Highlights of the MSF Scientific Day 2011

Keynote speech: The ethical imperatives of research and data sharing
James Whitworth, Head of International Activities at the Wellcome Trust, urged researchers to consider openly sharing data, to prevent unnecessary duplications and speed up new developments.

Session 1: Co-morbidity and resistance
Infections and antibiotic resistance in SAM http://www.youtube.com/watch?v=kxS68NWBux0
The prevalence of infections and carriage and acquisition of extended-spectrum beta-lactamase (ESBL) in children with severe acute malnutrition (SAM) was investigated in Niger. Of 311 children aged 6–59 months, 51 (17%) had bacteraemia, 48 (16%) a culture-confirmed urinary tract infection, and 44 (15%) microscopy-confirmed malaria. Carriage of ESBL at admission was 31% (17 of 55), and among ESBL-free children at admission, acquisition of ESBL during hospitalisation was observed in 94% (15 of 16). Key programmatic question: what is the impact of our infection control and antibiotic prescribing practices on the spread of multi-resistant bacteria?

Drug-resistant bacteria in burn sepsis in Iraq http://www.youtube.com/watch?v=a3x0cHiG7aY
389 blood samples were taken from 212 burn patients with sepsis syndrome in a burn centre in northern Iraq. The most common gram-negative organisms were Pseudomonas aeruginosa (22 isolates [33.8%]), Klebsiella pneumonia (8 [12.3%]), Acinetobacter baumannii (6 [9.2%]), and Enterobacter cloacae (5 [7.7%]). Gram-positive pathogens were less common: Staphylococcus aureus (17 [26.2%]) and S. epidermidis (7 [10.8%]). For gram-negative bacteria, the most reliably active antibiotics were imipenem, with overall resistance of 13.1%, and amikacin, with overall resistance of 46.4%. Empiric therapy for burn patients with sepsis in this region should include a carbapenem-class antibiotic (imipenem or meropenem). Infection control should be prioritised.

Visceral leishmaniasis in HIV coinfected patients http://www.youtube.com/watch?v=7wLJZyWcOsI
In India, 55 patients with visceral leishmaniasis (VL) and HIV coinfection showed encouraging initial treatment response and good long-term survival when treated with liposomal amphotericin B and combination antiretroviral treatment (cART). Median CD4 cell count at VL diagnosis was 66 cells/µL (IQR 38-112). 41 (74.5%) patients were cured, eight relapsed, six died. Mean CD4 cell count at 6 and 24 months after cART initiation was 187 and 261 cells/µL, respectively. A CD4 count below 200 cells/μL at 6 months after cART initiation was predictive of subsequent relapse. Increased availability of liposomal amphotericin B for VL and better access to HIV care are needed in resource-constrained settings.

Drug-resistant tuberculosis in Swaziland http://www.youtube.com/watch?v=15baLKD1O9g
A 2009 study in TB patients in Swaziland found multidrug-resistant TB (MDR-TB) in 7.7% of new patients and 34% of those previously treated. A case-control genotyping study included 93 fully susceptible control strains and 94 MDR case strains. Previous treatment and clustering were independently associated with MDR-TB. 89% of strains were clustered in the MDR-TB group with 49% of these in two clusters; 39% were clustered in the susceptible group. MDR-TB was largely driven by direct transmission. In the previously treated group, both primary transmission of MDR-TB and acquired resistance had occurred. The results show a high level of recent transmission of MDR-TB and urgent need for control measures.

Session 2: Controlling cholera in Haiti
A spatial analysis tool to aid cholera response http://www.youtube.com/watch?v=9XYuz7Kh2Sg
After the 2010 earthquake in Haiti, more than 200 000 cholera cases were reported in 3 months. Operational pressure made it difficult to quickly analyse the geographical spread of data, so field-friendly spatial analysis tools (Geospatial Information Systems) were investigated for their use in improving disease outbreak response. A correlation between water system breakdowns and increased cholera cases was seen and used to advocate improved water system maintenance. Cholera hotspots and incidence trends in neighbourhoods were easily visualised. Earlier, more widespread implementation might improve medical response. Field tests of this system early in future outbreaks are planned.

Physicochemical treatment of wastewater in Haiti http://www.youtube.com/watch?v=mdlQ4spFvGU
The Delmas cholera treatment centre in Port-au-Prince had onsite complications that prevented the use of infiltration pits and latrines to treat wastewater with high levels of Vibrio cholerae. A low pH coagulation/flocculation process using alum and a high pH protocol using hydrated lime were tested. Wastewater and coagulant were mixed in tanks and allowed to settle for 12 hours before the supernatant pH was adjusted to approximately 7.0 and pumped to onsite infiltration trenches. Both high and low pH processes produced an effluent that met WHO bacterial guidelines for unrestricted irrigation. Although the low pH approach might be cheaper to run, the high pH system produced a less offensive sludge.

Cholera treatment unit for pregnant women, Haiti http://www.youtube.com/watch?v=pZsz0V2dZ8E
Cholera in pregnancy is associated with a high risk of stillbirth or abortion. Rigorous rehydration, avoiding even short periods of severe dehydration, is important to prevent transitional hypoxia in the placenta. A cholera isolation unit for pregnant women was set up in the MSF hospital compound in Leogane and 102 pregnant women admitted. All women had intravenous access established at admission, irrespective of hydration status, and received antibiotics and glucose. 46 (45.1%) were mildly, 44 (43.1%) moderately, and 11 (10.8%) severely dehydrated. 81 (79.4%) women preserved their pregnancy, seven delivered a live newborn (6.9%), with one neonatal death 5 days later, and there were 14 (13.7%) foetal deaths. No maternal deaths occurred. The authors recommend establishing specialised units for pregnant women in large cholera outbreaks to allow closer and adapted follow-up of cholera and pregnancy status.

Session 3: Responding to unmet needs
Teleconsultation and telementoring in Somalia http://www.youtube.com/watch?v=rH7617_MR98
High security risks prevent international staff from working in MSF projects in Somalia. Local clinicians have had little or no opportunity for continuing education and there is no on-site supervision. Teleconsultation and telementoring (telemedicine) allow direct real-time contact between a doctor in Somalia and a Somali-speaking doctor in Kenya. A video camera is used to transmit footage of patients and charts. Teleconsultation was used in 222 paediatric cases, resulting in an added diagnosis that significantly altered case management in 125 (56%) cases. In 105 (47%) cases, a life-threatening condition had been missed by the local clinician. Clinicians in Somalia found the technology easy to use, with high patient acceptability. These preliminary findings show telemedicine can greatly improve paediatric case-management and the detection of life-threatening conditions. This approach could benefit other settings without access to specialised expertise.

Spinal injury in Sri Lanka
During the conflict between government forces and the Tamil Tigers in northern Sri Lanka, many people sustained orthopaedic trauma, including spinal cord injury. MSF set up a spinal cord injury rehabilitation programme, the first of its kind within MSF, with integrated medical, nursing, mental health, and physiotherapy treatment. Of 78 patients admitted, 61 (78.2%) were discharged and 6 (7.7%) defaulted. The 11 (14.1%) remaining patients were still undergoing rehabilitation in June 2011. Mean spinal cord independence measure (SCIM) score at admission and discharge showed an average improvement of 17 points. At 12 weeks follow-up, 22 (78.5%) of 28 patients had either maintained or improved their SCIM discharge score. The authors concluded that the programme improved patient prognosis for spinal cord injury and implementation should be considered in other contexts.

Caesarean delivery in sub-Saharan Africa http://www.youtube.com/watch?v=qe1v70VLY38
The proportion of patients undergoing caesarean section (CS), indications for CS, and incidence of post-operative infection were described in four emergency MSF obstetric programmes in Democratic Republic of Congo, Burundi, and Sierra Leone. Post-operative infections were categorised as superficial or deep. 1276 women underwent CS, 5.8% (3.8-6.4%) of all deliveries. The most common indication was obstructed labour (399 [31%]). Causes of seven (0.5%) maternal deaths included obstructed labour, eclampsia, uterine rupture, and antepartum haemorrhage. There were 174 (14%) neonatal deaths. The post-operative infection rate was 7.3% (93, range 1.70-10.4%); 93% of infections were superficial. The low infection rate suggests that CS can be performed safely in resource-limited settings. The low proportion of CS suggests that women in need are not accessing it. Maternal mortality could be lowered by improving access to antenatal and emergency obstetric services.

Lead poisoning in Nigeria
Lead poisoning caused by small-scale gold extraction in northern Nigeria has killed many children under 5 years. Epidemiological and environmental investigations identified 7 villages as grossly contaminated, with around 3000 children 5 years or younger potentially suffering acute lead poisoning. MSF provided outpatient partially observed DMSA (dimercaptosuccinic acid), an oral chelating agent, in affected villages, with more than 1100 children commencing treatment. Treatment protocol adjustments have reduced the burden on patients, but adherence is challenging and necessitates ongoing community education. At the start of treatment, 82% of patients had blood lead levels higher than 100 µg/dL. Average blood lead level was 166 µg/dL in children starting treatment in June 2010, but fell to 58-69 µg/dL for children starting between October 2010, and May 2011. Average decrease in blood lead levels was 15% (31 µg/dL) from start of treatment to May, 2011, with 7% reduced by more than 65 µg/dL. Mortality since start of treatment was 1%; most children are still on treatment or follow-up.

Session 4: Improving delivery of care
A decentralised HIV programme in rural Zimbabwe http://www.youtube.com/watch?v=nO82Rt0dC-0
A decentralised HIV programme was set up in 2004 by MSF and the Zimbabwe Ministry of Health. The outcomes of 6997 patients were described and the effect of the period of instability (2007, 2008) assessed. Patients were followed intensively for 3 months and then every 3 months, having been given a 3-month drug supply. Median follow-up was 330 days (IQR 93–594). Overall mortality was 6.5 (95% CI 5.9–7.1) and loss to follow-up 8.4 (95% CI 7.8–9.1) per 100 person-years. Loss to follow-up in the period of instability was significantly higher during the first 12 months on antiretroviral treatment. Provision of a longer antiretroviral supply reduced the burden of visits for patients and health professionals. Enabling other countries in the region to follow this model could lower workload and improve patient retention.

Tuberculosis and HIV integration in South Africa http://www.youtube.com/watch?v=8w7ofIGI4Xk
A study in a peri-urban township in South Africa assessed a “one stop shop” TB/HIV service - provision of TB and HIV care in the same health centre by the same members of staff. Patient files and clinic registers were reviewed in two nurse-led primary care clinics (one integrated, and one solely providing TB treatment). Integration resulted in significant reduction in time from start of TB treatment to antiretroviral treatment initiation (median 110 days pre-integration, 58 days post-integration) without negatively affecting TB treatment outcomes. Diagnosis of smear-negative and extrapulmonary TB increased, there were fewer problems with continuity of care, and case-note recording improved. Integration was broadly supported by staff and patients.

Mental health for displaced populations http://www.youtube.com/watch?v=cbaru-73MqQ
For more than 40 years, episodes of violence in Mindanao, Philippines, have led to civilian displacement. In 2008, MSF integrated a mental health programme into primary health care. Psychologists in mobile clinics assessed patients referred by trained clinicians. They provided psychological first aid and brief psychotherapy for common mental disorders. Outcomes were assessed with two self-reporting questionnaires. Of 661 patients diagnosed with a common mental disorder, 463 (70%) were seen at least twice. 377 defaulted. Scores at final assessment had improved for discharged patients and defaulters. Integrating mental health care into primary care is feasible, even in an unstable context.

Physical and sexual violence in Honduras
A study in Honduras defined the physical, social, economic, and policy-driven conditions which limit the access of street-based populations to protection and health care. Data were collected using questionnaires, completed by 283 participants (92%) who described multiple physical and sexual assaults, abuses of law enforcement agents, and marginalisation by the general population, health professionals, and peers. Of 119 participants, only 63 (53%) sought medical treatment after the self-reported most severe episode of physical aggression suffered the previous year. Of 161 who reported having suffered sexual aggression, only 30 (19%) sought medical treatment. Exposure to physical and sexual violence and the prevalence of mental health disorders was extremely high.

Abstracts and videos are available from http://www.msf.org.uk/eventdetail.aspx?fId=scientific_day_2011

Abstracts, list of posters and speaker profiles http://fieldresearch.msf.org/msf/handle/10144/145257