Sierra Leone and malaria: Moving towards a change in the national protocol?

ACCOUNT OF A KAILAHUN VOLUNTEER While France was in the middle of a record-breaking heat wave, it was raining in Sierra Leone. Claire, a doctor who usually practices at the Mondor hospital in Créteil, was on mission in Kailahun. Every day, children—especially infants—arrived in the hospital suffering from malaria. It was an emergency. There wasn't enough space for everyone. "This morning, like every morning over the last few weeks, it's gray outside. This is the rainy season. I hear there's a heat wave in France. Its victims, particularly the elderly, are flooding the hospitals, which sometimes find themselves overwhelmed. We're overwhelmed here, too. But we're dealing with children, particularly infants, who keep arriving because they have malaria. Every morning, I wonder what's waiting for me in the pediatric unit. "I feel like I'm taking a headlong dive when I enter this dark wattle and daub building, filled with cries and smells and crowded with human beings. We had to double the capacity of our children's unit from 30 to 60. We stuff two children and two mothers into each bed. "The worst is intensive care. There are around three children to a bed, in the midst of a tangle of oxygen tubes, infusion kits hanging from the beams and mothers sleeping on the ground. When a critically ill little one arrives, I quickly decide which baby is the least worse-off so that we can make room for the new arrival. Coma, convulsions, severe anemia, respiratory distress—in more than 80 percent of cases, we're dealing with malaria-related symptoms. Then you have to wait for the treatments to take effect. "I remember a little girl in respiratory distress whom we ventilated manually. It was lunchtime, everyone was tired, we were hungry and she still wasn't breathing. But her heart continued to beat so we kept ventilating, we aspirated her lungs and we ventilated some more. "Nurses, health aides, doctors — we took turns for several hours without really believing she would make it. And then she gave a big sigh, followed by disordered respiratory movements that became increasingly organized. Three days later, she was holding onto her mother's back, ready to return to the village. It was like magic. "Of course, it's not always like that. Death is too often present. But there are enough successes that I don't really ask myself if this work is worth the effort. Today, like every day, I keep moving ahead, convinced." Sierra Leone is recovering slowly from nearly 10 years of armed conflict that left tens of thousands of people dead and displaced nearly two million more. In spite of peace, living conditions remain extremely harsh, with an average annual income of less than 150 euros/person and life expectancy of no more than 40 years. Malaria is one of the major causes of death in Sierra Leone A Ministry of Health study showed that in the capital city of Freetown, the disease was responsible for 42 percent of pediatric deaths. In the southern part of the country, researchers were able to show that malaria was responsible for 27 percent of deaths among all population groups. But here, as in many other African countries, traditional anti-malarial treatments prove largely ineffective. In March, after a national-level resistance study and long discussions among the Ministry of Health, WHO, MSF and other NGOs, the Sierra Leone government finally announced adoption of a new national protocol, including artemisinin derivatives. By the end of 2006, ACTs should be available throughout the country. Now this political decision must be implemented. Médecins Sans Frontières in Kailahun The MSF hospital in Kailahun was set up in 2001 to enable the region's population, devastated by war, to obtain access to care. The facility treats many patients with malaria. In 2003, 65 percent of pediatric hospitalizations were due to this disease. Out of a total of nearly 15,000 outpatient visits, more than half—8,300—were malaria-related. Kailahun was also one of five sites in the resistance study conducted by MSF, WHO and other NGOs on malaria treatment. Begun in October 2002, this study confirmed high resistance rates to chloroquine (78.8 percent in Kailahun) and Fansidar® (46.1 percent in Kailahun). Resistance Study "Antimalarial resistance has reached crisis proportions in Sierra Leone. The efficacy of the current first-line treatment, CQ, is dramatically low, with obvious consequences for morbidity and mortality. This treatment should be abandoned as soon as possible, and combination therapy introduced. SP resistance, in steep ascent throughout Africa, is of concern in Sierra Leone, and precludes its effective use. A combination of artesunate and AQ should be prioritised for deployment; however, its efficacy should be verified in key sites. Artemether-lumefantrine (Coartem®) is an alternative option." - Excerpt from the report, "Efficacy of Antimalarials in Sierra Leone: Results From Six In Vivo Studies of Chloroquine, Sulfadoxine-Pyrimethamine and Amodiaquine." Francesco Cecchi, Epicentre- October 2003 Finally, A new treatment protocol For more than two years, MSF pressured Sierra Leone authorities to agree to the use of new treatments against malaria as the traditional medicines proved ineffective. Finally, last March, the Sierra Leone government announced during a working session with the WHO, MSF and other NGOs that it was adopting a new national malaria treatment protocol, including drug combinations with artemsinin derivatives. The NGOs were then invited to participate in setting up the ACT treatment structure. The Sierra Leone government has just submitted a request to the Global Fund to finance this protocol change. When funds become available, health care staff training in diagnosing and treating the illness with these new medications will have to be organized, as will the practical aspects of implementing ACT treatment. This enormous public health project should be completed by the end of 2006.