Global Health Fellowship

Nutrition module

SAM Defined

WFH < -3z scoresVisible severe wastingNutritional edema

20 M children worldwideMost in S. Asia + sub-Saharan Africa

5-20 x higher risk death: directly or indirectly↑ CFR in children w/ diarrhea +/or pneumonia

Largely absent from international health agenda Few countries have national SAM policies CTC + Facility based approach

CTC - Definition Community based model for delivering care to

malnourished people

Fast, effective, cost efficient assistance

Manner that empowers affected communities

Creates platform for longer-term

solutions

Main principlesBasic Public Health & Development &

Flexibility Coverage-decentralized

Good access to services

Engagement w/ & participation Local communities & infrastructure

Appropriate levels of intervention Simple protocols & supplies (RUTF local) Commensurate w/ resources

Sectoral integration Smooth transitions btw in-pt and out-pt

Capacity building Local HCP + outreach/case finding, F/U

Timeliness Early intervention to prevent progression

CTC classification of acute malnutrition

Moderate WFH, HFA: -3< SD score <-2 No edema Treated as out-pt

Severe w/out complications WFH, HFA: SD score <-3 Edema Treated as out-pt

Malnutrition w/ complications WFH, HRA: SC score -3 < SC <-2 Moderate or severe acute malnutrition Anorexia Life threatening clinical illness Admitted to in-pt care

In-patient care

↑ risks nosocomial infections Mother separated from family

↑ malnutrition in siblings↓ economic activity, food security household

Expensive Low coverage Overcrowding in-pt facilities

↑ mortality & morbidity

Elements in CTC:Initial Stabilization

In-pt phase of treatment of SAM w/ complications Identify/treat life threatening problems Treat infections, electrolyte, specific micronutrient imbalances Begin feeding

D/C to out-pt therapeutic program (OTP) ASAP appetite returns Major signs infection ↕ Irrespective of wt gain or WFH

Lower Resource allocation priority than out-pt care Once sufficient resources available for good out-pt coverage Good community understanding & participation

Fundamental difference: prioritization of resources 10-15% Stabilization Centers: small, little infrastructure, 1-2 skilled staff

Elements of CTC: Outpatient Therapeutic

Program (OTP) Direct admissions

Severe malnutrition w/out complicationsNo period on in-pt stabilization85% of OTP admissions (coverage)Important difference in CTC

Indirect admissionsMalnutrition w/ complicationsInitial in-pt stabilization in SCTransferred into OTP

Types of treatment for acutely malnourished

children Moderate acute malnutrition Supplementary feeding program w/ take-home rations FBF (micronutrient fortified mix of soya-cereal flour + vegetable oil + salt + sugar

Simple medicines (take at home) Severe acute malnutrition w/out complications

RUTF Simple medicines (take at home) Weekly check-ups + resupply of RUTF

MAM & SAM w/complications In-pt stabilization When appetite + complications controlled → OTP

CTC w/ RUTF Malnourished child > 6 mos age, with appetite

Standard dose of RUTF adjusted to wtConsumed at home, directly from containerMinimal supervision

RUTF supplied q 2-4 wk at distribution site – take home ration$3/kg if locally produced10-14kg or RUTF over 6-8wks

RUTF= Ready to Use Therapeutic Food

Energy dense mineral/vitamin enriched food Peanuts, milk powder, sugar, oil + mineral/vitamin mix Easily consumed by children > 6mo age 23kJ/g (5.5 kcal/g)/ 500kcal/pk (92g) BID x 4-6 wks

Equivalent in formulation to F100 Promotes faster rate recovery from SAM Oil based w/ low water activity

Microbiologically safe (pt w/ HIV, chronically ill) Stores for several months

Eaten uncooked, soft/crushable Ideal for micronutrient delivery (heat labile) ↓ labor, fuel, water demands

RUFT=Therapeutic Food

Local production ↓ cost significantly

Local formulations: no milk/peanuts, but local grains + pulses, sesame oil

Range of protein content

Quality control, aflatoxin contamination

Vehicles for probiotics + prebiotics + antioxidants

Bind CTC w/ food security/agricultural interventions, local income generation + home based care for AIDS

CTC SAM id: CHW or volunteers in community

MUAC < 115Nutritional edemaChildren 6-59 mos

Full assessment following IMCI Referral to in-pt orCTC w/ regular visits to health centre

Early detection + decentralized treatmentprevent progression + complications

Coverage Physical access, Understanding, Acceptance &

Participation Negative impact of poor coverage

Malnourished don’t receive careIn-pt services more visible, more demands

Essential stepsDistribution sites decentralized

○ Balance w/ access, cost, practicalities○ Dialogue w/ local communities served

Negotiation w/ local communities ○ Central to success of CTC○ Their concerns direct local program design

Participation Vital

Local communities & local health infrastructures from the start

May slow down initial implementation Ultimate benefits

↓ local alienation ↓disempowerment↓ undermining community spirit↑program impact↑ potential for successful handover

Protocols & Implementation Core treatments protocols of OTP

Objective: physiological & medical requirementsFixedShort & simple: 3 pagesEasily taught to local HCP in 1 day

Implementation of OTPContext specificFlexibility requiredStaffing, # & location of distribution sitesFrequency of distribution, selection of community

nutrition workersLinks w/ local practitioners, MOH

Rights & Choices

CTC programs: uphold rights of pts w/ SAM to access OTP

CTC programs: ¾ of caregivers of children w/ SAM w/ complications accepted in-pt stabilization

Cost Effectiveness

Core expenditures & economies of scale

TFCFixed capacity model: once center filled, others need to be

builtSmall economies scale: central offices, logistical support

CTCHigh initial & fixed cost: recruit/train/equip transport mobile

teams, decentralize food logistics, interact/mobilize community

Expansion to thousands pts w/ only extra cost of food & medicine

Limitations of CTC Decentralization

Aim: >90% target pop live w/in 1 day t/f walk to site Mobile teams to sites q wk/bi monthly Access: roads, security Pop confidence in mobile teams/RUFT delivery

Low density of malnutrition Low prevalence malnutrition + highly dispersed pop Cost/benefit diminishing returns Fragmented/absent communities (relative)

Can reduce participation, mobilization

Absence of formal health infrastructure (relative)

Networks of HCP, traditional healers

Future Developments of CTC

Approach in areas of high insecurity, urban areas “in situ” CTC w/ CHW ↑community implementation responsibility

Implementation by local MOH/local actors on longer term basis National growth monitoring program integrated into existing health

programs

↑ demand for CTC

New RUTF recipes, lower costs, locally made for supplemental feeding

Evidence

80% of Children w/ SAM who have been identified through active case finding, or through sensitizing & mobilizing communities to access decentralized services themselves, can be treated at home

CFR 4.1% Coverage ↑by 72%

Community based management of SAM. WHO, WFP, UN System Standing Committee on Nutrition, UN Children’s Fund

CTC

Preferred approach for emergency relief programs

Increasingly adopted for larger non emergency programs

WHO: larger-scale implementation