Archive for the ‘Community Based Treatment’ Category

Israel warns to destroy Gaza smuggling tunnels

Monday, December 29th, 2008


GAZA, Dec 25, 2008 (Xinhua via COMTEX News Network) — Palestinian witnesses said Thursday that Israeli aircraft had dropped leaflets on southern Gaza Strip, warning to destroy underground smuggling tunnels that extend out to Egypt.

More than 400 tunnels have been dug recently between Rafah city in southern Gaza Strip and Egypt to be used to smuggle fuel and goods into the Israeli-besieged Gaza Strip, according to media reports.

Residents of Rafah said that thousands of leaflets were dropped on their border town in the morning hours, which called on the tunnels owners to shut down their underground passages before having them destroyed after a 48-hour deadline.

Israel imposed a blockade on the Gaza Strip in June 2007 after Islamic Hamas movement seized control of the territory.

Last week, an Egyptian-brokered ceasefire between Hamas and Israel expired and Israel restored restrictions to cargo flow into Gaza after it briefly eased the flow during the six-month ceasefire.

The tunnels are used to smuggle a long list of products, starting from fuel and cooking gas to mobile phones.

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Woman’s Vet Skills Benefit Villages

Monday, December 22nd, 2008

Aminah Ghalib Mofhel has made good use of the veterinary training she received as part of a USAID-funded agricultural support program. The program aims to enhance livestock farming practices that increase production, market opportunities and employment in rural areas.

Organized by USAID in cooperation with the U.S. Army, the training provided skills in basic animal health care, hygiene, and appropriate animal husbandry techniques to 34 women from the five governorates where USAID is working.

Using these skills, Aminah is caring for her family’s fifteen sheep and goats. In addition, she has begun to care for the animals in the surrounding area, earning 2,000 to 3,000 Yemeni rials (about $10 to $15) a month.

She is helping to care for the goats and sheep of fifteen families, each with approximately 20 animals, in the area around the village of Mofrq Al-Sad in Marib Governorate, where she lives. This has led to a general increase in animal health in the area.

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A Young Mother Stands Up for Herself

Monday, December 22nd, 2008

Woman finds in herself the calling to help others overcome social stigma

Thanks to the work of courageous people such as Amira, the women from the Ray of Light program in Jordan have empowered themselves and each other.

“I always had trouble standing up for myself. Now, I understand that I have rights, and I can defend the rights of other women as well”, said Amira, an outreach coordinator for a women’s project in Jordan.

Ten years ago, Amira owned a beauty salon, drove her own car, and helped her husband pay the household bills.

Her life, however, changed in an instant when she was hit by a car. While she was left disabled and was learning to walk again, her husband divorced her. Penniless, she worried how she would support her two young children. Divorced women in Jordanian society are particularly vulnerable, and Amira was desperate to find a means to feed her children.

She became aware of a USAID-supported program called “Bushra” (Ray of Light), which provided her with hope and a future. Amira began working at Bushra as a peer educator to provide HIV/AIDS awareness and behavior change counseling activities for vulnerable women in low-income areas.

In Jordanian society, even the discussion of HIV/AIDS is a cultural taboo. Amira saw that she could help other women through this program. Added to the stigma of divorce, Amira also faced the perception in the community that she spread knowledge about an “immoral disease.”

The challenges did not stop Amira from continuing forward to make a difference in the lives of women whose stories were not much different than her own. Thanks to her energy and enthusiasm, she was soon offered a full-time position as an outreach coordinator.

Amira credits the USAID program with changing her life. She added, “I always had trouble standing up for myself. Now, I understand that I have rights, and I can defend the rights of other women as well. I talk to my friends and their children about HIV/AIDS and how they can protect themselves. I am supporting myself and my children again. I have come a long way

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Iraqi-Kurdish Women Learn to Read

Monday, December 22nd, 2008

U.S. supports literacy program for women and girls, access to books and periodicals

For two years, heavily-armed Ansar al Islam had controlled Biara, an ethnic Kurdish village perched in the hills just below the Iran border. During the control of Al Ansar, women and girls were kept from school and were not allowed to read. U.S. forces drove the terrorist group out - now the woman and girls of the village have an opportunity to attend literacy programs.

A small grant from USAID, working with the Coalition Provisional Authority, funded the Iraqi Kurdish development group that has opened literacy, sewing, hairdressing and other classes in Biara. Women in the village like Fatah are learning to read and have access to books and periodicals.

The group also offers classes at nearby villages in the steep mountains east of Suleimaniyah and north of Halabja where Saddam Hussein unleashed the world’s first nerve gas attack on civilians in 1988, killing 5,000 and injuring thousands more

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Development of Guidelines for Treatment of Children Suffering from Severe Acute Malnutrition

Saturday, December 20th, 2008

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDIAN PEDIATRICS

131 VOLUME 43__FEBRUARY

17, 2006

A. Introduction

In India, as per the National Family Health

Survey-II estimates, the burden of under-three

children with severe acute malnutrition

(SAMN), defined by the weight for height

criteria, is 2.8%. The mortality amongst

children with SAMN is high (typically 20-

30%), and has mostly remained unchanged.

According to the World Health Organization

(WHO) Guidelines, children suffering from

SAMN (weight for height below 3 SD of

NCHS reference population), require management

in hospital. Extrapolating the under-three

years prevalence of SAMN to the current total

population of India of 1100 million, it is

expected that 2.6 million under-five children

will be suffering from SAMN. In India, there

are only 0.9 million total hospital beds.

Admission of all children with SAMN is

thus not operationally feasible, and hence

home-based management is an unavoidable

alternative for a proportion of these subjects.

Preliminary evidence suggests that this

alternative may be acceptable, cost-effective,

and reduce morbidity and mortality.

In spite of a substantial burden, no

guidelines are currently available for effective

home based care and treatment of SAMN

children. A National Workshop was therefore

organized to develop possible guidelines that

can be delivered by a team of Auxiliary Nurse

Midwives (ANMs) of Health Department and

Anganwadi Workers (AWWs) of ICDS

Department for effective home based care and

treatment of children suffering from SAMN.

Deliberations were jointly organized by the

Department of Human Nutrition, All India

Institute of Medical Sciences, New Delhi and

Indian Academy of Pediatrics (Subspecialty

Chapter on Nutrition) from 11th to 13th

November 2005 at New Delhi. The list of

participants is enclosed as Appendix-I.

B. Conclusions and Recommendations

I.

 

Malnutrition and Child Mortality

SAMN is an important contributor

and underlying determinant of under-five

mortality. Strong scientific evidence exists on

synergism between undernutrition and child

mortality due to common childhood morbidities

including diarrhea, acute respiratory

infections, malaria and measles. The risk of

death is 20-60 times higher when severely

malnourished children suffer from any of

these morbidities. Despite improvement in

economy, health sector, literacy, and health

and nutrition indices, the prevalence of SAMN

identified by anthropometry continues to be

National Workshop on

“Development of Guidelines for

Effective Home Based Care and

Treatment of Children Suffering

from Severe Acute Malnutrition”

Correspondence to: Dr. Umesh Kapil, Professor,

Department of Human Nutrition, All India Institute

of Medical Sciences, New Delhi 110 029,

India.

E-mail: umeshkapil@yahoo.com

Writing Committee:

Piyush Gupta

Dheeraj Shah

H.P.S. Sachdev

Umesh Kapil

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132 VOLUME 43__FEBRUARY

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center, children managed at NRC demonstrated

earlier catch-up growth than those

managed at home; however, the differences

narrowed down in long term. Locally made

(pre-packaged) or home-prepared energy

dense foods have been successfully used along

with nutrition and health counseling.

IV.

 

Identification/ Diagnosis of Children

Suffering from SAMN

Considering various desirable attributes

including simplicity, acceptability, cost,

accuracy, reliability, objectivity, age independence,

functional consequences, prediction

(sensitivity, specificity), and minimal modifications

of the available programmatic

criteria, identification of SAMN may be based

on: (

 

 

i) clinical criteria (presence of ‘

visible

severe wasting

 

 

’ or ‘bipedal edema’) or (ii

) mid

upper arm circumference (MUAC) of <11 or

11.5 cm in children between 6-60 months of

age. However, the suggested MUAC cut-offs

are not based on Indian population, and need

validation.

MUAC has predictive ability for mortality

in newborns also. Possible use and cut-offs in

infants <6 months of age needs exploration.

MUAC may not be useful for evaluating

response to rehabilitation therapy for which

serial weight recording is desirable. Severe

malnutrition occurs over a long period, and

hence weight recording as per current practice

in ICDS should be continued.

The anthropometric criterion of “weight

for height” for diagnosis of SAMN was

considered complicated and operationally not

feasible, as it requires use of many tools and

complex calculation. This criterion may create

confusion amongst the health workers and

AWWs.

In spite of the ground realities of ongoing

programs, the most peripheral child health

unacceptably high, especially in under-three

children.

II.

 

Current Strategies for Management of

SAMN Children in India

The current strategies for identification

and management of children with SAMN

through existing health system involving

health functionaries such as AWW and ANM

are inadequate and need standardization.

Integrated Management of Neonatal and

Childhood Illnesses (IMNCI) strategy primarily

identifies SAMN children by subjective

clinical criteria of “

 

 

visible severe

wasting

 

 

” or “bipedal edema

”. For management,

the IMNCI strategy advocates hospital

referral for all SAMN children.

There is a need for formulating and

testing standardized guidelines for domiciliary

management of SAMN children who are

unable to utilize the referral facilities.

III.

 

Experience with Community based

Management of SAMN Children

Review of global experience indicates that

all 4 delivery systems, namely, (

 

 

i

) day-care,

(

 

 

ii) residential nutrition centers, (iii

) health

clinics, and (

 

 

iv

) domiciliary care can be

effective for treatment of SAMN children.

Interventions at the home level are more

economical. Provision of ready to use

therapeutic food (RUTF) for rehabilitation at

home was effective in 5 of 7 studies but its

cost, logistics of procurement and distribution,

and sustainability of supply need to be

carefully considered. Also, RUTF may at best

be regarded as a short-term option for foodinsecure

households.

Indian experience is limited to management

of SAMN children at Nutrition

Rehabilitation Clinic (NRC)/ home following

initial stabilization in the hospital. In one

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worker (AWW, ANMs) should identify

severely malnourished children, and get them

verified by higher level of functionaries

wherever feasible.

Role of family members including

mothers, Traditional Birth Attendants, link

workers in the community (

 

 

Jagat Chachi/Tai,

village adolescents, etc.

 

 

) in identification of

SAMN children needs active exploration.

All available opportunities for identification

of SAMN should be utilized so that

maximum children are covered. All possible

contact opportunities with children should be

exploited including home visits, anganwadis,

immunization outreach sessions, subcenter,

PHC and CHC clinics.

Registered Medical Practitioners (RMPs)

can be important stakeholders and be trained

as a part of community involvement. Formal

linkages between RMPs and government

functionaries can be developed for identification

and referral of SAMN children in the

community.

For urban slums and migratory populations,

a separate strategy based on future

governmental initiatives for identification of

SAMN children should be developed.

V.

 

Categorizing SAMN Children as

“Complicated” or “Uncomplicated” for

Deciding about Home-based

Management

Programmatically, it would be helpful to

categorize SAMN children into “complicated”

and “uncomplicated” cases based on simple

clinical tools.

Uncomplicated cases:

 

 

Children with SAMN

above the age of 6 months should satisfy the

following recommended criteria to be labeled

as “uncomplicated”. Child should be (

 

 

i

) alert,

(

 

 

ii) with preserved appetite, (iii

) clinically

assessed to be well (absence of general danger

signs and severe anemia, cough and difficult/

fast breathing, cold to touch and severe

dehydration), and (

 

 

iv

) living in a conducive

home environment. Home based management

could be feasible, acceptable, and cost

effective option for those children categorized

as “uncomplicated”.

Complicated cases:

 

 

All children below 6

months with SAMN should be presumed to be

“complicated.” Those older than 6 months but

not fulfilling the criteria for uncomplicated

as above should also be considered to be

“complicated”. Institutional care was considered

mandatory for “complicated” cases

because of high risk of mortality in poorly

supervised and ill-equipped settings.

VI.

 

Management of an Uncomplicated

SAMN Child at Home After Screening

Facility based management of SAMN

children, as per current WHO Guidelines

(1999) is the best option. For subjects who

cannot avail this option, alternatives need to be

explored, which include: (

 

 

i

) initial stabilization

at health facility followed by home

based management; (

 

 

ii

) initial assessment at

health facility followed by home based

management; and (

 

 

iii

) community based

evaluation by health workers followed by

home based management.

The ensuing recommendations for home

based care and treatments are primarily based

on expert opinion and African experience as

relevant scientific evidence is lacking in the

Indian setting. These recommendations should

be considered exploratory in nature pending

validation, especially under programmatic

conditions. The recommenda-tions for home

based care may act as a proxy for the

recommended WHO Guidelines on health

facility based management until evidence

indicates otherwise. It is unlikely that a single

system will suit all situations in the country.

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Experience indicates that home management

of SAMN is likely to be successful in

closely monitored conditions with standard

protocols, motivated staff and parents. An

effective home based care and treatment

program should be comprehensive and

simultaneously address nutritional, medical,

social, and economical aspects.

Diet:

 

 

Energy dense therapeutic diets with low

bulk are essential in the initial phase of

management. However, these should be

economical, available, and acceptable. These

diets could be (

 

 

i

) home based (prepared/

modified from the family pot) or (

 

 

ii

) ready to

use therapeutic food (RUTF). Feeding should

be frequent (6 to 8 times per 24 hours), active,

and hygienic. Commercially available international

RUTF may not be suitable

(acceptable, cost effective and sustainable) for

Indian settings.

Multiple micronutrient and mineral

supplementation should be provided orally as

per the WHO guidelines for inpatient management

of SAMN children.

Oral antibiotics (co-trimoxazole or

ampicillin) should be administered for 7 days

at initial enrolment to all SAMN children, if

not received earlier.

Single dose deworming should be given

(as per IMNCI guidelines) to SAMN children

above one year of age.

Hypothermia should be prevented by

maintaining environmental temperature and

covering the child well, particularly during

night.

Child should receive complete immunization

schedule for his age as per National

guidelines.

Children with diarrhea should be

preferably assessed at a higher level of health

care. Low-osmolarity ORS is to be used for

preventing and treating dehydration till

ReSoMal is available.

Imparting health education, improving

household food security, promoting community

participation, motivation and nutritional

counseling should be integral components of

home based care.

There is an urgent need to develop and test

indigenous and economical RUTF. There is

also an urgent need to develop indigenous

single formulations of: (

 

 

i

) multiple micronutrients

and (

 

 

ii

) mineral mix, and make them

commercially available for treatment of

SAMN children.

VII.

 

Reaching the SAMN Children for

Home Based Care through Existing

Health Programs

Broadly, the following programs (health

worker) were identified for convergence of

existing health and nutrition services to the

SAMN child: (

 

 

i) ICDS (AWW); (ii

) RCH II

including IMNCI (ANM); and (

 

 

iii

) National

Rural Health Mission (ASHA).

It was realized that involvement of

Panchayat

 

 

, Health and Rural Development is

essential for long-term solutions. After in

depth discussions endorsing the limitations of

ICDS, it was felt that ICDS is still the best

option available for reaching the SAMN

children.

There is a need to further empower ICDS

worker by giving her full time status or by

increasing their numbers per Anganwadi

Center to allow them to undertake home visits

for counseling of mothers of SAMN children.

VIII.

 

Nutrition Counseling to Mothers of

SAMN Children

Anganwadi worker should provide

nutritional counselling to mother of a SAMN

child. Health workers and doctors should

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135 VOLUME 43__FEBRUARY

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strengthen this counselling. Capacity building

of AWW was considered essential. The Foods

and Nutrition Departments and Medical

Colleges in the states could share this

responsibility.

Nutrition counselling should be primarily

based on IMNCI guidelines. It should promote

home based food. Small, frequent and energy

dense feeds should be promoted.

There should be a uniformity and accuracy

in the messages. Conducive environment

needs to be fostered for counseling. Besides

the primary care giver, counseling also needs

to be done for other decision makers in the

family.

Content of the message needs to be simple,

appealing, logical, short, technically correct,

culturally acceptable, and practical. These

messages need to be backed up by appropriate

services.

IX.

 

Monitoring of SAMN Child by AWW/

ANM after Initiation of Home Based

Treatment

Monitoring of SAMN child - following

enrolment in home based care program - can

be done by anthropometry (weight gain) and/

or clinical parameters (feeding patterns,

appetite, lethargy, loss of edema and danger

signs). Only the health workers should use

anthropometry. The clinical monitoring tools

for follow up of a SAMN should be similar for

mothers and the health workers.

Frequency of follow up visits by the health

worker/AWW should be: (

 

 

i

) first two weeks:

2 contacts / week separated by at least 48

hours; (

 

 

ii) 3-8 weeks: once a week; (iii

) from

8 weeks till 6 months: every 4 weeks (shift

back to weekly follow up if any danger signs

occur again); and (

 

 

iv

) end point: 6 months or

MUAC of 11 cm and more, whichever is

later.

The recommended anthropometric norms

for satisfactory improvement are: (

 

 

i

) no further

weight loss from the baseline in a nonedematous

child: at first follow up visit; and

(

 

 

ii

) weight gain of at least 100 g/week at

subsequent visits, irrespective of age.

Outcome of treatment were defined as

follows:

Non-responder (within first 4 weeks):

 

 

Child

does not lose edema in 4 weeks or does not

start gaining weight in 2 weeks. If the child

develops a danger sign at any time during first

4 weeks, the child should be referred to a

hospital. If no danger sign develops - discuss

with local health provides and decide on future

management;

Relapse (after 4 weeks):

 

 

Edema reappears or

there is no weight gain in two consecutive

visits or the child develops danger signs. The

child should be referred to hospital;

Recovered:

 

 

The child on a follow-up for a

minimum period of 12 weeks is free of edema

for at least 2 weeks, achieves mid upper arm

circumference of 11 cm or more, is gaining

weight regularly, is free of infection, and

immunized for age.

Transferred to health facility:

 

 

Non responders

and relapsed;

Defaulter:

 

 

Not traceable for at least 2 visits

(take the help of

 

 

panchayat

, and local leaders

to trace them); and

Death.

Epilogue

Home-based care for a substantial

proportion of children with SAMN is an

unavoidable alternative and recent experience

has shown that it could be acceptable, effective

and economical. The Workshop deliberations

suggest a need to streamline the home-based

management by strengthening community

 

 

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136 VOLUME 43__FEBRUARY

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based diagnosis, categorization, treatment,

follow-up and timely referral of these children

in order to reduce morbidity and mortality.

These measures need to be integrated into the

existing health set-up with coordination at all

levels of health functionaries. There is an

urgent need to test these recommendations in

pilot operational trials within the existing

health delivery systems.

Appendix-I

List of Workshop Participants

1. Dr. M. K. Bhan,

Ministry of Science & Technology,

New Delhi 110 003.

2. Dr. R.K. Srivastava,

Ministry of Health and Family Welfare,

Nirman Bhavan,

New Delhi.

3. Dr. Meenakshi Datta Ghosh,

Planning Commission,

Government of India,

New Delhi.

4. Mr. Chaman Kumar,

Ministry of Human Resource Development,

New Delhi 110 001.

5. Dr. B.N. Tandon,

House No, 2A Sector 26,

NOIDA 201301, UP.

6. Dr. B.N.S. Walia,

Chandigarh 160 036.

7. Dr. Shanti Ghosh,

Consultant MCH,

New Delhi.

8. Prof. H.P.S. Sachdev,

Maulana Azad Medical College

New Delhi 110 002.

9. Dr. K. N. Aggarwal

NOIDA 201301, Uttar Pradesh.

10. Dr. Panna Choudhury,

Maulana Azad Medical College and

Lok Nayak Hospital,

New Delhi 110 016.

11. Dr. Tarun Gera,

New Delhi 110 009.

12. Dr. N.K. Arora,

AIIMS, New Delhi.

13. Dr. Harish Kumar,

World Health Organisation,

New Delhi 110 011.

14. Dr. Dheeraj Shah,

GTB Hospital, New Delhi 110 095.

15. Dr. Sushma Sharma,

New Delhi 110 057 .

16. Prof. A. P. Dubey,

Maulana Azad Medical College,

New Delhi 110 002.

17. Dr. Nita Bhandari,

Society for Applied Research

New Delhi 110 017.

18. Dr. Shinjini Bhatnagar,

AIIMS, New Delhi.

19. Dr. Usha Kiran,

CARE India,

New Delhi 110 016.

20. Dr. Harish Chellani,

Safderjung Hospital,

New Delhi.

21. Dr. K. C. Bansal,

National Research Centre on Plant

Biotechnology

22. Dr. B. K. Tiwari,

Nirman Bhawan,

New Delhi.

23. Prof. Rakesh Lodha,

AIIMS, New Delhi.

24. Dr. Piyush Gupta,

Dilshad Garden, Delhi-110 095.

25. Dr. A. K. Patwari,

Kalawati Saran Children Hospital

New Delhi.

26 Dr. Deepika Nayar,

CARE India, New Delhi 110016.

27. Dr. Sarmila Mazumder,

New Delhi 110017.

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28. Dr. Kumud Khanna,

Institute of Home Economics,

New Delhi-110016.

29. Dr. (Mrs) Ritu Pradhan Sharma,

Government Home Science College,

Chandigarh.

30. Dr. Archana Sinha,

New Delhi 110 025.

31. Ms. Shashi Prabha Gupta,

Ministry of Human Resource Development,

New Delhi 110 001.

32. Dr. Anchita Patil,

National Consultant (Nutrition)

Jor Bagh, New Delhi 110 003.

33. Dr. Charan Singh,

Rural Health Center,

New Delhi.

34. Dr. Brinda Dube,

Research Associate, SAS,

New Delhi 110 017.

35. Dr. Sunita Taneja,

Research Co-ordinator, SAS,

New Delhi 110 017.

36. Dr. Neelam Bhatnagar,

New Delhi 110 048.

37. Dr. Rajib Dasgupta,

Jawaharlal Nehru University,

New Delhi 110 067.

38. Dr. Praveen Kumar,

Kalawati Saran Children’s Hospital,

New Delhi.

39. Ms. Aashima Garg,

Ghaziabad 201 002,

Uttar Pradesh.

40. Dr. Umesh Kapil,

Human Nutrition Unit,

AIIMS, New Delhi.

41. Dr. Shyam Prakash,

Human Nutrition Unit,

AIIMS, New Delhi.

42. Dr. V. Prakash,

Central Food Technology Research Institute,

Mysore.

43. Prof. Tara Gopaldas,

Tara Consultancy Services,

Bangalore 560 093.

44. Dr. V. K. Srivastava,

King George’s Medical University,

Lucknow.

45. Dr. Rajesh Kumar,

PGIMER School of Public Health,

Chandigarh 160 012.

46. Dr. Sandip Kumar Ray,

Calcutta Medical College,

Kolkata 700 073.

47. Dr. Shally Awasthi,

King George’s Medical University

Lucknow U.P.

48. Dr. Deokinandan,

Department of PSM

S. N. Medical College, Agra, U.P.

49. Dr. Surjit Singh,

PGIMER, Chandigarh 160 012.

50. Dr. N. C. De,

CINI, Kolkata 700 104.

51. Dr. Ashok Dyalchand

Institute of Health Management,

Maharashtra- 431 121.

52. Dr. Prakash V. Kotecha

Government Medical College

Vadodara 390 001.

53. Dr Sheila Aiyer

Medical College

Vadodara 390 001.

54. Dr. Sunder Lal

Haryana.

55. Dr. Subodh S Gupta,

MGIMS,

Sevagram, Wardha,

Maharashtra.

56. Dr. Harivansh Chopra,

L.L.R.M. Medical College,

Meerut.

57. Dr. Sharad D. Iyengar,

Action Research and Training for Health,

Udaipur-313 004.

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58. Dr. Bhavneet Bharti

PGIMER, Chandigarh.

59. Dr. P.K. Kar,

Rourkela 769 002.

60. Dr. Veena Singh

KGMU-JHU Collaborative Projects,

Scientific Convention Center,

Lucknow 226 003, U.P.

61. Dr. Sheel Sharma,

Department of Food Science & Nutrition,

Banasthali Vidyapith 304 022.

62. Dr. Tannaz J. Birdi,

The Foundation for Medical Research,

Worli, Mumbai 400 018.

63. Dr. Nerges F. Mistry,

The Foundation for Medical Research,

Worli, Mumbai 400 018.

64. Dr. Manisha Khale,

Institute of Health Management,

Pachod, Maharashtra 431 121.

65. Dr. Sampa Mitra,

All India Institute of Hygiene & Public Health,

Kolkata.

66. Dr. Samapti Mukhopodhyay,

Department of Pediatircs,

AIIMS, New Delhi.

67. Dr. Harsha Shah,

District Navsari 396 430.

68. Dr. Sharmishtha Patil,

District Navsari 396 430.

69. Dr. Naresh Gite, Director (Monitoring),

Rajmata Jijau Mother-Child Health &

Nutrition Mission, Cidco,

Aurangabad 431 003.

70. Dr. Isaac Rajesh,

Christian Medical College,

Ludhiana 141 008, Punjab.

71. Dr. Daksha Solanki,

SIFPSA, Lucknow 226 012.

72. Dr. Suruchi Katoch,

College of Home Science,

CSKHPKV,

Palampur 176 062.

73. Dr. Sangita Sood,

College of Home Science,

CSKHPKV,

Palampur 176 062.

74. Dr. S. R. Malhotra,

College of Home Science,

CSKHPKV,

Palampur 176 062.

75. Dr. Manjusha Molawane,

Integrated Child Development Services,

Navi Mumabi 400614.

76. Dr. Anjali Dewan,

Shimla 171 002 (H.P.).

77. Dr. Madhu B. Singh,

Desert Medicine Research Center,

Jodhpur 342 005.

78. Dr. Pooja Talikoti,

Jaipur 302 004.

79. Dr. A. Vanlanzawni,

Department of Social Welfare,

Mizoram.

80. Dr. Sadhna Singh,

College of Home Science,

Faizabad, U.P.

81. Dr. Bharati Kulkarni,

National Institute of Nutrition,

Hyderabad 500 007.

82. Mrs. Sarita Chauhan,

College of Home Science,

Faizabad, U.P.

83. Dr. Shashi Jain,

College of Home Science,

Udaipur, Rajasthan 313 001.

84. Dr. Arun T. Dabke,

Pt. J. N. M. Medical College,

Raipur, C.G.

85. Dr. Basanti Baroowa,

Jorhat, Assam.

86. Dr. MMadhurima Chaliha Kalita,

Assam Agricultural University,

Jorhat, Assam.

87. Dr. Arvind Kumar Singh,

L.L.R.M. Medical College,

Meerut, Uttar Pradesh.

RECOMMENDATIONS

INDIAN PEDIATRICS

 

 

139 VOLUME 43__FEBRUARY

17, 2006

88. Dr. Deepika Agrawal,

L.L.R.M. Medical College,

Meerut, Uttar Pradesh.

89. Dr. Anil Kumar Singh,

L.L.R.M. Medical College,

Meerut, Uttar Pradesh.

90. Dr. Manjula Uppal,

S. L. Bawa D.A.V. College,

Punjab.

91. Dr. Arun Aggarwal,

PGIMER,

Chandigarh

92. Dr. Jasvinder K. Sangha,

Punjab Agricultural University,

Ludhiana.

93. Dr. Ravinder Kaur,

Punjab Agricultural University,

Ludhiana.

94. Dr. Anita Kochhar,

Punjab Agricultural University,

Ludhiana.

95. Dr. S. Verma,

Punjab Agricultural University,

Ludhiana,

96. Dr. Chandra Kumar Dolla,

Regional Medical Research Center,

for Tribals,

Jabalpur, Madhya Pradesh.

97. Dr. Ashok Kumar Srivastava,

HIMS, Jolly Grant,

Dehradun.

98. Dr. Jayanti Senwal,

HIMS, Jolly Grant, Dehradun.

99. Prof. Sandhya Madan Mohan,

Department of Home Science,

Hospital Sector, Bhilai.

100. Dr. K. Geeta,

Banasthali, Rajasthan.

101. Dr. Seema Thakur,

Directorate of Social Justice of Empowerment,

Shimla.

102. Dr. Sanjay Chaturvedi,

U CMS, New Delhi 110 095.

103. Dr. Anju Kataria,

Bilaspur, Chhattisgarh 495 001

104. Dr. Ratna Sharma,

Government Medical College,

Guwahati, Assam.

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Changing the way we address severe malnutrition during famine .

Saturday, December 20th, 2008
    This year, yet again, saw widespread food insecurity and famine across the horn of Africa. Again, humanitarian agencies set up operations to implement various relief programmes. Nutritional interventions included general ration distribution to the whole of an affected population; blanket supplementary feeding to all members of an identified risk group; and targeted dry supplementary feeding centres for moderately malnourished and therapeutic feeding centres for the severely malnourished. As is usual in emergencies, many of the therapeutic feeding centres were hard to set up and did not achieve an adequate coverage of all the severely malnourished. This combination of delays and low coverage meant that many therapeutic feeding centres achieved little overall impact on mortality. I believe that the present focus on therapeutic feeding centres as the sole mode of treating severely malnourished people during famine is inappropriate and often counter-productive. A new concept of community-based therapeutic care is necessary to complement therapeutic feeding centres’ interventions if famine relief programmes are to address the plight of the severely malnourished in an efficient and effective manner. During an emergency, the community-based therapeutic care approach could quickly provide good coverage and appropriate treatment for large numbers of severely malnourished people. The principles behind community-based therapeutic care are, however, developmental, empowering communities to cope more effectively with crisis and with transition back to normality. This is very different to the therapeutic feeding centres’ approach that disempowers communities, requires very large amounts of external staff and resources, and undermines the infrastructure. Although emergency community-based therapeutic care programmes could be large-scale and implemented quickly, they could also evolve into developmental Hearth model nutritional programmes without changing their conceptual basis. Conversely, Hearth programmes, although largely sustainable, could in times of crisis quickly scale-up into rapid effective emergency interventions. Creating such a continuum between emergency and developmental approaches has long been a holy grail of humanitarianism.

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The sustainability of Community-based Therapeutic Care

Saturday, December 20th, 2008

 

Valerie Gatchell, Vivienne Forsythe and Paul-Rees Thomas

Concern Worldwide, 52-55 Camden street, Dublin 2, Ireland

Address for correspondence:

Valerie Gatchell -

 

 

valerie.gatchell@concern.net

Concern Worldwide

52-55 Camden street

Dublin 2

Ireland

This paper was written as a Technical Background Paper for an Informal Consultation held in Geneva

(21-23 November 2005) to discuss the community-based management of severe malnutrition. The

meeting was organised by the Department of Child and Adolescent Health and Development and the

Department of Nutrition for Health and Development of the World Health Organization, UNICEF and the

Standing Committee on Nutrition of the United Nations.

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noncommercial distribution- should be addressed to Publications, Marketing and Dissemination, World

Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: + 41 22 791 24 76; fax: + 41

22 791 48 06; email: permission@who.int).

The designations employed and the presentation of the material in this publication do not imply the

expression of any opinion whatsoever on the part of the World Health Organization concerning the legal

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distinguished by initial capital letters.

The World Health Organization does not warrant that the information contained in this publication is

complete and correct and shall not be liable for any damages incurred as a result of its use.

Abstract

Concern Worldwide is an international humanitarian Non Governmental Organisation that piloted and is

now implementing and researching community-based therapeutic care (CTC) approaches to managing

acute malnutrition. Experience in several countries suggests that there are key issues that need to be

addressed at the international, national, regional and community level for the community-based

treatment of acute malnutrition to be sustainable. While in emergency contexts external support for

treatment is often required, ultimately for treatment to be sustainable, services must be integrated into

the existing health service provision and locally available ready-to-use-therapeutic food must be

accessible.

Acknowledgements:

 

 

We would like to acknowledge Concern Worldwide field staff in Ethiopia, Malawi

and South Sudan for their contributions to this work.

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 1

Introduction

Community-based Therapeutic Care (CTC) is a new approach for the management and treatment of

severe acute malnutrition

 

 

1

(SAM). Until 2001, emergency response to high levels of acute malnutrition

was predominantly through Therapeutic Feeding Centres (TFCs). TFCs are large, in-patient centres

where patients are admitted for 21 days or longer. Centres are resource intense and are often very far

from those affected with acute malnutrition. Carers of malnourished children must often travel long

distances to access the services and coverage is low (1). Additionally, congregation of sick and

malnourished children in centres can enhance the spread of infection and increase morbidity and

mortality.

To address some of the challenges of traditional TFCs, Valid International developed the concept of

CTC. CTC is an innovative concept that mobilizes communities and supports local health services to

rapidly and effectively treat those with acute malnutrition in their homes. A typical emergency response

CTC programme is comprised of 4 elements: community mobilization, out-patient therapeutic care

(OTP) for cases of severe acute malnutrition without medical complications, in-patient care for those

with medical complications and supplementary feeding for those with moderate malnutrition to prevent

them from becoming severely malnourished.

Since 2001 evidence on the effectiveness of CTC in emergencies as an approach to the treatment of

severe acute malnutrition has been building through non-governmental organisation (NGO) and

government response in Ethiopia, Malawi, South Sudan, North Sudan, and Niger (2,3).

Concern Worldwide is an international, humanitarian NGO with experience developing and

implementing CTC programmes. Concern is also currently engaged in working directly with national

governments to build their capacity in the community treatment of acute malnutrition and to support the

adaptation of health and nutrition policy to incorporate community-based therapeutic care in several

countries. From Concern’s experience, for the out-patient treatment of severe acute malnutrition to be

sustainable, there are several issues to be addressed.

The purpose of this paper is to detail the evolution of the CTC approach from emergency situations to

different contexts from an NGO perspective, and to discuss key components required for CTC to be

sustainable, based on Concern Worldwide’s experience to date in Malawi, Ethiopia, South Sudan, North

Sudan, Bangladesh and Niger. The paper also highlights key challenges in moving forward sustainable

and effective community-based therapeutic care.

1

 

 

Defined as severe wasting (<70% weight-for-height of < -3 SD of the median NCHS/WHO reference) or oedema or a Mid Upper

Arm Circumference (MUAC) of < 110mm)

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 2

The emergency CTC approach and modifications to different

contexts

Over the past 3 years, the CTC approach to nutritional emergencies has evolved to address the

treatment of SAM in transition contexts (3). CTC programmes in Ethiopia and Malawi was initially an

emergency response to increased levels of acute malnutrition. However, as the overall food security

and nutritional situation improved the caseload decreased and the supplementary feeding component of

the programme was dropped for longer term health interventions while Concern focused on the

integration of the treatment of severe acute malnutrition at the basic health facilities. Therefore, in

transition contexts, Concern’s focus has included out-patient treatment of SAM in combination with

referral services for complicated cases (stabilization services) built on a strong community mobilization,

health education and wider support to strengthening the health system.

Additionally, high levels of severe acute malnutrition have been documented in sub-populations of non

emergency contexts and the need for an effective out-patient approach to the treatment of SAM in such

contexts is now being demanded.

As an example, in “high risk” areas of Bangladesh and Rwanda levels of SAM are concerning. In

congested areas of Saidpur and Parbatipur, Bangladesh, Concern health teams have documented

5.6% SAM (<70% weight-for-height of the NCHS/WHO reference) among children 0-23 months (n=160)

and 1.8% among children 24-59 months (n=274) for an average of 3.2% among all children under 59

months (n=444) (4). Additionally, in Rwanda, the 2005 Demographic and Health Survey found 0.9%

SAM (<-3 Z-scores weight-for-height of the NCHS/WHO reference) nationally among children 0-59

months, though a SAM prevalence of 1.4% was documented in the South region and 2.5% in the Kigali

Ville region (5).

The potential long-term application of a modified CTC approach to treat SAM in transitional and nonemergency

situations has brought to the forefront the sustainability of the CTC services (out-patient

therapeutic care, stabilisation care (SC), and community mobilization and screening).

Sustainability in the context of this paper is defined as strengthening the capacity of the health systems

to function effectively with minimal external input (6). This definition accepts that many Least Developed

Countries (LDCs) will require substantial contribution from external sources for a significant period of

time; but that this should not negate the goal of reducing dependence on external resources and

enabling local capacity to control and be accountable for its own health services and system.

Several challenges exist in sustaining effective community-based therapeutic care services and in

Concern’s experience, there are several requirements to sustain such activities.

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 3

Key requirements for sustainable CTC service provision

Integration of CTC is defined in this paper as incorporating CTC components of out-patient therapeutic

care, in-patient care and community mobilisation and outreach activities into national Primary Health

Care (PHC) systems. Integration of activities while maintaining the quality and effectiveness of services

with minimal external support is vital to sustainability.

Effective integration of CTC activities into the Primary Health Care system requires functioning systems

and associated support at different levels:

1.

 

 

National policy level:

Demonstrated commitment to a clear health policy and strategy to

address out-patient treatment of severe malnutrition

2.

 

 

Regional or district level

: Functional regional or district health system and appropriate capacity

for service provision

3.

 

 

Community level:

Strong community participation and active screening

In many countries, external financial and programming support may still be required at one or all of the

three levels above;

 

 

especially during an emergency.

However, excluding the cost of Ready to Use

Therapeutic Foods (RUTF) and drugs, the CTC approach itself does not bear significant inputs beyond

those targeted for the development and support of health systems. When analysing the cost of CTC

programme it must be recognised that as an intervention to address severe malnutrition, cost per

recovered child may be high but there are several indirect benefits to the PHC system including

capacity building of staff and rehabilitation of health structures that are not accounted for in a specific

CTC cost analysis.

National level

National commitment and policy change.

 

 

Fundamental to sustainable CTC programming is the

commitment by national Ministries of Health (MOH) as well as UN agencies to the methodology,

components and principles of community-based therapeutic care for severe acute malnutrition as

demonstrated by outlined steps to adopt relevant principles and protocols within national policy.

In countries where Concern is implementing or supporting CTC programmes, successful integration of

CTC activities into MOH PHC systems has been variable. Although there has been national level

support for implementation of CTC in a number of countries, the process of national policy change

takes time; however CTC implementation is informing and shaping the national policy debate in a

number of countries.

In Ethiopia, following effective (as determined by standard programme indicators of emergency nutrition

programmes in SPHERE (7)) implementation of CTC by Concern and other NGOs over a number of

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 4

years, 34

 

 

Worreda

level (district level) Health Departments have adopted CTC as best practice for the

treatment of severe acute malnutrition, through the support of 9 NGOs in 2005.

Meanwhile, evidence from CTC programmes has fed into the development of The National Nutrition

Strategy slated for approval in 2006. The strategy recommends the CTC approach to manage severe

acute malnutrition: “Community Based therapeutic feeding shall also be promoted with robust referral,

monitoring and follow-up systems to support it, including inpatient therapeutic care capacity within

government institutions. In this regard the institutional capacities shall be strengthened”.

Transitional governments, without such defined health policy or strategy, such as South Sudan, offer a

different set of challenges though may allow for quicker adoption of CTC protocols at a national level.

Like Ethiopia, in South Sudan, policy and strategy development is being informed by evidence from the

implementation of CTC over the last few years. Several NGOs are working at the national level in South

Sudan to establish assessment and treatment protocols for severe acute malnutrition following CTC

principles and protocols, as well as advocating for their inclusion in Primary Health Care manuals.

A crucial issue in the roll out and sustainability of CTC is the inclusion of management of severe

malnutrition as a core component within the minimum health services package, thus ensuring that staff

training and supply of commodities will be addressed/planned for.

Another key requirement is the need to address health financing policy issues to facilitate access to free

treatment for severe acute malnutrition. Where health care is not free then governments must put in

place strong policies and functional mechanisms that will reliably provide free treatment (medical

consultation, inpatient-care and drugs) for cases presenting with severe acute malnutrition.

Primary Health Care (PHC) system.

 

 

A PHC system encompasses services provided by the Ministry,

NGOs and community structures. For the CTC approach to be sustainable, a PHC system needs to be

in place, with adequate, accessible structures and staffing capacity able to provide basic health

services. It is through these facilities that CTC activities should be provided.

In the majority of emergency contexts ensuring functioning PHC facilities, in which to integrate CTC

services is challenging and often relies heavily on external resources. Implementing CTC in nutrition

emergencies can support and strengthen the PHC structure as opposed to previous emergency

responses which have traditionally focused on establishing parallel structures of service delivery (1).

In Concern experience, the process of integration is facilitated if links to existing PHC nutrition activities

such as Growth Monitoring and Promotion (GMP) Programmes are established in the initial setup

phase. Concern is in the process of linking these services in Malawi and Bangladesh; however there

are challenges, including the introduction of weight-for-height or Mid Upper Arm Circumference (MUAC)

to assess severe acute malnutrition in addition to weight-for-age.

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 5

Additionally, in order to increase coverage of treatment of severe acute malnutrition it is necessary for

other existing child health focussed interventions, such as out patient consultation services and

Integrated Management of Childhood Illness (IMCI) activities to incorporate assessment and treatment

of acute malnutrition. In theory such activities would become routine if incorporated into the Basic

Package of Health Services (BPHS) at a policy level.

Nutrition reporting and monitoring system.

 

 

Consistent and accurate reporting of severe acute

malnutrition would allow for the early detection of a deteriorating nutrition situation and could foster

timely scale-up of activities. However, in order for the primary health care services to be responsive to

changing levels of malnutrition over time, cases of acute malnutrition should be incorporated into

existing health management information system. In contexts where health management information

systems are weak, the need to monitor levels of severe acute malnutrition could be used as a catalyst

for improving reporting systems. In other contexts, reporting formats exist, yet are complicated and

challenging for local health workers and thus a simplified national format could allow for more accurate

and effective reporting. To support this, global reporting formats and protocols, like that of IMCI, need to

include standardized assessment criteria and treatment of acute malnutrition.

Training and capacity building

 

 

. Some NGOs involved in CTC programming are taking a long-term

look at the capacity development of staff in the primary health care facilities to support CTC services.

While this is a step forward, due to the high turnover of facility staff, the likelihood is that there will be a

continual need for training at facility level unless training is more formally institutionalized.

Training of health staff to implement CTC services requires national planning and support. To increase

the institutional knowledge at all levels of health service (facility based staff and extension/outreach

workers), training on the CTC principles, out-patient care and management of complicated acute

malnutrition needs to be incorporated into existing medical and nursing curricula of health training

institutions.

In Ethiopia, Concern and UNICEF are advocating for and supporting the development of training on the

principles and protocols of CTC as well as the management of complicated acute malnutrition in both

the nursing and medical curriculum at national and regional levels. Additionally, in South Sudan

Concern is working with UNICEF and another NGO involved in Primary Health Care to include training

on CTC protocols in the 1 year nursing course. Other countries with experience in CTC and out-patient

care for the management of severe acute malnutrition are not as advanced as Ethiopia and South

Sudan in this regard. It is fundamental to the capacity building of health services to implement

community-based therapeutic care, that these principals, protocols and management issues are

incorporated into health curricula at all levels for integration and sustainability.

Ready-to-Use-Therapeutic-Foods (RUTFs).

 

 

The development of RUTFs has allowed for the

development of out-patient therapeutic care. In emergency programmes, imported, commercially

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 6

produced RUTFs are currently used; however, as the CTC approach is modified to address severe

acute malnutrition in longer-term emergencies, post-emergency contexts, or even developmental

contexts, RUTF needs to be more easily accessible and affordable for the approach to be sustainable.

Local RUTF Production

 

 

. The CTC model promotes the local production of RUTF to increase economic

activity in the area or country of production and to increase access and availability of RUTF through

reducing cost. Among others, local production of spread RUTFs is currently being developed by NGOs

 

 

2

in Malawi, Ethiopia and Bangladesh. Experience in the local development of RUTF has identified

several challenges to the production and distribution of RUTF locally, including sourcing quality

ingredients, licensing, and quality control.

The original spread RUTF recipe contains 5 ingredients: peanut butter, vegetable oil, powdered sugar,

dry skim milk and a mineral vitamin mix (8). RUTF production in Ethiopia has been challenged with

difficulty importing ingredients not available locally, particularly dry skimmed milk and the mineral

vitamin mix, highlighting the need to produce a RUTF from

 

 

locally available

ingredients (2).

Alternative RUTF recipes, nutritionally equivalent to that of the original peanut-based formula, using

only locally or regionally available ingredients are being trialled in Malawi and Ethiopia. Demand for

RUTF in both countries is high so if the trials are successful, the scale-up of production could reduce

costs; though analysis of the most cost effective location of production units within each country is still

to be undertaken.

However, even if local RUTF becomes more accessible, there is still need for international donors to

consider long-term support of the final RUTF product for programming.

Regarding transport, in most countries, the Ministry of Health transports drugs that are listed as

essential on the national drugs list. However, like F-100 and F-75, milk-based diets (9) used in inpatient

treatment of severe acute malnutrition, RUTF is a therapeutic product, and these are not on the

essential drugs lists. Therefore, the MOH is not responsible for RUTF transportation.

Licensing and Quality Assurance

 

 

. The issue of national licensing and approval of local production

needs to be researched in each context of proposed production so that delays and constraints are

avoided. The classification of RUTF as a drug, nutritional supplement or food has implications on

production and transport so it is crucial to establish this as early as possible.

In Ethiopia RUTF is classified as a food and is being produced by a food producer. Currently this is

working sufficiently; however in order to include RUTF on the essential drug list in the future, RUTF has

to be registered as a drug, a process that is detailed and often time consuming. This process has yet to

begin in Ethiopia.

2

 

 

Concern Worldwide in partnership with Valid Nutrition in Ethiopia and Malawi, and the Peanut Butter Project in Malawi

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 7

To facilitate the local production of RUTF, as either a drug or a food, there needs to be a network of

laboratories accredited to test and analyse RUTF as part of a wider quality assurance programme.

Regional level: Functional regional health system and appropriate capacity for

service provision

The overall capacity required for a sustainable CTC programme depends on the scale and the

magnitude of the prevalence of severe malnutrition as well as the existing local capacity in the

country/programme area. To date, CTC has been implemented in emergency situations and currently

these programmes are in the process of integrating CTC activities into the MOH. However the level of

inputs and the type of relationships between the NGO’s and the MOH partners for implementation is

variable, depending on the context, MOH capacity and the pattern of malnutrition.

Integration as a process

 

 

. Speed and ability to integrate a primarily International NGO-led CTC

programme depends on the structure, capacity and level of the Ministry of Health from the outset.

Experience from Malawi, Ethiopia, Niger, Sudan and Bangladesh demonstrates the breadth of

challenges when attempting to integrate CTC activities within different contexts. Key challenges to

integration in different contexts where Concern has been working include:

•

 

 

Lack of basic health services to integrate OTP/SC services into South Sudan.

•

 

 

Due to outbreaks of disease such as malaria and poor coverage of basic health services, the

CTC programmes in Niger were characterised by case-loads in OTP/SC that were much

higher than seen in other countries with nutrition emergencies.

•

 

 

In developmental contexts like Bangladesh with GMP programmes, standard indices for

assessing malnutrition are weight-for-age, not MUAC or weight-for-height for the assessment

of severe acute malnutrition. Height and MUAC are now also being collected in a pilot study in

a small programme area to assess severe acute malnutrition.

A challenge to integration in some of Concern’s CTC programmes has been the short-term funding

mechanisms available from the donor community which constrain the ability of an NGO or government

to build the capacity of the primary health care services to implement CTC services.

Additionally, Concern’s experience in several countries has demonstrated that the inclusion and full

participation of the Ministry of Health right from the outset is crucial to longer term integration,

ownership of the service and national sustainability. In Wollo, Ethiopia, MOH

 

 

worreda

administrative

staff were seconded to Concern for on-the-job training in OTP supervision for 4 weeks, additionally

clinic staff were seconded to Concern’s mobile teams to build their capacity and understanding of

assessment and out-patient treatment activities. In Malawi, clinical nursing staff along with CTC nutrition

staff at facility and regional level were trained in wider CTC concepts. Wider understanding,

conceptually and practically, of CTC programming at all levels of national health services from the onset

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 8

of programming allows for easier integration. However gaining full participation of the range of actors is

often challenging in over-stretched health systems.

Spectrum of inputs and capacity for CTC integration into MOH.

 

 

The composition of external inputs,

both in scale and type, from an NGO partner aiding the implementation of a CTC programme, depends

not only on levels of severe and moderate malnutrition, but also on local capacities to manage and

respond to the situation. Hence two scenarios with comparable prevalence of acute malnutrition could

see two different levels and types of

 

 

external

input.

In addition to the analysis of the context and prevalence of malnutrition, the required level of external

input to implement community-based therapeutic care should be assessed through a comprehensive

and participatory capacity assessment of the health facilities and system. Health capacity assessment

is an essential component within the programme analysis stage in order to analyse the type and scale

of external support required.

The diagram below (Figure 1) demonstrates the spectrum of external inputs required to implement

community-based therapeutic care based on 1) the capacity and structure of the local/regional MOH

PHC system to respond and 2) the magnitude of the situation.

In emergency situations, levels of external inputs are most likely to be high. However, as emergency

levels of malnutrition decline and numbers receiving out-patient care decrease, external support shifts

from logistically heavy hands-on implementation, towards a supervisory role. Supervision is regarded as

stepping back from direct implementation in support of MOH implementation, shifting support to

supervision, monitoring, and periodic training.

The sustainability of Community-based Therapeutic Care (CTC) in non-acute emergency contexts

Gatchell et al. 9

Implementation inputs/activities:

•

 

 

Staff- range of staff at all

levels including programme

staff including coordinator,

manager, nutrition teams,

nurse, logistics (10-20 in

project area)

•

 

 

Training- intensive training for

community volunteers, health

facility staff, nurses, MOH

supervisory staff, etc.

•

 

 

Data collection and analysisroutine

surveys, collection and

entering of OTP data, analysis

of data to inform programme

•

 

 

Monitoring- weekly/2 weekly

monitoring of all activities

•

 

 

Supplies- RUTF, routine

meds, scales and height

boards, possibly structures

•

 

 

Logistics- vehicles, transport

of staff and RUTF to OTP

sites

Supervision inputs/activities

 

 

:

•

 

 

Staff- no implementing

staff, only technical support

and supervisory staff (2-4 in

project area)

•

 

 

Training- refresher training

for community volunteers,

health facility staff, nurses,

as needed, based on

monitoring visits

•

 

 

Data collection and

analysis- routine surveys,

assistance with analysis of

programme data

•

 

 

Monitoring- monthly

monitoring of MOH OTPs

and community activities

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Should the rehabilitation phase of treatment for children with severe malnutrition (marasmus or kwashiorkor) take place within communities or as inpatients?

Saturday, December 20th, 2008

Primary Reviewer:

 

1 Royal Children’s Hospital, Melbourne Australia
2 London School of Hygiene & Tropical Medicine, UK
 

Date posted: 31st March 2006, Updated March 2008

The World Health Organization has produced guidelines for the management of common illnesses in hospitals with limited resources. This series reviews the scientific evidence behind WHO’s recommendations. The WHO guidelines, and more reviews are available at
http://www.who.int/child-adolescent-health/publications/CHILD_HEALTH/PB.htm

This review addresses the question: Should the rehabilitation phase of treatment for children with severe malnutrition (marasmus or kwashiorkor) take place within communities, or as inpatients?

The WHO Pocketbook of Hospital Care for Children defines severe malnutrition as the presence of oedema of both feet, or severe wasting (<70% weight-for-height/length or <-3SDa), or clinical signs of severe malnutrition.  It advises admission of all children with severe malnutrition.  The timing of discharge has to take into account the benefit of further inpatient care versus nosocomial infections, loss of earnings and available community support.  Continued care as an outpatient to complete rehabilitation and prevention of relapse will be required.(Pocketbook chapter 7.4.7, page 184).  In a recent joint statement with the World Food Program, the United Nations and WHO, (‘Community Based Management of Severe Acute Malnutrition’), defines malnutrition as a Mid Upper Arm Circumference of less than 110mm in children aged 6-59 months.  It advises active case finding in the community, admission to hospital of only those children with complications, and community management with ready to use food (RTUF).  This shift has its strongest evidence in the setting of field operations in complex emergencies where lack of resources has made inpatient treatment impractical, and the approach has been adopted in non-emergency settings.

This review intends to present the evidence as to whether the rehabilitation phase for children with severe malnutrition (marasmus or kwashiorkor) should take place within communities, or in settings where children are inpatients.

 

Introduction:

Once severely malnourished children have been treated for acute problems in the stabilization phase of treatment, they require a longer phase of rehabilitation to enable catch up growth.  Treatment in this phase includes frequent intake of energy and nutrient dense food, and education for the mother or carer.  There has been discussion over the last 30 years as to the best setting for rehabilitation.  Inpatient rehabilitation is costly, carries risks of cross infection, and is disruptive to families.  Rehabilitation in ambulatory settings seems economically more sustainable, but the clinical effectiveness of such programs compared with inpatient treatment has not been established. 

The following categories have been used in the past to describe care settings [1], and will be utilised in this review to make clear the interventions employed in different studies.

  1. Inpatient hospital treatment

  2. Residential rehabilitation centres where children live as inpatients. Their mothers or carers accompany them, assist in food preparation, and receive education.

  3. Day stay rehabilitation centres, where children spend 6-8 hours per day and take several meals, for most days each week. Mothers or carers often attend, and education activities occur.

  4. Ambulatory treatment, which may include supplements for home, and education for mothers or carers.

Methodology

The following search strategies were employed:

Cochrane library, ‘nutrition disorder’ AND ‘child’ – no relevant reviews

Pub med database, ‘nutrition disorders AND (hospital OR ambulatory care OR home care services) AND humans AND (infant OR child), and restricting to systematic reviews - 31 articles found, 5 relevant.

Same search using the clinical filters ‘therapy’ and ‘specific’ - 75 articles found, 6 relevant.  Same search using the clinical filters ‘therapy’ and ‘broad’ 472 further articles, and 10 further relevant articles were found.

Pub med database ‘RTUF’ using clinical filters ‘therapy’ and ‘broad’ found 1 further relevant article.

Titles were read to select articles pertaining to malnutrition in developing countries.  The abstracts of these were then read, and articles not dealing with the rehabilitation phase of treatment were excluded.  The remaining relevant articles were retrieved.  If abstracts were not available, the complete article was sourced.  One economic analysis (type 2b), three randomized controlled trials (type 1b), one systematically allocated trial (type 2b), and one large observational study (?type) were identified.

 

Results

One study compared the cost effectiveness of different methods of care delivery for malnourished children in Dhaka, Bangladesh, and reported the clinical data, cost analysis, and follow up in three separate papers [2, 3, 4]. (Type 1b trial, type 2b economic evaluation). 437 children aged 12-60 months were randomised to three treatment options – inpatient nutritional rehabilitation centre, day care facility where they attended 6 days per week, or to domiciliary care in the home after one week of day care treatment, where they received weekly and then fortnightly visits from experienced health workers. Previous studies had indicated home care may be inappropriate for children under 1 year of age. Treatment continued until 80% of National Centre for Health Statistics expected weight for height was achieved. No food supplements were supplied for home. Children were excluded from the study if they had a critical, metabolic or congenital illness, or lived over 10km from the hospital. Children whose parents requested a change of group, who needed more than an initial 7 days of daily care, and children who died, were excluded from analysis – a total of 24% of patients were thus excluded after randomisation. Cost analysis was very detailed, and disaggregated into institution and parent costs. The study found statistically significant differences between the domiciliary, day care and inpatient groups with regard to institution costs (US$29, US$59, US$156, p<0.0001), and between the domiciliary and other groups with regard to time taken to reach 80% of National Centre for Health Statistics expected weight for height (at home 35 days, day care 23 days, inpatient 18 days, p<0.001), rate of oedema loss (at home 19 days, day care 13 days, inpatient 11 days, p<0.001), rate of weight gain (4, 6, 11 g/kg of body weight/day, p<0.001), and cost to parents (at home 6363 taka, day care 2517 taka, inpatient 1552 taka, p<0.0001). There was no difference in mortality rates between the 3 groups (all groups <5%). The conclusion was drawn that the interventions were clinically equal and that there was no detriment to domiciliary group children in taking longer to reach 80% of expected weight for height.  The authors combined institutional and parental costs to calculate that domiciliary care was 1.6 times more cost effective as day care, and 4.1 times more cost effective than inpatient care.  However, it would be clearer to say home care was more cost effective for the health service, but not for the parents.  Most discontinuations occurred in the day care group, and a survey of parents at the end of the study found most preferring the domiciliary care option.  Fortnightly follow up occurred for 12months. 23% of children were lost to follow up, significantly more from inpatient group than the other two.  Follow up revealed high morbidity (mean 7 episodes of diarrhoea for the year), low mortality (2.3%), continued weight gain (mean weight for height 91% National Centre for Health Statistics expected value), and persistent stunting of height.  Except for less cough and fever being reported in the domiciliary care group (p 0.03), there were no differences at follow up between intervention groups.

The authors of one randomised controlled trial aimed to demonstrate the effect of rehabilitation under optimal inpatient conditions.  They studied 81 malnourished children in Jamaica [5], and compared full rehabilitation in hospital (to 95-100% National Centre for Health Statistics weight for length - average stay 40 days), with a short hospital stay followed by ambulatory rehabilitation (average hospital stay 18 days).  Both groups received 6 months of standard community health service care following discharge, with the short stay group also being supplied with a daily high energy supplement at home for three months, and then ceasing rehabilitation regardless of clinical parameters.  Results were expressed as standard deviation units from the National Centre for Health Statistics expected value for age.  Children were followed up every 6 months after discharge from hospital for three years.  Weight for age from the time of discharge from hospital until 2 years of follow-up was greater in the long stay group (mean -2.49, standard error 0.12 at discharge, mean -1.2 standard error 0.2 at two years) than the short stay group (mean -3.38, standard error 0.16 at discharge, mean -1.9 standard error 0.2 at two years).  The short stay group did not achieve the weight for age of the long stay group at any of the follow up points, despite the three months of supplementation. Length for age from 12 months- 3 -until 30 months of follow up was significantly greater in the long-stay group (mean -1.8,standard error 0.2 at 12 months, mean -0.8standard error 0.2 at 30 months) than in the short stay group (mean -2.6, standard error 0.3 at 12months, mean -1.4, standard error 0.2 at 30months).  By the end of 36 months of follow there were no differences between groups, and the weight and height of children in both groups approached that expected in their home community.

Another randomised trial compared rehabilitation in a malnutrition ward of a hospital (the level of care being between that of a hospital and nutritional rehabilitation centre) to rehabilitation in a community program (which was somewhere between a day-care rehabilitation program and ambulatory care) of 100 malnourished children in Niger [6]. Existing programs were used, and therefore reflected care as it was actually delivered in Niger at the time.  The study found no statistically significant difference in mortality or in weight for height between the two groups after 6 months of follow up.  However, the mortality rate in both groups was very high (41%in the hospital group, 33% in the ambulatory rehabilitation group), and the study was presumably underpowered to detect this clinically significant difference of 19.5% between the groups.  Children lost to follow up were not included in the mortality analysis, the actual periods of rehabilitation were short, being about 12 days, and no measure given of when children were deemed to have completed rehabilitation.  The study did find a significant difference in the cost of treatment, with hospital rehabilitation costing 120% more than ambulatory rehabilitation (p<0.001). (Type 2b economic analysis).

 

One study compared hospital rehabilitation with rehabilitation at home using RTUF [7].  1178 children who presented to seven nutrition rehabilitation units (NRU) in Malawi were systematically allocated to receive either standard inpatient therapy (WHO guidelines, with rehabilitation stage commenced in NRU but often completed at home with cereal and legumes), or home therapy with all of the rehabilitation phase of treatment at home using RTUF.  Eligible children had a WFH of >-2 SD, and children with severe oedema, anorexia and systemic infection were excluded.  Weight for height Z score <-2 was more likely to be achieved in the RUTF (79%) than the standard therapy group (46%, p<0.001).  Relapse or death was less likely in the RTUF group compared with the standard therapy group (8.7% compared with 16.7%, p-<0.001).  Lower rates of cough, fever, diarrhea over the first 14 days of treatment were reported in the RTUF group (p<0.001).  The lack of formal randomization, due to poor acceptance of this in the community, necessitated prospective systematic allocation, designed to control for differences in presentation during different seasons.  However, the RTUF group had higher initial weight for height z scores, and the authors postulate that mothers of moderately malnourished children may have only presented when the home RTUF option was being offered by the rehabilitation centres, as this would have been less disruptive to families.

A randomised controlled trial compared the efficacy F-100 with RTUF during the rehabilitation phase in a therapeutic feeding centre in Senegal [8].  Seventy malnourished children (weight for height z score <-2) in Senegal received either F-100 or RTUF ad libitum during the rehabilitation phase of management.  Those in the RTUF group had a greater mean daily energy intake, consuming 808 kJ per kg per day, compared with 573 kJ per kg per day in the F-100 group (p<0.001).  Average weight gain was greater in the RTUF group, who gained 15.6g/kg/day, compared with 10.1g/kg/day in the F-100 group (p<0.001).  The more wasted children had the largest weight gains.  The RTUF group had a shorter duration of rehabilitation of 13.4 days, compared with 17.3 days in the F-100 group (p<0.001).  The study was not blinded due to the differences in appearance of the two food options.

A large observational study of a field operation in Malawi [9] involved nearly 3000 malnourished children treated with RTUF at home via 12 centres with three different staffing models, and reported the outcomes for severely and moderately malnourished children in terms of recovery (85% and 89% respectively), failure (3% and 4% respectively) or death (1% and 2% respectively).  The authors assert that outcomes were acceptable based on comparison with Sphere guidelines and the Prudhon case fatality index, and thus home based therapy with RUTF yields acceptable results, with no differences in outcome with different staffing models.

 

Summary

Full nutritional rehabilitation can occur in an inpatient setting, and in one study the benefits were measured in growth advantage for two years after the intervention (level A evidence).  Compared with inpatient rehabilitation, ambulatory rehabilitation (without food supplied) costs less to the health service but costs more to parents (level B evidence).  Ambulatory rehabilitation took 17 days longer to achieve equivalent growth indices to children treated as in-patients in one study, and did not achieve the same improvements in weight gain and growth measurements after 6 months in another (level A evidence).  Rehabilitation with RTUF in the home setting was more likely to achieve recovery, and had lower rates of relapse, death and infection than rehabilitation partly in hospital and partly at home with local foods (level B evidence).  Children given RTUF as inpatients during the rehabilitation phase consume more energy, gain more weight, and have shorter rehabilitation than those given F-100 (level A evidence).  Large programs of home therapy have been developed, which can achieve large coverage of populations.  In the absence of large randomised trials, the evidence for these being superior to inpatient management remains incomplete.. Current opinion would suggest that a combination of inpatient and outpatient programs should exist, the former for more complicated cases and the latter for improved access to treatment on a larger scale.

 

References

 

     

  1. Bengoa JM. Nutritional rehabilitation. In Beaton GH, Bengoa JM (eds) Nutrition in preventive medicine. Geneva: World Health Organization, 1976; pp. 321-34. 
  2. Khanum S, Ashworth A, Huttly SR Controlled trial of three approaches to the treatment of severe malnutrition. Lancet. 1994 Dec 24-31;344(8939-8940):1728-32. [Medline] 
  3. Ashworth A, Khanum. Cost-effective treatment for severely malnourished children: what is the best approach? Health Policy Plan. 1997 Jun;12(2):115-21. [Medline] 
  4. Khanum S. Ashworth A. Huttly SR. Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study. American Journal of Clinical Nutrition. 67(5):940-5, 1998 May [Medline] 
  5. Heikens GT, Schofield WN, Dawson SM, Waterlow JC. Long-stay versus short-stay hospital treatment of children suffering from severe protein-energy malnutrition. Eur J Clin Nutr. 1994 Dec;48(12):873-82. [Medline]
  6. Chapko MK, Prual A, Gamatie Y, Maazou AA Randomized clinical trial comparing hospital to ambulatory rehabilitation of malnourished children in Niger. J Trop Pediatr. 1994 Aug;40(4):225-30. [Medline]

  7. Ciliberto M, Sandige H, Ndekha M, Ashorn P, Breind A, Cilibeto H, Manary M.  Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children:  a controlled, clinical effectiveness trial.  American Journal of Clinical Nutrition 2005;81 864-70.[Medline]

  8. Diop E, Dossou NI,,Ndour MM, Briend A, Wade S. Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severelymalnourished children: a randomized trial.  Am J Clin Nutr 2003;78:302–7.[Medline]
  9. Linneman Z,  Matilsky D, Ndekha M, Manary M, Maleta K, Manary M  (2007) A large-scale operational study of home-based therapy with ready-to-use therapeutic food in childhood malnutrition in Malawi
    Maternal & Child Nutrition 3 (3) , 206–215 [Medline]

Annette Connelly 1, Secondary Reviewer: Ann Ashworth Hill 2

  

 
 

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Community-Based Treatment of Severely Malnourished Children

Saturday, December 20th, 2008

According to UNICEF, almost a quarter of Haiti’s children suffer from chronic malnutrition, as evidenced by their stunted growth. Our nutrition program meets the immediate needs of severely malnourished children through a nutrition treatment which uses two products called Nourimamba and Nourimil – both produced through our Zanmi Agrikol program – given to children identified in our clinics and by our accompagnateurs, or community health workers. In cooperation with Zanmi Agrikol, PIH and ZL treated nearly 3,464 malnourished children in 2007 across Central Haiti and the Artibonite District, and created opportunities for agricultural training and production for over 100 Haitian farmers and families.  We are also providing meals to over 9,000 children daily through our school lunch program. 

Treating Childhood Malnutrition

Through nine clinics across Central Haiti and the Artibonite District, ZL clinical staff plays a key role in improving the health of our malnourished patients. In addition to patients who arrive at our clinics, our community health workers (whom we call accompagnateurs) also encounter children suffering from malnutrition during home visits in the community. They refer these children and their families to our clinical sites, where children receive medical care and nutritional support until they regain a healthy weight.   

For our most severely malnourished patients, PIH and ZL have been using a therapeutic food treatment program since November 2006, called Nourimanba. Nourimanba, a “Ready to Use Therapeutic Food” (RUTF), is made from a peanut butter base combined with milk powder, vegetable oil, sugar and a specially formulated vitamin mix for malnourished children.  Because of its oil and peanut butter base, Nourimanba has a low water content, which resists bacterial growth and allows it to be safely stored for months.  As it is “ready to use,” no cooking is required, allowing parents to easily feed it to their children at home, eliminating or reducing the amount of time children need to spend in the hospital.  Although used in Africa and Asia, ZL was one of the first organizations in Haiti to begin treating severely malnourished patients with RUTF. Moderately malnourished children are prescribed a food supplement made from a cereal-legume blend made of beans and either rice or corn, called Nourimil. Once severely malnourished children have responded to Nourimamba, they receive Nourimil as a part of their treatment plan. Based on the results of our initial trial in November 2006 (where 30 children at two of our sites saw significant weight gain after just two weeks) in 2007 PIH/ZL scaled up the use of these two foods to eight of our nine sites, which benefited 3,464 malnourished children in 2007. 

Producing Nourimanba and Nourimil

Through a program called Zanmi Agrikol (“Partners in Agriculture”), we produce Nourimanba and Nourimil at our main site in Cange, and when ZL first began using these products for the malnutrition program in late 2006, we purchased all of the necessary ingredients.  The initial success of Nourimanba/Nourimil treatment and our subsequent scale-up has created a unique opportunity for poor farmers: once we saw the effectiveness of the RUTF, we began growing the main ingredients—peanuts, corn, and beans—at a 35 acre production farm that Zanmi Lasante operates at Corporant, located near our main site in Cange. In 2007, 45 Haitian farmers were employed at the production farm in Corporant. Because of the growing need for the ingredients of Nourimanba/Nourimil, in addition to the production farm, PIH/ZL also purchases crops from local farming families. In 2007, PIH/ZL provided the seeds and use of our tractor to 40 local farming families in Corporant.  We then bought the crops they yielded for our Nourimanba/Nourimil production.  

Both Nourimanba and Nourimil are prepared and packaged in our processing center in Cange, where we have employed and trained local men and women in the roasting, mixing, packaging and distribution of these products.  In 2007, we employed 13 local women and 3 local men who produced and packaged 22,280 kilograms of Nourimanba and 87,200 lbs. of Nourimil for use in our clinics.  

Providing Daily School Lunches

An important component of our solution to the short-term consequences of malnutrition among poor Haitians is to offer daily lunches to school-children through our education program. For years, parents in central Haiti have faced a terrible choice. They could send their children to school with empty stomachs, in the hope that they might gain the skills to someday escape poverty. Or they could keep them at home to help produce or secure much-needed food and water for the family to survive. PIH and ZL saw this need, and in 2006 we launched a lunch program at schools near our clinic sites.  

In each of the communities where we provide school lunches, PIH employs local women to prepare the meals from hundreds of giant sacks of rice and beans. The benefits of this program are enormous, and yet the cost is minimal – just 27 cents per child per school day.  Now that parents no longer have to choose between education and food for their children, school attendance has increased significantly, and so have the attention spans and classroom performance of the children once they get to school. In 2007, 9,315 children and 266 teachers received daily school lunches free of charge through the program, as we increased our reach to include 27 schools, up from the 21 schools we served in 2006. 

It costs only $125 to treat a severely malnourished child with Nourimanba, only $60 to supplement a moderately malnourished child with Nourimil, and a mere $49 to provide a child with an entire school year’s worth of daily lunches. Currently, PIH and ZL are able to use these immediate interventions to meet the combined needs of approximately 12,800 children.

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Factors affecting uptake of Community-Based Therapeutic Care (CTC) In Nsanje

Saturday, December 20th, 2008

N Kabwazi 1, A Nkoroi2
1. Independent Consultant
2. CTC Programme Manager (Nsanje) –Concern Worldwide.

Objective
To identify and investigate factors affecting uptake of CTC in Nsanje district, further bring out an understanding of cultural practices in relation to malnutrition, community perception and treatment of malnutrition.

Methods
The study used the following qualitative methods: focus group discussions, in-depth individual interviews, body mapping activities, and time-activity profiles.

Results
Women in Nsanje have very little control over resources and decision making processes relating to their and their children’s health. This was found to be a major factor as it influenced child welfare in terms of what they ate, quantity and nutritional quality. The family finances impacts on children’s wellbeing. If father had enough money, he was able to buy “good1” foods. Some cultural beliefs such as dzwade2, delayed access to treatment of malnutrition as most community respondents believed that the child was sick/ malnourished because the parents had not followed cultural taboos regarding child rearing. Community leaders are instrumental in ensuring that children are properly looked after and, socialised to become useful members of their communities. They also work together with other government and non-government agencies to ensure that the people of the communities are healthy.

Recommendations
Community stakeholders such as traditional healers and religious groups need to be involved in all stages of the programme. More and appropriate Information Education Communication (IEC) materials should be developed and used at community level. Use of other innovate approaches at community level to inform/educate community on issues relating to gender, health and nutrition. There is also need to conduct more regular community review workshops so that programme progress is monitored.

  1. “Good” foods are those foods with high nutritional value such as eggs, meats, and fruits.
  2. Dzwade are set of social taboos that parents or all members of the family must follow when a baby is born in the family.

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