MSF
April 2013

Niger 2013
Tackling the deadly
combination of malaria
and malnutrition© Juan Carlos Tomasi

Index

3A cycle of malnutrition

4Malnutrition and malaria, a deadly combination

6

Extensive malaria peak in 2012

8

Innovative approaches
to reduce mortality rates in 20139

A public health problem

10Challenges

Cover picture:
Madaoua Hospital, Tahoua region. Niger.

2 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition

“There are six of us in the family. We do not have enough food foreveryone because we have not been able to harvest our crops. Therainy season has already started but the millet has not grown yet.
Last year’s crops are finished. We always face the same problem.”Hadiza Adamou, 30 years old, from Madaoua, Tahoua region, July 2012.

© Juan Carlos Tomasi

Women grinding grain in a village in Niger.

A cycle of malnutrition
In the Sahel region, life is governed by the seasons. A short but
intense rainy season lasts from May to September, followed by along dry season from October to April. People rely heavily on cropsgrown during the rainy season. Typically there is a long lean period
between harvests, knows as the ’hunger gap’, when people live on
their dwindling food supplies as they wait for the next harvest.

© Juan Carlos Tomasi

Years are ‘good’ or ‘bad’ depending on the specific climaticconditions and the resulting volume of the harvest. However,malnutrition is endemic in some areas of the region and, even in
a ’good’ year, during the hunger gap, acute malnutrition often
rises above the alert threshold of 10 percent in children under five,with frequent peaks reaching or even surpassing the 15 percent
emergency threshold.
In Niger, this recurring situation reached crisis levels in 2005,
generating a major emergency response by national and internationalorganisations. The government of Niger responded by adopting anovel protocol for the treatment of malnutrition, involving a homebased model of care and a new product known as ready-to-use
therapeutic food. The therapeutic food could be fed to a child athome by its mother, so freeing up hospital beds and medical staff,
and allowing the treatment to be decentralised into the community.
By moving away from the previous hospital-based model of care, thetreatment of children with severe acute malnutrition (SAM) could
now take place on a massive scale. This system, set up during theemergency response, has since been implemented throughout thecountry.

Feeding time at Madaoua hospital.

Number of children treated for severe acutemalnutrition in Niger (2006/2012)
400,000

300,000

200,000

100,0000
2006

2007

2008

2009

2010

2011

2012

Source: Unicef, Ministry of Health of Niger.

3 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition© Juan Carlos Tomasi

Admissions ward at Madaoua hospital.

Malnutrition and malaria, a deadly combination
The period of the hunger gap, when malnutrition is at its peak,coincides with the rainy season, when mosquitoes breed and thenumber of malaria cases shoots up.

Seasonality in undernutrition, malaria,
and rainfall in Niger, 2007

Severe Acute Malnutrition (SAM)

Malaria

180
160
140

6120

5100

480

360

240

12000
Hunger PeriodHarvest

Rainfall (mm)7Sept.

8May

SAM and Malaria Cases (% of year total)

RainfallMalnutrition and malaria combine in a vicious circle that has a huge
impact on morbidity and mortality among the most vulnerable in thepopulation. Malnourished children have very weak immune systems,
so their bodies are less able to fight diseases such as malaria,
diarrhoea and respiratory infections. Children who are sick withthese diseases are also more likely to become malnourished.
In tandem with its efforts to tackle malnutrition, the governmentof Niger has put in place several measures to reduce childhoodmortality. For the past few years, children under five havereceived free healthcare, while significant steps have been madein immunisation coverage, recruitment of health staff and in thenumber of malaria cases treated.

Source: Plos Medicine.

4 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition© Juan Carlos Tomasi

Médecins Sans Frontières (MSF) has also carried out a number ofspecific activities in Niger aimed at tackling this chronic emergency
by improving access to healthcare for pregnant women and children
under five. In 2012, medical teams in the regions of Zinder, Maradiand Tahoua run outpatient feeding programmes in some 37 healthcentres. Severely malnourished patients who needed hospitalcare were admitted to inpatient feeding centres in Zinder, Magaria,Madarounfa, Guidan Roumdji, Madoua and Bouza hospitals.
In districts including Madarounfa, MSF is working with local
medical organisation Forum Santé Niger (FORSANI) to develop
child healthcare projects which integrate the prevention and early
treatment of both malaria and malnutrition in order to reduce
mortality and morbidity among this vulnerable age group.

Admissions ward at Madaoua hospital.

LYBIA
ALGERIA

Agadez

NIGER

MALI

Diffa
CHAD

TahouaZinderNiameyBouza
Madaoua

Maradi

ZinderNiameyGuidanRoumdji

Dosso

Magaria

L. ChadMadarounfa

BURKINA FASOrge
Ni

NIGERIA

BENIN

5 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition© Juan Carlos Tomasi

Malaria testing in a health center of Madaoua.

In Madaoua district, MSF has implemented a strategy to diagnose
and treat children suffering from malaria as early as possible.
Known as PECADOM (from the French ‘Prise En Charge A
Domicile’), it aims to bring malaria diagnosis and treatment intorural areas where previously it was unavailable. Health agents inoutreach health posts and community health workers in villages
far from medical facilities have been trained to diagnose and treat
simple cases of malaria. Meanwhile a network of nurses travel by
motorcycle and camel across the region, distributing diagnostic tests
and treatments to the health agents and making sure that they areused correctly.
“In rural areas, access is a serious problem. Testing and treatment isonly available at health centres –and not always then. Sometimes,
the closest health centre is five or even 10 hours away, making it
impossible for a pregnant mother carrying a sick child to walk to
the nearest health centre for treatment. She usually tries natural
remedies and traditional medicine, only going to the health centre
when her child is very sick and suffering convulsions, severe anaemia
or neurological disorders.”
Esperanza Santos, MSF emergency team in Niger, 2012.

Extensive malaria peak in 2012
In 2012, the malaria peak was much higher than in 2011. Fromthe beginning of the year to 7 October, there were 2,630,075 malaria
cases reported in the country and 3,049 deaths – compared to
1,961,811 cases and 251 deaths in the same period of 2011. InMadaoua and Bouza districts, Tahoua region, one of the areas where
MSF works, the increase of cases was significant.

Weekly incidence of malaria 2011 and 2012

10,00010,000

8,000

8,000

6,000

6,000

4,000

4,000

2,000

2,000

01 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
Weeks

2011

2012

Numberof cases

Bouza
Total number of cases 2011: 39,448Total number of cases 2012: 81,956

Numberof cases

Madaoua
Total number of cases 2011: 88,580
Total number of cases 2012: 146,306

01 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
Weeks

Source: Ministry of Health

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Niger 2013 Tackling the deadly combination of malaria and malnutrition

Due to the high incidence of malaria, there was a major increasein the number of malnourished children with malaria admitted tohospitals. In Madaoua district hospital, where MSF is running thepaediatric and malnutrition wards, 17,306 children were admittedwith severe acute malnutrition in 2012, around 57 percent of themsuffering from malaria.
“Severe acute malnutrition can be treated on an outpatient basis
when there is no other related complication; this means we are able
to reach many more children, and it is better for the families too.
However, because of the very high prevalence of malaria, we areadmitting to hospital a much higher percentage of malnourishedchildren who are seriously ill. These children have a very weak
immune system, so their bodies are less able to fight the disease.
Then malaria becomes fatal.”
Cristian Casademont, MSF medical referent for Niger, October 2012.

© Juan Carlos Tomasi

MSF conducted retrospective mortality surveys in both Madaoua
and Bouza to gain more information about death rates frommalaria. Looking at the period from 20 July to 9 December 2012,a total of 5,708 people were surveyed, 1,078 of them children underfive. The results were even worse than anyone had anticipated.
Main results of the survey
Crude mortality rate:
2.4/10,000/day

45.4% of deaths
due to malaria

Emergency threshold:
1/10,000/day

Under-five mortality rate:
7.0/10,000/day

60.7% of deaths
due to malaria

Emergency threshold:
2/10,000/day

64.8% died at home

22% died in hospital

Diagnosis of malaria in a health center of Madaoua.

These mortality rates far exceed the emergency threshold.
The crude mortality rate is twice the level considered an emergency
by the WHO, while the under-five mortality rate is three times theemergency threshold. The impact of malaria on the mortality of thepopulation is significant, accounting for more than half of the deathsof children under five. And even with the efforts made to improve
people’s access to healthcare, 64.8 percent of the deaths
occurred at home.
The mortality survey gives us an insight into only two districts within
Niger, and it is not possible to extrapolate these figures to the entire
country. However, these results must be taken into account when
preparing a response to the hunger gap and malaria season in 2013.

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Niger 2013 Tackling the deadly combination of malaria and malnutrition© Juan Carlos Tomasi

Innovative approaches
to reduce mortality rates in 2013
In 2013, once again Niger will face hunger and malaria. Even with
better harvests than last year, the number of malnutrition cases isagain expected to be very high at close to 300,000.
Over recent years, models for combating malnutrition have shiftedto include prevention as a key element in tackling the problem.
Following the same logic, more work needs to be done on preventingmalaria.

Health center pharmacy. Madaoua District.

© Juan Carlos Tomasi

Explaining the use of the mosquito nets. Madaoua District.

During 2013, and based on its experience in 2012, MSF is planning
to increase activities aimed at improving malaria prevention withincommunities. MSF will continue training community health staff
and community leaders on how to detect and treat malaria, and willcontinue distributing mosquito nets. MSF will also make artemisinincombination therapies (ACT) more widely available in health centres,
and will increase PECADOM activities to make diagnosis andtreatment more available in rural areas.
If security conditions allow, MSF also plans to implement a new
strategy in Madauoa district for preventing malaria, known asseasonal malaria chemoprevention (SMC). With SMC, children
aged from three to 59 months are provided with a full course ofantimalarial treatment during the peak malaria season. So fromJuly until October, children under five will take three tablets ofamodiaquine and one of sulphadoxine/pyrimethamine over a threeday period once every month.
Last year, MSF implemented this strategy in Mali and Chad withpromising outcomes. In Mali, where the strategy reached morethan 165,000 children in Koutiala district, there was a 66.5 percent
reduction in consultations for simple malaria within the first weeksof distributing the medicines, and a 70 percent reduction in children
admitted to hospital with severe malaria. In Chad, where thepreventive strategy reached 11,000 children, in the eight weeks
following the first distribution of the medicine, teams recorded a78 percent reduction in the number of patients with simple malaria
treated in the health centres.
In March 2012, the WHO recommended the strategy of seasonalmalaria chemoprevention based on research carried out in Africancountries with high levels of seasonal malaria. Niger’s Ministry of
Health has also adopted the strategy, and plans to implement it inseveral areas of the country.

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Niger 2013 Tackling the deadly combination of malaria and malnutrition

“We need to look for innovative approaches to tackling malnutrition
and malaria – and we need to work on two levels at the sametime: prevention and cure. Historically we have been more focusedon treatment, so working on prevention is quite new for MSF. Yearafter year we hear about the dual crisis in Niger. We need to act tostop people continuing to die from preventable causes.”
Luis Encinas, programme manager for Niger, april 2013.

© Juan Carlos Tomasi

Medical consultation at Madaoua hospital.

© Juan Carlos Tomasi

Public awareness session. Madaoua District.

A public health problem
Malnutrition is endemic in Niger, and more than 368,000 children
with severe acute malnutrition were treated in the country in 2012.
Numbers in previous years were also very high, with 307,000 treatedin 2011 and 330,000 in 2010. However, this does not necessarily
indicate that Niger has more cases of severe acute malnutrition thanelsewhere in the region, but that a higher percentage of children has
access to treatment. The more than one million children treated formalnutrition in the past three years shows the huge efforts made by
the government of Niger to tackle the problem.
Malaria is also a recurrent problem, according to the incidence of thedisease and the number of cases reported, and needs to be tackled
at the same time and with equal urgency. Both are public healthproblems in Niger and should be addressed as such.
To tackle this fatal combination requires a holistic approach, which
integrates the treatment of severe acute malnutrition with a strong
malaria component. It should become part of the set of basic
health measures aimed at young children, like immunisations, andsupported with nutritional supplements to help children grow up
strong and healthy.
It is also crucial to improve people’s access to healthcare bydecentralising it to rural areas, which will allow common pathologies
to be diagnosed and treated early, and which will prevent healthfacilities becoming overwhelmed by large numbers of complicatedcases. Key strategies to prevent and treat malaria, such as seasonalmalaria chemoprevention and PECADOM activities, should bepart of this decentralised approach, together with nutrition andimmunisations, in order to achieve integrated assistance that isbased on people’s needs and is not focused on one problem to theexclusion of others.

9 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition

“The effort being made to treat severe acute malnutrition in Niger istremendous, and this needs to be supported. The problem in 2012
was that a massive plan for treating severe acute malnutrition wasprepared and implemented, but it excluded other health needs, inparticular malaria prevention and immunisations. The response was
tailored to the malnutrition crisis, and failed to take account of thefact that even if you provide children with appropriate nutrition, you
can still lose them to malaria or a respiratory infection which could
have been prevented by a pneumococcal vaccination. There is a needfor an integrated response, rather than for pushing one response to
the exclusion of others, which can have a detrimental effect on thesurvival of children.”José Antonio Bastos, MSF Spain president, April 2013.

© Juan Carlos Tomasi

Patient in MSF programme. Madaoua District.

Challenges
Despite the innovative preventive strategies being implemented thisyear in Niger, MSF is concerned by the current delays in funding
mechanisms for malaria rapid tests and treatments. A lack of rapid
tests and artemisinin combination therapies (ACT) was alreadyidentified last year, and with the peak malaria season on its way,
MSF is concerned about the availability of the crucial tests andtreatments in Niger in coming months.
Other challenges are presented by the security situation in Niger. It
deteriorated during 2012 and early 2013, mainly due to the conflicts
in Mali and Nigeria, which limited the capacity of humanitarian
workers to access people in need. MSF had to constantly assess
the security situation and take measures that would allow it tocontinue its work; the restrictions on access inevitably complicatedthe implementation of MSF’s medical and humanitarian activities.
In the rest of 2013, security conditions may hamper the deploymentof humanitarian aid in Niger, so it is vital to prepare in advancealternative strategies that can be implemented in even the mostdifficult conditions.

Written and edited by
Médecins Sans Frontières
April 201310 MSF

Niger 2013 Tackling the deadly combination of malaria and malnutrition