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The case of Sierra Leone
Nadine de Lamotte - MSF OCB
London Scientific day, 7 June 07
Use of mortality data in humanitarian response
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Introduction
• Two mortality surveys.
• Focus on 2nd survey.
• Operational response to surveys with specific focus on malaria.
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Map of Sierra LeoneMap of Sierra Leone
Liberia
Guinea
Atlantic ocean
Freetown
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Country background.
• War officially over in January 2002.
• Sierra Leone “famous”for its poor health indicators (OMS 2006):– MMR: 2,000/100,000 live births.– Under 5 mortality the highest in the world at
282/1000 live births.– Life expectancy at birth: 37 male / 40 women.
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Local context: Bo.
• Second largest city in Sierra Leone.
• Population of the district: 500 000.
• Hyper-endemic for malaria.
• National malaria protocol changed in 2004 to ASAQ after efficacy studies showed high failure to SP & CQ.
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OCB operations in Bo.• MSF in Bo since 1995. • Actual target population: 150 000.• 1 MSF hospital (530 admissions/month).• 1 therapeutic feeding centre (150
admissions/month).• 5 clinics (25 000 consults/month).• Malaria is key morbidity/mortality hence
lobbying for country ACT implementation.
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1st mortality survey: April – June 2005
Part of 3-sample access to health care survey to document access barriers in different systems of payment:
- Cost recovery in MOH area
- Flat fee in MSF H area
- Free care in OCB area
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Results: death/10.000/day.
Jun-05CMR 1.7 [1.4-2.0]
< 5 MR 3.5 [2.6-4.4]
• Total deaths reported as being due to malaria /fever: 39%.
• In < 5 deaths: 62%.
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Operational response to survey
=> Need to do sensitisation of local population on malaria, “show” Paracheck and ACT in the villages, distribute bed nets.
• Jan - June 2006: mapping of villages, population data, recruitment & training of outreach teams. Outreach & bed net distribution started in June 06.
• Monitoring bed net use: around 80% of the bed nets were seen hanging.
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2nd mortality survey Sept 2006:
Reassess mortality following 2005 survey:
- Retrospective mortality in catchment area of the clinics.
- Causes of death (verbal autopsy). - Health seeking behaviour in those that died.
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Methods
• Study population: (127 565) 4 chiefdoms Sth Bo.• Sampling method: 3 level cluster; each cluster= 30
children/ families.• Family questionnaire: composition, mortality
(recall period 97 days), health seeking behaviour.• Child questionnaire: anthropometric data. • Analysis: EpiInfo, deaths / 10.000 / day.
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Results (1)
• 907 families included.
• Total n = 5179 (<2yrs=8.4%; <5yrs=76%)
• 89 deaths (<2yrs=32, 2-5yrs=13, >5yrs=44)
Mortality rateMortality rate /10 000 people / day/10 000 people / day
95% confidence 95% confidence intervalinterval
CMR 1.8 1.3 - 2.2
<2 MR 7.3 5.1 – 9.5
<5 MR 3.7 2.5 – 4.9
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Results (2)Malaria related mortality.
• < 2 yrs = 71% (n=23), but recall period covering peak season (39% in June 05).
• < 5yrs = 53% (n=7) (62% in June 05).
• All malaria deaths = 42% (n=37).
• Died at home (all) = 74%.
• Died at hospital (all) = 25%.
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Health Seeking Behaviour, prior to death
56,2
12,56,3
12,5
38,4 38,4
4,513,612,5
2322,7
15,9
43,1
0102030405060
Type of Consultation
Per
ceta
ge
of
the
dea
ths
<2 years
2-5 years
>5 years
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Limitations
• Sampling error: sampling methodology, rainy season means remote villages inaccessible and more malaria (versus 2005 survey).
• Measurement error: definition of malaria as fever in survey (over-estimation?).
• Recall bias: long period of recollection, lack of maternal deaths (stigma?).
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Operational response to 2nd survey: 3 year pilot plan.
=> Bring ACT closer to population via PHUs:
• Identification / mapping of 5 PHUs per clinic, staff training on RDT & ACT use (March 07).
• Prospective mortality follow-up through weekly data collection at community level.
• Continue sensitisation of population on malaria and health seeking behaviour.
• Op research agenda: study ACT efficacy < 2, mortality surveys, baseline study…
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Rendez-vous in 3 years…