Medical achievements

In 2013, our teams combated a wide range of diseases in a great number of emergency settings. Among the major interventions were those against hepatitis E in South Sudan, measles in Syria and the Democratic Republic of Congo (Congo) and cholera in several countries. Overall, we provided 2,310,964 outpatient consultations, and admitted some 82,000 patients into our healthcare facilities. We treated 412,019 patients for malaria, of whom 45% were children under five years old.

Outbreak response

Hepatitis E
In line with our Strategic Plan priority, in 2013 we invested a lot of effort in fighting disease outbreaks. In South Sudan, we continued our intervention against the hepatitis E outbreak in the refugee camps in Maban County, Upper Nile State. This disease can lead to complete liver failure, coma and death and can also cause miscarriage or premature delivery. Hepatitis E infection is incurable and the incubation period is long. Our teams had no option but to treat patients’ symptoms and support them as best they could through intensive medical care. Control measures implemented included improving hygiene by means of better water and sanitation provision and health education. The emergency lasted until the end of the summer, and over the year our teams treated 7,482 patients. However, even with the best possible care, it is impossible to prevent all deaths from the disease, and regrettably 162 patients died.

Measles and polio
The collapse of the healthcare system due to the violence in Syria led to the first outbreak of measles in the country in 10 years. MSF OCA vaccinated 37,325 out of the 70,000 children vaccinated across the country by MSF as a whole. We also treated more than 1,100 cases of the disease.

In October, an outbreak of polio was declared in Syria. MSF teams working in Ar-Raqqah helped local health staff and other NGOs to plan and conduct large-scale mass polio campaign activities. In addition they assisted with supplementary polio vaccination activities in all the MSF-supported health facilities across north-eastern Syria. MSF teams also provided training and support for local health actors to enhance active case detection and case management of suspected polio patients.

Another measles outbreak to which we responded was in Katanga Province in Congo, where we vaccinated 150,352 children.

Cholera
In 2013 we combated cholera in Nigeria, Haiti and Congo (North and South Kivu and Katanga provinces), treating 7,899 patients overall.

We also conducted MSF’s first cholera vaccination campaign. Between 27 December 2012 and 2 February 2013 we vaccinated 75,092 people against cholera in the Maban County refugee camps in South Sudan’s Upper Nile State.

Following this intervention, we published a report on the usability and the feasibility of the vaccine used. The report found that the campaign was highly feasible, in particular in a closed camp setting with ample time to prepare. However, it noted the importance of good communication with the target community. Moreover, it was clear that a well-oiled logistical and medical apparatus was needed, along with good coordination with the authorities and other organizations, in order for a large number of people to be vaccinated in a short period. Finally, the campaign was expensive to carry out.

Malaria
In September a sizeable outbreak of malaria occurred in the region around the city of Am Timan in the south-east of Chad. As the Chadian government was unable to respond adequately to the outbreak, we organized a large-scale intervention and an additional medical team to support government medical staff. We also opened a special clinic. By the end of October, 3,266 patients had been treated.

“New” disease outbreaks
In 2014, we aim to improve our tools to combat disease outbreaks, focusing on guidelines and software. We will also work towards developing the most appropriate approaches to epidemic surveillance, preparedness and response for diseases we have hardly encountered before. Rabies, meningitis C and hepatitis E were examples of uncommon outbreaks we faced in 2013.

Furthermore, we will develop additional training for our teams in handling outbreaks, and will organize an outbreak management simulation day.

Tuberculosis and multidrug-resistant tuberculosis

The fight against multidrug-resistant tuberculosis (MDR-TB) is one of our strategic priorities. This disease originally appeared as a consequence of TB treatment not being completed or being carried out with faulty medication, enabling the TB pathogen to survive and acquire resistance to the drugs used. The resulting new strains are resistant to “traditional” TB treatment, while remaining as highly communicable as the original form, for example through coughing. The current treatment for MDR-TB takes 2 years and involves taking an immense number of pills, which have very serious side effects, such as nausea, deafness and even psychosis. Moreover, the success rate of the treatment is only around 50 per cent and it is very expensive. In 2012, prompted by this, and the worrying increase in the incidence of MDR-TB worldwide, MSF drafted an ambitious plan to develop better treatment options.

At the start of 2013, we were fortunate to receive a generous contribution of €6.8 million from the National Postcode Lottery Dream Fund for our fight against MDR-TB. During the year there were several hopeful developments regarding MDR-TB. Two new TB drugs were released – the first for nearly half a century – and the roll-out began of a rapid test that cuts the wait for test results from weeks to hours. MSF launched an online TB manifesto to highlight the issue of MDR-TB and gather support. Over 5,000 signatures were received by the end of the year. We started drawing up the first research plans, work that continued into 2014.

In the field of “regular” TB, we continued our activities aimed at securing interim improvements in the treatment of the disease. We lobbied the health ministries in several of our project countries to accept a 9-month treatment regimen, which has less serious side-effects than the conventional two-year regimen. We successfully introduced this regimen in 3 projects in Congo, Chad and, until our departure, Somalia. We also obtained approval from the Ministry of Health in Swaziland, while in Myanmar and Uzbekistan we are still awaiting approval.

We also further expanded the use of the GeneXpert diagnostic test device, which is now used by 30 projects (as against 22 in 2012). This device detects the presence of TB and resistance to the main drug used to fight it, rifampicin, within 2 hours. We also continued to improve infection control. We have treated “regular” TB in 31 projects and drug-resistant TB in 13 projects.

Neglected diseases

In the field of “neglected diseases’”, one of our strategic priorities, we made progress regarding kala-azar and sleeping sickness.

Kala-azar
Kala-azar, or visceral leishmaniasis, has long been a key priority for MSF. Left untreated, almost all those affected will die. MSF has joined a new consortium which in 2013 has won a historic 34 million euro tender to radically improve the control of kala-azar in East Africa and South Asia, in collaboration with ministries of health and local partners. The aim is to establish a sustainable scale-up of, and improved access to, diagnostics and treatment. MSF intends to make its expertise and vast experience available to the consortium in a technical support role, for example by allowing ethically reviewed drug trials to be conducted in its projects.

Sleeping sickness
Sleeping sickness is transmitted by tsetse flies and attacks the nervous system. If left untreated, it usually leads to coma and death. In 2013, our dedicated mobile team conducted major screening and testing operations in South Sudan and Congo and found a large pocket of sleeping sickness patients in Orientale Province, Congo. Across the two countries, we screened 22,879 suspected cases.

Surgery

An important achievement in 2013 with regard to our surgical strategic priority was the opening of the emergency surgery project in Ramtha, Jordan. During the year, the project treated 181 seriously wounded Syrian refugee patients, all of whom were in a critical condition, and carried out 408 surgical interventions.
Overall, we performed 9,928 surgical interventions in 2013, 3,415 of which were Caesarean sections. In 2014 we aim to improve the training we provide to our MSF surgeons in the field.

Psychiatric care

In 2013, we achieved our strategic target of providing emergency psychiatric care in 90 per cent of our basic health care projects where an international doctor was available. Before departing on mission, doctors receive relevant extra training in psychiatry. We have also begun to include psychotropic drugs in our emergency medical kits. Psychiatric consultation is available via email or Skype from the Amsterdam office.

In 2013 we provided regular psychiatric care (treatment or verified referral) alongside general medical care in 30 projects, including all projects where we provided care for both HIV/AIDS and MDR-TB. These diseases have a severe psychological impact and the drugs used to treat them can have psychiatric side effects.

Lead poisoning

In northern Nigeria in 2010, MSF started treating what is considered the biggest epidemic of lead poisoning ever recorded. In several villages in Zamfara State, a very high incidence of unexplained deaths among children had been recorded. The cause of mortality proved to be lead poisoning resulting from artisanal gold mining. This involves crushing and drying the ore in the open air, which contaminates the groundwater and soil of villages with lead-bearing dust. Children are particularly affected due to their playing on the ground, the stage of their development and their low body weight.

MSF started a project in the 8 most affected villages, which was well under way by the beginning of 2013. Lead poisoning is treated by chelation therapy, which gradually removes the lead from the bloodstream by binding it to an agent that leaves the body with the urine. The treatment progressed better than expected. More than 1,000 children had already been discharged from treatment by December 2012.

To prevent recontamination, other organizations had meanwhile remediated the soil in the affected villages. State funds for the remediation of the village of Bagega, the last one to be done, were finally released in February 2013. Without this, treating the population was meaningless for the risk of recontamination. Fortunately, a much smaller than expected number of affected children was found in the village.

At the end of 2013, 1,582 children were still undergoing treatment. There are concerns for other villages potentially affected, although at this time MSF is unaware of any with the same levels of morbidity and mortality as previously seen. MSF continues to monitor the situation.

Medical error policy

MSF operates according to what is – within the humanitarian sector – a groundbreaking medical error policy, with the objective of learning from errors and, if necessary, correcting procedures to prevent further errors of a similar kind. The policy ensures appropriate disclosure and follow-up for any patients adversely affected by medical errors.

In 2013, 9 missions reported a total of 28 medical errors. The most commonly reported were medication errors, where a drug was either prescribed or administered incorrectly. MSF encourages its staff to report errors and emphasizes that MSF prioritizes medical safety and fosters an open learning environment.
See also the blog post “To Err is Humanitarian”, by former MSF medical director Leslie Shanks.

Professional competence

In 2013 2 cases were referred to the MSF medical commission on the basis of concerns raised about the professional competence of an individual to practise medicine in our complex settings. As a matter of policy, MSF does not publicly report on the outcome of professional competency cases.

Medical developments in 2014

In 2013 we completed a major study which we had been carrying out into the prevention of malnutrition in children suffering from one of 3 common childhood illnesses (malaria, respiratory tract infection and diarrhoea). The trial at the centre of the study involved randomizing over 2,000 children in Goronyo, Nigeria, to receive either routine care, micronutrient supplements or ready-to-use therapeutic food. Follow-up was over a period of 6 months to measure incidence of malnutrition. Analysis of the results is ongoing. It has meanwhile become clear that in this situation, supplementation to sick children did not reduce malnutrition.

In 2014, we will start 2 pilot projects focused on new, simplified models of chronic disease care – one in Congo and one in Jordan, treating Syrian refugees. In some of our project countries we are seeing more and more chronic diseases, such as diabetes, chronic obstructive pulmonary disease and heart disease. Moreover, chronic diseases are emerging in the context of ongoing humanitarian emergencies such as that in Congo. The pilot projects should enable us to improve our understanding and ultimately provide better care for patients with these conditions.