From Project to Protocol: MSF research in practice

As we countdown to MSF Scientific Days 2020, the MSF scientific days team examine how new medical practice in humanitarian contexts can effect real change.

At the time of writing, the global COVID-19 pandemic continues to evolve quickly. Medical research is spiralling in its search for treatments and vaccines, and the innovation arena is pumping out more new technologies and equipment than ever before. Calls for the sharing of knowledge, learning, and resources are heard daily. Scientific journals and media outlets are making all COVID-19 related content free to access. And the world is developing a new understanding and respect for medical research, humanitarian innovation, and the life-saving importance of knowledge-sharing.

With that in mind, we are pleased to announce that this year’s MSF Scientific Days – International will go ahead as a fully virtual conference on May 13^th and 14^th. Understandably, global attention is captured by the ongoing COVID-19 crisis. However, it is crucial that the we do not allow the plight of other epidemics that trudge on in the shadows, to slip from focus.

To mark the 17^th edition of this annual conference, we look back at research presented in previous years and ask, “where are they now?”

Cholera vaccines

The use of oral cholera vaccine (OCV) has increased since 2011, when the first OCV suitable for large-scale use, became available. The vaccine could be added in the cholera outbreak control toolbox or used pre-emptively and preventively for most at risk populations. Although there were several successful implementations of mass campaigns (including by MSF), the limited availability of the vaccine and the recommended 2-dose delivery schedule with 2 weeks interval, made the large-scale reactive use difficult. Evidence suggested that a single OCV dose provides some short-term protection and may prevent more cases in an outbreak than providing 2 doses to half of the people. During the 2015 cholera outbreak in Juba, South Sudan, we assisted the Ministry of Health (MOH) with adopting this single-dose strategy when only limited amount OCV was available. We documented high short-term effectiveness of single dose (87.3%). Less than a year later, we assisted MOH in Lusaka, Zambia, during cholera outbreak and were able to repeat single dose OCV campaign, and again documented high effectiveness. Those two experiences influenced WHO recommendations regarding OCV use in outbreaks, and since then, the use of one dose to immediately control the outbreak, with second dose delivered at later stage has become the norm.

Revolutionising ultrasounds

In a remote corner of South Sudan, MSF assists the MOH with provision of paediatric and maternal healthcare. However, limited access to diagnostic tools can make some cases difficult to treat. A patient requiring an x-ray will need to endure a 15-minute drive across unpaved roads to the nearest working machine. And traditional ultrasounds are large, expensive, and complex, making them difficult to source and difficult to use.

Considering this, in 2017, MSF began a feasibility study to assess the use of point-of-care ultrasound – or POCUS – in this remote location. These small, portable hand-held devices enabled MSF staff to conduct real-time, accurate diagnosis at the bedside.

Initially, POCUS training focused on pulmonary diagnosis; bacterial pneumonias, tuberculosis, and unrecognised heart disease accounting for a large burden of disease in this setting. Scale-up was swift, and soon MSF midwives in South Sudan began using POCUS to assist with the delivery of more than 400 babies per month. Roll-out continued to three other projects in Agok, Malakal, and Lankien, with 60 MSF staff trained in using POCUS and over 1500 ultrasounds performed in the last 2 years. Moreover, three of the initial trainees have become trainers – two have conducted month-long trainings in other projects and a third is now the intersectional POCUS focal point for MSF in South Sudan.

These notable successes in uptake are the first steps in MSF’s goal to become a global expert in POCUS use and research. Read an MSF doctor’s experience of using POCUS here.

MUAC for Mothers: handing power back

During a review of the annual statistics for malnutrition in 2010, a medical team in Niger noted a recurring problem. The late presentation of children; coming in at very late stages of severe, acute malnutrition, that resulted in high hospitalisation numbers. Offhand, a question was raised: “why don’t we train mothers how to screen their kids?” And so the MUAC for Mothers or Family MUAC research project was born.

Having initially established on a small scale that mothers and caregivers could indeed be trained to effectively and correctly use mid-upper arm circumference (MUAC) bracelets, the teams from ALIMA (the Alliance for International Medical Action) and its Nigerien partner BEFEN (Bien Être de la Femme et de l’Enfant au Niger) quickly progressed to a larger pragmatic study comparing one district where 13,000 mothers at ALIMA quickly progressed to a larger pragmatic study comparing one district where 13,000 mothers were trained to screen by MUAC with another district where the standard practice of community healthcare workers screened children for malnutrition. Children in the zone where mothers screened by MUAC were admitted at an earlier stage of malnutrition and required fewer hospitalisations at less cost.

MUAC for Mothers was quickly adopted by ALIMA teams in other countries, reaching 2 million caregivers since 2016. The governments of Mali, Niger, and Burkina Faso have included the strategy in their national plans, and dozens of NGOs have carried out their own programming, and the approach will be part of the UN’s Global Plan for Wasting.

MUAC for Mothers is also a part of ALIMA’s ongoing OptiMA studies (Optimising MAlnutrition Treatment) which are investigating simplified treatment protocols. Results from the first single-arm trial in Burkina Faso were presented at the MSF Scientific Days in London and recently published in the British Journal of Nutrition. ALIMA and its partners from INSERM are conducting randomised control trials in DRC and Niger, as well as several operational pilots, to continue building evidence to improve the treatment of children with acute malnutrition.

And the ALIMA team keep on delivering. In a follow-up study, the researchers revisit children that had initially recovered from acute malnutrition under OptiMA in Burkina Faso to assess the chance of relapse. Want to know what they found? Join us online on May 13^th and 14^th for MSF Scientific Days International (London) 2020.