of high defaulter rates; similar to 2011, these
rates of more than 15% were observed in
nine out of 15 (60%) programmes, of which
eight were above 20%. These defaulting
rates are linked with mobile populations (India, Bangladesh and Mali), security problems
(Pibor) or geographical access during the
2.3.1. Therapeutic Feeding Programmes
rainy season (Gogrial). Unexpectedly, high
defaulting was also observed in refugee set-
lem could have been tackled earlier, raising
In Therapeutic Feeding Programmes (TFP)
tings (Maban in South Sudan and Maurita-
the question of whether the elderly are a “ne-
with both ATFC and ITFC components, the
nia). In Mauritania, it was clearly linked with
glected population” in this context. The role
proportion of patients needing hospitalization
acceptability of the programme by the Touar-
of MSF for this vulnerable population in the
ranged from 1.4% (Mauritania) to 46.1% (So-
eg population and population movements in
context of population displacement and rup-
malia) in 2012 (table 4, Annex). The overall
and out of the camp. After some investment
ture of social networks and social structure
admission of infants younger than six months
of the team with the community health work-
MEDICAL ACTIVITY REPORT 2012
needs to be discussed.
A new protocol based on a simplified MidUpper Arm Circumference (MUAC)-for-height
Table 3: Annual numbers of treated patients
SAM
MAM
Selective feeding and sick patients
Total
2008
51,349
54,774
734
106,857
years of age, but documentation/lessons
2009
42,947
21,677
7,442
72,066
learned could not yet be done. Questions
2010
55,324
4,127
65,500
124,951
were raised about the possibly overly restric-
2011
59,874
2,553
33,766
96,193
tive MUAC cut-off used for adults. This
2012
55,354
298
4,443
60,095
was introduced for the children over five
should be investigated further.
MAM: moderate acute malnutrition; SAM: severe acute malnutrition
ers, the rate decreased from 40-60% to 25%
- Nutritional and retrospective mortality sur-
dren under five years of age. In 2012, the
in December. In Mali the defaulter rate was
veys were conducted in Mauritania (Mber-
nutritional support for PLW switched to an
high during the first three months of the pro-
ra camp), Sierra Leone, and South Sudan
adolescent clinic, with special focus on
gramme, and then decreased gradually to
(Pibor; Doro and Batil refugee camps in
pregnant and lactating adolescents. The
between 20 and 25% in October and No-
Maban). Additionally, rapid nutrition and
overall objective of this project is to expand
vember and 5% in December. In Maban, the
food security assessments were per-
OCB knowledge and experience on urban
yearly result is skewed by four months of
formed in Afghanistan (Mukhtar camp),
settings and on malnutrition in Asia, and to
high defaulter rates; the rest of the year, this
Mali (Koulikoro, Mara, Mopti), Mauritania
advocate for the CMAM approach in Bang-
rate varied between 4% and 12%.
(Assaba), as well as active community
ladesh. In 2012, the following research
screening (MUAC + oedemas) in Niger,
studies were completed and published:
- “Weight evolution, morbidity and case
and the Gondama Referral Centre (GRC) in
- Field visits were performed to South Su-
fatality among children assessed as be-
Sierra Leone (14.2%). In the latter, this is to
dan (twice) for support to the refugee
ing severely malnourished by weight-for-
be expected as the project focuses only in-
emergency response.
height (<-3 Z-score) criteria but not us-
six months. HIV projects were not included in
this comparative analysis.
2.3.2. Supplementary
Feeding Programmes
3. Training
ing
mid-upper
arm
circumference
(MUAC) in a slum setting in Dhaka,
- Two sessions of the Nutrition E-learning
Bangladesh” (with a poster presentation
module, which is a tutorial shared with ref-
at the MSF UK Scientific Day and an oral
erents of OCA and OCBA, have been or-
presentation at the OCB Operational
ganised. The translation of the module to
Research Day).
This year, except in the HIV programme in
French was finalised but due to technical
Kenya, there were no Supplementary Feeding
problems during importation on the Doke-
Programmes (SFP). In some contexts, the
os platform, two sessions were cancelled.
SFP was covered by other NGO’s (e.g. refu-
-Nutritional input was provided to other
per on children accepted, one on PLW
trainings, including the Populations in Pre-
under peer review (with a poster presen-
carious Situations course (PSP), the Man-
tation at the MSF UK Scientific Day and
agement of Health Services course (MHS),
an oral presentation at the OCB Opera-
the Logistics Coordinator Course (LCC).
tional Research Day).
gee emergencies) or by the MoH and the WFP
(e.g. Niger). The one SFP in Kenya and Specific Targeted Nutritional Support activities are
documented in tables 5 and 6 (Annex).
2.4. Operational Activities
- “Acceptability of Plumpy-nut for community based therapeutic feeding in a slum
setting in Dhaka, Bangladesh”: one pa-
- A collaborative project with “Global Health
- “Does the 65 cm height cut-off as age
-Niger: In Guidan Roumdji the evolution of
Media” was initiated for development of
proxy exclude children eligible for nutri-
the security situation jeopardised the su-
training videos on nursing, hygiene and
tional assessment in Bangladesh?”
pervision of the programme. In 2012, the
medical procedures in collaboration with
malaria peak arrived one month earlier and
the paediatric and hygiene referents.
coincided with the malnutrition peak. The
paediatric ward and ITFC were overloaded
with patients (the admissions doubled
4. Operational Research
and Developments
- “Severe malnutrition in children presenting to health facilities in an urban slum in
Bangladesh”.
- The documentation on “Feasibility and
compared to 2011: 4,240 versus 2,157).
4.1. Publications
outcomes of a community based ap-
During 17 weeks (from mid-August to mid-
Several papers on the Bangladesh pro-
nutrition among children <5 years in an
November) more patients were admitted
than during all of 2011 (2,528). This situation impacted the quality of care and the
mortality during that period, which increased to 8.5 in September and 9.9% in
October. In Dakoro, the handover of the
gramme and one on the impact of water and
sanitation on nutrition programme results in
Niger were published over the course of
2012 (cf. Operational Research and Documentation section, §5.).
project to the national NGO BEFEN, sup-
4.2. Ongoing Studies
ported by the international NGO ALIMA,
- The “Treatfood project”, aimed at evaluat-
was completed in September.
ing therapeutic approaches to MAM, was
proach to managing severe acute malurban slum setting in Dhaka, Bangladesh” is still ongoing.
- In South Sudan, sitting height was measured in two nutritional surveys to calculate
the Sitting-Standing-height ratio to evaluate influence of body shape on the weightfor-height index, but preliminary analyses
were not conclusive.
- Sierra Leone: MSF support to the ITFC,
abandoned in its current form because of
which was already transferred to the dis-
the lack of an available setting to conduct
trict hospital, stopped in the beginning of
the study – planning of a revised project is
The revision of a number of nutritional tools
the year. The Intensive Care Unit providing
ongoing.
and guidelines continued in 2012:
care for malnourished children with severe
complications, and the infant ward for infants younger than 6 months remained in
the GRC.
-Bangladesh: operational research in this
setting continued (cf. §4.2.).
- As mentioned, the project in an urban slum
4.3. Tools and Guidelines
- The release of the “Nutrition Pocket
setting in Dhaka, Bangladesh had a sizea-
Guide” has been delayed due to shifts in
ble operational research component (cf.
human resource.
§2.4.). This project focuses on Community
61
tensive care cases and infants younger than
20. nutrition
grammes, except in Niangara, DRC (7.1%)
during the hunger gap season.
- The revisions to the Nutrition guidelines
Management of Severe Acute Malnutrition
are still ongoing in collaboration with the
(CMAM) and primary health care for chil-
Nutrition intersectional working group.
MEDICAL ACTIVITY REPORT 2012
Mortality rates remained below 5% in all pro-
5. Looking back and ahead
Lessons learned for 2012
- In 2012 the Nutrition unit was again confronted by human resource gaps. As a consequence, some projects were delayed,
as priority was given to the emergencies.
- Results of the Bangladesh operational research on admission criteria confirm that in Asia, it might be safe to use MUAC
and oedema only as admission criteria to nutritional programmes. This study should be repeated in African contexts.
- A new focus was placed on malnutrition in children over five years of age during the emergency in South Sudan. This crisis
highlighted the need for paying more attention to other vulnerable groups, especially the elderly, in emergencies. During the
previous years the focus was mainly on children below three years of age.
Prospects for 2013
- The admission criteria (especially MUAC) to TFP in African contexts and the influence of body shape on weight-for-height index
will continue to be explored.
- Access to proper vaccines will be improved, as detailed in the Expanded Programmes of Immunisation (EPI) in nutrition programmes.
- The management of infants less than six months old (including neonates) will be improved, and in collaboration with the Paediatrics and
Sexual and Reproductive Health (SRH) referents, support to breastfeeding in nutrition programmes (at the ITFC and ATFC level) will be
further developed. The breastfeeding protocol will be revised and breastfeeding support strategies will be discussed.
- A pilot project on CMAM will be launched and documented in Niger.
- The OCB experience on management of adolescents and adults should be expanded and work should be done on admission
criteria if an opportunity arises in emergencies. A standard protocol for nutrition support in PLW will be developed.
MEDICAL ACTIVITY REPORT 2012
20. nutrition
62
- At the level of trainings, the first sessions of the E-learning in French will be completed and the content of the nutrition trainings
will be revised to be in line with the international nutrition guideline when the latter will be published. Training videos will be
developed on nursing, hygiene and medical procedures.
MSF MEdical Department OCB
Operational Research
& Documentation
1. Overview
A number of achievements were made over the course of 2012. These included: diversification of the
Operational Research (OR) agenda and scientific publications following the re-allocation of
responsibility of HIV/tuberculosis (TB) to the Southern Africa Medical Unit (SAMU) and non-HIV/TB
research to the Luxembourg OR unit (LuxOR). The numbers of publications reached a new all-time
high at 81 articles in peer-reviewed journals, to a large extent due to the success of the ongoing OR
courses. Several original articles and viewpoints made an influence on policy and practice, including
influencing the direction of the 2013 World Health Report, which is focused on research for universal
health. 2012 also saw the completion of the first MSF-led OR course in Luxembourg (initiated in
2011), and the launching of two new courses managed by MSF, in Europe and in Africa. Excellent
outcomes were achieved for all these courses, with 88% of the participants meeting all their
milestones, and a 12-month and 24-month publication success rate of 77% and 93% respectively.
These courses have now been accredited by the World Health Organisation (WHO) and will lead to a
strategic WHO umbrella initiative to promote and catalyse the model globally.
63
An important milestone over the course of 2012 was the organisation of the first OR day by OCB in
conjunction with the General Assembly. Oral and poster presentations were held in four broad
domains: the day was well-attended and was considered a great success. This event will continue
in a yearly fashion, to be attended by MSF members, external scientists and partners as a forum for
dissemination of MSF work.
further, with SAMU being the primary focus
for all research on HIV/TB-related subjects
(cf. HIV/Tuberculosis section) and LuxOR
providing support to research on all other ac-
Launch of the MSF OR courses
Creation of the LuxOR unit
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
tivities of OCB, including capacity building in
various areas linked to the operational pros-
provided by the OR courses, which were ex-
covered 15 broad topics, representative of
pects. This diversification into non-HIV/TB-
panded significantly over the course of 2012
most medical activities conducted by OCB
related subjects was facilitated through site
(cf. §4.): of the approximately 72 study proto-
(cf. §5. & fig. 2) – domains which remained
visits, including new visits to Egypt and DRC
cols developed over the course of 2012, 48
underrepresented included mental health,
to identify new areas of research (mental
(66%) were designed in the context of the
health promotion and infection control, and
health, sexual and reproductive health, vac-
OR courses. This highlights the vital impor-
expansion of OR to these topics is foreseen in
cination, neglected diseases, sexual vio-
tance of these courses in bringing research
2013. As was done in previous years, book-
lence), follow-up visits to Burundi and Sierra
to areas where it is lacking and for diversify-
lets (hard copy and CD) of all peer-reviewed
Leone to consolidate existing research initia-
ing knowledge.
OCB publications were compiled and distrib-
tives, and opening of a consultancy-based
microbiologist position in Lashkar-Gah (Hel-
uted to missions, partner sections, donors
2.2. Scientific publications
and collaborating institutes.
on antibiotic resistance (cf. Laboratory sec-
A marked increase was observed in peer-re-
tion, §4.). A site visit to Niger to develop the
viewed OCB-related publications, from 52 in
2.3. Research dissemination
research portfolio on nutrition was planned
2011 to 81 in 2012 (fig. 1), also due to the
Dissemination of research findings beyond
for 2012, but was cancelled due to security
success of the OR courses which were initi-
the scientific manuscript stage, and the
constraints. Another important contribution
ated in MSF in 2011 and expanded over the
translation of such findings into policy and
to the broadening of the OR agenda was
course of 2012 (cf. §4.). These publications
practice is one of the main goals of OR. Over
mand), Afghanistan, for the first OCB study
21. Operational Research and Documentation
The OR portfolio was successfully diversified
90
80
70
60
50
40
30
20
10
0
MEDICAL ACTIVITY REPORT 2012
2.1. Diversification
of the OR agenda
Figure 1: OCB-related publications by year up until 2012
No. of publications
2. Programme activities
ular. Within MSF, the first OR newsletter was
Figure 2: OCB-related publication themes in 2012 (n=81)
Hospitals
1%
Surgery &
Anaesthesia
1%
circulated within OCB during 2012, and sevConflicts &
Humanitarian
Emergencies
4%
eral articles on OR appeared in the Contact
magazine.
OR 11%
The Public Health Action journal is an open
Sexual &
reproductive health
6%
access journal that provides a home for opHealth policy 6%
Drug Safety
4%
erational research with a mission to provide
health solutions for the poor in low- and middle-income countries. The journal is now
Non-communicable
diseases
9%
Health systems &
programme monitoring
12%
Other infectious
diseases
5%
used by operational researchers world-wide
and MSF collaborates closely with partners
to support the journal.
2.4. Research impact
Nutrition
4%
For the first time, a methodology on how to
Malaria
1%
HIV 14%
TB
11%
systematically evaluate the impact of OR was
published in The Lancet and entitled “Is operational research delivering the goods. Assess-
HIV/TB
11%
ing the journey to success in low income
countries”. A specific template for such evaluations was developed for OCB, and a pilot
the course of 2012, dissemination was
LuxOR-organised medical conference in
analysis of this approach was presented at the
achieved through a number of channels in-
Luxembourg.
OR day in June. This pilot analysis indicated
cluding: the operational research day conducted in Brussels; participation in conferences; the MSF field research website;
specific press communications; a new oper-
64
ational research newsletter; and support for a
journal dedicated to operational research –
Public Health Action. These are described in
21. Operational Research and Documentation
brief below.
MSF Field Research website (www.fieldresearch.msf.org), which archives MSF-authored publications from over 100 journals
and 35 publishing houses and makes them
available free-of-charge. More than 30,000
MSF publications were downloaded from this
website over the course of 2012, reflecting the
One of the major dissemination activities in
high demand for MSF scientific output and il-
2012 was the organisation of the first OCB
lustrating the merit of open access publica-
Operational Research day, in conjunction
tion. The website was also directly linked from
with the General Assembly. A total of 16
the MSF Luxembourg website, improving its
presentations were made and 25 posters
visibility. A recent collaboration with MSF New
were displayed. The four main oral presenta-
York has improved the timeliness of uploading
tion slots and titles included Maternal and
articles and the medical directors have ap-
Child Health, Hospitals and Surgery, HIV and
proved a streamlined policy of seeking pub-
TB, and Neglected Field Research. It was
lisher permission.
considered a great success in terms of en-
that OR performs relatively well in influencing
MSF and national/international policy & practice (81% and 63% respectively), but improvement of programme performance is insufficiently documented (only observed in 30% of
the cases) to fully assess the impact of OR.
Although there are several examples, a few notable examples of research impact in 2012 included the study on reduction in maternal
mortality in Burundi and Sierra Leone, which
showed how the MSF model of providing obstetric care could rapidly reduce maternal mortality at district level to achieve the Millennium
Development Goal 5. This study will be featured in the World Health Report 2013. An advocacy article on the need to change detrimental
and
judgemental
language
in
tuberculosis published in the International
hancing the credibility and perceived value of
One OR study, on the reduction of maternal
Journal of Tuberculosis and Lung Disease led
OR in MSF, especially OCB, and served as
mortality in Burundi and Sierra Leone, re-
to a global survey by the WHO-Stop TB part-
an excellent forum to promote and dissemi-
ceived massive press attention: it became
nership and has resulted in the development of
nate operational research. It will henceforth
the focus of an international documentary
a specific handbook “guide” on TB language
become a yearly event and will be attended
and was associated with several press re-
that will be released in 2013. Finally an editorial
by MSF members, external scientists and
leases and advocacy pieces. In addition, the
on the need for research to impact policy on
partners.
European Commission Development Coop-
the ground, published in Tropical Medicine &
eration Directorate had a meeting with MSF
International Health, influenced the direction of
to discuss the subject.
the World Health Report 2013.
ternational conferences, such as the MSF UK
At the level of OR visibility, a document outlin-
Scientific Day in London, the International
ing the vision, goal, strategies and outputs of
3. Medical Activity Report
AIDS Society (IAS) meeting in Washington,
the Union-MSF OR group was written up and
The fourth edition of the annual OCB Medical
the meeting of the International Union Against
will be published over the course of 2013.
Activity Report for 2011, covering 20 techni-
Tuberculosis and Lung Disease in Kuala
This document will be used for marketing
cal domains, was completed and published.
Lumpur, the Quetelet Chair on Adult mortality
and fundraising for OR in general and for the
Publication of the report was strategically
and morbidity in Louvain-La-Neuve, and a
support of the MSF-Union courses in partic-
synchronised with the medical coordinator
Additionally, a number of poster and oral
MEDICAL ACTIVITY REPORT 2012
Another ongoing dissemination tool was the
presentations were given at national and in-
days, the OR day and the OCB general as-
ment, 2) Data management and analysis,
launched and should help long term retention
sembly, in order to allow for timely integration
and 3) Paper writing and data presentation.
in MSF. By December 2012, four MSF fel-
and inputs into the 2013 Operations pros-
During 2012, LuxOR team members were
lows had led 79 research projects and pro-
pects and plans. Data collection from the
involved in the first African MSF course (Ken-
duced 28 publications, showing the value of
field for this document was again synchro-
ya), two European MSF courses (Paris and
OR fellows in advancing and sustaining re-
nised with the Typology data collection to
Luxembourg), the Pacific Union course (Fiji),
search in MSF.
avoid double work in data compilation.
and the Asian Union course (Nepal).
4. Training/Capacity building
The outputs have been compelling, with six
The
MSF-Union
completed courses and 69 participants. Six-
modular training course in OR has been ex-
ty one (88%) completed their milestones, 68
tended to four continents (Africa, Europe,
submitted their papers to a peer reviewed
Asia & the Pacific region) and has been fine-
journal, of which 39 (57%) have been pub-
tuned during 2012. This course, which has
lished. In terms of cohort analysis, 12 month
been deemed a “best practice” example by
publication success is 27/35 (77%) and at 24
WHO, the IAS and the Global Fund, offers
months, 13/14 (93%). These results have
three practical training modules, covering 1)
been published in the Public Health Action
A full list of the 81 publications of 2012 is pro-
Research questions and protocol develop-
Journal. A fellowship programme has been
vided in the Annex.
unique
output-oriented
A specific MSF-Union alumni website has
been developed and will be launched in
2013. This will bring together all the course
students of the MSF-Union group in various
continents and will serve to improve networks, alliances and advocacy, as well as assess impact on policy and practice.
5. List of publications
6. Looking back & ahead
Lessons learned for 2012
- The modular OR course is highly successful, with large numbers of applications for each individual course and high rates
of success for participants finishing the course. However, organisation of and facilitation at these courses represents a sizeable
activities needs to be safeguarded.
- High turnover of Medcos and staff from the Operations Department affect the sustainability of research studies. There were also misun-
65
portion of LuxOR staff members’ time, and a healthy balance between the course research work and field visits and other related OR
derstandings due to lack of background knowledge on the purpose of specific OR initiatives. This was exacerbated by late requests for
support and abrupt closures of projects where requests were made for documentation support. This will need closer collaboration
between operations, the operational and medical departments.
- The expansion of operational research to areas where there is no research culture and where no data monitoring systems exist is
a major challenge and requires additional resources and dedicated time in 2013 and beyond. This may also require additional dedicated
- The costs related to supporting open access publications are a problem. Most open access journals charge from between
1000 to 1500 US$ per article. In some cases, waivers have been obtained, allowing reduced or no costs for MSF, but the
problems still persists. “Pooled funding” to support open access submissions is needed as well as advocacy for donors to
create mechanisms that support open access publications.
- There have been some difficulties with ethics approval for SAMU projects by the MSF ethics review board (ERB). Protocols not developed
with LuxOR staff input have been channeled through LuxOR without their input. This has led to some misunderstandings, and a new
procedure is proposed for 2013.
Prospects for 2013
- A further streamlining of the ethics review procedure, which is sometimes perceived as arduous, is foreseen. Specifically,
21. Operational Research and Documentation
human resources.
course of 2013. MSF will set up for the first time an Institutional Ethics Review Board in India, which will be considered a national ethics
committee and will facilitate all MSF related research in India.
- Completion of two prospective non-HIV studies, on antibiotic resistance in Afghanistan and a risk factor analysis for typhoid fever in
Kikwit, DRC, is scheduled for 2013. Other new themes to be added to the OR portfolio are emergency interventions and mental health.
- An expansion of the LuxOR unit to other operational centres, most notably OCG, is foreseen: this should allow further
diversification of the OR agenda and will build a stronger research network and optimise existing resources within MSF.
In the same vein, enhanced collaborations with the Brazil Medical Unit (BraMU) is also on the agenda.
MEDICAL ACTIVITY REPORT 2012
an exemption procedure for publication of data generated through surveys is being negotiated and is expected to be finalised over the
- Further consolidation and expansion of the OR courses is foreseen. Two MSF-run courses will be organised in 2013: one in
Ethiopia and one in Luxembourg. Support will also be provided to the Union courses in Paris and Nepal, and an alumni network
for all participants of past and present courses will be launched. Additionally, following accreditation of the courses by WHO,
a course according to the MSF-Union blueprint will be run in Estonia in 2013. A strategic consortium for promoting and supporting OR is
being led by WHO under the umbrella of SORT-IT (Strategic Operational Research Training Initiative).
MEDICAL ACTIVITY REPORT 2012
21. Operational Research and Documentation
66
- Following the success of the first OR day in 2012, it will be conducted again in 2013 conjunction with the General Assembly.
MSF MEdical Department OCB
Paediatric Care
1. Overview
Although paediatric care concerns children from birth through adolescence, children under five years of
age (referred to as under five’s in this report) are most at risk of disease and death and remain the primary
target for intervention. OCB data confirm that malaria, lower respiratory tract infections (LRTI), diarrhoea
and neonatal pathologies are the main causes of disease and death in children under five.
Neonates constitute a particularly vulnerable population, accounting for 43 % of global under five mortality
(WHO, 2012). Over the past decade, while the number of under five deaths worldwide has decreased, the
proportion of under five deaths occurring during the first month of life (the neonatal period) has continued
to increase.
2. Programme activities
Figure 1: Disease profile in children < 5 in OCB OPD, 2012
2.1. Under five care
2.1.1. Under five outpatient care
In 2012, 673,274 under five outpatient consultations were conducted in OCB projects,
representing 37% of all outpatient department (OPD) consultations, a proportion
67
2012 was characterized by improved reporting on neonatal activities and a modest increase in focus on
neonatal care in OCB. In 2012, neonatal conditions accounted for 10% of under five inpatient morbidity
and 26% of under five inpatient mortality, a marked increase compared to prior years (when routine
reporting was not yet implemented). Adapted equipment is gradually being introduced in the MSF
International Technical Coordination (ITC) catalogue. A chapter on neonatal units was included in the OCB
guideline “Planning and design of health facilities”; neonatal clinical guidelines are under revision. Several
OCB projects have begun to focus more on the physical environment and human resource needs of these
children, for instance in the Gondama Referral Centre (GRC - Sierra Leone), Burao (Somaliland), Guidan
Roumdji (Niger), and Timergara (Pakistan).
Malnutrition
1%
Others
10%
Urinary tract
infections
1%
Non bloody
diarrhea
16%
Trauma, wounds, burns
2%
Eye diseases
4%
Bloody diarrhea
1%
Intestinal
parasitosis
2%
Skin infections
5%
which has increased slightly from 35% since
2011. Roughly one third of all under five outpatient consultations occurred in Niger: 9%
contributions in terms of volume of under five
outpatient consultations were the emergency
interventions in the Maban region of South
Sudan (15% - cf. Emergency Unit section,
§2.2.1.), outreach activities in Bo, Sierra Leo-
Fever of
unknown origin
1%
URTI 20%
ne (8%), the health centres and mobile clinics
Detailed data were available for the projects
portant contributor to morbidity outside of
in Masisi, DRC (8%) and the OPD of Ahmad
using the Epicentre tools and/or MINOS (cf.
Africa. When only emergency department
Shah Baba hospital in Kabul, Afghanistan
Health Informatics section, §2.). In these pro-
(ED) data were considered (6% of OPD data),
(9%). Health centre support was discontin-
jects, the disease profile for under five chil-
accidental trauma, wounds and burns con-
ued during 2012 in Bo, Sierra Leone, with the
dren was similar to that of previous years:
tributed 21% to overall morbidity.
exception of the largest health centre in Gon-
respiratory tract infections represented 39%
dama, close to the hospital. A new project,
of the reported morbidity (half of which were
Concerning tuberculosis (TB), a total of 334
Abu Elian (Egypt), focusing exclusively on
LRTI), followed by malaria (18%), non-bloody
cases (0.1% of all morbidity) were suspected
under five outpatient care opened in August
diarrhoea (16%), skin infections (5%) and eye
in under five children, showing that little
2012.
diseases (4%) (fig. 1). Malaria was not an im-
measurable improvement has been made in
22. Paediatric Care
and 25% in Guidan Roumdji. Other important
LRTI 19%
Malaria
18%
MEDICAL ACTIVITY REPORT 2012
in Dakoro, which was handed over in 2012,
case detection and/or reporting of TB at the
Figure 2: Main pathologies in children < 5 in OCB IPD, 2012
health centre level. Fever of unknown origin
Non bloody
diarrhoea
9%
represented 1% of outpatient morbidity, and
some of these cases may in fact represent
Others
19%
undiagnosed TB. Implementation of a symptom-based TB screening questionnaire needs
to be systematised at health centre level.
Non-communicable chronic diseases, including asthma, represented only 0.2 % of
Lower respiratory
tract infections
17%
Malnutrition 1%
Anaemia (clinical)
2%
overall outpatient consultations, and 1% if
ED only data were included. Kibera (Kenya)
will pilot a project with a paediatric compo-
Fever of unknown
origin
1%
Neonatal diseases
10%
nent on outpatient management of chronic
diseases (including sickle cell disease and
epilepsy).
2.1.2. Under five inpatient care
Measles 2%
Surgical cases 1%
Trauma, wounds, burns, accident
3%
Septicemia
2%
Severe Malaria
33%
In 2012, 35,435 children under five were admitted to the inpatient services in 21 OCB projects, representing 48% of all admissions to
Figure 3: Main causes of mortality in children < 5 in OCB IPD, 2012
the inpatient department (IPD), a proportion
Non bloody
diarrhoea 3%
which has remained stable since 2011. Two
projects, the GRC in Bo, Sierra Leone and
Guidan Roumdji in Niger, represented half of
Lower respiratory
tract infections
12%
Others
23%
all under five admissions. Two other large paediatric projects (in terms of volume of inpatient
activities) were handed over during the course
68
of 2012: Lashkar-Gah (Helmand), Afghanistan
(handed over to OCA) and Dakoro, Niger
Malnutrition 1%
(handover to the NGO ALIMA). The decision
Tuberculosis 1%
was made not to open a new paediatric hospital in Juba, South Sudan.
Severe Malaria
27%
Data for the paediatric inpatient wards were
aggregated for the projects using the Epicentre tools or MINOS. Severe malaria (33%),
Neonatal diseases
26%
LRTI (17 %), neonatal pathologies (10%), and
Anaemia (clinical) 1%
non-bloody diarrhoea (9%) were the leading
Meningitis
1%
under five exit diagnoses from OCB hospitals
Septicaemia
(suspicion) 5%
(fig. 2). Data for severely malnourished children admitted to inpatient therapeutic feed-
laria (27%), neonatal pathologies (26%), LRTI
remains a considerable killer, and it is thus
(12%), septicaemia (5%), and non-bloody
essential to continue focusing on compre-
diarrhoea (3%) (fig. 3). Suspected TB, menin-
hensive care for children with severe malaria,
The inpatient mortality rate for under five chil-
gitis, clinical anaemia and malnutrition each
including injectable artesunate, antibiotic
dren discharged from paediatric wards was
accounted for 1% of hospital mortality. CFR’s
treatment in case of co-infection, appropriate
6.5% (target < 10%), the defaulter rate 3.3
for the main contributors to hospital mortality
fluid management, feeding and nursing care
%, and the transfer rate 3.1 %. Only three
are reported in figure 4.
for comatose children, and management of
ing centres (ITFC) are reported elsewhere (cf.
22. Paediatric Care
Nutrition section, §2.3.).
projects had inpatient mortality rates exceeding 10% - Lashkar-Gah and Khost in Afghanistan and Kabezi in Burundi - although the
MEDICAL ACTIVITY REPORT 2012
latter two projects include only neonates as
under five population. In Lashkar-Gah, the
proportional morbidity (41%) and case fatality
rate (CFR - 34%) were especially high for
neonates, confirming the need to target this
population for intervention.
Overall, severe malaria had a CFR of 6%,
compared to published inpatient CFR’s usually exceeding 10 %. Although injectable artesunate was successfully implemented in
the projects with the highest burden of severe malaria (Guidan Roumdji in Niger and
the GRC in Sierra Leone), this relatively low
CFR, which has remained unchanged since
2011, is likely attributable at least in part to
complications (hypoglycaemia, seizures).
Neonatal pathologies, the second leading
cause of inpatient mortality in OCB projects
after severe malaria, are discussed in more
detail below (cf. §2.2.). Of note, the burden of
malaria in the neonatal population remains
poorly quantified in OCB projects. This
should be improved in 2013.
The five most important causes of hospital
an over-diagnosis of severe malaria cases in
LRTI were the third major cause of under five
mortality in these projects were severe ma-
our projects. Nevertheless, severe malaria
inpatient mortality. Although the CFR for
first time in 2012, neonatal diagnoses were
Figure 4: Case fatality rates in children < 5 in OCB IPD, 2012
Meningitis
systematically included in the IPD Epicentre
22.0
tools.
19.6
Septicaemia (suspicion)
Tuberculosis
16.5
Overall, 75% of inpatient neonates in OCB
16.2
Neonatal diseases
Malnutrition
projects were discharged, 16% died in hos-
8.4
pital, 4% were referred, and 5% defaulted.
5.4
Severe Malaria
Although no international benchmarks exist
4.4
"Lower respiratory tract infections
to evaluate these results, the following tenta-
3.7
Anaemia (clinical)
tive targets have been set by the Paediatric
2.0
Non bloody diarrhea
0
5
10
15
20
25
Working Group for inpatient neonatal mortality, based on a literature review and empirical
LRTI was 4% overall, it ranged from 2% to
Finally, meningitis, which also contributed 1%
project data:
11 % (in the GRC, Sierra Leone). In projects
to under five inpatient mortality, remains as-
with a high CFR for pneumonia, some of the
sociated with a high CFR of 22 %. Early sus-
≤ 10%: gold standard
deaths attributed to LRTI could be due to
picion and treatment are essential to de-
underdiagnosed TB, although this can only
crease the burden of mortality and morbidity
be speculated. Generally, implementation of
in these children.
number of suspected TB cases on paediatric wards remains very low (0.3% of morbidity), while fever of unknown origin represents
1% of inpatient morbidities. Moreover, the
diagnosis of TB is often made late, which is
reflected by its high inpatient CFR of 17%.
An additional challenge in paediatric inpatient settings (e.g. Lashkar-Gah, Guidan
Roumdji, the GRC) is that children suspected of TB are referred to National TB Programmes, where treatment initiation or continuation cannot be guaranteed.
Septicaemia and non-bloody diarrhoea were
proximately one third of all deaths from malaria, pneumonia and diarrhoea. Malnutrition
contributed to 1% of under five inpatient
deaths in 2012, compared to 10 % in 2011.
However, since data collection tools allow
only a single diagnosis, it remains difficult to
reliably interpret these results, and the true
While one quarter of under five inpatient mortality in 2012 was due to neonatal pathologies, neonates were the leading cause of
under five inpatient deaths in Martissant
(Haiti), Burao (Somaliland), Masisi (DRC), Dakoro (Niger), and Lashkar-Gah (Helmand, Afghanistan), accounting for 48-64% of under
five inpatient deaths in those projects.
burden of deaths attributable to malnutrition
Severe neonatal infections (34%), conditions
in paediatric OCB projects (outside of ITFC)
linked to preterm birth/low birth weight (29%),
remains uncertain. The management of mal-
and birth asphyxia (21%) were the main caus-
nourished children is quite specific and,
es of death in inpatient neonates (table 1). Al-
therefore, screening of all children on paedi-
though neonatal tetanus had the highest case
atric wards for malnutrition is essential (cf.
fatality rate (46%), it contributed only 4% to
Medical Structures section, §2.3.1.).
overall neonatal inpatient mortality. Three
quarters of cases of neonatal tetanus were
the fourth and fifth leading causes of under
2.2. Neonatal care
five inpatient mortality, with CFRs of 20% and
Data was analysed for the projects using the
2% respectively. Early recognition and man-
Epitools, MINOS, or the individual neonatal
agement of critical illness (including shock
database (cf. Health Informatics section,
Stratification of mortality data by birth weight
and severe dehydration) remain essential.
§2.3.). In terms of volume, 16% of all inpa-
was possible by aggregating data from pro-
Following the 2011 Fluid Expansion As Sup-
tient neonatal activities took place in vertical
jects that implemented an individualised neo-
portive Therapy (FEAST) trial and a 2012 in-
obstetric programmes (Khost, Kabezi), 12%
natal database (Burundi, Niger, Sierra Leone,
tersectional meeting with outside experts,
in pure paediatric and nutrition programmes
Afghanistan - fig. 5). Although extremely low
fluid recommendations for children with
without MSF obstetrical activities (Guidan
birth weight (< 1,000 g) and very low birth
shock and severe infection were revised.
Roumdji) and 72% in integrated programmes
weight (1,000-1,499 g) babies had very high
These revised algorithms for malnourished
(including obstetrical and other activities).
inpatient mortality rates, 81% and 51% re-
and non-malnourished children should be
Overall, 61% of inpatient neonates were ad-
spectively, they represented only 1% and 6%
fully implemented in 2013.
mitted from MSF health structures, 21% from
of neonatal inpatient admissions (data not
home, and 18 % from other health struc-
shown).
Clinical anaemia contributed 1% to overall
mortality in OCB projects, with a CFR of 4%.
Haemoglobinopathies, in particular sickle cell
disease, although not a part of routine data
collection, are increasingly being reported as
problems in specific projects, such as Guidan
69
be strengthened in OCB projects. The total
Globally, malnutrition is associated with ap-
> 20%: to be improved
tures. Based on data from projects with maternal programmes, 12% (for GRC, Masisi,
and Khost) to 22 % (Burundi) of neonates
born in MSF health structures required inpatient admission because of complications.
reported in a single project, Lashkar-Gah (Afghanistan), where 46% of neonatal admissions were home deliveries.
22. Paediatric Care
dren (such as clinical algorithms) needs to
16-20%: acceptable
For babies < 1,000 g, technological limitations
(e.g. lack of ventilator support) are an important factor explaining the high mortality. Considering current resource- and technological
limitations in OCB projects, successful out-
Roumdji and the GRC. Improved inpatient
Neonatal pathologies as a proportion of un-
comes are rare in this category of neonates.
protocols for these children will be developed
der five IPD morbidities increased from 5% in
Individual projects (e.g. the GRC) have started
in 2013. Specific data collection could also
2011 to 10% in 2012 (with peaks of 29% in
to implement a supportive, non-invasive ap-
help better define the burden of disease in in-
Masisi and 22 % in Ahmad Shah Baba). This
proach for these babies, including special at-
dividual OCB projects.
is primarily due to better reporting. For the
tention to counselling of mothers. For the very
MEDICAL ACTIVITY REPORT 2012
tools to improve the diagnosis of TB in chil-
11-15%: good
low birth weight babies (< 1,500 g), care re-
Table 1: Neonatal causes of mortality and case fatality rates in OCB IPD, 2012
mains intensive in terms of human resources,
Proportional mortality
Case fatality rate
Severe neonatal infections
34%
12%
Conditions linked to preterm
birth/low birth weight
29%
25%
Birth asphyxia
21%
18%
approach whereby gestational age (although
Neonatal tetanus
4%
46%
not always simple to assess) is also taken into
Congenital malformations
4%
22%
Other neonatal diseases
8%
11%
and the capacity to implement inpatient care
for these babies may not be present in all contexts. This does not exclude a case-by-case
consideration.
Among low birth weight babies (1,500
g-2,499 g) and those with a birth weight ≥
2,500 g, data show that relatively good out-
Figure 5: Neonatal inpatient mortality stratified by birth weight in OCB IPD, 2012
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
comes can be achieved with the available
81%
means. This supports the implementation of a
minimum package of neonatal care in all pro-
50%
jects for neonates ≥ 1,500 g. The minimum
17%
21%
11%
package of neonatal care, as well as different
levels of care according to different contexts,
were discussed in 2012 and will be refined in
< 1000 g
1000- 1499 g
1500- 2499 g
> 2500 g
Neonates with an unknown birth weight represented 3.6 % of all inpatient neonates.
BW: birth weight
Unknown weight
2013 in collaboration with the Sexual and Reproductive Health referents.
3. Looking back and ahead
Lessons learned for 2012
70
- Neonatal lives can be saved with limited technology. However, physical space and dedicated trained human resources in sufficient
numbers are essential.
- The Kabezi project in Burundi (to be closed in 2013) set a very good model for linking maternal and neonatal care. In emergency
obstetrical programmes, there is a need to think about neonatal services from the outset, since 10- 20% of babies may need inpatient
care.
- The package of neonatal care cannot always be linked to the package of maternal care since neonates born at home or in other health
structures are also seen in our paediatric programmes.
Prospects for 2013 The priorities in 2013 will be:
- A sustained focus on improving neonatal care, since neonates are contributing significantly to morbidity and mortality in OCB projects.
22. Paediatric Care
- Further defining different levels of neonatal care according to the context, a minimum package of neonatal care and the limitations of
neonatal care.
- Improving data collection in OPD and emergency settings, so that appropriate and targeted interventions can be implemented
(suggested).
Other activities will include:
- Improving the quality of OCB paediatric care through a transversal approach, focusing on the main causes of morbidity
MEDICAL ACTIVITY REPORT 2012
and mortality in children.
- Increased attention to nursing care, hospital hygiene, and hospital management in hospital settings, and scaling up the level of
emergency and intensive care in the GRC, Sierra Leone.
- Support to other disciplines, such as for the implementation of TB diagnostic tools and for routine and catch-up vaccination
in under five programmes.
- Opening of a comprehensive health care project in DRC (with primary and secondary health care components), which is expected
to have a significant volume of under five activities.
MSF MEdical Department OCB
Pharmacy
1. Overview
The emergencies in Syria and South Sudan and the increased activities in countries with import
constraints such as Ukraine, Afghanistan, Pakistan and India continued representing significant
challenges to the medical supply chain. The complexity of the global pharmaceutical market and the
evolving regulations in developing countries remained the main challenges and have forced MSF to
specialize its supply chain to the specificity of each context and also to interact more closely with the
National Drug Regulatory Authorities (NDRA). Support to the medical and logistic teams on quality
monitoring, rational medical procurement, and data quality continued and improved in 2012.
At a logistical level, annual medical forecasts and order chronograms were pooled for all missions,
allowing anticipation of global needs and facilitating the medical procurement flow. Standardisation of
the essential medicines lists and matching overall needs with procurement forecasts at the central level
by MSF Supply (one of the three European procurement centres) can now be done with the help of an
online webtool called “the Portal”. Appropriate selection, procurement and distribution are necessary
precursors to the rational use of medicines.
71
Major changes occurred at supply level with the move of the MSF Supply site from Merchtem to NederOver-Heembeek, the start of the new Supply Unit under a unique Supply & Logistics Support Director,
contributing to the restructuring of MSF Supply departments, and the creation of a Supply Chain director
position.
2. The MSF Quality
Assurance Scheme
Table 2: Number of new inclusions of medical articles
in the MSF list of essential medicines (2009-2012)
New inclusions
2.1. Updates of
the MSF medical list
Type of articles
Each year, the typology of procured medicines, which overlaps and is published in tandem with the standardised protocols of the
2009
2010
2011
2012
Drugs
11
9
12
48
Medical Supplies
& Equipment
13
22
23
1
Total
103
48
45
49
2.2. Identification and
validation of drug sources
Fifteen products have been validated by MSF
pharmacists in 2012 (table 3). Also in 2012,
two exceptional validations were given by the
Medical Directors - one for Streptomycin sulfate (1 g, powder, vial) and one for Paramomycin. Reporting on local procurement has
Clinical Guideline, is updated according to
World Health Organisation (WHO) Essential
Medicines List (EML) (table 1 & 2). Some key
new inclusions in 2012 were:
- Midazolam, 1 mg/ml, 5 ml amp
- Antiretrovirals: Darunavir 300 mg tab, etravirine 100 mg tab, raltegravir 400 mg tab,
dispersible tablets for paediatric use
Table 3: Number of drug dossiers approved (2008 - 2012)
Drug dossiers approved
Validation route
2008
2009
2010
2011
2012
MSF full product assessment
28
15
25
20
15
WHO pre-qualification
61
28
35
35
48
Medical Director Waiver*
1
1
0
6
2
* Exceptional approval based on risk/ benefit analysis. WHO: World Health Organisation
(ABC/3TC and AZT/3TC)
23. Pharmacy
new protocols, specific field needs, and the
- TB drugs: linezolid 600 mg coated tab (re-
Table 1: Number of new codes created for medical articles in the MSF list of essential medicines (2006-2012)
Type of articles
New codes created
2006
2007
2008
2009
2010
2011
2012
Number of active
medical codes in 2012
Number of codes
de-activated in 2012
Drugs
98
115
137
106
41
75
52
610
24
Medical Supplies & Equipment
146
185
404
224
236
141
215
1,686
64
Total
244
300
541
330
277
305
267
2,296
88
MEDICAL ACTIVITY REPORT 2012
served for drug-resistant TB)
Figure 1: Medical procurement typologies in OCB missions
2.8%
6.4%
0.1%
3.5%
1.5%
0.6%
2.5%
4.8%
10.1%
1.6% 1.6%
3.5%
0.2%
0.1
%
0.8%
5.8%
16.3%
4.7%
4.8%
2.4%
0.3%
1.1%
International
2.1%
20.3%
International with constraints
1.6%
1.1%
Mixed supply with MoH
Local
improved, though it still remains underreported in some countries. The risk/benefit evalu-
72
ation of local procurement and final approval
too often rely on scarce evidence and information.
2.3. Alerts on quality
and the awakening voice
of local markets
In 2012 two batch recalls and seven quality
alerts of medical items were issued by the
Table 5: Evaluation of local pharmaceutical market (2010 - 2012)
Year
Number of manufacturers
approved
Number of wholesalers
approved
Number of countries
evaluated
2010
5
28
14
2011
6
11
9
2012
14
69
12
ing surveillance systems. This could be im-
countries (Mexico, Lebanon, Pakistan, Tur-
proved with a wider presence of pharmacists
key, Iran and Iraq), 14 manufacturers were
in MSF missions.
approved, and 69 wholesalers were approved in the 12 visited countries (including
MSF-European procurement centres concerning OCB projects (table 4).
the aforementioned countries, and: Russia,
Table 4: Number of quality related communications
(2010 - 2012)
Evidence of problems was reported for products marketed in highly regulated countries
and also for products purchased locally. The
23. Pharmacy
need for local medicine procurement in coun-
Number of
communications
2010
2011
2012
portation constraints, rather than an overall
Quality alert
3
4
7
improvement of the pharmaceutical market.
tries where MSF cannot import or faces im-
mission pharmacists in OCB missions, the
Batch recall
3
3
2
reporting of quality problems has slightly in-
Total
6
7
9
creased for internationally and locally pro-
3. Medical procurement
MEDICAL ACTIVITY REPORT 2012
two complaints from the field resulted in an
MSF recall.
Considering the weaker regulations applied to
pharmaceutical production and distribution in
In 2012, 19 out of 29 missions dealt with
challenging medical procurement systems:
for seven missions the medical procurement
cured medical items. Regarding the quality
complaints concerning all five MSF sections,
South Africa) (table 5). These visits reflect the
Quality related
communications
silence from the field on this topic is still worrisome, but with an increasing presence of
Ethiopia, Myanmar, Zimbabwe, Lesotho and
3.1. Enforcement of
legislation increases
procurement workloads
relied on the local market, five received part
of their medicines from the public distribution
flow and seven others faced difficult importation rules, leading to sporadic local purchases (fig. 1). In countries where local purchase
was unavoidable, the unreliability of the local
resource-poor settings, quality monitoring/
The year 2012 was very demanding in terms
pharmaceutical market complicated the sup-
pharmacovigilance procedures must be en-
of assessment of local markets. An evalua-
ply and led to a heavy workload, in particular
forced at all levels of the medicine’s life cycle,
tion of the local pharmaceutical market was
as the enforcement of the quality of medi-
particularly in countries that lack post-market-
conducted in 12 countries. In six of these
cines on the local markets is typically out-
paced by the regulations enforced by the
NDRA on medical humanitarian organisations such as MSF. Overall, for an increasing
proportion of medicines, MSF cannot guar-
Table 6: OCB Total Medical Expenditures in 2011 and 2012
Medical items
OCB Total Medical Expenditure (M€)
2011
2012
Medicines
14.0
12.4
Vaccines
0.9
0.6
Small medical supplies
6.3
4.0
centres. The quality of medicines cannot be
Medical equipment
2.3
2.7
assessed at the product level in the field, and
Medical kits
1.9
2.4
therefore securing the supply chain through
Total
25.4
22.1
antee the quality of the medical items purchased in the local markets to the same level
as the ones from the European procurement
international procurement will remain the pri-
- Improved centralisation of information on
local purchases
less than in 2011 (table 6). An additional 1,6
M€ was spent on therapeutic food, mainly in
South Sudan and DRC.
3.3. Need for collaboration
with the NDRA
The development of pharmaceutical regulations in developing countries, while in princi-
A mere five out of 26 missions were respon-
ple a positive change, is increasingly gener-
sible for 59% of the total expenditure of med-
ating importation constraints, with NDRAs
icines (fig. 2): DRC as the second largest
enforcing regulations which previously did
OCB operation, Guinea and Zimbabwe for
not apply to MSF. However, the NDRAs in
programme ARV’s and gap filling of the pub-
developing countries are not yet able to en-
- Developing methods for easier local pro-
lic distribution system, Ukraine for the DR-TB
force international standards of quality and
curement with higher quality assurance,
programme and South Sudan for the emer-
the same stringency to the local market,
such as better practices of visual inspec-
gency intervention together with the running
which remains relatively unlegislated, leading
tion at reception and quality monitoring
projects.
to increased risks on local purchases (cf.
- Enhanced intersectional collaboration on
local procurement through mutual procurement activities and increased numbers of intersectional pharmacy positions
§3.1). Moreover, national laboratories often
along the medicine shelf-life
- Integrated pharmacovigilance practices as
a standard activity in each project
Figure 2: Top 5 countries in terms of medicines
procurement expenditures in 2012
activities, and much MSF time and resources
were devoted to counter-analyses while
20%
- Increased capacity both to negotiate with
NDRAs and to track the local regulatory
lack capacities and budget for quality control
Zimbabwe
42%
DRC
environment through country pharmacists
batches of medication were quarantined, resulting in shortages at field level.
Guinea
The negotiation space at country level is usu-
Ukraine
ally limited. While collaborations with some
In 2012, 18 missions purchased medicines
South Sudan
NDRAs over the past few years proved to be
locally: one mission is in a highly regulated
Others
effective in facilitating the inflow of quality
(cf. §3.3).
16%
country (Italy), seven missions have a database implemented (Lebanon, Bangladesh,
6%
6%
10%
medicines, thus assuring uninterrupted treatments for OCB patients, procurement of
Ethiopia, India, Kenya, Pakistan and Ukraine),
medicines was excessively time-consuming
three missions have sent the validation form
in 2012 for countries such as Zimbabwe, Af-
(Afghanistan, DRC and Zimbabwe) and seven missions have purchased locally without
any recommendation regarding quality (Bahrain, Egypt, Haiti, Mozambique, South Africa,
Lesotho and Turkey). The validation forms to
approve local purchases have been sent to
The top 5 items of the medical procurement
list were responsible for almost 16% of the
total expenditure of MSF Supply turnover in
the families Drugs, Equipment and Medical
Supplies ( 20 M€ ) (table 7).
ghanistan, Pakistan, Ukraine, India, North
Sudan, and Ethiopia. Pharmacists from HQ
had set areas of collaboration with the NDRA
during field assessments, but there is a need
to monitor the evolution of importation requirements and, if necessary, to maintain col-
the missions and were used, and a checklist
laborations. Intersectional pharmacist posi-
for reception control should be implemented
tions have played an important role in
in 2013 together with the Standard Opera-
supporting the operations to identify possible
tion Procedure (SOP) – Local Purchase. Also
in 2013, a pharmacovigilance scheme should
be implemented in MSF projects.
3.2. MSF expenditure
The total expenditure for OCB medical procurement (medicines, vaccines, small medical supplies, medical equipment and medical
kits) in 2012 was 22.1 M€, of which 18.2 M€
were procured through MSF Supply. This
73
through:
amount represents approximately 3.3 M€
Table 7: Top 5 items covering almost 16 % of the MSF Supply turnover of the families Drugs,
Equipment and Medical Supplies
Item
Tenofovir 300 mg/ Lamivudine 300 mg/ Efavirenz 600 mg, tab
Expenditure €
Percentage
1,275,049
6%
Lamiv (3TC) 150mg / Zidov (AZT) 300mg / Nevir (NVP) 200mg tab
711,608
4%
Test, Malaria HRP-2, rapid (SD BIOLINE), 1 test
561,025
3%
Vaccine Meningitis multidose, 1 dose, fl.
361,075
2%
Amoxicilline, 250 mg, tab
280,645
1%
23. Pharmacy
its medical accountability for local purchases
MEDICAL ACTIVITY REPORT 2012
ority. Additionally, MSF has started to enforce
solutions for difficult countries, such as India,
The global responsibility over the entire sup-
given to the pharmacist to work in the end-
North Sudan, Kenya, and Ethiopia. The im-
ply chain will fall under the new Supply Unit,
user units and a better dynamic in stock
portation constraint remains in Pakistan and
implying a handover of responsibility and the
analysis due to the fact that two different de-
the Intersectional Pharmacist position is ex-
up-scaling of the quality levels where it is the
partments had to commit mutually on data
pected to be created in 2013.
most vulnerable (capital and project). This in-
reporting and decision making. A complete
cludes defining and designing a supply strat-
assessment on the impact of the integration
egy per project. In order to reach these goals,
on administrative and technical management
new positions were opened: three Supply
activities in DRC is planned in 2013.
Additionally, it is imperative that the possibility of importation of medical items is assessed
during exploratory missions and that all new
project plans include medicine supply in their
Memorandum of Understanding (MoU).
4. Rational Use
of pharmaceuticals
the good functioning of the project, and is
defined by the nature of the product (without
any notion of quantity). It is specific for every
project and based on the type of activities
Supply Medical (pharmacist). This latter posi-
6. Human resources
of Good Distribution Practices (GDP), under
6.1. Pharmacy
management positions
the command of the Pharmacy and GDP Di-
The general recognition that all missions
rector of the Supply Unit. Standard supply
should include a country pharmacist position
key performance indicators (KPI) will be de-
and/or a project pharmacy position (mostly
fined and systematically collected on a
for hospital project) is well established and
monthly basis, and followed at field level.
was fulfilled at 83%. Emergency interventions
in 2012 showed that pharmacists were sys-
and operational objectives. Starting in 2012,
Courses on the standard medical stock man-
all OCB missions/projects were asked to
agement software were ongoing in 2012. The
work on their Standard List, in coherence
number of missions using the tools reached
OCB missions counted a total of 65 staff in-
with the preparation of the Annual Review of
89% compared to 75% in 2011 and 68% in
volved in full time pharmacy positions, 55 of
Operations.
2010. Isystock was utilized by 54% of the mis-
which were occupied by qualified pharma-
sions; Logistix by 29% and both tools by 4%.
cists. Table 9 shows the distribution of quali-
The increasing coverage could be tentatively
fications by position.
The Standard List consolidates the discussion between projects, coordination, and the
cell on needs, and supports the consistent
use of authorized clinical protocols, providing
74
tation Officers (MIO) Supply and one MIO
tion will be mostly focused on implementation
A Standard List is a list of items essential for
explained by the systematic utilization of the
tools at the occurrence of an emergency.
tematically sent when emergencies occurred.
36 active expatriate OCB pharmacists, including 12 new recruits, were permanently in
a comprehensive inventory of pharmaceuti-
The user manual to collect stock indicators
the field in 2012 (compared to 27 in 2011
cals required for the best practice manage-
on Isystock was introduced in July 2012. The
and 23 in 2010). 30% of those carried out
ment of most acute and chronic diseases
procedure for Logistix is still pending. Regret-
more than one mission. The pharmacist’s
encountered in the project.
tably, only seven out of the 15 concerned
pool included approximately 40 pharmacists.
All OCB mission/projects’ Standard Lists, as
missions presented their KPI, of which three
Permanent recruitment is ongoing to ensure
only partially. Although the following figures
coverage with turnover.
well as their annual forecasts (the quantification of the needs) are included in a tailored
23. Pharmacy
Chain Officers SCO, three Mobile Implemen-
are far from being representative of OCB mis-
6.2. Trainings on pharmacy
management
tool, called ‘the Portal’.
sions, they give some indication on stock
5. Pharmacy management
No new missions were integrated under the
2012 saw a new OCB end-to-end supply
supply in term of stock management in 2012.
chain with as main objectives ensuring ser-
A quick evaluation was done in the four exist-
vice and quality at all segments of the supply
ing integrated countries (Bangladesh, Bu-
chain for the benefits of OCB operations, op-
rundi, DRC, and Sierra Leone), showing that
timizing costs linked to the supply chain,
the major difficulties were in getting skilled
complying with ever growing (inter-)national
staff, clarifying roles and responsibilities be-
regulations and constraints, ensuring that
tween all parties, and setting a proper com-
A three-day workshop was organised in Jo-
supply does not encounter a bottleneck, and
munication flow. Fortunately, some added
hannesburg, South Africa, from 26 to 28
adding value to operations at project level.
value of integration was reported: more time
February. The objective was to provide gen-
value and expired drugs (table 8).
The usual yearly drugs management courses
continued to be provided in 2012 (intersection advanced pharma week hosted by OCG
in English and with simultaneous translation in
French, intersection supply and order management course at project level in French,
Supply manager courses).
MEDICAL ACTIVITY REPORT 2012
Table 8: Partial indicators reported in 2012
Indicators
in euro
Burundi
DRC
Mali
Niger
Pakistan
South Sudan
Zimbabwe
All projects
whole year
All projects
whole year
All projects
whole year
All projects
whole year
All projects
whole year
Maban
July-Dec
Murambinda
whole year
Average Stock
Value
118,106
2,366,976
335,053
431,746
927,657
645,173
912,241
5,736,952
Incoming Value*
236,212
3,392,837
434,053
1 228,186
860,141
945,296
2,177,764
9,274,489
Expiries Value / %
9,495 (4.0%)
166,961 (4.9%)
984 (0.2%)
8,536 (0.7%)
80,550 (9.4%)
11,048 (1.2%)
16,294 (0.7%)
293,868 (3.2%)
* Incoming Value: denominator to calculate the proportion of expired drugs. DRC: Democratic Republic of Congo
TOTAL
cused on HIV-AIDS programmes and mixed
Table 9: OCB full time pharmacy management positions in the field in 2013
Expatriate Staff
supplies. The idea was to develop solutions/
National Staff
Qualified Pharmacists
Nurses
Qualified Pharmacists
Doctors/Nurses
Mission level
10
0
11
2
Project level
8
0
14
7
Other positions
(coaching/support),
supply, stock manager)
6
0
6
1
Total
24
0
31
10
alternatives/methods adapted to specific situations. 13 participants with different backgrounds (pharmacist, medical and non medical), MSF staff, and Ministry of Health (MoH)
staff attended, coming from South Africa,
Lesotho, Malawi and Zimbabwe projects.
The experience was successful and should
be encouraged in the future.
eral knowledge and to revise the procedures
Good Pharmaceutical Practices in South Af-
on drugs management in MSF along with the
rica and context-related system, mainly fo-
7. Looking back and ahead
Lessons learned for 2012
The growing complexities of the pharmaceutical markets and the changing legislative framework in many developing countries continued
and have created an increasing workload not only for HQ pharmacists but also for field pharmacists. The reinforcement of MSF’s Quality
Assurance Scheme for countries bound to local purchase has been implemented and improved with the creation or updating of the
databases. The intersectional pharmacist positions have managed to coordinate the different MSF sections and to maintain coherence in
the procurement policies and relations with the NDRA. Other challenges remained with the implementation of the intersectional procurement
procedures (implemented in few countries) and improvement of the collaboration with the NDRA.
The Transport Policy has been finalized and implemented at MSF Procurement Centre level.
Collection of data on local purchases and donations has improved slightly, but still needs to be strengthened and implemented by all missions.
There is an important and rewarding professional role for pharmacists beyond pharmaceutical product supply and management. The
75
However, collection of stock management indicators with reporting on losses was far from successful and will remain a major challenge.
pharmaceutical product should be seen not as an end in itself- but rather as a means to an end. When medicines are used for the greatest
possible benefit of each individual patient and the society as a whole, improvements in health as well as cost savings will result.
Prospects for 2013
The lobbying for paediatric formulations better adapted to the needs of children in MSF settings should continue to be addressed
in 2013. Medicines with only one source approved should continue to be addressed as well.
The Pharmacovigilance and Bioequivalence policies are expected to be finalized and implemented in 2013. The Waste Management of
Pharmaceuticals list is also expected to be finalized and implemented in 2013.
The Transport Policy is expected to be fully implemented at field level over the course of 2013-2014.
In order to standardize and increase the adherence by the missions, the Local Purchase SOP and Donation SOP are expected to be
implemented in 2013.
the most effective available, the safest possible, and convenient for the patient. By preventing or detecting and resolving drug-related
problems that can lead to drug-related morbidity and mortality, and by promoting and contributing to the rational use of drugs, pharmaceutical services can make a unique contribution to the outcome of drug therapy and the quality of care. Pharmaceutical care cannot exist in
isolation from other health care services. It must be provided in collaboration with patients, physicians, nurses and other health care
23. Pharmacy
More attention should be drawn to the part of a pharmacist’s task that is to ensure that a patient’s drug therapy is appropriately indicated,
raise the pharmacist’s level of responsibility, and will require philosophical, organizational and functional changes.
Among its objectives, the new end-to-end approach of the supply chain will target the increase of the level of warehouse management in
the field, in order to achieve a better stock level management, to guarantee a higher level of quality regarding premises and devices, and to
raise awareness of safety issues. Another concern will be to define a strategy regarding the minimum standards to implement at the local
and international level in order to ensure a high level of quality throughout distribution (in a broad sense), and to inform and train the different
actors (down to project level) to the defined GDP standards. Lastly, added to the existing KPIs, new objective KPIs should be defined in
order to ensure continuous improvement. The follow-up of those KPIs will allow the projects to assess their improvement and should ensure
the positive evolution of the supply and the Supply Unit.
MEDICAL ACTIVITY REPORT 2012
providers. Changing the focus of pharmacy practice from products and systems to ensuring the best drug therapy and patient safety will
MSF MEdical Department OCB
Sexual and
Reproductive Health
1. Overview
The total number of projects with one or more Sexual and Reproductive Health (SRH) components
decreased from 46 projects in 2011 to 40 projects in 2012. An SRH component was implemented
in three new projects and five emergency interventions. In parallel, a total of seven projects were
closed, and a number of missions with a historically strong SRH component refocused their
activities. This large number of project closures as well as reorientations of existing projects
resulted in a decrease of the total number of projects and activities. However, missions already
implementing SRH activities continued to increase their activities, and improvements of indicators
such as coverage of postnatal care (PNC) and prevention of mother-to-child transmission (PMTCT)
of HIV were noted.
2. Programme activities
2.1. Antenatal care
The overall number of projects offering Antenatal Care (ANC) and total ANC consultations
decreased in 2012 (table 1). This overall decrease in consultations was due to the clo-
76
sure of certain projects, the handover of others and underreporting. For example, while
the Thyolo project in Malawi reported the largest number of ANC in 2011, this mission no
longer offered the full ANC package to the
women in 2012, as the project focus shifted
to Prevention of Mother-to-Child Transmission of HIV (PMTCT) and away from regular
SRH activities. A similar trend was observed
for the Mavalane project in Mozambique.
Data on women who received ANC and were
MEDICAL ACTIVITY REPORT 2012
24. sexual and reproductive health
tested for HIV can be found in the PMTCT
section (cf. §2.9.).
Despite the increase of ANC consultations in
most of the projects offering ANC, providing
adequate coverage (4 focused visits during
pregnancy) remained challenging. Women
tended to come late in pregnancy and many
attended only one or two ANC consultations
(reflected by the high ratio of first consultation
to total consultations in table 1).
projects (e.g. Abu Elian in Egypt and the Ma-
mONC facility. Three hospital projects (in
ban emergency in South Sudan, cf. Emer-
Sierra Leone, Burundi and Pakistan) did not
gency Unit section, §2.2.1.). However, some
cover normal deliveries; rather, they man-
gaps remain in the implementation of the
aged complicated deliveries referred from the
complete core package of ANC activities (as
district health centres. In projects not offering
documented in the “SRH core package of
delivery, a referral system was in place for pa-
activities in MSF projects” by the SRH inter-
tients either to another MSF project, an NGO,
national working group). For example, routine
or a Ministry of Health (MoH) facility, with
haemoglobin testing for first ANC visits is still
MSF covering the costs.
not implemented in all projects, and some
Total deliveries decreased since 2011 (table
activities such as partner tracing for syphilis
and Sexual Transmitted Infections (STI) remain challenging. Systematic “test and treat”
for malaria is not implemented in all countries; this remains especially challenging in
non-endemic countries, particularly considering that some missions reported a concerning percentage of women testing positive for malaria (e.g. 37% in Sierra Leone and
39% in Niangara, DRC).
2). Here too, closure/reorientation of several
missions contributed to this decrease, particularly the Thyolo mission in Malawi (which
has reported an average of 20,000 deliveries
a year since 2009). However, projects covering deliveries have tended to expand, reflecting the successful promotion of institutional
deliveries. One of the strategies to promote
institutional delivery has been the maternity
waiting home (MWH), which brings women
closer to the health facility and reduces the
2.2. Obstetrics
geographical barrier at the end of their preg-
A total of 27 projects performed deliveries in
2012. All these projects offered emergency
obstetric care and 16 provided Caesarean
sections and blood transfusions, rendering
them Comprehensive Emergency Obstetric
nancy. In 2012, this strategy was highly successful in Masisi. The Operational Research
Unit plans to document the success of the
Masisi MWH in 2013, in order to learn from
this experience and promote the MWH strat-
and Neonatal Care (CEmONC) projects.
egy to the different missions and operations.
Some projects provided only Basic Emer-
The rates of stillbirths and low birth weights
Similarly to 2011, the core package of ANC
gency Obstetric and Neonatal Care (BE-
varied significantly between the different pro-
activities was foreseen at the start of new
mONC) but had a referral system to a CE-
jects. While context and epidemiological pro-
Table 1: OCB ANC activities, 2007-2012
Number of projects offering ANC
Number of consultations (total):
Number of consultations (first visit):
ANC: antenatal care
2007
2008
2009
2010
2011
2012
31
41
33
29
27
24
175,585
243,131
318,242
247,068
258,132
169,672
71,212
105,981
99,457
117,489
113,149
79,889
Table 2: OCB obstetrics activities, 2007-2012
Number of projects doing deliveries
Number of deliveries
2007
2008
2009
2010
2011
2012
32
31
29
26
24
27
30,948
37,584
53,995
58,107
72,348
47,908
Number of projects with BEmONC
8
14
20
22
24
36
Number of projects with CEmONC
18
14
14
17
16
16
2,096
2,508
2,918
4,007
6,438
5,411*
Number of Caesarean sections
* Numbers differ from those reported in the Surgical Activities section (§2.5.): Caesarean sections from e.g. Cange, Haiti were not included here, as only the surgical
intervention and not the full mother and child medical care is an OCB responsibility there. BEmONC: Basic Emergency Obstetric and Neonatal Care; CEmONC:
Comprehensive Emergency Obstetric and Neonatal Care.
Table 3: OCB postnatal activities, 2007-2012
Number of projects offering PNC
Number of consultations done
2007
2008
2009
2010
2011
2012
17
26
20
24
21
23
8,675
17,631
29,625
21,489
21,680
18,985
2008
2009
2010
2011
2012
PNC: postnatal care
33
36
25
27
27
85,701
159,724
64,363
53,635
47,662
file of the country play a role, other SRH ser-
in 2012. This may be in part due to the Mus-
stayed stable this year (2,909 versus 2,995 in
vices offered by MSF, the MoH or other
lim culture, where women tend to stay at
2011), with closures and handover of several
partners, and their quality, affect maternal and
home 40 days after delivery; however, the
projects being compensated by increases in
neonatal morbidity and mortality. For exam-
Dakoro project in Niger saw a high uptake of
other programmes (such as Zimbabwe).
ple, access to quality ANC (not provided in all
PNC (3,206 PNC on 2,079 deliveries). These
projects) is vital to the prevention of stillbirths
numbers indicate, in the case of Niger, that
and low birth-weight babies.
either women tended to come back for the
2.6. Sexually transmitted
infections
second postnatal care visit after delivery, or
As in previous years, collection of data on
that women who have delivered at home
consultations for sexually transmitted infec-
come in for postnatal consultations.
tions (STI) was challenging, due to limitations
2.3. Postnatal care
Twenty-four projects offered PNC in 2012, an
increase from the previous year. Despite this
of the data collection tools and the fact that
increase, there was a decrease in the overall
2.4. Family planning
total PNC consultations (table 3), due in part
Family planning (FP) consultations, offered in
care (ANC, PNC, FP, vertical HIV projects,
to underreporting of data, mainly in projects
27 projects, decreased slightly from 2011
etc.). 25,503 STI consultations were report-
that closed and did not report on partial data
(table 4), again due in part to closure of cer-
ed this year; however, this is likely an under-
(Nimba, Liberia; Tripoli, Libya; Malakand, Pa-
tain projects during the year. Even in settings
estimation.
kistan; and Galgaduud, Somalia).
such as Afghanistan where FP could be con-
Fifteen projects that have been offering PNC
since 2010 have seen gradual increases in
activities. In some cases, the growth of project activities has been impressive. For example the Kamrangirchar project in Bangladesh showed an almost seven-fold increase
in activities compared to 2011, and the
Lashkar-Gah project in Helmand, Afghanistan has seen a four-fold increase of PNC
activities since 2010. If PNC coverage is calculated using MSF-assisted deliveries as denominator, PNC uptake has increased from
19% in 2011 (840 PNC on 4,385 deliveries)
STI treatment is provided at multiple levels of
sidered a sensitive issue, FP coverage con-
2.7. Fistula repair
tinued to expand this year. However, a num-
Two fistula campaigns were implemented
ber of emergency obstetric care projects
during 2012: one in Masisi, DRC and one in
offered no FP. This gap in services needs to
Gogrial, South Sudan. The Gogrial mission
be addressed, as every emergency obstetric
successfully completed its first fistula cam-
care project should in principle offer free FP
paign, performing operations on 36 fistula
to its beneficiaries. Overall, FP activities
patients. During both campaigns an expat
should be strengthened, particularly in pro-
fistula surgeon and midwife were sent to
jects with high Caesarean section rates, as
support the field teams.
women have a higher risk of dying during
pregnancy after previous Caesarean section.
2.5. Sexual violence
Additionally, the long-term holistic project in
Burundi performed 486 surgical interventions, representing a significant increase in
activities from the previous year. Along with
to 27% in 2012 (1,431 PNC on 5,329 deliver-
Care for victims of sexual violence (SV) was
offering holistic care for obstetric fistula, this
ies for projects reporting data across both
offered in 22 projects, although only 16 pro-
projects serves as a training centre for expa-
years). In Afghanistan, the PNC uptake in-
jects reported SV cases in the annual data
triate surgeons on fistula repair (four sur-
creased only slightly, from 6% in 2011 to 8%
collection. The reported number of cases
geons were trained over the course of 2012)
24. sexual and reproductive health
Number of consultations done
MEDICAL ACTIVITY REPORT 2012
Number of projects with family planning
77
Table 4: OCB family planning activities, 2008-2012
Table 5: OCB fistula repairs, 2007-2012
2007
2008
2009
2010
2011
2012
2
1
5
4
4
3
83
146
156
178
429
551
Number of projects offering surgical repair for fistula
Fistula repairs done
and as a centre for operational research on
cline from last year. In India, abortion laws are
- OCB hosted the Advanced Life Support in
early non-surgical treatment of fistula with
not restrictive; however, in certain regions
Obstetrics (ALSO) training in Denmark
urinary catheters. In total OCB provided 551
where sex before marriage is not permitted
twice.
surgical fistula repair interventions, a 28% in-
due to religious/customary laws, national
crease of activities from 2011 (table 5). Some
doctors will only perform TPR for married
interventions were performed as repeat/fol-
women.
low-up interventions, and the total number of
MSF offers post-abortion care in a remarka-
Cape Town, South Africa (cf. HIV/Tubercu-
ble number of projects by ensuring that staff,
losis section, §2.9.).
women operated for fistula was 408 (cf. Surgical Activities section, §2.6.).
78
adolescents workshop that was hosted in
- OCB provided one facilitator to the OCP
age incomplete abortions or complications of
fistula patients were referred to partner or-
induced abortion. A total of 23 projects pro-
ganisations. The implementation of system-
vided post-abortion care to 5,031 patients.
atic catheterisation after obstructed labour
Nonetheless, the number of projects offering
- SRH modules were included in the Prepa-
remained challenging for various reasons. In
post-abortion care should be higher, since all
ration for Primary Departure (PPD) course
some of the EmONC projects, the bed ca-
BEmONC and CEmONC projects should be
(twice), the Management of Health Servic-
pacity was limited due to large volume of ac-
able to offer this package of care. These sta-
es (MHS) course (three times), the Basic
tivities. This was exacerbated by the fact that
tistics reflect the urgent need for access to
Logistics Courses (BLoC, twice), the Pop-
patients need to be admitted for a long peri-
post-abortion care by all women of repro-
ulation in Precarious Situation (PSP)
od of time, in particular those who live at a
ductive age.
course (once), and the Health Promotion
International Women’s Health training for
coordinators.
course (once).
a limited bed capacity.
2.9. Prevention of motherto-child transmission of HIV
The MSF SRH International Working group
An overall total of 57,829 pregnant women
tropical medicine were hosted at the Institute
were tested for HIV in nine projects across
of Tropical Medicine in Antwerp.
which is a challenge for maternities that have
had contracted a fistula expert to visit the different fistula projects in order to analyse and
capitalise the MSF obstetric fistula care in the
different OC’s. A report will be presented by
seven missions. The uptake of HIV testing in
pregnant women was high, ranging from
62% (in the Roma, Lesotho project) to 99%
- The SRH theoretical and practical modules
for midwives and nurses who are studying
- The module on “the role of the midwife in
developing countries” was hosted by OCB
at the Union Professionnelle des Sages
the working group in 2013.
(in the Kabezi, Burundi project). In Burundi,
2.8. Safe abortion
providing only emergency obstetrical care,
- A presentation on “Urgent delivery, Mater-
implying that women were tested for HIV dur-
nal death: the avoidable crisis,” was host-
ing labour. The perinatal HIV transmission
ed by OCB during the “Sexual and Repro-
rate and post-breastfeeding transmission
ductive Health and Rights in Emergency,
rate were 3% and 5% respectively. There
from policy commitments to implementa-
was an average PMTCT coverage of 83%
tion” event, at the Belgian Humanitarian
among all HIV positive women attending
Aid Unit in Brussels.
Unsafe abortions are responsible for a significant proportion of maternal morbidity and
24. sexual and reproductive health
Reproductive Health for adolescents in the
In Afghanistan, Ethiopia and Sierra Leone,
substantial distance from the maternity,
mortality (estimated at 13% of the global maternal mortality) for women in countries
where access to safe abortion is limited. By
providing comprehensive abortion care, the
risk of maternal morbidity and mortality related to unsafe and incomplete abortions is
reduced. The package of comprehensive
abortion care includes termination of pregnancy on request (TPR), post-abortion care
and family planning.
PMTCT testing was implemented in a project
ANC. For the Burundi mission, total PMTCT
coverage was achieved: of the seven women
testing positive during labour, all received
treatment. Specific information on PMTCT in
vertical HIV projects is provided in the HIV/
Tuberculosis section.
in the MSF structure or through referral to a
3. Training and
human resources
partner organisation. Across these projects,
- In 2012, two international SRH trainings
1,636 TPR were performed in 2012. As in
were hosted, one in English by OCB and
2011, most of the TPR were performed in
one in French by OCG. For the interna-
Khayelitsha project, South Africa, where
tional SRH training hosted by OCG, OCB
abortion is legal. The Nagaland project in In-
provided three facilitators to support the
dia has the second highest number of TPR
three days of the training.
TPR was provided in 13 projects, either withMEDICAL ACTIVITY REPORT 2012
drugs and equipment are available to man-
- OCB facilitated the module on Sexual and
done, although there was a considerable de-
Femmes Belges (UPSFB).
- A presentation of the CURGO project, Burundi, was given at the event organised
around Mother’s Day, related to “Are we
achieving Millennium Development Goals
4 and 5?” organised by the International
Centre for Reproductive Health (ICRH) in
Ghent, Belgium.
4. New developments
and innovations
-Finalisation of the International Cervical
Cancer policy paper, by the SRH International Working Group.
- Finalisation of the “Urinary tract infection in
pregnancy” protocol.
- Translation of the SRH logical framework
mented in emergency settings, but very
- In 2011, it was noted that the high work-
and indicator list into French and updating
few SRH tools have been adapted to
load of midwives compromises the quality
of the PMTCT indicators.
emergencies. Thus an SRH in emergen-
of SRH care and leaves little time for the
cies toolkit has been developed.
implementation of the vast number of rec-
-Finalisation of the “ALSO Memento”
adapted to MSF field settings. This me-
- An SRH individual electronic patient regis-
mento was created in order to start the
ter database has been designed, and was
decentralisation of the ALSO training in the
sent for piloting to Khost (Afghanistan),
field in 2012.
Timergara (Pakistan) and the Gondama
- The video for the use of Ultrasound in MSF
Gynaecology and Obstetric programmes
was finalised. Additionally, two powerpoints (on basic ultrasound and ultrasound
after 20 weeks) for training have been
made. These tools are aimed at producing
a complete ultrasound training toolkit.
- As highlighted in the 2011 SRH activity report, SRH activities are increasingly imple-
Referral Centre, Bo (Sierra Leone).
ommendations provided during site visits.
To address this issue, support midwives,
and provide coordination in the field, the
Mobile Implementation Officer (MIO) Midwife position was created in 2011. This
MIO position supported and trained first
- The emergency obstetric care projects in
mission midwives in the projects of Burao
Burundi and Sierra Leone were the subject
(Somaliland), Batil (Maban emergency,
of an operational research study and sub-
South Sudan, cf. Emergency Unit section,
sequent large-scale press release, leading
§2.2.1.), Timergara and Karachi (Pakistan)
to much attention for the role of MSF in
and Kabul (Afghanistan).
reduction of maternal mortality (cf. Operational Research & Documentation section,
§2.3.).
5. Looking back and ahead
Lessons learned for 2012
- The MIO Midwife position was highly successful and performed a large number of site visits, which were well received.
- The strategy for collaboration with traditional birth attendants is not harmonised across missions, but is left to the discretion
- Guidelines on implementation of MWHs are urgently needed.
79
of the different coordination teams.
- Some emergency obstetric care projects still do not provide FP, even though free and qualitative FP should in principle be offered
in all emergency obstetric projects.
Prospects for 2013
- A guidance paper on collaboration with Traditional Birth Attendants (TBAs) will be developed.
- The strengths and weaknesses of the MWH approach will be documented and an implementation paper on MWH paper
- All missions offering TPR will be encouraged to conduct a context analysis and develop a modus operandi, hopefully with the full support
of operations.
- The SV database used in the Kenya, Egypt and DRC missions will be analysed in collaboration with the OR team.
- The “SRH in emergency” toolkit will be finalised and disseminated to the field and operations.
- The ALSO will be decentralised in the Pakistan and Afghanistan mission.
- The ALSO training will be held twice (May and October 2013) in Denmark.
- The International SRH course will be organised in September 2013.
24. sexual and reproductive health
will be developed.
MEDICAL ACTIVITY REPORT 2012
- Field visits will be conducted to the Kenya, Egypt, Afghanistan, Burundi and Somaliland missions.
MSF MEdical Department OCB
Surgical
Activities
1. Overview
While much progress has been made in the face of the burden of communicable and preventable
diseases worldwide, the global burden of surgical diseases remains “neglected”, and continues to
increase. The inequalities in surgical care are great: globally, more than 75% of health resources
(human and material) for surgery are used by less than 25% of the population. In the environments
where MSF works, these inequalities are larger still.
During 2012, OCB provided essential, life-saving surgery, with low-tech requirements, based in district
hospitals or primary health centres with surgical capacity. In parallel, following new operational
strategies, OCB also provided high-standard orthopaedic care (e.g. osteosynthesis) in some projects.
In addition, specialized surgical care was provided to women with obstetric fistula in various locations.
Surgical activities were also supported as a functional part of non-emergency projects, and in some
cases included a training component to build/strengthen the capacity of local staff.
80
2012 saw no major interventions following accidental trauma (such as was seen in Haiti in 2010) or
violent trauma (e.g. the Ivory Coast in 2011). However, surgical activity was supported in conflict areas
such as Syria, Mali, and Mauritania. OCB also provided indirect support in some cases by supplying
material to perform surgical procedures.
2. Programme activities
aspect of a surgical programme) and the
were two projects doing orthopaedic sur-
trends in direct surgical activities (i.e. support
gery, which saw large volumes of patients
2.1. Surgical activities
at project and mission level
provided to surgical activities, but manage-
with violent trauma.
Five new surgical projects opened in 2012,
2.2. Surgical activities
by indication
sharp increase both in absolute numbers
In all 22 OCB projects with surgical activities
jects performing orthopaedic surgery.
and seven projects were closed or handed
over. Some projects continued to provide
non-surgical care after the surgical component was ended. At the end of 2012, there
were 15 OCB projects actively performing
surgical activities. Surgical activities varied
across projects, depending on context and
need. For example, certain projects, such as
Tabarre, Haiti and Timergara, Pakistan, were
MEDICAL ACTIVITY REPORT 2012
25. surgical activities
exclusively dedicated to emergency surgical
care. In contrast, the Khost project (Afghanistan) is an MSF health structure exclusively
ment the responsibility of another actor).
during 2012 (seven closed over the course of
the year and 15 active at the end of 2012),
15,813 primary interventions (new cases)
were seen in 2012, representing a decrease
of 18% from 2011 (19,296). This decrease in
activities is linked in part to the handover and
closure of several large projects (e.g.
Lashkar-Gah
in
Helmand,
Afghanistan,
Lubutu in DRC, Dakoro in Niger and Dargai in
dedicated to maternal/neonatal health, as is
Pakistan).
the Kabezi (Burundi) project (table 1, Annex).
In terms of direct surgical activities (cf. §2.1.,
In contrast, the Gitega project (Burundi) is a
19 projects), 14,583 primary interventions
highly specific OCB structure exclusively
were performed in 2012, a decrease of 9%
dedicated to obstetric fistula repair; this pro-
from the previous year. When comparing the
ject provides a good example of a strategy
relative percentage of different indications for
towards a neglected disease (obstetric fistu-
surgery in 2012 with those in 2011, some
la) where activities are performed all through
significant changes can be observed (fig. 1):
the year.
- Violent trauma as a cause for intervention
- Accidental trauma, in contrast, shows a
(60%) and proportionally (9%). This increase can be directly linked to the pro- Obstetrical pathology remained the major
cause for intervention in 2012, representing almost half of the new cases. This follows the trend of last year; however, there
is a decrease in absolute numbers from
2011. In part for this reason, OCB surgical
patients overall were predominantly women, and/or under the age of 30.
- For other pathologies, there is a proportional decrease of cases of approximately 10%.
Figure 1: Indications for surgery, expressed
as percentage in relative weights, 2009-2012
100%
Others
90%
Obstetrical
80%
Accident
70%
Violence
60%
50%
Similarly to the previous years (cf. Medical
remained below 10% this year (8.8%).
Activity Report 2011), in the analyses below
However, an increase in absolute numbers
30%
a distinction will be made for the overall
of new cases from the prior year was ob-
20%
trends in surgical activities (taking into ac-
served. While 2012 was not marked by
count all projects where OCB supports any
emergency projects in conflict areas, there
40%
10%
0%
2012
2011
2010
2009
2.3. Performed anaesthesias
During 2012, OCB provided anaesthesia for
100%
20,443 interventions (in all the 24 projects),
90%
an 11% decrease from 2011 (22,964). The
80%
total number of anaesthesias equals the total
70%
number of entrances to the operating department (OD); it is higher than the number of
proach uses functional operating theatres
Figure 3: Surgical interventions, percentage
in relative weights, 2009-2012
60%
50%
40%
primary interventions because some proce-
30%
dures were re-interventions.
20%
and existing project staff, thereby allowing
Minor/wound
surgery
Other gyn/obs
& urology
Orthopaedics/
specialized
Visceral
surgery
Caesarean
section
19,145 entrances to the OD were reported in
2012, similar to the previous year (19,644).
The stable level of performed anaesthesias
(entrances to the OD) in combination with the
decrease in new cases (around 9%) can be
explained by the increase of new cases with
accidental trauma (around 10%) that often
require re-interventions (fig. 2).
pered in the project. Thus, both permanent
and intermittent projects have proven effective in treating this neglected condition (cf.
Sexual and Reproductive Health section,
§2.7.).
2.7. Emergent surgery
10%
For direct surgical activities (in 19 projects),
normal surgical activities to continue unham-
0%
2012
2011
2010
2009
Emergent surgeries are urgent or delayed
cases (with a wait of no more than a few days
vious year (fig. 3). This is due to the fact that
without significant morbidity). These are in
the absolute quantity of interventions in 2012
contrast to planned elective surgery, which
decreased, while there are still two hospitals
can be delayed for a significant period of time
devoted to orthopaedic care. Visceral sur-
without an increase in morbidity. MSF per-
gery was reduced to around 37% in absolute
forms certain planned procedures that are
numbers, and 7% as a proportion of total
considered essential and address conditions
surgeries.
(amenable to a proven surgical treatment)
that may not endanger the patient’s health
immediately but cause the patient suffering,
handicap, or disability.
Comb/Others
Caesarean section is a vital category of surgi-
Local/Reg
cal intervention, having a direct impact on
In 2012, 16,996 emergent cases were re-
Intubated
maternal mortality. Due to their specificity,
ported in direct surgical activities, represent-
General
most Caesarean sections are performed as a
ing 89% of surgeries, slightly higher than in
Spinal
matter of urgency, and they are considered a
2011 (84%). This slight increase of emergent
40%
first intervention every time with a new pa-
cases can be linked to the performance of
30%
tient. For 2012, the OCB projects with direct
the specific surgical hospitals with orthopae-
10%
activities performed 5,296 Caesarean sec-
dic activities. Emergency Caesarean sec-
0%
tions, a drop from the previous year, when
tions (usually categorized as urgent) make up
6,255 surgeries were performed. The relative
another large portion of this type of surgery,
weight of this type of intervention was 36%
as do trauma cases, which often present a
as opposed to 39% in 2011 (fig. 3).
substantial number of minor/wound cases
90%
80%
70%
60%
50%
20%
2012
2011
2010
2009
2.4. Surgical procedures
by type
22,212 surgical procedures were reported in
all 22 OCB projects in 2012. Direct surgical
activities (in 19 projects) represented 20,865
interventions. These numbers are higher than
the number of performed anaesthesias because in some cases more than one surgical
procedure took place during an anaesthesia
procedure/intervention. In the analysis below,
however, only the 19,145 primary interventions of direct surgical activities will be included: not all projects systematically reported on
multiple procedures per anaesthesia, and
therefore only the primary intervention is taken into account to avoid any bias.
In 2012, there was a decrease in Caesarean
sections, not only proportionally (around 4%),
but also in absolute numbers (around 15%).
However, the quantity of performed Caesarean sections is still above the numbers of
2009 and 2010. In contrast, the proportion of
orthopaedic/specialized surgery increased
substantially in 2012, doubling from the pre-
that can be delayed.
2.6. Obstetric fistula
Obstetric fistula is a complication of delivery
2.8. Order of the intervention
that occurs in resource-poor settings lacking
A surgical intervention is either a first/primary,
comprehensive emergency obstetrical care,
a planned re-intervention, or an unplanned
and particularly timely Caesarean section.
re-intervention. This indicator is linked to the
This condition affects the poorest levels of
difference between the number of registered
the society, where women are stigmatised
new cases (first/primary intervention) and the
and often excluded from the community due
entrances to the OD. It also indirectly reveals
to the smell and leakage arising from untreat-
the type of patients managed (e.g. wounds
ed obstetric fistula. During 2012, 408 pa-
and burns often have multiple re-interven-
tients with obstetrical fistula underwent surgi-
tions). Unplanned re-interventions can be a
cal repair, an increase from previous years.
quality indicator because they represent
Women who have been treated for obstetric
post-operative complications of surgical pro-
fistula are followed for six months post-sur-
cedures that can be linked to professional
gery to track their recovery.
performance, availability of medical materi-
The continuous, holistic project of Burundi
(Gitega), focusing exclusively on obstetric fistula repair, was quite effective, treating 352
25. surgical activities
100%
81
2.5. Caesarean section
als, availability of a post-operative recovery
room, or quality of nursing follow-up of the
patient in the hospitalisation ward.
women in 2012. However, the vertical, sea-
Of the direct surgical activities in 2012, 76%
sonal integrated approach of DR Congo (Ma-
were primary interventions, 23% planned re-
sisi) project also continued with success, and
interventions, and 1% unplanned re-interven-
similar activities in Gogrial (South Sudan)
tions. Compared with the previous years,
commenced this year. The seasonal ap-
there is a slight but significant increase of
MEDICAL ACTIVITY REPORT 2012
Figure 2: Types of anaesthesia, percentage
in relative weights, 2009-2012
planned re-interventions from the levels in
2011 (17.5%) to the levels previously observed in 2010 (23.4%). This can be explained by the performance of orthopaedic
centres with their high volume of trauma-related patients, similar to the influx of traumarelated patients in post-earthquake Haiti in
2010, as these morbidities require several
re-interventions during treatment.
equal or higher than 3, it is considered as a
risk factor for anaesthesia and for the development of post-operative surgical site infections. In general, more than 95% of the patients arrived at the OCB operating room with
Course, surgical activities in OCB (twice).
Emergency/Intensive Care) unit. Specialist
- Future Surgical Approach, MSF Norway,
doctors such as surgeons and anaesthesiol-
on surgery within MSF – status quo and
ogists are scarce and ones that can operate
reflections for the future.
in resource-limited settings are rarer still. The
GAS (Gynaecology, Anaesthesia, Surgery)
skills and knowledge and the expected skills
- MSF UK Scientific Day: presentation of “A
holistic approach to managing a neglected
disease: the MSF experience on Obstetric
Fistulae from Burundi.”
and knowledge regarding the strategies and
- Surgical Round Table, Singapore with MSF
needs of the OCB Operations Department.
Hong Kong, on MSF monitoring of surgical
This year, GAS specialists training was pro-
activities.
vided for:
- OCB Operational Research day, presenta-
- Expatriate surgeons in obstetrical surgery,
tion on: “Surgical activities in the 2011 Ivo-
trauma and orthopaedic surgery, and ob-
rian conflict: who are the patients and what
stetric fistula.
are their needs?”
a ASA score of 1–2, meaning that less of 5%
- National medical doctors performing sur-
- MSF Hong Kong, V GAS week on drugs,
of patients had a severe systemic disease or
gery in orthopaedic, obstetric, and general
materials and equipment; policies, guide-
a severe incapacitating disease threatening
surgery.
lines, and protocols; surgical data collec-
his/her life.
82
(twice in English and once in French).
-Management of Health Services (MHS)
specialists, taking into consideration their
peri-operative morbidity and mortality. If it is
agement and the importance of oxygen
Reanimation, Gynaecology/ Obstetrics, and
The American Society of Anaesthesiologists
fitness. The ASA score is a good predictor of
- Biomedical course on anaesthesia man-
SAGE (Surgery/Orthopaedics, Anaesthesia/
training schemes target different types of
into six subgroups by preoperative physical
- National nurses in anaesthesia manage-
Peri-operative mortality, defined as any death
ment. In Haiti, participating nurse-anaes-
occurring between the induction of the an-
thetists received an MoH diploma after
aesthesia and the patient discharge from the
training.
recovery room (the immediate recovery period), occurred in 0.2% of direct OCB surgical
activities (33 deaths), a slight decrease in
percentage over 2011 (0.3%). Not included
are other post-operative periods, since time
spent at the hospital varied between projects
and surgical pathologies. Also, in the postoperative period, non-surgical causes of
death were possible, making data interpretation difficult. The peri-operative mortality rate
is strongly associated with the patient’s ASA
score, emergency procedures, and the type
of indication for surgery, as well as the available type of supportive care and resuscita-
25. surgical activities
Training is an important core activity of the
2.9. Peri-operative mortality
(ASA) score subjectively categorises patients
MEDICAL ACTIVITY REPORT 2012
3. Human resources
and training
tion. Therefore, cross-sectional comparisons
between projects can be misleading. However, this indicator is still useful for comparison within a project over time.
- Community Health Officers in Sierra Leo-
tion; war surgery, damage control surgery,
and field anaesthesia.
-Management of Health Services Course
(French). MSF Burundi, on surgical activities in MSF-OCB
ne, Bo, on obstetric emergent surgical
- Trauma Seminar International Orthopaedic
care, in joint venture with CAPA care (Nor-
Association – Hong Kong, presentation of
wegian NGO). This is a response to the
“Doctors without Borders: Surgery under
acute lack of surgical providers in the
any Condition? Minimum requirements for
country.
Surgical Activity in Disasters”; “Quality Assurance for Disaster Relief. Surgery: MSF
4. Operational Research
and presentations
The SAGE unit published three peer-reviewed articles in scientific journals this year
(cf. Operational Research & Documentation
section, §5.: manuscripts and 73, 75 and
77). Presentations were conducted at the following events:
- Surgical Master Course at MSF Italy and
Verona University on principles of war surgery and ballistics, and field anaesthesia
and pain management.
Surgical Data Collection”; “Preparing humanitarian workers for disaster relief surgery: MSF Surgical Training Week.”
- International School of Brussels, presentation of MSF and Surgery
- International Society of Fistula Surgeons
Congress. Dhaka, Bangladesh, presentation of “Obstetric Fistula in Burundi: a holistic approach to managing a neglected
disease.”
5. Looking back and ahead
Lessons learned for 2012
- Overall misunderstanding by several GAS specialists on the difference in level of surgical care between the developed world
and MSF settings occurred. Some are too specialized and lack general surgery skills, while some also had an incomplete vision
of the project.
- A balance needs to be found between expectations of performing surgical activities and the required pre-conditions
and field realities.
- A high turnover of specialists and a high proportion of one-shot specialists risks compromising quality care.
- Some GAS specialists lack managerial and teaching skills in supporting operational needs.
- Supervision and evaluations of GAS specialists were absent in some projects.
- The MSF documents regarding surgical activities are not widely known at mission/field level.
- There were large fluctuations in the need for specialists, without maintenance of a critical volume in the field to keep efficiency
in the human resource pools.
- A clear impact was observed on the performance of GAS specialists by missing briefings in headquarters due the need for an “urgent”
departure to the field. A day spent in briefings avoids long complications in activities in the field. Moreover, lack of briefings in headquarters of mission and field coordination posts had in some cases a detrimental result for surgical provisioning.
- A gap in the expert opinion of the referents led to the purchase of non-standard or unneeded material in some projects.
In most of such cases, the specialist requesting the material did not receive it, and the specialist that followed did not use it.
Prospects for 2013
- GAS specialists will be trained in managerial and teaching skills, or more specialists with the correct background will be recruited.
83
- Support to the field will be continued.
- The strength and support for trauma/orthopaedic surgical programmes will be increased.
- The support for sexual and reproductive health activities by surgeons will be increased.
- The present MSF surgical/anaesthesia related documents: policies, guidelines and protocols will be revised (intersectionally).
- The guidelines on wound dressings and on circumcision will be finalised.
- Guidelines for paediatric surgery and burn programmes in MSF settings will be developed.
- Mass disaster response from the GAS specialist side will be strengthened.
- The monitoring of surgical activities will be improved through quality indicators.
- Build-up tools for “standard” surgical activities will be improved by defining different types of contexts.
- The close collaboration with other organisations, in complementary (e.g. Handicap Int., SICOT for orthopaedic specialists)
centres.
MEDICAL ACTIVITY REPORT 2012
- Operational research will be conducted on the predictive values for haemorrhagic shock and head trauma in the specific OCB trauma
25. surgical activities
and synergistic (e.g. FNUAP for obstetrical fistula, ICRC for war surgery) relationships, will be continued.
MSF MEdical Department OCB
Vaccination
1. Overview
Throughout 2012, headquarters (HQ) support for vaccination activities in OCB missions was rather
weak due to human resources constraints. On the other hand, efficient field support was provided by
the Mobile Implementation Officer (MIO) in three missions.
Evaluations of missed vaccination opportunities were done in six countries, providing a better
understanding of the unmet vaccination needs.
The total number of doses administered through routine vaccination activities in all projects decreased
by 12% and post-exposure vaccination activities decreased by 13% compared to 2011. The number
of cases of vaccine-preventable diseases detected routinely in several of our missions is alarming.
Activities in Expanded Programmes of Immunisation (EPI) urgently need to be strengthened in these
countries.
84
2. Programme activities
Table 1: Distribution of programmes with routine vaccinations, 2012 (n=343,678)
Among the 73 medical projects managed by
Type of programme
OCB in 2012, 27 (37%) reported vaccination
OPD / ANC
activities.
IPD
2.1. Routine vaccination
activities
A total of 343,678 routine vaccinations
Number of doses
Proportion
288,836
84.0%
21,536
6.3%
Nutrition
0
-
HIV
0
-
33,306
9.7%
Post-exposure
ANC: antenatal care; IPD: inpatient department; OPD: outpatient department
(310,372 as EPI and 33,306 as post-exposure) were administered in OCB projects over
the course of the year 2012. This represents
a reduction of 48,748 doses (12.4%) compared to 2011. This decrease is distributed
equally between EPI and post-exposure vac-
MEDICAL ACTIVITY REPORT 2012
26. vaccination
cinations.
7,743 doses in 2011), which may reflect the
victims of sexual violence, drop-out rates
closure of the SGBV programme in Liberia.
were 83% from the first to third dose of hepa-
Vaccination of newborns in MSF programmes is either very weak or goes unreported. Available data show that only 22% of
titis B and 88% for the two-dose tetanus
vaccinations.
Despite the revision of the vaccination policy
in HIV programmes and lobbying to integrate
The vast majority of routine vaccinations
children born in OCB structures get vacci-
(84%) were given through outpatient depart-
nated with Polio 0 or BCG vaccines. The ad-
ment (OPD) and antenatal care (ANC) con-
ministration of anti-rhesus immunoglobulin
sultations, while 6.3% were reported by inpa-
post-delivery is not yet reported, although
grammes in 2012.
tient departments (IPD) (table 1). Of note,
1,280 doses of this product were supplied to
The trend towards a decreasing proportion of
data on routine vaccination performed in nu-
the field in 2012.
tetanus vaccination observed in 2011 was
trition programmes is often incorporated into
OPD data reporting, which gives a false impression of inactivity on the nutritional programme side.
The quality of vaccination follow-up provided
within OCB programmes is poor. Drop-out
rates in the pentavalent vaccine (for diphtheria, pertussis, tetanus [or DPT], Haemophilus
Overall, post-exposure vaccination repre-
influenzae type B, and hepatitis B) from the
sented 9.7% of OCB routine vaccinations.
first to third dose among children were 38%,
Almost 90% of post-exposure vaccines and
while drop-out rates for tetanus vaccination
derivatives were administered to wounded
among pregnant women between the first
patients, while the other 10% targeted vic-
and the third dose was 78%. Unfortunately,
tims of sexual and gender-based violence
drop-out rates were even higher in post-ex-
(SGBV). The number of vaccinations per-
posure vaccination. They reached 59% in the
formed by the SGBV projects in OCB de-
series of four doses required for rabies vac-
creased by almost half over the last year
cination and 91% between the two doses of
(3,456 doses administered in 2012 vs.
tetanus vaccination of wounded patients. In
this activity into the follow-up of the patients,
no vaccinations were reported by HIV pro-
continued in 2012. It now represents 31% of
all routine vaccinations (compared to 40% in
2010) but remains the major antigen given
routinely. The two other major vaccines (the
first polio and the second DPT or pentavalent
vaccination) continued to increase and represented respectively 26% and 19% of all routine vaccination performed by OCB in 2012.
Over the last two years, measles vaccination
given routinely decreased from 18% to 9%
and pneumococcal vaccination (PCV) increased from 2% to 3% (fig. 1).
Figure 1: Distribution of the antigens administered
in routine vaccination in OCB programmes, 2012
(among 27 projects reporting vaccination activities;
n=343,678)
3% 2%
9%
Two preventive mass vaccination campaigns
An outbreak of yellow fever also occurred in
against measles were performed by the
South Sudan, but all efforts made by the field
emergency missions in Mali and Mauritania.
teams to request permission to intervene
A total of 1,102 children aged 6 to 59 months
(case management and vaccination) were
were vaccinated through the nutrition inter-
unsuccessful.
Tetanus
vention in Mali (in Douentza and Mopti) and
Polio
the vaccination campaigns targeting the ref-
DPT/Pentavalent
ugee camp of Fassala in Mauritania reached
3. Developments
and innovations
BCG
16,472 children aged 6 month to 15 years
Due to major human resource constraints all
Measles
old (cf. Emergency Unit section, §2.2.2.).
year long, objectives and ambitions set for
Preventive cholera mass vaccination in South
2012 had to be reduced. The comprehensive
Sudan was prepared in 2012, but ultimately
report on health promotion in vaccination
only took place in January 2013. In 2012,
and the technical tool for self-training on mul-
2.2. Evaluation of missed
vaccination opportunities
OCB responded to cholera outbreaks in
ti-antigen coverage surveys could not be fi-
DRC, Haiti, Guinea and Sierra Leone by
nalized. None of the field missions introduced
treating more than 15,200 cases. There was
new vaccines, but several projects were nev-
The results of six missed opportunity evalua-
no reactive vaccination campaign launched
ertheless developed:
tions done during 2012 at the exit from health
to respond to these outbreaks.
- The use of solar refrigerators for routine
PCV
Others
19%
26%
structures supported by MSF are presented
in table 2. Other evaluations were done in Niger, Somaliland and Afghanistan but results
are still pending.
vaccination activities was continued in Ni-
2.4. Vaccine-preventable
diseases
angara (DRC). A system using cold packs
rather than ice packs for passive cold
This year saw a sizeable number of reported
chains was set up in all covered health
Results indicate that missed vaccination op-
cases of diseases that are preventable by EPI
structures.
portunities varied between 15% and 48% in
(table 3). The detection of such large num-
children and between 14% and 30% in wom-
bers in several countries such as Afghani-
en of childbearing age. There seems to be an
stan, DRC, and Niger is of major concern,
improvement compared to last year’s results,
and indicates an urgent need to reinforce
although the low proportion of people who
routine vaccination in all OCB projects run in
would have agreed to be vaccinated if the
these countries.
-The frequently asked questions sheet
(FAQ) on vaccine-preventable diseases
was finalized. It is pending international
85
validation before distribution.
vaccination had been proposed needs to be
investigated further.
Table 3: Distribution of cases of preventable diseases detected in OCB projects, 2012
2.3. Mass vaccination
campaigns
Suspected disease
Cases
Major countries affected
Measles
2,305
Somalia (801), Afghanistan (679), DRC (305), South Sudan (163)
Meningitis
678
Afghanistan (416), South Sudan (89), DRC (49), Haiti (24), Somalia (26),
Pakistan (15)
Tetanus
132
Afghanistan (108), Kenya (12), South Sudan (4), DRC, Somalia, Ethiopia,
Haiti
Neonatal Tetanus
61
Afghanistan (36), Pakistan (8), Niger (7), DRC (6), Sierra Leone, North
Sudan
nation campaigns (225,430 in DRC and
Acute Flaccid
Paralysis
185
DRC (158), Afghanistan (10), Ethiopia (9), Niger, India, South Sudan,
Sierra Leone
132,249 in South Sudan). Two smaller epi-
Diphtheria
53
Kenya (30), Afghanistan (17), DRC (6)
Pertussis
783
Niger (608), South Sudan (81), Afghanistan (53), Ethiopia (23), DRC,
Sierra Leone
Risk of rabies
828
Afghanistan (441), DRC (167), India (105), Kenya (51), Ethiopia (50)
In 2012, OCB responded to major measles
outbreaks in DRC and South Sudan. A total
of 7,168 cases were treated during these
two outbreaks and more than 357,679 persons were vaccinated through mass vacci-
demics were detected and responded to in
Burundi and Ethiopia, where respectively
20,000 and 662 individuals were vaccinated.
DRC: Democratic Republic of Congo
Table 2: Evaluations of missed vaccination opportunities, 2012
Place
Structure
Date
Target
Sierra Leone (Bo)
General Hospital
Jan 2012
0-59 months
134
n
Missed opportunity*
48%
97%
South Sudan (Gogrial)
PHCC
Sep 2012
0-12 months
203
15%
74%
DRC (Niangara)
OPD
Nov 2012
0-59 months
118
19%
45%
DRC (Niangara)
IPD
Nov 2012
0-59 months
77
21%
50%
DRC (Niangara)
OPD
Nov 2012
W 15-45 y
159
14%
57%
DRC (Niangara)
Maternity
Nov 2012
W 15-45 y
33
30%
60%
* Missed Opportunity = proportion of target population exiting a health structure that has missed an opportunity of being vaccinated during their visit.
** Agreed = proportion of individuals with missed vaccination opportunities that would have agreed to be vaccinated if vaccination had been proposed.
IPD: inpatient department; OPD: outpatient department; PHCC: primary health care centre
Agreed**
26. vaccination
11%
MEDICAL ACTIVITY REPORT 2012
30%
- The OCB protocol and toolkit for studying
missed vaccination opportunities was finalized and used for all evaluations performed in 2012.
4. Training
- OCB gave support to one training on Responding to Epidemics (REPEPI, in French)
and to the vaccination module of the Management of Health Services (MHS) course.
- Three decentralized trainings on EPI were
organized in Niger (Guidan Roumdji), India
(Mon and Chhattisgarh), and DRC (Niangara).
5. Looking back and ahead
Lessons learned for 2012
- In 2012, the MSF International Vaccination Working group completed a four-year analysis of vaccination activities at the international level,
concluding that not enough resources had been provided to reach the goal of increasing routine vaccination activities in MSF. Last year,
OCB projects implementing vaccination lacked efficient support from HQ, which could explain the reduction in the number of routine
vaccinations performed in OCB missions.
- Fortunately, 2012 was a very quiet epidemic year. The extension of the preventive vaccination campaigns with the Meningitis A conjugate
vaccine (MenAfriVac) in countries along the meningitis belt probably played a major role in the reduction of the occurrence of meningitis
outbreaks over the last years. OCB should support this initiative in countries where it has activities.
- Implementation of EPI in the field requires good collaboration and strong interest from the team. It cannot start before all the necessary
material is available in the field. The presence of an expatriate is needed to set up the system, train the staff and supervise the start of the
activities. Another visit needs to be planned after six months to evaluate the system, provide direct support, and correct mistakes.
86
- Specific reports suggested that vaccination coverage improved in SGBV projects, was still weak in nutrition programmes, and remained
completely absent in HIV projects. The concerned International Working Groups (IWG) should work on mutually satisfying data collection tools.
- Documentation of missed vaccination opportunities increased in 2012 and provided a more comprehensive picture of the problem.
Prospects for 2013
- The routine vaccination activities will be increased in nutrition and HIV programmes, following the new protocols that have been agreed on
internationally (antigens and schedule).
- Routine vaccination activities will be emphasised in programmes developed in South Sudan, Sierra Leone, Niger and DRC. Specific focus
will be put on DRC, where OCB will coordinate international efforts to introduce new vaccines and boost vaccination in all programmes.
- Emergency preparedness will be reinforced in countries at risk and investigations and response to outbreaks will be strengthened.
- The MSF response to meningitis and measles outbreaks is to be refined according to current understanding of epidemiology and context.
- The use of new vaccines (PCV, cholera) in reactive or preventive mass vaccination campaigns needs to be explored.
MEDICAL ACTIVITY REPORT 2012
26. vaccination
- The missed vaccination opportunities will continue to be documented in order to better tackle the unmet needs.
Qualitative studies are envisaged to better understand reticence to vaccination wherever identified.
- Reporting of vaccination activities and follow-up of vaccination indicators in all projects needs to be strengthened.
MSF MEdical Department OCB
Water, Hygiene
and Sanitation
1. Overview
The 2012 activities of the Water, Hygiene and Sanitation (WHS) unit were dominated by interventions
in the refugee camps in South Sudan and Mauritania. Emergency responses to viral haemorrhagic
fevers (VHF) in DRC and Uganda, hepatitis E in South Sudan and cholera responses in Sierra Leone
and Guinea, and to some extent in Haiti were also important in scale. Additionally, installation of WHS
infrastructures in state-of-the-art MSF hospitals was high on the operational agenda in 2012.
The intersectional WHS working group continued to serve as an expedient platform for development
and dissemination of tools and guidelines and for harmonising intersectional WHS activities.
Operational collaborations, such as interactions on the WHS approach during the refugee crisis in
South Sudan or VHF outbreaks in Uganda and DRC, were successfully managed by the working
group, and a large number of tools for further standardisation of WHS activities were developed. All
outputs of this intersectional collaboration were shared through Tukul.
Similarly to 2012, OCB did not manage any
vertical WHS projects due to its transversal
or integrated nature, while almost all OCB
projects included a WHS component. Systematic scanning for WHS needs was performed for all OCB projects – trained Water
and Sanitation (WatSan) personnel from the
pool were then sent to the field if the WHS
needs proved too complex or large for the
- A new issue that needed attention was
scaling of sterilisation equipment and destruction of the heating element by high
water calcium levels in the MSF-supported
hospital in Libya.
- Chemical water quality is a challenge faced
in an increasing number of contexts due to
agricultural and industrial pollution – in
2012 an emergency investigation was initiated in Zimbabwe.
- Provision of water by boreholes was complicated in Bo hospital in Sierra Leone, as
state-of-the-art hospitals are important
consumers of water as well as producers
of waste water that needs to be treated
before discharge into the environment.
This was also the case in the new Kibera
clinic in Kenya and during the installation of
WatSan infrastructures in Imey hospital in
Ethiopia.
- In Somaliland a WatSan visit was initiated
in 2012 to improve the degraded WatSan
situation in a prison where in particular the
field staff. In 2012, a focus was placed on
-Regarding water quality, state-of-the-art
providing expert WHS support to established
borehole rehabilitation techniques were in-
missions, while the WHS needs in the large
troduced in Niger to avoid repeated drilling
OCB emergency interventions were mainly
of new boreholes, and drilling machines al-
- The typhoid fever situation in Harare was
addressed by polyvalent staff with technical
lowing ground water exploration up to 100
studied in collaboration with Epicentre and
support from headquarters. About 45 WHS
metres deep were implemented for refu-
revealed post factum the importance of
experts supported projects in 10 missions
gees in inhospitable areas in South Sudan.
two contaminated wells in the transmis-
(Afghanistan, Guinea, Haiti, Niger, DRC, Si-
Satellite imaging was used to detect water
sion. Bucket chlorination was implement-
erra Leone, Mauritania, South Sudan, Zim-
sources in South Sudan when all surface
ed as an emergency intervention. An im-
babwe and Malawi).
water was consumed by refugees and de-
proved technical solution was studied and
tection of groundwater became an impor-
will be implemented in 2013 in prepared-
tant challenge during the dry season.
ness for potential future outbreaks.
sanitation component will need an innovative approach.
27. Water, hygiene and Sanitation
2.1. Activities at project
and mission level
2.2. Specific WHS interventions
and field visits
MEDICAL ACTIVITY REPORT 2012
2. Programme activities
87
In addition to the strong support of the WHS unit to both regular and emergency OCB projects, a
large number of operational research and innovative initiatives were launched over the course of the
year. These included support to the Operations Department to identify a context for a project on
prevention of infant diarrhoea, which was approved by the MSF Innovation Fund; refining the
intervention strategy for hepatitis E in South Sudan, for cholera in Haiti and Guinea and for typhoid
fever in DRC and Zimbabwe; testing of the chemical water quality in health structures; contribution to
an intersectional effort in Haiti to compare several methodologies of waste water treatment in medical
infrastructures; development of new borehole rehabilitation techniques in a nutritional project in Niger;
and trialling novel water identification and drilling techniques in South Sudan.
-Installation of water and sanitation infra-
- Preparation and organisation of a common
of the new Dengue kit and listing the
structures in Mauritanian refugee camps
expert to compare and validate waste wa-
missed opportunities where use of this kit
was an important challenge given the par-
ter treatment equipment in Haiti.
would have been helpful.
ticular security situation on the ground and
the delays faced by other humanitarian actors to become operational.
- New approaches were being developed to
combat cholera in Guinea and Malawi.
- VHF outbreaks in Uganda and DRC required WHS expertise to set up the treatment centres, limit the transmission of the
disease in the population and train and
collaborate closely with the national Minis-In the Kabezi project of Burundi, mud
streams provoked by heavy rain and erosion flooded the hospital. In collaboration
with the Musée Royal d’Afrique Centrale
Research Unit (LuxOR) enabled the WHS
The WHS unit, in close collaboration with the
tions in peer reviewed journals in 2012 (cf.
intersectional working group, was involved in
the generation of a broad array of documents
and guidelines (disseminated during 2012),
including:
ous Situations”, published in 2012 as MSF
Public International MSF guideline.
- An update of the international WHS library
list.
-Technical and editorial support to two
repetition of this event was studied with
World Health Organisation (WHO) publica-
the help of satellite imagery.
tions: 1) Malaria control in complex emer-
The intersectional working group on Water,
Hygiene and Sanitation has been active
since 2007 to improve the intersectional coherence for WHS issues. Over the course of
88
4.1. Documents, guidelines
(MRAC) of Tervuren, Belgium, the risk of
3. International coherence
2012, activities of the WHS working group
included:
gencies – an interagency field handbook 2)
Menstrual Hygiene Manual.
The close collaboration with the Operational
working group to generate several publicaOperational Research & Documentation section, §5., publications 55, 61 and 81). Additionally, a considerable number of operational
research initiatives were launched over the
course of 2012:
- A cross-sectional, random-sample survey
to assess water chlorination as an intervention against cholera and to identify risk
factors for cholera transmission in Cité
Soleil, Haiti, during the cholera epidemic
(manuscript submitted to the Ethics Committee in Haiti).
- A study comparing the Rotating Biological
Contactor as packaged sewage and sul-
- A number of MSF manuals, such as 1) a
lage plant (managed by OCB), the upflow
draft version of the waste water manual, 2)
sand filter clarifier (managed by OCA), a
the construction and operation manual for
single septic tank (managed by OCP) and
the intermediate metal burner, 3) an up-
multiple septic tanks in line (managed by
date of the medical waste-related manuals
OCG) in health structures in Haiti (study
(demontfort, safety box reducer, emergen-
planned in spring 2013).
- Three meetings of the working group, with
cy facilities, waste zone operator manual).
-A study into the feasibility, acceptability
minutes and presentations disseminated
- A contribution to the evaluation of the Ma-
and impact of postnatal health facility dis-
ban South Sudan intervention (to be pub-
tribution of water filters on diarrhoeal mor-
lished in 2013).
bidity and mortality in infants (study ac-
through Tukul.
- Exchange of experience and improved coherence on technical approaches in the
context of VHF, disseminated through an
intersectional “lessons learned” document.
- A conference call was organised to discuss the common action plan of 2013.
27. Water, hygiene and Sanitation
4.3. Operational research
- The “Public Health Engineering in Precari-
try of Health (MoH) staff.
- Organisation of a technical day in Amsterdam on cholera guidelines.
- A contribution to the evaluation of the container hospital of Tabarre in Haiti.
- A contribution to the GPS-GIS strategic
positioning document in collaboration with
OCG
4.2. Tools
(including
The WHS unit, in close collaboration with the
shared human resources under the form of
intersectional working group, was involved in
WHS pools) in emergencies, especially in
the generation of a series of tools:
VHF outbreaks in Uganda and DRC.
- Scaling of sterilisation equipment: follow-
-
Intersectional
collaboration
- Development of common operational approaches, such as an update of the recommendations on long-lasting insecticidetreated nets (LN) to streamline purchasing
MEDICAL ACTIVITY REPORT 2012
4. Developments
and innovations
for central or field emergency stocks, and
field visits by experts for incinerators used
in Haiti.
-Systematic updates of the WHS group
space on Tukul, including technical documents, digital maps, presentations and
meeting minutes.
up on impact of water softeners on scaling
process + other alternatives.
- Chlorination: verification of a pool tester
measuring residual chlorine.
- Water testing: testing the compact dry EC
test as an alternative to bacteriological water testing with Delagua kit.
- Cholera bed: a new cholera bed was developed in collaboration with a new supplier.
- Dengue: capitalisation on the practical use
cepted by the MSF Innovation Fund and
awaiting identification of an appropriate
operational context).
- A cross-sectional study to verify chemical
water quality in MSF-supported medical
infrastructures, in collaboration with SGS
(study protocol under development by the
end of 2012).
- Assessing the effect of refugee camp location on the capacity to meet humanitarian
standards in the 2011/12 South Sudan
refugee crisis.
- Pre-emptive protocol to be submitted to
the ethical committee, aiming to improve
the evidence base for WHS interventions
in cholera control.
- A study on how the detection of early epidemic risk factors, combined with a timely
malaria vector control intervention, can
prevent the evolution and impact of malaria epidemics, using Wajir district, Kenya,
as a case study.
gation to determine water and sanitationrelated risk factors in high transmission
global humanitarian aid event organised in
Brussels
- Participation in the Roll Back Malaria meeting in Geneva.
-Presentation on “The development of
-Participation in the “Humanitarian medi-
onsite wastewater treatment in Cholera
cine and extractive industries” workshop
Treatment Centers”, “Desludging with
organized by the MSF reflection unit in Ge-
- Performing a typhoid fever outbreak inves-
tractor and vacuum trailer in Haiti”, “Biode-
neva.
tigation to determine water and sanitation-
gradable bags as emergency sanitation in
related risk factors and high transmission
urban settings: the MSF field experience”
zones during the 2012 outbreak in Harare,
during the interagency sanitation work-
Zimbabwe
shop in Delft.
zones during the 2011 outbreak in Kikwit,
DRC.
(cf.
Epidemiology/Epicentre
section, §2.1.).
-Participation as observer in the WASH
cluster meeting at the Water, Engineering
and Development Centre of Loughborough University, UK.
- Presentation of “The Haitian population fac-
- External training (e.g. Institute of Tropical
4.4. Communication
ing cholera for the first time: awareness ef-
Medicine, Bioforce, University of Johan-
forts and applied anthropology”, “Using
MSF experience in WHS activities was ac-
nesbourg, Liverpool School of Tropical
modern mapping techniques to identify pri-
tively shared at multiple platforms through
Medicine).
ority areas for WASH intervention during a
scientific presentations and discussions, in-
typhoid outbreak in Harare, Zimbabwe”,
cluding:
“The development of onsite wastewater
- Presentation on “WHS activities for cholera
treatment in Cholera Treatment Centers”
prevention in communities living adjacent
and “Does village water supply affect chil-
to Lake Kivu or Rusizi river, Cyangugu
dren’s length of stay in a therapeutic feeding
Province, Rwanda” on the 6th World Water
program in Niger? Lessons from a Mé-
Forum in Marseille.
decins Sans Frontières program” on the
- Presentation on “Does village water supply
affect children’s length of stay in a therapeutic feeding program in Niger? Lessons
Emergency Environmental Health Forum in
the London School for Hygiene and Tropical
Medicine.
5. Training & human resources
The WHS unit was involved in over 50 fulltime days of dedicated trainings – including
the WHS module of the Populations in Precarious Situations (PSP) training, the WHS in
Emergencies training (English and French),
the Response to Epidemics (REPEPI) course
and the Water, Engineering and Development Centre course – as well as providing
WHS components for trainings such as the
from a Médecins Sans Frontières program”
-Presentation of “Mudstream predictive
Preparation for Primary Departure (PPD)
on the OCB Operational Research Day in
model in Kabezi, Burundi” in collaboration
course, Management of Health Structures
Brussels (cf. Operational Research & Doc-
with the MRAC Tervuren.
(MHS) course, Basic Logistics Course
umentation section, §2.3.).
- Presentation of “WASH in a Medical Hu-
-Presentation on “Reflective analysis on
manitarion Organisation” to the IUPWARE
practice of humanitarian health – Ebola a
group of the Universities of Brussels and
case study” in the “Ecole des hautes
Leuven.
études en Santé Publique” in Paris
- Presentation of innovative WHS tools developed by MSF on Aidex international, the
- WHS input during a one week MSF module in medical masters training on Tropical
(BLoC), and others. Additionally, in an inter-
89
- Designing a typhoid fever outbreak investi-
sectional collaboration, new modules were
developed on GPS mapping with Google
Earth, practical aspects of VHF isolation
practices, pipe installations and Emergency
Preparedness (Eprep).
Surgery in Verona University, Italy.
Lessons learned for 2012
The intersectional working group continues to demonstrate its worth and has managed to harmonise the WHS activities of
the different sections. The dedicated working group space on Tukul is a well-suited communication channel for the working group,
but information flow could benefit from further attention.
An increasing number of operational research studies focusing on WHS has been launched. This serves to improve the
international visibility of OCB WHS activities and will increasingly allow OCB to shape the WHS agenda of other actors in the field.
27. Water, hygiene and Sanitation
6. Looking back and ahead
Prospects for 2013
The high level of technical support to the field on all WHS issues will be maintained, and the systematic scanning of WHS needs
in projects, feeding into the Annual Review of Operations process, will continue. Particular attention will be devoted to the improved information flow between headquarters and the field, improved knowledge and skills both at headquarters and field level through intersectional
WHS trainings, and further roll-out of innovative tools. Additionally, the unit will attempt to influence the WHS agenda
MEDICAL ACTIVITY REPORT 2012
A close collaboration with the Operational Research Unit has been forged in the process, to the mutual benefit of both units.
and strategies of other actors in the field through increased sharing of the MSF experience through different communication channels
(including conferences, peer-reviewed literature, etc.).
Perspectives concerning the intersectional working group work include interacting on cross-cutting issues with other working
groups (such as nutrition, HIV, tuberculosis, malaria, VHF, etc.), further positioning of the working group in a number of strategies,
a comparison of the WHS training trajectories to harmonise the process. Furthermore, a common WHS policy paper, endorsed by
the medical and logistical directors platforms, will be developed and its implementation monitored.
The “Public Health Engineering in Precarious Situations” has been published in 2012 as MSF Public International MSF guideline
and will be translated into French in 2013.
In terms of training perspective, a collaboration with the “Office Internationale d’Eau” will be sought, in order to be able
MEDICAL ACTIVITY REPORT 2012
27. Water, hygiene and Sanitation
90
to offer trainings for WatSan experts who already did the WHS in Emergencies course and are in need of expert skills.
MSF - Operational Centre Brussels - MEdical Department
OCB MEDICAL ACTIVITY Annex of tables
and data
MSF-OCB - Belgium - Brazil - Denmark - Hong Kong - Italy - Luxembourg Norway - South Africa - Sweden
MSF MEdical Department OCB
annex of tables and data 2012
Contents
92
Contents
pages
section 05: medical Data
Table 1: OCB global summary of outpatient and inpatient data using Epicentre OPD/IPD/Gynobs Tools in 2012
93
section 07: Emergency Medicine
Table 1: OCB emergency department activities in 2012 (as reported by 13 projects) 94
section 10: Evaluation unit
Table 1: Findings and recommendations from evaluations carried out during the course of 2012 95
section 12: Health Promotion and Socio-Anthropology
Table 2: OCB emergency interventions with HP activities, 2012
Table 3: OCB projects with HP/anthropological activities, 2012
98
99
section 16: Laboratory
Table 1: OCB laboratory activities, 2012
101
section 19: Mental Health
Table 1: MH activities integrated into OCB medical projects, 2012
Table 2: OCB MH activities in emergency/short term interventions, 2012
102
103
section 20: Nutrition
Table 4: OCB therapeutic feeding programmes in 2012 by project Table 5: OCB supplementary feeding programmes in 2012 by project
Table 6: OCB targeted food or nutritional support in 2012 by project
104
105
105
section 21: Operational Research & Documentation
105
section 25: Surgical Activities
Table 1: Overview of OCB surgical activities per project, 2012
108
8,498
NA
13.8
1,383
13,986
3.7
4,727
17,380
NA
NA
NA
NA
NA
NA
50.4
1,590
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Burundi
DRC
2,103
25.1
5,007
14,809
3.8
1.0
95.2
8,994
4,284
9,044
68,095
176,936
186,163
353
0.0
290
4,758
3.8
6.7
89.4
624
233
631
7,087
27,256
27,922
Ethiopia
NA
NA
1,937
NA
1.5
1.9
96.6
4,001
1,060
4,117
7,756
51,387
64,548
Haiti
annex of tables and data 2012
section 05: medical Data
4,160
8.8
673
4,328
2.7
15.1
82.2
1,833
207
1,890
8,684
50,782
53,080
India
ANC: antenatal care; DRC: Democratic Republic of Congo; IPD: inpatient department; NA: not available; N°: number
N° of Family Planning
consultations
Caesarean sections
N° of deliveries
N° of ANC consultations
6.4
13.5
Defaulters %
Deaths %
80.2
20,096
8,392
Discharged %
N° of IPD exits
<5 yrs
41,781
77,742
20,857
N° of <5 yrs
N° of IPD admissions
NA
42,537
261,590
New cases
46,674
Bangladesh
263,534
N° of Consult
Afghanistan
Table 1: OCB global summary of outpatient and inpatient data using Epicentre OPD/IPD/Gynobs Tools in 2012
Kenya
93
18,007
NA
NA
12,090
NA
NA
NA
NA
NA
NA
32,655
87,314
116,016
Mali
40
1.0
96
436
3.0
1.0
96.0
99
58
111
1,524
4,772
4,862
Niger
3,928
0.0
1,640
26,534
5.2
0.4
94.4
12,575
12,407
12,574
196,945
197,274
240,385
3
18.1
94
5,062
2.3
0.2
97.6
573
205
647
9,254
34,203
35,635
North Sudan
8
44.7
1,461
NA
8.0
2.7
89.3
7,267
7,601
8,754
47,901
56,554
56,554
Sierra Leone
NA
9.3
658
NA
4.1
0.0
95.9
197
171
230
NA
NA
NA
Somaliland
Total
37,100
12.4
28,815
90,124
5.9
6.1
77.0
56,258
34,618
58,855
499,424
990,605
1,095,373
MSF MEdical Department OCB
section 05:
Medical Data
section 07: Emergency Medicine
Jan-Dec
34,286
0.2
22.7
Jan-Dec
9,881
0.6
99.9
0.1
7.8
21.4
20.5
6.3
823
Jan-Sep
36,854
ND
22.9
ND
0
26
ND
32.6
4,095
Lashkar-Gah
Afghanistan
Kunduz
Jan-Mar
1,379
0
13.8
ND
ND
ND
ND
ND
460
Lubutu
DRC
Jan-Dec
4,921
ND
22.3
ND
ND
ND
ND
40.3
410
Masisi
Jan-Dec
4,591
ND
6
ND
ND
ND
ND
47
383
Niangara
Haiti
Jul-Dec
21,752
0.1
66.9
0
4.5
ND
42.1
14.7
3,625
Martissant
94
Feb-Dec
2,873
0.1
92.8
0.6
2.4
61
29.6
5.1
279
Tabarre
DRC: Democratic Republic of Congo; ED: emergency department; GRC: Gondama Referral Centre; ND: no data available
Months of data
Total number of cases
Mortality rate
Percentage of Trauma
cases
ND
ND
Admission rate
Defaulter rate
ND
Female percentage
2
3 0.5
Percentage of
patients < 5 years
Referral rate
2,857
Kabul
Mean cases
per month
Project ED
Table 1: OCB emergency department activities in 2012 (as reported by 13 projects)
annex of tables and data 2012
Oct-Dec
1,220
0.3
16.6
2.8
5.4
0
46.8
26.5
505
Jan-Dec
76,310
1.2
18.8
ND
2
ND
ND
ND
6,272
Timurgara
Pakistan
Karachi
Jun-Dec
4,963
0.7
1.8
0.2
1.1
92.5
45.8
86.1
709
GRC - Bo
Sierra Leone
Jan-Dec
7,212
1.4
28.8
2
1
23.3
41.2
18.2
627
Burao
Somalia
Jan-Dec
3,655
0.6
9.9
ND
2.1
34.1
ND
36
305
Jan-Dec
1,760
0.3
12.8
ND
0.1
13.7
ND
47.2
147
Pibor
South Sudan
Gogrial
India
Jan-Dec
7,489
ND
ND
ND
ND
ND
ND
ND
624
Nagaland
MSF MEdical Department OCB
section 07:
Emergency Medicine
MSF MEdical Department OCB
section 10:
Evaluation unit
Table 1: Findings and recommendations from evaluations carried out during the course of 2012
Project
Main Findings
Main recommendations
Mozambique, Maputo: Evaluation of stakeholder perceptions. Report presented to the
Cell and available on Tukul.
- The MSF presence is seen as very relevant: pioneering
HIV treatment and representing a reliable partner.
Handover
- MSF implementation strategies are appropriate
and ‘day to day’ presence is seen positively.
- Gap filling and substitution are perceived as
unsustainable; some stakeholders believe MSF has
unintentionally contributed to insufficient programme
ownership among the MoH health centre staff.
- Developing and implementing innovative models of care
is seen as very appropriate and a particular strength
of MSF.
- Infrastructure support (donations of laboratory
equipment, drugs, reagents and supplies) is much
appreciated but some stakeholders feel there are
shortcomings in system strengthening.
- Partners feel that MSF is integrated well in the national
health care system but with some limitations.
- Overall communication and coordination is perceived
as very good but there is room for further improvement.
- Most stakeholders feel that MSF advocates
appropriately.
- Some stakeholders state that financial implications
of MSF proposed changes should be given more
consideration.
- Most stakeholders feel that the handover of first line
support is premature although the health leadership
finds the handover timely and is fully supporting it.
- The difficulties absorbing the human resources are
perceived as the biggest challenges.
- A good handover communication strategy was
highlighted by several stakeholders as being of
importance.
- The handover steering committee is perceived
as an excellent participatory approach.
- Capitalise on the opportunities of the handover
steering committee and foster ownership through
participatory planning and monitoring.
- Identify realistic solutions to cover the upcoming
human resources gap e.g. provincial common fund,
other funds, continued MSF sub-agreement or
identifying a local NGO for the psychosocial care
component.
- Use the strength and capacity of MSF for innovation
to design and implement an accelerated targeted
capacity-building strategy that focuses on health
centre management and all the relevant critical
departments, including, pharmacy, laboratory,
reception, data collection, monitoring and evaluation,
clinical, PMTCT and psychosocial support.
- Together with partners, assess the need for
institutional support to the City Health Directorate i.e.
provincial supervision capacity for HIV care and
treatment, and consider on-going support after
handover.
- Continue to further develop the urban community ARV
groups as a user-friendly patient empowering strategy
that can help keep retention in care at an acceptable
level in the Mozambican context of overburdened and
understaffed health facilities.
- Develop a handover communication strategy for the
different target groups, spelling out clearly which areas
MSF is going to hand over and which areas MSF will
continue to support.
95
- The impact of MSF work is substantial; MSF stands for
quality HIV care, good service organisation and good
treatment outcomes.
Future role of MSF
- For the development of the future MSF programme
support, capitalise on the positive handover steering
committee experience and use participatory planning
methods, involving all relevant stakeholders, and
design the new programme and coordination
mechanisms in a way that will foster true partnership
and partners’ ownership right from the beginning.
annex of tables and data 2012
section 10: evaluation unit
- Stakeholders feel that MSF has still an important role
to play in HIV programmes in Mozambique.
Project
Main Findings
Main recommendations
Sanou MSF: Evaluation of the training
programme. Report presented across
departments and available on Tukul.
Appropriateness
For headquarters
- The target group for Sanou MSF is defined as all MSF
staff, whether national or international.
- Develop a broader range of Sanou materials from
which coordinators can select the most appropriate.
- The objectives defined for the training do correspond
to the identified needs.
- Update the Sanou training materials regularly.
Pertinence and appropriateness
- The methodology of Sanou MSF is appropriate
although it could be more culturally appropriate and
contextually relevant.
- Material is not translated and widely accessible to MSF
staff e.g. speakers of local languages, etc.
- Adaptations and translations risk distorting
the international nature of MSF.
- Develop a standard ‘participant evaluation form’
and reporting format.
- Centralize all reporting and feedback for analysis
and follow-up.
Effectiveness
- Continue to use the existing coordinators while also
developing new ones.
- Senior staff said Sanou has made a noticeable
difference to staff motivation and improved HR
management.
- International staff participation is very important
to the success of Sanou.
- Proper participant evaluation has not always been
undertaken and followed.
- Reports from facilitators have not been consistent
and little analysis has been done.
- Proper coordination of Sanou is time consuming
but is a critical factor for its success.
Efficiency
96
- Develop an accreditation system for Sanou facilitators.
- Develop a central (OCB) implementation plan for
Sanou.
- The benefits of Sanou are not restricted to new staff,
national staff or junior staff.
- Sanou was developed as a cost effective solution
which capitalises on mission capacities.
- The role of the Coordination Teams in organising
has not always been clear.
- Not always clear which department is responsible
for leading Sanou.
- Some larger missions have recruited someone
just to coordinate Sanou.
- Ensure that Sanou is fully integrated into other HR and
training initiatives including the on-going development
of the PPD.
- Explore further options for maximizing the use of
Sanou intersectionally.
For the field
- Ensure that Sanou trainings delivered in local
languages (and those that are simplified and
shortened) have adequate international staff input to
reflect the international nature of MSF and to ensure
that discussions on different cultures can be effective.
- Ensure that proper attendance records are kept locally
in missions and are available centrally (HQ) to monitor
the progress of Sanou roll-out.
- Ensure every Sanou MSF participant completes the
standard evaluation form.
- Ensure a short report in a standard format is prepared
by the Sanou coordinator and kept in the mission
giving feedback points on how the training went.
- Develop a mission-based Sanou roll-out plan that
includes intended coverage, timescale, resources
required and responsibility for overseeing and monitoring. These plans for implementing Sanou should be
reflected in the Annual Review of Objectives process.
- Some missions have developed shorter Sanou
trainings.
- Make adequate resources available in missions for
coordinating Sanou either through an HR Development
Officer or a mission Sanou coordinator.
- Translating and simplifying the materials has made
Sanou more accessible in some missions.
Sanou and beyond
Impact
- Sanou has been very positive with over 90% of
respondents reporting a positive impact on their
motivation.
section 10: evaluation unit
- Promote international staff participation in Sanou.
-
- Sanou MSF has been effective in fulfilling its overall
objective.
annex of tables and data 2012
- Provide a Sanou lead in HQ to support and coordinate
centrally.
- Sanou reportedly has positive impacts on many
other operational areas.
Continuity and connectedness
- Sanou MSF is connected to current OCB
and intersection HR initiatives
- For all projects and initiatives, document the identified
needs and defined objectives as well as a plan for how
these needs will be met. This helps implementation
and follow-up on results.
Project
Main Findings
Main recommendations
Pakistan: Review of operational choices
and decisions 2005-2010. Report presented
to the cell and available on Tukul.
History
Improving strategic clarity
- The OCB Pakistan mission has experienced three
distinct phases:
- Define the broader ‘strategic’ objectives of the mission,
including using operations in Khyber Pakhtunkhwa to
help facilitate access to other areas with high levels
of need by building local networks and trust, and
incorporate these into the key documents for the
mission and projects.
- Phase 2: Response to numerous displacements;
challenges relate to external factors inherent in a
conflict environment;
- Phase 3: Expanding (scope of) operations; increasing
public profile and medical activities.
Acceptance
- General suspicion or mistrust towards NGOs based
on belief (cultural, religious, economic and political).
Generalized and not directed specifically at MSF.
- Improving acceptance is achieved primarily through
provision of ‘quality’ and free services.
- Acceptance of MSF is localized and conditional
(on the provision of services).
- Security has been a major challenge for the Pakistan
mission and improving acceptance of MSF is one key
to improving its security.
- Factors that limit MSF reaching those most in need
include poor security, the need for international staff
and the decision not to accept armed guards.
- Factors affecting beneficiaries’ services include:
transport (availability and cost), lack of awareness
and cultural restriction.
- People (groups) excluded from services likely include
the rural poor and women (who face additional cultural
barriers).
- The communications strategy was the primary tool
for overcoming the challenges relating to negative
perceptions of NGOs.
- The visibility strategy (dynamic process rather than a
written document) has also had a significant positive
impact.
- The networking strategy (documented) ensured a
broad network and constant contact with stakeholders
but fails to engage third level groups or the general
population.
- The MSF intersectional agreement (documented) was
identified by few although many talked about elements
of it.
- Cultural sensitivity (including dress and other forms
of behavior) was recognized by all and had a positive
impact.
- Ensure that briefings to all staff, and particularly expats,
give equal weight to both the strategic rationale and
the medical rationale for programme intervention in
order to manage expectations and limit frustrations.
- Ensure project documents are clear about the strategic
objective and clearly define what activities will be
carried out in order to achieve it. In particular they
need to be clear how the MSF presence will help gain
access to other areas of high levels of need and how
the extent to which this has been successful will be
measured.
- Ensure clearer and more consistent justification of
operational choices and decision making in key
documents and briefings so it is clear why MSF has
decided to work in its current locations, given that
there are high levels of health needs everywhere in the
region. Locate the current choices within the broader
context and strategic objectives of the mission.
Improving communications
- MSF has not effectively communicated its identity
to the general population. In order to improve
acceptance, it is important that MSF establishes
contacts at community level. Therefore, extend
the communications and networking strategies to
include the general population or groups who might
be representative of them (for example teachers, taxi
drivers etc.).
- Provide additional external support for teams in order
to directly engage with the population.
- Ensure that this engagement with the population does
not support or overly focus on dominant local groups
or individuals but also includes those who are often
excluded.
97
- Phase 1: Set up of early operations; specific challenges
and constraints relate to location and type of activities;
- Ensure that teams continue to gather information
about the needs and perceptions of the population,
so that any changes or new needs can be responded
to and services remain appropriate.
- There is limited awareness of MSF amongst patients.
Re-orientate the communications strategy to place
the patients at the centre and make them the primary
ambassadors for MSF’s services.
- Final report pending
- Final report pending
DRC: Evaluation of the PUC project
- Postponed until 2013
- Postponed until 2013
Haiti: Capitalisation on lessons learned from
Martissant
- Postponed until 2013
- Postponed until 2013
ARV: antiretrovirals; DRC: Democratic Republic of Congo; HQ: headquarters; HR: human resources; MoH: Ministry of Health; NGO: non-governmental organisation;
PMTCT: Prevention of Mother-To-Child Transmission of HIV; PPD: preparation for primary departure course; PUC: Pool d’Urgences Congo
annex of tables and data 2012
South Sudan: Evaluation of the Maban
Refugee Emergency
section 10: evaluation unit
- The human resources strategy (refers to various
initiatives to improve HR development) has been
successful in retaining highly motivated staff.
MSF MEdical Department OCB
section 12: Health Promotion and
Socio-Anthropology
Table 2: OCB emergency interventions with HP activities, 2012
Country
Emergency in 2012
Type of HP activities
Mauritania
Conflict
- Promotion of MSF services
- Health education on primary health care (in camps and for the local population)
South Sudan
Doro
- Health Surveillance (mortality, nutrition, etc.)
- Promotion of MSF services
- Health education (in the health facilities and in the camp) on all relevant medical topics
(maternal health, nutrition, etc.)
- Prevention of faeco-oral diseases (Hepatitis E, etc ).
Sierra Leone
Cholera
-
-
-
-
annex of tables and data 2012
section 12: Health Promotion and socio-Anthropology
98
HP: health promotion; KAP: Knowledge, Attitude and Practice
Promotion of MSF services
Health education on cholera
Prevention activities on transmission of cholera
KAP survey on hygiene practices
Project
Key activities in 2012
Lashkar-Gah (Helmand)
- Participation in the study on antibiotic resistance (cf. Laboratory section, §4.)
- Revision of all HP activities and messages
- Specific focus on hygiene
Kabul
- Starting up HP activities
- Health education on all relevant topics (maternal health, nutrition, etc.)
Kunduz
- Starting up HP activities
- Specific focus on blood donation and personal hygiene
Bangladesh
Kamrangirchar
- HP activities in the PHC clinics: ANC/PNC, waiting area, etc.
- HP activities in the community: active screening for malnutrition, social case assessments, promotion
of the services for women’s health
- Survey on barriers to accessing SRH services for adolescent and young women
Burundi
Kabezi
- Health education on SRH: family planning, kangaroo methods, ANC/PNC, STI
- PMTCT: opt out strategy for all women
Gitega
- Promoting services in the community
- Screening strategy in the different provinces
- Inside the health centre of Urumuri: health education on fistula, hygiene, nutrition, malaria, etc.;
physiotherapy activities; recreation activities
Niangara
- Awareness campaign and mobilisation for routine EPI activities
- Evaluation of the sexual violence component strategy
- Ongoing health education activities in the hospital
Masisi
- Satisfaction survey on the medical care provided to the HIV patients in Masisi Hospital
- Rationalization of the network of “mamans conseillères” for victims of sexual violence
- Ongoing health education activities in the hospital and in the community
HAT
- In Kikongo: mobilisation for screening population and HP activities on vector control strategies
- In Kasai oriental: exploratory mission to collect info on socio-cultural context, perception of HAT,
health seeking behaviour; awareness campaign and mapping of the area
Kinshasa PUC
- Cholera intervention in Mbandaka
- Ebola intervention in collaboration with OCBA
Kinshasa Coordination
- Satisfaction survey for MSF staff and their beneficiaries regarding their medical care
Nasr City Cairo
- Ongoing collection of info on migrant profiles and their migration path
- Coaching of the HP supervisor
- Ongoing HP activities
Abu Elian
- Defining the HP strategy
- Hiring an HP team and training for treatment of children under five
- KAP survey on health seeking behaviour for women and children under five
Imey
-
-
-
-
Haiti
Choscal, Sarthe, Martissant
- HP activities in the different projects: Choscal, Sarthe and Martissant
India
Chhattisgarh
- HP activities supporting all the medical activities in the different health facilities and in the catchment
areas: PHC, malaria, nutrition, tuberculosis, maternal health, etc.
- Supporting the context analysis of the area affected by conflict
Nagaland
- HP activities in OPD, IPD & communities on all medical issues tackled in the hospital: SRH, hygiene,
malaria, blood donations, etc.
- Specific focus on tuberculosis patients
Italy
Migrant’s health
- Promotion of services in collaboration with the MoH and a local NGO
- HP activities on tuberculosis in closed centres for migrants
- HP activities on Chagas for Latin American migrants in theBergamo area
Niger
Dakoro
- Ongoing HP activities
- Preparing disengagement phase and reduction of activities
Guidan Roumdji
- HP activities in the community: nutrition and tuberculosis defaulters tracing; community meetings;
individual interviews of patients lost to follow up
- HP activities in ATFC: health talks, appetite tests, individual interviews, reference briefings, referral
briefings
- HP activities in ITFC: specific support on routine vaccination, health talks, television spots, recreation
activities, cooking demonstrations, counselling
Dargai
- Supporting the disengagement phase and the closing process of the project
Timergara
- In the hospital, HP activities moved from purely supporting health care waste management to all
relevant medical topics: hygiene, maternal health, diabetes, etc.
- Specific support on measles
- Design of a new strategy to start HP activities in the community through the Lady Health Workers
Karachi
- Hiring and training of an HP team
- Opening of the project in October 2012. HP activities launched in the clinic since the beginning:
PHC, maternal health care, information on MSF
- HP activities in the community: promotion of the services targeting specific communities
Bo (outreach)
- Ongoing HP activities in five outreach areas
Egypt
Ethiopia
Pakistan
Sierra Leone
Promoting MSF services in East and West Imey communities
HP activities for the patients and caretakers in East and West Imey health centres
HP activities in the community through mobile clinics (four outreach locations)
Closing of the project: designing the HP exit strategy
section 12: Health Promotion and socio-Anthropology
DRC
annex of tables and data 2012
Afghanistan
99
Table 3: OCB projects with HP/anthropological activities, 2012
Somaliland
Burao
- HP activities on hygiene and maternal health in the hospital
- Mobilization for fistula campaign
- Meetings with key people from the community (to be organized in the hospital)
South Soudan
Gogrial
- In the PHC centre: refreshment of HP topics, prioritization of HP messages and adaptation/creation
of related tools for each department; exit interviews on drug use; daily games activity in ITFC
- Supporting the measles vaccination campaign
- Mobilization for fistula campaign
- In the community: defaulter tracing for tuberculosis and nutrition, meetings with key people, referral
system, surveillance system
Pibor
- Changing the setup of the HP team: HP team fully integrated in other departments
- HP activities supporting all relevant medical topics: SRH, malaria, EPI, hygiene, nutrition, tuberculosis,
blood transfusion
- Specific activity on SRH: 18 month campaign: from pregnancy to PNC
- HP activities in the community: defaulter tracing, meetings with key people, etc.
South Africa
Johannesburg
- Cleaning campaign in several urban slum buildings
- Zimbabwe
Harare (sexual violence)
- Develop adapted tools for promotion of services
- Awareness raising on sexual violence: partnership with other actors and with the MoH; networking;
training of volunteers from partner organization; participation to key events (specific celebration days);
and health talks in the clinic
annex of tables and data 2012
section 12: Health Promotion and socio-Anthropology
100
ANC: antenatal care; ATFC: ambulatory therapeutic feeding centre; DRC: Democratic Republic of Congo; EPI: extended programmes of immunisation; HAT: human
African trypanosomiasis; HIV: Human Immunodeficiency Virus; HP: health promotion; IPD: inpatient department; ITFC: inpatient therapeutic feeding centre; MoH: Ministry
of Health; NGO: non-governmental organisation; OCBA: MSF Operational Centre Barcelona; OPD: outpatient department; PHC: primary health care; PMTCT: prevention
of mother-to-child transmission; PNC: postnatal care; PUC: pool d’urgences Congo; SRH: sexual and reproductive health; STI: sexually transmitted diseases;
TB: tuberculosis
MSF MEdical Department OCB
section 16: Laboratory Table 1: OCB laboratory activities, 2012
No. of Labs
HIV & TB
Kinshasa
1
1
TB
Transfusions
(only)
Hospital
(transfusions
included)
Other
Project status
Ongoing
Lubutu
Closed
Masisi
1
Niangara
1
Bandoudu/Kasai
1
Burundi
Bujumbura
1
1
Somalia
Galgaduud
1
1
Somaliland
Burao
1
Kenya
Nairobi
1
1
Ongoing
Guinea
Conakry
1
1
Ongoing
Gueckedou
1
1
Port-Sudan
1
Pibor
1
Gogrial
1
Niger
Dakoro
1
Guidan Roumdji
1
Haiti
Port-au-Prince
2
India
Nagaland
1
Ukraine
Donetsk
1
Ethiopia
Imey
Zimbabwe
1 (HAT)
Expected
closure
Ongoing
Ongoing
1
Ongoing
1
Expected
closure
1
1
Ongoing
Ongoing
1
Ongoing
1
1
Expected
closure
1
Ongoing
1
Ongoing
1
Ongoing
1 (MDR-TB)
Ongoing
Closed
Dire Dawa
1
Birch. B.
1
Gutu
1
New
1
Ongoing
1
New
1
Ongoing
Murambinda
1
Khayelitsha
1
1
Musina
1
1
Expected
closure
KwaZulu-Natal
1
1
New
Thyolo
1
1
Ongoing
Nsanje
1
1
New
Sierra Leone
Bo
1
LESOTHO
Roma
1
Mozambique
Maputo
Tete
South Africa
Malawi
1 (MDR-TB)
Ongoing
1
Ongoing
1
New
1
1
Ongoing
1
1
Ongoing
Angonia
Afghanistan
Total Active
Laboratories
101
South Sudan
Ongoing
Ongoing
section 16: Laboratory
North Sudan
1
1
Closed
Kabul
1
Khost
1
Lashkar-Gah
(Helmand)
1
Kunduz
1
33
35
1
Ongoing
1
New
1
Expected
closure
1
15
3
9
Ongoing
9
2
__
ANC: Antenatal Care; DRC: Democratic Republic of Congo; HAT: Human African Trypanosomiasis; MDR-TB: multidrug resistant tuberculosis; TB: tuberculosis
annex of tables and data 2012
DRC
Project
MSF MEdical Department OCB
section 19: Mental Health
Table 1: MH activities integrated into OCB medical projects, 2012
Country
Project
Type of activities
No. individual
consultations1
No. group sessions
New MH activities
Pakistan
Karachi
MH support integrated within the OPD in an urban slum.
199
(Mid Oct-Dec)
33 (444 persons)
Afghanistan
Lashkar-Gah (Helmand)
MH support integrated within the medical OPD services
(MH activities will be handed over to OCA early 2013).
285
(Nov-Nov)
NA
Egypt
Cairo
SV activities for migrants from the different communities.
205
(May-Dec)
NA
South Sudan
Doro
MH support to the refugees from Blue Nile state (group and individual)
with a specific attention to the beneficiaries of nutritional activities
(since September).
401
1,547 (946 therapeutic
or discussion groups 53,093 persons)
Haiti
Tabarre
MH support to patients referred by medical teams in the hospital
(since May)
247
NA
102
Ongoing MH activities
Egypt
Cairo
Psychological and psychiatric support for migrants from
the different communities.
1115
NA
Afghanistan
Kabul
MH support integrated within medical services of Ahmad Shah Baba
district hospital, Kabul.
NA
NA
Pakistan
Timergara
Psychological support integrated in the MSF medical services
(postoperative care, emergency room and mother and child health).
1,545
76 (1,109 persons)
Kenya
Kibera
SV centre, Olympic, in the outskirts of the Kibera slum.
1,082
NA
Kibera
MH support integrated within the PHC and HIV/TB consultations.
Sierra Leone
Bo, Gondama Referral
Centre
MH support integrated within the referral centre
(GRC, secondary level) for nutrition, TB, HIV and SV.
491
6
South Africa
Musina, migrants from
Zimbabwe
Care for SV victims.
133 cases (no
of psy consultations ND)
NA
DRC
Masisi
Psychological support to SV victims.
887
10 (71 persons)
Haut Uélé, Niangara
Psychological support to victims of the conflict, including SV victims
1,338
51 (605 persons)
Zimbabwe
Murambinda, HIV
project
Psychological support to victims of sexual, domestic or political
violence provided by counsellors to the patients of the HIV cohort.
ND
ND
Zimbabwe
Harare
Care for SV victims.
904 patients
NA
India
Mumbai
Psychological and psychiatric support for MDR-TB/3 line HIV patients.
3,004
369
Ukraine
Donetsk
Psychological and psychiatric support of MDR-TB/HIV patients in prison.
824 (April-Dec)
61 (1027 persons)
(April-Dec)
Bahrain
Manama
Psychological support for the victims of violence; trainings in MH.
ND
NA
Libya
Misrata, Sirte
Individual consultations in two prisons.
Individual and group sessions for victims of conflict in the community.
Training of national psychologists in MoH hospitals and schools.
76
(Jan-March)
157 (3,893 persons) (JanMarch)
Tripoli
Psychological support and SV activities to migrants and IDPs.
Individual consultations and group support for medical teams in hospitals.
162
(Jan-March)
35 (Jan-March)
Somalia
Galgaduud
Psychopharmacologic treatment of MH disorders by medical staff in Guri
El Hospital.
ND
NA
Liberia
Monrovia
SV project integrated within 2 MoH structures: New Kru Town clinic
and JDJ clinic.
644 patients
(Jan-June)
NA
Haïti
Port-au-Prince, Martissant
Individual consultations and group support in IPD, OPD, and SV care.
1,486
NA
ND
ND
rd
annex of tables and data 2012
section 19: Mental Health
Project closures
Bo, outreach project
Sierra Leone
1
MH support integrated within 5 PHC clinics for nutrition, TB, HIV
and abortion.
Not including HIV counselling sessions
ER: Emergency Room; IDP: Internally Displaced Persons; IPD: Inpatient Department; MH: mental health; MoH: Ministry of Health; NA: not applicable; ND: no data
available; OPD: Outpatient Department; PHC: Primary Health Care; SRH: Sexual and Reproductive Health; SV: Sexual Violence; TB: Tuberculosis/MDR-TB: multidrug
resistance tuberculosis
Table 2: OCB MH activities in emergency/short term interventions, 2012
1
Country
Project
Type of activities
No. individual
consultations 1
No. group sessions
South Sudan
Batil
MH support to the refugees from Blue Nile state
(group and individual) with a specific attention
to the beneficiaries of nutritional activities. (Oct-Dec)
40
142 (1,216 persons)
Jamam
MH support to the refugees from Blue Nile state
(group and individual) with a specific attention
to the beneficiaries of nutritional activities.
ND
ND
Doro
Cf. new project.
Pibor
Post immediate psychological support of the community
(including national staff)-training in Psychological First Aid
after acute episode of violence. (Feb-March)
77
ND
Syria
Beirut
Regular training for Syrian MH professionals
(counsellors and psychiatrists).
NA
NA
Bahrain
Dubai
Training of Bahraini professionals linked to victims
of violence.
NA
NA
Not including HIV counselling sessions.
annex of tables and data 2012
section 19: Mental Health
103
MH: mental health; NA: not applicable; ND: no data available
MSF MEdical Department OCB
section 20: Nutrition
Table 4: OCB therapeutic feeding programmes in 2012 by project
Country
Project locations
No. patients
% hospitalized
% cured*
% died*
% defaulted
Vertical programmes/Emergencies
DRC
Goma (refugees)1
25
25
75
0
0
Mauritania
Mbera Malian refugees
3,877
1.4
39
1
51
Assaba
1,653
5.7
70.5
0.4
24.8
Mali
Mopti, Douentza
1,418
26.2
65
3.3
26.4
South Sudan
Maban refugees (Doro, Batil)
5,454
8.4
67.9
0.9
24.52
888
71.1
65.9
4.6
29.5
Integrated programmes Afghanistan
Lashkar-Gah, Kabul
Bangladesh
Kamrangirchar (Dhaka)
1,126
NA
50.9
0
41.2
DRC
Niangara, Lubutu
319
41.4
69.8
7.1
19.3
Ethiopia
Imey
653
19.6
ND
ND
ND
India
Chhattisgarh (Ayam Pradesh)
Niger
Dakoro, Guidan Roumdji
185
NA
8.4
0.6
89.7
29,814
18.7
82.6
2.7
6.9
3
14.2
2.5
Sierra Leone
GRC (Bo)
1,059
100
Somalia
Guri-El (Galgaduud)
636
46.1
ND
ND
ND
North Sudan4
Darfur: Shaeria
549
5.6
85.5
1.7
11.1
South Sudan
Pibor, Gogrial5
7,293
5.3
68.2
1.6
30.2
ND
ND
ND
ND
ND
405
3.4
57.9
2.9
11.0
83.7
104
HIV programmes *
DRC
Kinshasa
Kenya
Nairobi/Kibera
6
Data based on beneficiaries of 6-59 months of age for vertical and integrated programmes and beneficiaries of all age groups for HIV programmes.
DRC: Democratic Republic of Congo; NA: not applicable; ND: no data received
1DRC Goma: 3 weeks activity. Hospitalised indicates transferred, as no ITFC was present. No data available on outcomes of transfer.
2The defaulter rate was especially high in January and from June to August. Long lengths of stay were also noted, which improved when protection rations were
introduced. In the other months, the defaulter rate was between 4 & 12%.
3Only ICU and < 6 months. < 6 months represent 26% of admissions. “Cured” includes cured and transferred to MoH ITFC and ATFC.
4As the project has been temporarily suspended by national security and medical computers containing data were not updated, some weeks are missing.
5In South Sudan, outcomes were calculated on the first semester (data was not available for the second semester).
annex of tables and data 2012
section 20: nutrition
6Kibera: hospitalised indicates transferred, as no ITFC was present.
Table 5: OCB supplementary feeding programmes in 2012 by project
Country
Project
No. patients
% cured*
% died*
% defaulted*
Kibera/HIV clinics
298
69.1
2.3
15.8
HIV programmes Kenya
*
Data based on beneficiaries of 6-59 months for vertical and integrated programmes and beneficiaries of all age groups for HIV programmes.
NA: not applicable; ND: no data received
Table 6: OCB targeted food or nutritional support in 2012 by project
Country
Project
No. patients
Type of programme
India
HIV/TB Mumbai
25
Nutrition during illness
Guinea
HIV Conakry & Gueckedou
143
Nutrition during illness
Kenya
HIV Kibera
444
SFC FBF
South Sudan
Pibor
3,831
Nutrition support for PLW
FBF: Fortified Blended Flour; ND: no data; PLW: Pregnant and Lactating Women; SFC: Supplementary Feeding Centres; TB: tuberculosis
MSF MEdical Department OCB
section 21: Operational Research & Documentation
105
List of OCB-associated publications, 2012
1.Viewpoint: Zachariah R, Harries AD, Srinath S,
Ram S, Viney K, Singogo E, et al. Language in
tuberculosis services: can we change to patientcentred terminology and stop the paradigm of
blaming the patients? Int J Tuberc Lung Dis. 2012
Jun;16(6):714-7.
2. State of the art: Bianchi L, Dahmane A. La recherche opérationnelle ou «la science des meilleures pratiques» Le modèle de Médecins Sans
Frontières. EHL-Info. 2012;20:43-4.
3.Viewpoint: Zachariah R, Ford N, Maher D, Bissell
K, Van den Bergh R, van den Boogaard W, et al.
Is operational research delivering the goods? The
journey to success in low-income countries. Lancet Infect Dis. 2012 May;12(5):415-21.
4.Viewpoint: Harries AD, Zachariah R. Applying
DOTS principles for operational research capacity
building. Public Health Action. 2012;2(4):101-2.
5.Viewpoint: Harries AD. Operational research: getting it done and making a difference. Public Health
Action. 2012;2(1):1-2.
6.Viewpoint: Zachariah R, Draguez B. Operational research in non-governmental organisations: necessity or luxury? Public Health Action.
2012;2(2):31.
7.Viewpoint: Zachariah R, Reid T, Ford N, Van den
Bergh R, Dahmane A, Khogali M, et al. The 2012
world health report ‘no health without research’:
the endpoint needs to go beyond publication outputs. Trop Med Int Health. 2012 Aug 16.
8.Viewpoint: Zachariah R, van Griensven J. Crossing the divide: expanding the scope of operational
research in Public Health Action. Public Health Action. 2012;2(4):98.
9. Original research: Bissell K, Harries AD, Reid AJ,
Edginton M, Hinderaker SG, Satyanarayana S, et
al. Operational research training: the course and
beyond. Public Health Action. 2012;2(3):92-7.
2. Viewpoint – comment on (10): Ditiu L, Kumar B.
Tuberculosis care: why the words we use matter.
Int J Tuberc Lung Dis. 2012 Jun;16(6):711.
3. Viewpoint – comment on (10): Baral S, Newell
J. Language in tuberculosis services. Int J Tuberc
Lung Dis. 2012 Aug;16(8):1129; author reply -30.
4. Viewpoint – comment on (10): Biot M, Saranchuk P, Ellman T, Bygrave H, Bemelmans M.
Change to patient-centred terminology in tuberculosis: an important step, but what about the
treatment strategies? Int J Tuberc Lung Dis. 2012
Nov;16(11):1559-60.
5. Original research: Decroo T, Van Damme W,
Kegels G, Remartinez D, Rasschaert F. Are Expert Patients an Untapped Resource for ART
Provision in Sub-Saharan Africa? AIDS Res Treat.
2012;2012:749718.
3. Health Programme Monitoring
& Management
6. Original research: Kondapaka KK, Prasad SV,
Satyanarayana S, Kandi S, Zachariah R, Harries
AD, et al. Are tuberculosis patients in a tertiary
care hospital in Hyderabad, India being managed according to national guidelines? PLoS One.
2012;7(1):e30281. (Union-MSF course student)
7. Original research: Lumala R, van den Akker T,
Metcalf CA, Diggle E, Zamadenga B, Mbewa K,
et al. CD4 testing at clinics to assess eligibility
for Antiretroviral therapy. Malawi Medical Journal.
2012;24(2):25-8.
8. Original research: Delai MY, Gounder S, TaylerSmith K, Van den Bergh R, Harries AD. Relationship between education and training activities and
tuberculosis case detection in Fiji, 2008–2011.
Public Health Action. 2012;2(4):142-4. (UnionMSF course student)
9. Original research: Lal PG, Wilson NC, Gupta PC.
Attributable deaths from smoking in the last 100
years in India. Current Science. 2012;103(9):108590. (Union-MSF course student)
10.Original research: Cornell M, Schomaker M,
Garone DB, Giddy J, Hoffmann CJ, Lessells R,
et al. Gender differences in survival among adult
patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS Med. 2012
Sep;9(9):e1001304.
11.Original research: Ram S, Kishore K, Batio I, Bissell K, Zachariah R, Satyanarayana S, et al. Pretreatment loss to follow-up among smear-positive
pulmonary tuberculosis cases: a 10-year audit
of national data from Fiji. Public Health Action.
2012;2(4):138-41. (Union-MSF course student)
12.Original research: Afutu FK, Zachariah R, Hinderaker SG, Ntoah-Boadi H, Obeng EA, Bonsu FA, et
al. High initial default in patients with smear-positive pulmonary tuberculosis at a regional hospital in
Accra, Ghana. Trans R Soc Trop Med Hyg. 2012
Aug;106(8):511-3. (Union-MSF course student)
13.Original research: Errol L, Isaakidis P, Zachariah R, Ali M, Pilankar G, Maurya S, et al. Tracing
patients on antiretroviral treatment lost-to-followup in an urban slum in India. J Adv Nurs. 2012
Nov;68(11):2399-409.
14.Original research: Rasschaert F, Koole O,
Zachariah R, Lynen L, Manzi M, Van Damme W.
Short and long term retention in antiretroviral care
in health facilities in rural Malawi and Zimbabwe.
BMC Health Serv Res. 2012 Dec 5;12(1):444.
section 21: Operational Research & Documentation
2. Health Systems & Health Policy
1. State of the art: Edginton M, Enarson D, Zachariah R, Reid T, Satyanarayana S, Bissell K, et al. Why
ethics is indispensable for good-quality operational
research. Public Health Action. 2012;2(1):21-2.
annex of tables and data 2012
1. Operational Research
15.Original research: Namuwenge PM, Mukonzo
JK, Kiwanuka N, Wanyenze R, Byaruhanga R,
Bissell K, et al. Loss to follow up from isoniazid
preventive therapy among adults attending HIV
voluntary counseling and testing sites in Uganda.
Trans R Soc Trop Med Hyg. 2012 Feb;106(2):84-9.
(Union-MSF course student)
HIV
16.State of the art: Bygrave H, Saranchuk P, Makakole L, Ford N. Feasibility and benefits of scaling
up antiretroviral treatment provision with the 2010
WHO antiretroviral therapy guidelines in rural Lesotho. International Health. 2012;4:170-5.
17.State of the art: Lynch S, Ford N, van Cutsem
G, Bygrave H, Janssens B, Decroo T, et al. Public
health. Getting HIV treatment to the most people.
Science. 2012 Jul 20;337(6092):298-300.
18.Review: Andrieux-Meyer I, Calmy A, Cahn P,
Clayden P, Raguin G, Katlama C, et al. Preferred
antiretroviral drugs for the next decade of scale up.
J Int AIDS Soc. 2012;15(2):17986.
19.Review: Harries AD, Zachariah R. AIDS Review.
Africa Health. 2012:42-3.
20.Review: Sabapathy K, Van den Bergh R, Fidler S,
Hayes R, Ford N. Uptake of Home-Based Voluntary HIV Testing in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. PLoS Med. 2012
Dec;9(12):e1001351.
21.Viewpoint: Roberts T, Bygrave H, Fajardo E, Ford
N. Challenges and opportunities for the implementation of virological testing in resource-limited settings. J Int AIDS Soc. 2012;15(2):17324.
annex of tables and data 2012
section 21: Operational Research & Documentation
106
22.Guidelines: Meintjes G, Maartens G, Boulle A,
Conradie F, Goemaere E, Hefer E, et al. Guidelines
for antiretroviral therapy in adults. Southern African
Journal of HIV Medicine. 2012;13(3):114-33.
23.Original research: Davies MA, Boulle A, Technau
K, Eley B, Moultrie H, Rabie H, et al. The role of
targeted viral load testing in diagnosing virological
failure in children on antiretroviral therapy with immunological failure. Trop Med Int Health. 2012 Sep
14.
24.Original research: van Lettow M, Akesson A,
Martiniuk AL, Ramsay A, Chan AK, Anderson
ST, et al. Six-month mortality among HIV-infected
adults presenting for antiretroviral therapy with
unexplained weight loss, chronic fever or chronic
diarrhea in Malawi. PLoS One. 2012;7(11):e48856.
25.Original research: Wandeler G, Keiser O, Mulenga L, Hoffmann CJ, Wood R, Chaweza T, et al.
Tenofovir in second-line ART in Zambia and South
Africa: collaborative analysis of cohort studies. J
Acquir Immune Defic Syndr. 2012 Sep 1;61(1):418.
26.Original research: Estill J, Aubriere C, Egger M,
Johnson L, Wood R, Garone D, et al. Viral load
monitoring of antiretroviral therapy, cohort viral
load and HIV transmission in Southern Africa: a
mathematical modelling analysis. Aids. 2012 Jul
17;26(11):1403-13.
HIV/Tuberculosis Co-infection
27.Review: Harries AD, Lawn SD, Getahun H, Zachariah R, Havlir DV. HIV and tuberculosis--science
and implementation to turn the tide and reduce
deaths. J Int AIDS Soc. 2012;15(2):17396.
28.Viewpoint: Kumar AMV, Gupta D, Gupta RS,
Satyanarayana S, Wilson N, Zachariah R, et al.
HIV testing in people with presumptive tuberculosis: time for implementation. Lancet Resp Dis.
2012;Early online.
29.Viewpoint: Saranchuk P, Bedelu M, Heiden D.
Retinal Examination Can Help Identify Disseminated Tuberculosis in Patients With HIV/AIDS. Clin
Infect Dis. 2013 Jan;56(2):310-2.
30.Original research: Isaakidis P, Varghese B, Mansoor H, Cox HS, Ladomirska J, Saranchuk P, et al.
Adverse events among HIV/MDR-TB co-infected
patients receiving antiretroviral and second line
anti-TB treatment in Mumbai, India. PLoS One.
2012;7(7):e40781.
44.Original research: Jonnalagada S, Harries AD,
Zachariah R, Satyanarayana S, Tetali S, Keshav
Chander G, et al. The timing of death in patients
with tuberculosis who die during anti-tuberculosis
treatment in Andhra Pradesh, South India. BMC
Public Health. 2011;11:921. (Union-MSF course
student)
31.Original research: Kerschberger B, Hilderbrand
K, Boulle AM, Coetzee D, Goemaere E, De Azevedo V, et al. The effect of complete integration of
HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. PLoS One.
2012;7(10):e46988.
Malaria
32.Original research: Kanyerere HS, Mpunga J,
Tweya H, Edginton M, Harries AD, Hinderaker SG,
et al. Timing of antiretroviral therapy and effects
on tuberculosis treatment outcomes in HIV-coinfected patients in Malawi. Public Health Action.
2012;2(4):174-7. (Union-MSF course student)
45.Original research: Bawo LL, Harries AD, Reid T,
Massaquoi M, Jallah-Macauley R, Jones JJ, et al.
Coverage and use of insecticide-treated bed nets
in households with children aged under fi ve years
in Liberia. Public Health Action. 2012;2(4):112-6.
(Union-MSF course student)
33.Original research: Rangaka MX, Wilkinson RJ,
Glynn JR, Boulle A, van Cutsem G, Goliath R, et al.
Effect of antiretroviral therapy on the diagnostic accuracy of symptom screening for intensified tuberculosis case finding in a South African HIV clinic.
Clin Infect Dis. 2012 Dec;55(12):1698-706.
34.Original research: Bedell RA, Anderson ST, van
Lettow M, Akesson A, Corbett EL, Kumwenda M,
et al. High prevalence of tuberculosis and serious
bloodstream infections in ambulatory individuals presenting for antiretroviral therapy in Malawi.
PLoS One. 2012;7(6):e39347.
35.Original research: Fenner L, Reid SE, Fox MP,
Garone D, Wellington M, Prozesky H, et al. Tuberculosis and the risk of opportunistic infections and
cancers in HIV-infected patients starting ART in
Southern Africa. Trop Med Int Health. 2012 Nov
30.
Tuberculosis (including
drug-resistant tuberculosis)
36.Review: Ahuja SD, Ashkin D, Avendano M, Banerjee R, Bauer M, Bayona JN, et al. Multidrug
resistant pulmonary tuberculosis treatment regimens and patient outcomes: an individual patient
data meta-analysis of 9,153 patients. PLoS Med.
2012;9(8):e1001300.
37.Review: Cox H, Ford N. Linezolid for the treatment of complicated drug-resistant tuberculosis: a
systematic review and meta-analysis. Int J Tuberc
Lung Dis. 2012 Apr;16(4):447-54.
38.Viewpoint: Cox H, Ford N, Hughes J, Goemaere
E. Linezolid for multidrug-resistant tuberculosis.
Lancet Infect Dis. 2013 Jan;13(1):16.
39.Original research: Cox H, Escombe R, McDermid C, Mtshemla Y, Spelman T, Azevedo V, et al.
Wind-driven roof turbines: a novel way to improve
ventilation for TB infection control in health facilities. PLoS One. 2012;7(1):e29589.
40.Original research: Coulborn RM, Panunzi I, Spijker S, Brant WE, Duran LT, Kosack CS, et al. Feasibility of using teleradiology to improve tuberculosis screening and case management in a district
hospital in Malawi. Bull World Health Organ. 2012
Sep 1;90(9):705-11.
41.Original research: Nagaraja SB, Kumar AM,
Sachdeva KS, Ramachandran R, Satyanarayana
S, Bansal A, et al. Is one sputum specimen as
good as two during follow-up cultures for monitoring multi drug resistant tuberculosis patients in
India? PLoS One. 2012;7(9):e45554. (Union-MSF
course student)
42.Original research: Malhotra S, Zodpey SP, Chandra S, Vashist RP, Satyanaryana S, Zachariah R, et
al. Should sputum smear examination be carried
out at the end of the intensive phase and end of
treatment in sputum smear negative pulmonary TB
patients? PLoS One. 2012;7(11):e49238. (UnionMSF course student)
43.Original research: Kundu D, A MVK, Satyanarayana S, Dewan PK, Achuthan Nair S, Khaparde K,
et al. Can follow-up examination of tuberculosis
patients be simplified? A study in chhattisgarh, India. PLoS One. 2012;7(12):e51038. (Union-MSF
course student)
Nutrition
46.Original research: Dorion C, Hunter PR, Van den
Bergh R, Roure C, Delchevalerie P, Reid T, et al.
Does Village Water Supply Affect Children’s Length
of Stay in a Therapeutic Feeding Program in Niger? Lessons from a Medecins Sans Frontieres
Program. PLoS One. 2012;7(12):e50982.
47.Original research: Shams Z, Zachariah R, Enarson DA, Satyanarayana S, Van den Bergh R, Ali
E, et al. Severe malnutrition in children presenting
to health facilities in an urban slum in Bangladesh.
Public Health Action. 2012;2(4):107-11. (UnionMSF course student)
48.Original research: Ali E, Zachariah R, Hinderaker
SG, Satyanarayana S, Kizito W, Alders P, et al.
Does the 65 cm height cut-off as age proxy exclude children eligible for nutritional assessment in
Bangladesh? Public Health Action. 2012;2(4):1036. (Union-MSF course student)
Other Infectious Diseases
49.Viewpoint: Hasker E, Lutumba P, Chappuis F,
Kande V, Potet J, De Weggheleire A, et al. Human
african trypanosomiasis in the democratic republic
of the congo: a looming emergency? PLoS Negl
Trop Dis. 2012 Dec;6(12):e1950.
50.Original research: Isaakidis P, Mansoor H, Zachariah R, Da Silva EA, Varghese B, Deshpande A, et
al. Treatment outcomes in a cohort of patients with
chronic hepatitis B and human immunodeficiency
virus co-infection in Mumbai, India. International
Health. 2012;4:239-45.
51.Original research: Khonje A, Metcalf CA, Diggle
E, Mlozowa D, Jere C, Akesson A, et al. Cholera
outbreak in districts around Lake Chilwa, Malawi: Lessons learned. Malawi Medical Journal.
2012;24(2):33-7.
52.Original research: Luque Fernandez MA,
Schomaker M, Mason PR, Fesselet JF, Baudot Y,
Boulle A, et al. Elevation and cholera: an epidemiological spatial analysis of the cholera epidemic
in Harare, Zimbabwe, 2008-2009. BMC Public
Health. 2012;12:442.
Non-Communicable Diseases
53.Viewpoint – comment on (64-67): Maher D.
The power of health information - the use of cohort monitoring in managing patients with chronic
non-communicable diseases. Trop Med Int Health.
2012 Oct 11.
54.Viewpoint – comment on (64-65): Mullins J.
Cohort reporting improves hypertension care for
refugees. Lancet. 2012 Aug 11;380(9841):552.
55.Original research: Khader A, Farajallah L, Shahin
Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort
monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for
Palestine refugees in Jordan. Trop Med Int Health.
2012 Sep;17(9):1163-70.
56.Original research: Khader A, Farajallah L, Shahin
Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort
monitoring of persons with diabetes mellitus in a
primary healthcare clinic for Palestine refugees in
Jordan. Trop Med Int Health. 2012 Oct 11.
57.Original research: Lin Y, Li L, Mi F, Du J, Dong Y,
Li Z, et al. Screening patients with Diabetes Mellitus for Tuberculosis in China. Trop Med Int Health.
2012 Jul 25.
58.Original research: Li L, Lin Y, Mi F, Tan S, Liang
B, Guo C, et al. Screening of patients with tuberculosis for diabetes mellitus in China. Trop Med Int
Health. 2012 Jul 25.
59.Original research: Kirui NK, Pastakia SD, Kamano JH, Cheng S, Manuthu E, Chege P, et al.
Important co-morbidity in patients with diabetes
mellitus in three clinics in Western Kenya. Public
Health Action. 2012;2(4):148-51. (Union-MSF
course student)
Drug Safety
Conflicts & Humanitarian Emergencies
70.Viewpoint: Baouab TB, del Valle H, Derderian
K, Ponthieu A. Looking beyond legal status
to human need. Forced Migration Review.
2012;39:19-20.
71. Original research: Zachariah R, Bienvenue
B, Ayada L, Manzi M, Maalim A, Engy E, et
al. Practicing medicine without borders: teleconsultations and tele-mentoring for improving
paediatric care in a conflict setting in Somalia?
Trop Med Int Health. 2012 Sep;17(9):1156-62.
72. Original research: Coloni F, Van den Bergh
R, Sittaro F, Giandonato S, Loots G, Maes P.
Biodegradable bags as emergency sanitation in
urban settings: the field experience. Waterlines.
2012;31(1-2):122-32.
60.Original research: Wadonda-Kabondo N, Hedt
BL, van Oosterhout JJ, Moyo K, Limbambala E,
Bello G, et al. A retrospective survey of HIV drug
resistance among patients 1 year after initiation of
antiretroviral therapy at 4 clinics in Malawi. Clin Infect Dis. 2012 May;54 Suppl 4:S355-61.
61.Original research: Chu KM, Manzi M, Zuniga I,
Biot M, Ford NP, Rasschaert F, et al. Nevirapineand efavirenz-associated hepatotoxicity under programmatic conditions in Kenya and Mozambique.
Int J STD AIDS. 2012 Jun;23(6):403-7.
62.Original research: Gsponer T, Weigel R, Davies
MA, Bolton C, Moultrie H, Vaz P, et al. Variability of growth in children starting antiretroviral
treatment in southern Africa. Pediatrics. 2012
Oct;130(4):e966-77.
63.Viewpoint: Besada D, Van Cutsem G, Goemaere
E, Ford N, Bygrave H, Lynch S. The case for Option B and Optional B+: Ensuring that South Africa’s commitment to eliminating mother-to-child
transmission of HIV becomes a reality. Southern
African Journal of HIV Medicine. 2012;13(4):17881.
107
Sexual and Reproductive Health
66.Original research: Chu K, Cortier H, Maldonado
F, Mashant T, Ford N, Trelles M. Cesarean section
rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres.
PLoS One. 2012;7(9):e44484.
67.Original research: Tamura M, Hinderaker SG,
Manzi M, Van den Bergh R, Zachariah R. Severe
acute maternal morbidity and associated deaths in
confl ict and post-conflict settings in Africa. Public Health Action. 2012;2(4):122-5. (Union-MSF
course student)
Surgery & Anaesthesia
68.Guidelines: Sever MS, Vanholder R, Workgroup
on recommendations for the management of crush
victims in mass disasters. Recommendations for
the management of crush victims in mass disasters. Nephrol Dial Transplant. 2012;27(Supplement
1):i1-i67.
Hospitals
69. Original research: van den Boogaard W,
Manzi M, Harries AD, Reid AJ. Causes of pediatric mortality and case-fatality rates in eight
Médecins Sans Frontières-supported hospitals
in Africa. Public Health Action. 2012;2(4):11721. (Union-MSF course student)
annex of tables and data 2012
65.Original research: Tayler-Smith K, Zachariah R,
Hinderaker SG, Manzi M, De Plecker E, Van Wolvelaer P, et al. Sexual violence in post-conflict Liberia:
survivors and their care. Trop Med Int Health. 2012
Aug 12. (Union-MSF course student)
section 21: Operational Research & Documentation
64.Original research: Tayler-Smith K, Zachariah R,
Manzi M, Van den Boogaard W, Nyandwi G, Reid
T, et al. Achieving the Millennium Development
Goal of reducing maternal mortality in rural Africa:
an experience from Burundi. Trop Med Int Health.
2012 Nov 20.
MSF MEdical Department OCB
section 25: Surgical Activities
Table 1: Overview of OCB surgical activities per project, 2012
Mission
AFG
AFG
AFG
AFG
BDI
BDI
COD
COD
COD
COD
Project
Kabul
Khost
Kunduz
Lashkar-Gah
Gitega_OF
Kabezi
Lubutu
Masisi
Niangara
Nyabiondo
1,356
1,867
352
1,242
222
1,712
705
129
Patients
N°
623
55
Cases
N°
690
57
3138
2329
486
1317
242
2026
806
130
Procedures
N°
736
58
3,812
2,423
510
1,394
260
2,120
874
130
Mean Age
Years
27
29
23
29
35
26
30
27
35
26
Female
%
60.5
100.0
14.4
39.6
100.0
100.0
48.6
80.6
46.1
99.2
All trauma
%
21.0
0.0
99.1
30.4
0.0
0.0
6.7
13.6
10.9
2.3
Violent trauma
%
4.2
0.0
24.9
6.9
0.0
0.0
1.8
7.3
3.5
2.3
Caesarean section
%
28.6
70.9
0.0
20.2
0.0
85.5
21.2
59.9
11.1
88.4
Post-op infection
%
ND
3.6
ND
ND
5.4
3.6
ND
1.1
ND
ND
Primary intervention
%
90.3
96.5
43.2
80.2
72.4
94.3
91.7
84.5
87.5
99.2
Emergent cases
%
74.6
100.0
100.0
78.4
0.2
100.0
59.5
90.7
62.3
100.0
Minor/wound surg
%
38.8
1.8
57.6
36.2
0.2
7.0
28.1
30.2
35.9
5.4
Spinal anaesthesia
%
31.9
71.9
12.4
25.4
99.0
64.5
59.1
53.8
43.3
75.4
Spinal / C-Section
%
84.3
92.3
NA
55.4
NA
76.5
85.1
92.9
73.1
81.6
%
0.0
0.0
0.2
0.3
0.0
0.1
0.0
0.2
0.0
1.5
min/day
114
85
383
448
122
210
206
341
128
25
Intra-Op mortality
annex of tables and data 2012
section 25: Surgical Activities
108
Occupancy rate
NA: not applicable; ND: no data
LSO
NER
PAK
PAK
SLE
SOM
SOM
SSD
SYR
Roma
Dakoro
Dargai
Timurgara
Bo
Burao
Guri-El
Gogrial
Jabal-Akkrad
TOTAL
984
1,192
530
117
387
124
1,392
978
1,084
245
377
131
15,804
1046
1828
621
122
391
124
1659
1019
1246
346
652
168
20,443
1,093
1,944
637
124
396
133
1,819
1,208
1,266
386
664
223
22,210
34
31
28
27
28
31
31
25
29
22
24
26
54.9
24.4
56.4
68.4
77.5
100.0
82.8
99.4
73.9
49.0
53.8
20.6
15.9
90.1
14.2
25.6
0.5
0.8
15.9
0.3
19.7
58.0
37.9
84.0
1.2
18.2
1.1
0.9
0.0
0.0
5.5
0.2
10.0
32.7
13.8
69.5
18.3
0.0
10.6
29.1
61.5
83.1
64.6
69.4
39.1
19.2
12.7
5.3
ND
3.7
ND
ND
ND
ND
ND
2.5
0.5
ND
ND
ND
94.1
65.2
85.3
95.9
99.0
100.0
83.9
96.0
87.0
70.8
57.8
78.0
46.3
100.0
68.0
90.2
74.9
93.5
99.6
99.5
97.4
100.0
93.4
98.8
14.7
33.5
60.5
23.8
0.5
4.0
19.4
5.5
29.1
67.9
72.7
68.5
47.7
35.7
19.8
3.3
71.4
83.9
49.7
47.5
42.1
11.3
12.4
15.5
88.3
NA
92.9
11.8
81.9
90.3
81.5
69.4
84.7
80.9
62.5
71.4
0.2
0.2
0.3
0.0
0.0
0.0
0.2
0.0
0.2
0.6
0.3
0.0
441
494
79
62
171
49
285
188
196
91
78
85
109
IND
Mon
section 25: Surgical Activities
HTI
Tabarre
annex of tables and data 2012
HTI
Cange
OCB Medical Activity Report 2012
MSF-OCB
94 Rue Dupré
B-1090 Bruxelles
Belgium
Technical support & coordination
Luxembourg Operational Research (LuxOR)
MSF-Luxembourg
68 Rue de Gasperich
Luxembourg
Compilation and editing
Sokhieng Au
Rafael Van den Bergh
Further information and reprints
Dr. Rony Zachariah
E-mail: rony.zachariah@brussels.msf.org
Tel: + 352 332515
Fax: + 352 335133