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Projets MSF Ped-Nut Dans Le Sahel Juin 2013 Programmes Pédiatriques et Nutritionnels dans la Bande Sahélienne Médecins Sans Frontières 2007-2012 Dr. Susan Shepherd Médecins sans Frontières Plan de la Présentation Indicateurs santé-nutrition infanto-juvénile dans le Sahel et au Mali Résultats initiaux d’un programme de soins pédiatriques: SPE et soins curatifs L’analyse approfondie de la croissance des enfants admis à un programme nutritionnel basé sur le perimètre brachial [PB] Les pistes de réflexion Simplification de la prise en charge Malnutrition Aigue Sévère Prévention de la Malnutrition Aigue Sévère [MAS] Profil de la Mortalité Infanto-Juvénile Distribution of Childhood Deaths by Age: Nigeria, Mali, Burkina Faso, Niger & Chad 2010 28% 0-27 d 1-59 m 72% Epidémiologie Sahélienne Causes of Mortality Children 1-59 months: Nigeria, Mali, Burkina Faso, Niger & Chad 2010 ~30% mortalité paludisme ~20% mortalité évitable par la 4% 2% 4% vaccination 4% 27% Malaria Other Pneumococque Pneumonia 16% Diarrhea Hémophilus B Meningitis Injury Rougeole AIDS Méningococque Measles 20% 23% (rotavirus) Prévention ‘non-spécifique’ pour le ~40% restant: supplémentation nutritionnelle Mortalité Infanto-Juvenile - 2011 Mortalite Infanto-Juvenile: Countdown 2013 200 176 169 146 150 125 U5 MR 98 97 100 82 U1 MR 66 NN MR 49 42 50 34 32 deces/1000naissances 0 Mali Tchad Burkina Faso Niger http://www.countdown2015mnch.org/country-profiles Accessed 20 juin 2013 Countdown to 2015 – Mali 45% de la mortalité < 5 ans liée à la sous-nutrition. Black, RE Lancet 6 juin 2013 Retard de Croissance Prevalence Retard de Croissance (T/A <-2Z) enfants < 5 ans 2000-2010- et objectif 2020 60 47 50 39 40 35 % RC 2000 28 30 % RC 2010 20 % RC 2020 10 % enfants de %< enfants 5 ans 0 Mali Tchad Burkina Faso Niger Retard de Croissance par Région - Mali 50 40 30 Prevalences Retard de Croissaince au Mali par regio 20 % enfants10 < 5 ans 0 Kayes Koulikoro Sikasso Ségou Mopti Bamako n Gao Tombouctou SMART 2012 Kidal SMART 2011 Données demographiques & anthropometriques Koutiala Cercle, Sikasso Region Retard de croissance < 5 ans Sikasso Region : 35.4% [30.9-37.4] (SMART Aug-Sept 2012) Koutiala Cercle : 44.9% [38.6-51.1] (Epicentre mai 2012) MAS 6-59 m Koutiala Cercle 3.4% [2.7- 4.3] Population Koutiala 660,000 6-11 m 6.7% [4.7-9.4] < 5 ans 160,000 12-24 m 5.4% [2.9-5.7] (Epicentre mai 2012) Soins Pédiatriques Complets – Konséguéla Age (months)Check-up ITN Vaccination PlumpyDoz PlumpyDoz Growth 250 kcal/d Ration 1 X X Polio 0, BCG 2 Polio 1, Penta,pneumo 3 Polio 2, Penta, pneumo 4 Polio 3, Penta, pneumo Konséguéla 5 6 X 3 tickets 4 pots Population: 33,000 7 4 pots 8 4 pots Aire de santé la plus 9 X Measles, Yellow Fever 3 tickets 5 pots 10 4 pots grande de Koutiala 11 4 pots 12 X 6 tickets 5 pots 180 nouveau-nés 13 to 17 5 pots/mo inclus chaque mois 18 X 6 tickets 5 pots 19 to 23 5 pots /mo 2,090 visites de suivi 24 X X Prise en charge curative: chaque mois pour Agents palu aux villages Consultations ambulatoires enfants < 2 ans PCIMA ambulatoire interne Hospitalisation pediatrique Transport medicalise Résultats Konséguéla - 2012 5644 enfants inclus Mars 2010 – Dec 2012 2061 enfants ont complété le programme en Dec 2012 97.2% enfants completement vaccinés à l’âge de 2 ans {50% Koutiala, Epicentre 2012} Allaitement 99% à 6 m - 96% à 18 m 94% à 12 m - 44% à 24 m 16 décès/1000/an chez les 6-23 m {64/1000/an chez 1-11 m, 121/1000/an chez 12-59 m, DHS 2006} Prevalence MAS mai 2012 6 à 11 mois 4.5% {Koutiala – 6.7%} 12 à 23 mois 1.7% {Koutiala – 5.4 %} Retard de croissance (T/A <-2Z) réduit de 34% à l’âge de 2 ans Tendances Retard de Croissance Konséguéla vs Rural Koutiala 2010-2012 médiane Prévalence RC à 21-24 mo: 33% 50% iLiNS-ZINC: Preliminary results [Hess SY; Abbeddou S; Yakes E; Some JW; Prado E; Ouedraogo ZP; Guissou R; Vosti SA; Ouedraogo JB; Brown KH] Growth: Stunting prevalence at 18 mo reduced by 25% in intervention groups [endline prevalence 29% in II groups combined vs. 39% in DI group] Development: Moderate-to-severe developmental delay reduced at 18 mo: •42% reduction in motor delay •37% reduction in language delay •28% reduction in personal-social delay Conclusion: Providing 20 g of LNS daily for 9 months, along with malaria and diarrhea treatment, significantly improved growth and development in young Burkinabe children Conférence Internationale contre la malnutrition : Ensuring adequate nutrition for infants and young children 13 Coût Soins Préventifs de l’Enfant à Konséguéla Scenario 1 Scenario 2 Complementary food add seasonal malaria supplement 250 kcal/d chemoprevention EPI Vaccines* (incl PCV) $27.00 $27.00 Check-up visits (6) $30.00 $30.00 Sick visits (6) (incl meds) $24.00 $24.00 ITN (2) $7.25 $7.25 Complementary food supplement $113.00 $113.00 Malaria SMC (3 rounds) $2.00 Vaccinator Salary Incentives included in check-up visits Matrone/Midwife Total cost/child $201.25 $203.25 Cost/child/month $8.39 $8.47 MSF contribution 83.0% 83.1% *cost must be adjusted to include transport, cold chain and waste Rotavirus vaccine 2 doses @ $2.45 each Coût Soins Préventifs de l’Enfant à Konséguéla Scenario 2: Cost Components of Comprehensive Pediatric Package. Konseguela Mali 1% 13% EPI Vaccines* (incl PCV) 15% Check-up visits (6) Sick visits (6) (incl meds) ITN (2) 55% Complementary food supplement 12% Malaria SMC (3 rounds) 4% Coût total par enfant = 100,000 FCFA dont 55,000 FCFA pour complément alimentaire SPE plus efficient? Scenario 3 add Rotavirus vax and reduce suppl to 120 kcal/d EPI Vaccines* (incl PCV) $32.00 Check-up visits (6) $30.00 Sick visits (6) (incl meds) $24.00 ITN (2) $7.25 Complementary food supplement $50.00 Malaria SMC (3 rounds) $2.00 Vaccinator Salary Incentives included Matrone/Midwife in check-up visits Total cost/child $145.25 Cost/child/month $6.05 MSF contribution 73.0% *includes 2 doses of Rotavirus vaccine at $2.45 each Coût total par enfant = 73,000 FCFA dont 24,000 FCFA pour complément alimentaire CPS et admissions PNT Koutiala 2012 Admissions Nut Hebdomadaires Koutiala et Konseguela 2010-11-12 CPS 300 250 200 2010 150 2011 100 2012 50 no d'enfants admis 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 semaine epidemio Admissions Nut: 2010 = 7632 Consultations OPD: 2010 = 63,300 (%palu 57.6%) 2011 = 6732 2011 = 73,648 (45.6%) 2012 = 6954 2012 = 80,658 (40.4%) Admissions Kwashiorkor Koutiala 2012 Admissions for Kwashiorkor - Koutiala Nutrition Program 2012 120 100 80 60 No kwash adm 40 20 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Malnutrition v. Paludisme à Koutiala Admissions WHZ <-3 vs malaria RDT positivity - Koutiala 2012 80.0% 70.0% 60.0% 50.0% % WHZ admissions 40.0% % malaria RDT pos 30.0% 20.0% 10.0% 0.0% 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Kwashiorkor admissions to Koutiala Nutrition Program vs % malaria RDT positivity Koutiala 2012 80.0% 70.0% 60.0% 50.0% % kwash admissions 40.0% % malaria RDT pos 30.0% 20.0% 10.0% 0.0% 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 MSF au Burkina Faso 2007-2011 Les Objectifs du Programme MSF Prise en charge de la malnutrition aigue avec une approche communautaire: simplification du protocole et decentralization du dépistage. Identifier et admettre pour traitement les enfants atteints de malnutrition aigue en utilisant uniquement le périmètre brachial [PB] et/ou oedèmes comme critère d’admission Evaluer le PB à la fois comme critère d’admission et critère de sortie Pourquoi le Périmètre Brachial? Avantages Simple, rapide, peu couteux Facile à comprendre pour les agents de santé et les mères Cohérence: une seule mesure pour dépistage, admission Meilleure couverture Défis Peu d’experience préalable dans l’utilisation comme mesure unique (avec oedemes) comme critere d’admission au PNT Comment déterminer le seuil pour admission? Quel critère de sortie est le plus adapté? Sélection Critère d’Admission (1) P/T<-3Z n=1397n=552 n=579 MUAC<115mm P/T<-3Z n=1168n=781 n=1347 57 Enquêtes Nutritionnelles faites par Epicentre entre 2000-2009, portant sur MUAC<120mm 57,400 observations Sélection Critère d’Admission (2) PB < 115 mm = 1131 enf selectionnes P/T < -3Z = 1949 PB < 120 mm = 2128 <-3Z + < 115 mm = 2528 PB < 125 mm = 5197 Sélection Critère de Sortie 15 % gain de poids par rapport au poids d’admission Absence de pathologie Recommendation OMS en 2007 Méthode Saisie individuelle de l’âge et des paramètres anthropométriques à l’admission, à chaque visite de suivi et à la sortie Base de données anonymisée portant sur 50,841 cas Permet la comparaison entre enfants par dégré de malnutrition aigue à l’admission: PB < 100 mm PB 100- < 110 mm PB 110 – 114 mm PB 115 - < 120 mm Résultats sept ’07 – mars ‘09 Critère de sortie = 15% gain de poids < 100 mm 100-110 mm 112-114 mm 116-118 mm Total Périmètre brachial à l'admission n 1306 6018 5378 12090 24792 % adm 5.3% 24.3% 21.7% 48.8% 100.0% DMS jours 46.6 50.6 52.9 56.6 53.9 périmètre brachial à la sortie - moyen mm 119.4 126.8 131 133.8 P/T à la sortie - moyen Z score OMS -2.6 -1.8 -1.4 -1.3 Gain de poids moyen g/kg/j 8.0 ± 4.3 6.1 ± 7.3 5.3 ± 2.9 4.7 ± 4.9 Gain de PB moyen mm/j 0.7 ± 0.31 0.5 ± 0.27 0.4 ± 0.25 0.4 ± 0.23 Réponse au Traitement: Sept’07 – Mar ‘09 Goossens S, et al.
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