Global burden of acute malnutrition and the latest innovations in the field

From the classical approach to the latest innovations in the field: Community-based Theurapetic Care (CTC)

Eleni kakalou, MDMSc International Health-Health Crises Management

5th Medical Department, Evangelismos General Hospital

FOOD IS NOT ENOUGHWithout essential nutrients millions of children will die

“Eating millet porridge every day is the equivalent of living off bread and water.

With luck, toddlers here might have milk once or twice a week. Young children are

so susceptible to malnutrition because what they eat lacks essential vitamins and

minerals to help them grow, remain strong and fight off infections.”

200 million malnourished children 20 million severely malnourished children

50% of deaths attributable to malnutrition for <5yrs

Dr. Susan Shepherd, MSF Medical Coordinator for the nutritional programme in Maradi, Niger

Causes of death in children under 5 years

Source: WHO, based on C.J.L. Murray and A.D. Lopez, TheGlobal Burden of Disease, Harvard University Press,Cambridge (USA), 1996; and D.L. Pelletier, E.A. Frongillo andJ.P. Habicht, ‘Epidemiological evidence for a potentiatingeffect of malnutrition on child mortality’, in American Journalof Public Health, 1993:83.

The vicious cycle

Latin America and the Caribbean

Sub-Saharan Africa

Equitable growth

The success story

CTC-Pilot project

2000, Ethiopia :

• TFC prohibition lead to out-patient treatment

• Clinical outcome and effectiveness equal or better

Collins and Sadler, 2002

CTC-development

• 2001 Darfur, Sudan: 25,000 pts treated

• 2002 Valid International, Concern FANTA/AED: formalization and 3yr research

• 2004-5: Maradi, Niger: MSF treated 60,000 pts with outcome that surpassed the classical approach

CTC principles

• Maximum coverage and access

• Timeliness

• Appropriate care

Ready–to-Use Therapeutic Food (RUTF)

• Late 1990’s by researcher Andre Briend and Nutriset a private company making (nutritional products for humanitarian relief)

• RUTF is an energy-dense mineral/vitamin-enriched food, specifically designed to treat severe acute malnutrition (Briend et al.,1999)

• Equivalent in formulation F100, WHO recommenede treatment of malnutrition (WHO, 1999/a)

• RUTF promotes a faster rate of recovery from severe acute malnutrition than standard F100 (Diop et al., 2003)

New classification of malnutrition

Collins and Yates, 2003

Screening and Admission by MUAC

Decision chart for SPF programmes

(CTC

man

ual,

Valid

, 200

6)

Community mobilization

(CTC manual, Valid, 2006)

Admissions, exits and total number in OTP in Malawi, 2002-3

(CTC manual, Valid, 2006)

Health impact of malnutrition

• Physical growth• Morbidity and mortality (Infection etc)• Mental capacity• Child bearing potential• Chronic heart disease• Diabetes• Hypertension

Stunting and mental capacity

Malnutrition as a disease

Malnutrition: from one to generation to the next

Maradi, Niger 2005

• MSF treated over 60,000 severely malnourished

children using RUTF • 38,000 severely malnourished children

were treated • Cure rate > 90%• 4 hospitals and 17 emergency outpatient

feeding centresField Exchange. Emergency Nutrition Network. Scaling up the treatment of

acute childhood malnutrition in Niger. Issue 28; July 2006

Scaling up to moderately malnourished children, 2006

• 65,000 malnourished children treated• 11 Out-patient treating centers• 92,5% acute moderate malnutrition in OTP (recovery rate 95.5%)• 7,5% acute severe malnutrition in SC (recovery

rates 81.3%)• Gain weight 5.8g/Kg/day vs 3g/Kg/day• Defaulter’s rate 3.4%

1. Field Exchange. Emergency Nutrition Network. Management of moderate acutemalnutrition with RUTF in Niger. Issue 31; September 2007

2. A Retrospective Study of Emergency Supplementary Feeding Programmes. Dr.Carlos Navarro-Colarado. June 2007. ENN and SC UK. Available at http://www.

ennonline.net/research

A mother’s experience

“I prefer to come here once a week rather than stayingin a treatment centre, because I have to take care of thefields and my other children – I have three other childrenat home.”“I have no-one to look after my other kids, my oldest girlis only 10 years old, I have no-one to help me. Withoutthis place I wouldn’t have sought help, even if my childwas very sick, because I can’t leave my other childrenalone for weeks.”

Mothers of children receiving therapeutic RUF outpatientcare in Magari, Niger

Funding

• At a current cost of €3 per kilo, total product cost would amount to €750 million to treat the 20 million children that WHO estimates have severe acute malnutrition.

• However, considering that raw materials account for at least 50% of locally produced product and that the most significant cost is powdered milk, the future cost will be

higher

Rising price of milk

Cost for SAM

• MSF estimate based on RUTF needed to treat all cases of Severe Acute Malnutrition (258,000 tons for 20 million children at an average of 12.9 kilos per child

• Price per treatment: 38.7 euros, Jan 2008

• During the emergency in Darfur in 2004, six different NGOs implemented the various components of the CTC programme in El Geneina

• TFC interventions were run by MSF-France and MSFSwitzerland; medical care was provided through clinics operated by MSF-Switzerland and Medair

• OTC was provided by Concern, Tearfund and SC-US and outreach by Medair, Concern and MSF-Switzerland

• Collaboration between the NGOs for coherent protocols and referral was facilitated by Valid and United Nations International Children’s Emergency Fund (UNICEF)

• This cooperation resulted in the decongestion of inpatient care and the more efficient use of resources. It enhanced case-finding, case follow-up and hygiene promotion

• Case fatality rates for severely malnourished individuals fell and programme coverage increased dramatically

Source: (Walsh and Faroug, 2004)

Case study 2: Collaboration in Darfur, 2004