The case of Sierra Leone

Nadine de Lamotte - MSF OCB

London Scientific day, 7 June 07

Use of mortality data in humanitarian response

Introduction

• Two mortality surveys.

• Focus on 2nd survey.

• Operational response to surveys with specific focus on malaria.

Map of Sierra LeoneMap of Sierra Leone

Liberia

Guinea

Atlantic ocean

Freetown

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.

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.

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.

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

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%.

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.

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.

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.

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

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%.

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

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?).

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…

Rendez-vous in 3 years…