Early results from urban SAM treatment programme in Chad

By Aimé Tamberi Makiméré, Emilienne Soubeiga, Deo Katsuva Sibongwere and Geza Harczi

Aimé Tamberi Makiméré is the President of the Board of Directors, Alerte Santé, a Chad non-governmental organisation and coordinator of the Epicentre research base in Niger.

Sister Emilienne Soubeiga is a general practitioner (medical) and the Director of the Notre Dame des Apotres Health Centre, Ndjamena

Mahamat Bechir, PhD, is the Director of the Chadian CNNTA, National Centre for Nutrition and Food, Ministry of Health, Chad.

Deo Katsuva Sibongwere is the Chad Country Medical Coordinator for ALIMA, formerly medical coordinator for MSF.

Geza Harczi is the Operational Medical Manager for the Dakar operational Office of ALIMA, as well as MSF France’s Medical Advisor and Project Manager.

The authors gratefully acknowledge the work and support of the Ministry of Health, the population of N’djamena, the ALIMA and Alerte Santé staff and the European Commission Humanitarian Office (ECHO), especially the Ndjamena Regional Health Director, Dr Barah Somallah, and the Njdamena South and North Health Districts Directors; Dr Néhémie and Dr TCHITOUANKREO, District Health Directors; Maria Mendoza-Baret, Project Coordinator, N’djamena, ALIMA; Guillaume Le Duc, Desk Manager Niger, Chad and DRC; ALIMA and the Dakar Operational Office, ALIMA.

This article shares the early results of a new urban programme to treat severe acute malnutrition in the city of N’djamena, Chad. It was submitted by ALIMA, an international NGO that aims to support and work with national efforts to respond to medical catastrophes that includes acute malnutrition, and by Alerte Santé a medical NGO from Chad.

N’djamena is located in the Sahel region of Chad, close to the border of Cameroon and has over one million inhabitants. Nutritional surveys recently conducted by the Chadian Ministry of Health (MoH) and UNICEF in 2012 and early 2013¹ showed a nutritional crisis in nine of the 11 regions of the Chadian Sahel (GAM (global acute malnutrition) >15%). In comparison, the situation in N’djamena seems relatively better off. Acute malnutrition rates for children under 5 years indicate a ‘serious’ situation in 2012 (13% GAM and 1.8% severe acute malnutrition (SAM)), and a ‘precarious’ one in 2013 (6.7% of GAM and SAM 1.2%).

However, the challenge here is not prevalence, but caseload- a phenomenon common to many urban settings in the Sahel and largely overlooked. Indeed among all the regions in Chad surveyed in 2012, N’djamena had the highest caseload of children affected by GAM per region - estimated at 22,000 children at the time of the survey. It is hard to accurately assess the annual incidence of SAM in N’djamena due to the absence of community based management of acute malnutrition (CMAM) services and limited data. However, based on the most recent prevalence estimation (1.2%) among a population of about 200,000 under-five children and using a specific programming tool², the SAM annual caseload in N’djamena could be as high as 5,200 cases.

A mother with her baby being assessed at an ATFC

In 2010, Médecins Sans Frontières (MSF) implemented a short-term nutritional programme addressing SAM in the context of a measles epidemic that provided treatment to over 5,000 children. Since then, only two relatively small ATFCs (ambulatory therapeutic feeding programmes) have been in operation: one implemented by the Notre des Dames des Apotres health centre with little international support and another by a new and small local non-governmental organisation (NGO) APCEM-PVT (Association pour la Prise en Charge des Enfants malnutris et Personnes Vulnérables au Tchad - Association for the Treatment of Malnourished Children and Vulnerables Persons in Chad). Clearly, up until recently, children with SAM in the capital have had very minimal access to medico-nutritional care despite renewed efforts by the MoH, exemplified by the recent commitment of Chad to the SUN movement (May 2013).

In April 2013, the Chadian medical NGO, Alerte Santé, and the international NGO, ALIMA (The Alliance for International Medical Action), started providing support to the MoH to treat SAM in the capital city of N’djamena, Chad. The programme is funded by ECHO and receives in-kind support from UNICEF. The programme covers two of the four health districts in the N’Djamena Health Region. The objective is to increase access to nutritional rehabilitation in the capital, to reduce morbidity and mortality due to malnutrition among children under 5 years, and to understand better SAM in urban settings in the Sahel. The programme provides support to four ATFCs integrated in MoH health centres and an ITFC (Inpatient Therapeutic Feeding Centre) run by ALIMA/ Alerte Santé in partnership with Notre Dame des Apôtres.

There were a large number of new admissions from the start of the programme even without any active case finding strategies. After only three months, 3,133 children were admitted to the four ATFCs supported by ALIMA, while the two other ATFC run by other NGOs had admitted more than 1000 new SAM cases for the same period. The rate of admissions has reached 300 new admissions per week. A notable feature of the programme is that children are brought to the centres without any information campaign.

Early programme results

While it is too early to draw firm conclusions, first results from the field team are as follows.

Ninety per cent of admissions are children aged 6 to 23 months old; this confirms that nutrition vulnerability is highly concentrated in young children as observed in the 2012 survey³.

Programme indicators are satisfactory and improving: the recovery rate is 85.9%, death rate is 3.2% (and decreasing), defaulter rate is 5.1%, and transfer rate (for medical cases needing specialised care or those cases that are transferred to another ATFC) is : 5.8%. These rates are improving every week. It appears that good geographic accessibility and free, available and quality health care are contributing factors to good attendance and ownership of the programme by parents. Many parents are really amazed seeing how their children get better in a short period of time.

Over the same period, 463 children were admitted to the ITFC, i.e. a hospitalisation rate of 14.7%. About one third of admissions are referred from other medical structures. Most of them are very sick and in urgent need of intensive care. The hospital mortality rate in the ITFC is still relatively high at 11.8%, but has significantly decreased over time. As often occurs when beginning nutritional programmes, the first weeks of a programme draw very severe cases that have been without care for a long period. Many have acute complications such as sepsis, acute diarrhoea, severe respiratory infections, malaria, and severe anaemia. HIV and TB prevalence seem to be higher than in other nutritional programmes in the region, although data are still to be analysed. According to MoH data, N’Djamena town has one of the highest prevalence of HIV (7 to 8%) and TB (566/100,000 inhabitants) while the national prevalence is 3.5% for HIV. The national incidence rate for TB is 399/100,000.

Health conditions appear to be similar or worse in the town to those in rural areas. This has also been reflected in the mortality rates observed in previous surveys, i.e. in N’djamena an under-five’s mortality rate (U5MR) of 1.05 [0.48-2.3] deaths /10,000 /day was observed in 2012, the third highest rate in the 11 regions surveyed, behind Guera and Salamat (see Table 1). The same type of survey indicated an even higher U5MR of 1.24 [0.59-2.63] at the beginning of 2013. ALIMA and Alerte Sante are considering investigating further the genesis of malnutrition in N’Djamena and other related consequences on children’s health.

Under 5 years mortality rate greater than the alert level of 2/10,000
children under 5 years/day

Early conclusions

This programme has already made us consider that urban SAM is common in the Sahel and largely overlooked. We don’t know what future admission trends for the programme are likely to be or its current coverage. While we initially planned sensitization activities, we have put these on hold for fear of being overwhelmed, especially on the ITFC side, even though we are now planning to treat over 7,000 SAM cases this year. Among this intake there will be many medical complications requiring more beds and staff. We are facing a problem of high bed occupancy rate. Despite a gradual increase from 20 to 35 beds, this is still insufficient. According to current data, the required bed capacity for this urban ITFC would be between 75 and 100. We hope that the positive support provided from MoH authorities will help us to solve this problem in the coming weeks.

Finding medical human resources in Chad is also a challenge. While being in the capital city does help, it does not compensate for the lack of qualified and trained staff for a country facing nutritional crisis. Our plan for 2014 would be to set up a referral ITFC with the MoH that could also be the training centre for health professionals in management of malnutrition.

In conclusion, the findings of our work in N’Djamena suggest the need to scale up CMAM treatment availability in large Sahelian cities, to integrate these services into routine health care and to develop programme capacity to host and treat complicated cases of acute malnutrition in need of hospitalisation.

For more information, contact: Aimé Makiméré, Alerte Santé, email: as_presi.asso@yahoo.fr and Geza Harczi, ALIMA, email: geza@alima-ngo.org

¹See: http://foodsecuritycluster.net/sites/default/files/Rapport_Final_SMART_Sahel_Tchad_
2012_VF_0.pdf and http://www.cmamforum.org/Pool/Resources/RAPPORTFINAL- SMART-SAHEL-FEVRIER-2013.pdf

²Mark Myatt, www.cmamforum.org/Pool/Resources/caseloadCMAM-June-2012(1).pdf

³GAM prevalences among children 6-29 months and 30-59 month of age were estimated at 20.1% and 6.6% respectively, meaning that a 6-29 month old child was more than 3 times at risk of being malnourished (‘relative risk’).