Niger 2005

Dr Milton Tectonidis, London 2006

OperationsQuestions

"…‘regular’ starvation has to be distinguished from violent outbursts of famines…"(Amartya Sen, Poverty & Famines 1981)

MSF Maradi Program

Ready to Use Therapeutic Foods (RUTF)

July 2001-2004Six outpatient centresOne inpatient centreSevere + special cases only9,632 admissions83.5% cure rate

2004

Clear Signs (W12)

March 2005 DAKAR, 21 December (IRIN) Due to poor rains and a severe locust outbreak, Niger this year registered a record grain deficit of 223,487 tons.

peak period 2004

GAM 19.6 (28.2), SAM 2.9 (4.1)GAM 19.3 (28.5), SAM 2.4 (4.4)

U5MR 2.2 – 2.4/10,000/d

April - May 2005

EPICENTRE SURVEYS

May 25, 2005MSF Launches Emergency Operation to Combat Malnutrition in Niger

Niger Nutritional Surveys January to September 2005

NEW SC & OTC (RUTF)+ Protection & Discharge Rations March 2005 (Dakoro)May 2005 (Aguié, Tessaoua, Mayahi)

TARGETED BLANKET FEEDINGlate July 2005 (Maradi) late Sept 2005 (Zinder)

Angola 2002Darfur 2004

May 2005 MSF Niger Emergency Strategy

Steve Collins

Inpatient centresOutpatient points

Family rationsTargeted blankets

Pediatric unitsSupport to OPDs

July - October 2005

July 25, 2005 Preventing Severe Malnutrition in Maradi, Niger The first distribution finally took place on Saturday, July 23…

October 26 2005 - The Targeted Supplementary Feeding Initiative in Zinder A joint effort of MSF, UNICEF and the World Food Programme.

Hunger gap

Malnutrition in Maradi

39,158 admissions60% of admissions in 13 weeks95% of admissions < 85 cm40%+ between 75 & 85 cm

91.4% cure rate3.2% death rate

4.7% default rate

2005

Program indicators 2005

A recent survey… confirms that the children of Niger still face high levels of malnutrition. Malnutrition rates range from 9% to 18%, and inadequate infant and young child feeding practices are likely causes.

Cultural factors and social behaviours, such as inadequate infant and young child feeding practices, have a major impact...

December 2005

Malnutrition conceptual framework

The most common cause of protein-energy

malnutrition is parents’ poor child feeding and

caring practices….”

FOODCARE

orHEALTH

?

World Bank 2006

Population, Cereal Production & Food Aid Niger 1980- 2005

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Years

Cere

al (

met

ric t

ons)

0

2000

4000

6000

8000

10000

12000

14000

Popu

latio

n (t

hous

ands

)

Maradi, Tahoua19841987

Zinder1997

Maradi20012005

Food availability in Niger

Food accessibility in Niger

Hunger gapPrices

Deluxe WFP ration2261 kcal

12% proteins20 % lipids

ITEM QUANTITE Cereal 400 gr Pulse 60 gr Oil 25 gr CSB 100 gr Sugar 15 gr Salt 5 gr TOTAL 605 gr

102 100

143

38

117

34

222

144

82

130109

020406080

100120140160180200

Ener

gy

Prot

ein Fa

t

Vit A

-re

tinol

Vit C

Folic

Aci

d

Nia

cin

equ.

(B3,

PP)

Rib

o-fla

vin

(B2)

Thia

min

(B1)

Cal

cium Iro

n

Percentage

Food quality & dietary deficiencymonotonous cereal-pulse diets

dietary diversificationfood fortification

nutrient supplementation

Type I nutrientsspecific signs of deficiency

Type II nutrientsgrowth failure

iron, copper, seleniumcalcium, iodine

vitamins A, B, D, E, K

nitrogen, essential amino acids

sodium, potassium, chloridephosphorus, sulphur

zinc, magnesiumtissue repair and growth ceasesno convalescence from illness

anorexia and wasting

Nutrient deficiency, growth & malnutrition

Mike Golden

R. Shrimpton. The timing of growth failure (data from 39 studies)

60 million wasted

Nutrient deficiency, growth & malnutrition

130 million underweight150 million stunted

Nutrient dense pastes (equivalent to F-100 + Fe)Ready to eatNo added water – contamination freeIndividualised packaging

Increased capacityOutpatient treatmentMultiple, decentralized sitesInclude the "moderates"

Improved resultsEarly diagnosis (recruitment)Expanded coverageQuality referral care

Ready to Use Therapeutic Foods (RUTF)

Designed to encourage rapid weight gain

MSF Emergency Nutrition current strategies

2005 blanket feeding2006 therapeutic feeding

2004 protection rations2005 discharge family rations

therapeutic feeding + targeted food aid

General population

At risk

Acute malnourished

general distribution

blanket feeding

therapeutic feeding

QualityCoverage

NUTRITION

FOOD AID

family rations

MSF Emergency Nutrition current strategiesAngola 2002 TFC + blanketsDarfour 2004 TFC + OTC + protection rations (+ blankets)Niger 2005 SC + OTC + protection rations + food ration (+ blankets)

ACUTE MALNUTRITION W/H < 80%

MUAC < 110 mmEdema

COMPLICATED NON-COMPLICATED

ANOREXIASevere pathology

Apathy

Inpatient OutpatientAPPETITE

No severe pathologyAlert

MUAC/edema only ?adjustable thresholds

include other age groups

DeinstitutionalizeSimplify

adjust discharge criterialighten follow-up

strengthen referral capacitydischarge quickly

Acute malnutrition - further work

Anthropometry – individual risk

acute weight loss

RUTF ?Treatment by

illness episode ?

Extend benefits

Anthropometry – individual risk

"healthy" reference children

rural village age peers

child with pertussis

poor & incomplete catch-up growth

RUTF ?Treatment by

illness episode ?

Extend benefits

I ncidence of admissions by district/ canton Maradi 2005Districts / Cantons Under 5 pop Admissions Incidence (/ 1000/yr)

District Guidam Roumdji 78452 11 303 144,1Guidan Roumdji Town 2357 111 47,1Guidan Roumdji 11901 2741 230,3Chadakori 15855 1264 79,7Tibiri Maradi 18432 4040 219,2Saé Saboa 14879 1602 107,7Guidan Sori 15027 1545 102,8

Maradi Niger 2005Up to 25% incidence of severe malnutrition (50% for < 85 cm)

South Sudan 1993Herwaldt et al.70% U5 < -2 ZS

Anthropometry – population risk

RUTF ?Therapeutic Blanket ?

Extend benefits

pregnancy & lactation

new therapeutic products & strategies

micronutriments +/- calories

"acute" malnutrition

illness episodeconvalescence weight loss

weaning foods

HIV-TBchronic diseaseration supplement

MSF nutrition

RAPID WEIGHT GAIN TARGETED SUPPLEMENT

RUTF RUSF

Nutrients

RUSF

Acute weight loss

General population

Acute malnourished

General ration quantity & quality

RUTF for rapid weight gain

Strategy (who is at risk ?)Targeting (what supplement ?)

RUSF for specific target group

At risk groups

MSF emergency nutrition