Seasonal paediatric calendar.

Abstract

As a paediatrician with Médecins Sans Frontières, there is a sort of seasonal calendar mapped out, and for almost half the year from June it says ‘malaria season’. Last year when I was briefing in New York before heading to Aweil in the north of South Sudan, the operations team were showing me the malaria graphs of the last few years; you could definitely see the trends, but each year the start of the peak varied by a few weeks as well as when the peak occurred, how high it was, and when it resolved. We could see the trends repeating themselves but we had no idea in which direction it would go in 2015. In Aweil, in the end, it peaked in a huge way. You do not want to be caught by surprise, but it can still be a challenge to recognise that a peak is coming – even though it happens every single year. We want to avoid the situation of two or three children on each bed because extra tents have not been put up, to be scrounging for staff, and facing stock-outs of tests, drugs – or blood. Because if you imagine going from a hospital unit of say 100 beds, to up to 400, it is a little bit crazy. Our catchword for the annual and regular explosion in admissions is the ‘accordion effect’. It happens in Mali, where I was in 2014. We can go from a daily patient census of 80–100 at baseline, to up to 300–400. Typically, how it works is you are seeing your patients every day and then you will start to see more frequent ‘positives’ on the malaria rapid tests; you may start to see this before the actual rainy season starts. The patients start to come in, and you track this a little more closely. As the season picks up you see admissions ballooning, you see the children with complications increasing and you start seeing presentations in later stages of malaria, not just the simple malarias; the severity is on the up. You start having more children with more severe malaria in the intensive care units: the ones presenting with cerebral malaria or really severe anaemia needing blood transfusions, and the ones recovering, or still struggling. You have to start adapting your clinical care and your approach to things. In the off-season, you are always thinking about malaria, but it may not be what you first think about. The first thing you think about during the peak is malaria. But, you have to not forget the other things that the children can be presenting with. We have seen everywhere that diagnoses get missed because we say ‘it's the peak, they have malaria’ or something related, when in fact it is something else that can look similar. I know that what my colleagues in Aweil and in Koutiala are doing now is keeping an eye on things, as I do from a distance, because the peaks are not the same in the two areas. In fact, as much as possible, the teams have been planning long in advance, from the end of the last year's peak, to put in place the human resources and logistics to deal with the ‘accordion’. Meanwhile preventive activities have continued, including bed net distribution and pre-emptive seasonal malaria prophylaxis. Declines in malaria morbidity have been championed in recent years, but my tropical medicine specialist colleague says that in MSF projects, we are not seeing similar reductions, and the reasons seem complex. So what does this year hold for Mali, South Sudan, Chad and other countries where we work? Only time will tell.