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Community-Based Therapeutic Care of Severe Acute Malnutrition

in Oromiya Region, Ethiopia

Presented By: Team 1 Adam Scott, Angela Montesanti, Carol Combs, Samuel Gentle, Susie Harvey

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Ethiopia Health Statistics: At a Glance

• Birth Rate: 43.66 births / 1,000 population (#7 highest in the world)• Infant Mortality Rate: 80.8 deaths / 1,000 live births (#18 highest in the world)• Total Fertility Rate: 6.12 children born / woman (#9 highest in the world)

General Information: Oromiya State

• Population: 28 million people• 86.2% population live in rural areas• 95% of energy produced from hydroelectric power• Agriculture = 45% GDP; 85% total employment • “breadbasket of the Horn”• Oromo ethnic group = 32.1% total population of Ethiopia; Oromo language is the 3rd

most common language in Africa• Oromos currently marginalized by national government because of their national

liberation movement called Oromo Liberation Front (OLF)

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Severe Acute Malnutrition

http://www.savethechildren.org.uk/en/9245.htm

Severe Acute Malnutrition (SAM) is an urgent, life-threatening condition characterized by one or several of the following:

Visible severe wasting A Weight-for-height ratio below 3 standard deviations of the median WHO growth

standards A MUAC <110mm Presence of nutritional edema

Children with SAM have a 9.4 fold higher rate of mortality compared to their non-malnourished counterparts.

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Two Approaches

Inpatient Treatment• Hospital care for SAM has a

significantly reduced mortality for children. With treatment including therapeutic diet and care for any co-morbidities

• Limited usefulness due to lack of facilities, man-power and high cost

Community-based Management

• Care for non-complicated cases of SAM in the child’s community/home with the use of RUTFs

• Outcomes comparable to inpatient care

• Drawbacks:– Complicated Cases– Education– Screening

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Location of Intervention

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Arsi Negele• Presence of Medicins Sans Frontieres (Doctors Without Borders)• Lack of NGO involvement compared to similarly affected regions in the

area• High prevalence of severe malnutrition in children• Proximity to the airport• “A recent mass screening in Siraro, Shalla, Arsi Negele, Shashemene and

Adaba in West Arsi zone through Enhanced Outreach Strategy (EOS) by the regional and zonal administration supported by UNICEF has revealed that out of 184,670 children screened, a total of 4,614 children (2.5 per cent) have been identified as severely malnourished. Response is ongoing accordingly.”

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OrganizationalFlow Chart

DirectorMD/MPH

Medical OfficerCRNP/BSN

Recruiter

Community Health Worker

1

Women worker(s)

Community Health Worker 2

Women worker(s)

Community Health Worker 3

Women worker(s)

Community Health Worker 4

Women worker(s)

RUTF Production Manager

Farmers

Finance and Logistics

MBA

Awareness and Public Relations

MPH

Assistant Directors

Preparation(1-2 mos)

Action(2 mos)

Follow Up(2 mos)

Sustainability(continuous)

Phases of Action

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Phase I – Preparation

Recruitment CHW Training

Community Assessment Promotion Teams

Local Teams Educate Mothers

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Recruitment

• Recruitment officer will seek out community health workers currently practicing in urban areas of Ethiopia

• These individuals will be paid a salary and will be housed at our location

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Community Assessment

• During recruitment efforts, the recruitment officer will also be in charge of identifying suitable living arrangements for the CHWs, as well as storage facilities for supplies

• Proper locations for secondary screenings will also be necessary during this time

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CHW Training

• CHWs will be taught about SAM, along with the necessary protocols with which to identify children who have SAM– MUAC < 110mm– Bipedal edema

• In addition, CHWs will be educated on other public health measures such as clean water and sanitation

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Promotion Team

• While recruitment and education initiatives are underway, a promotion team will be enlisted.

• The purpose of this team will be to begin to promote the large-scale secondary screening to come in the following weeks to evaluate children who meet SAM criteria

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Local Teams

• Once adequately trained, CHWs will seek out community leaders and healers to form a local team of screeners and educators

• CHWs will be in charge of educating these locals, predominately women and mothers, to screen for SAM and to educate on public health issues

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Mothers in the Community

• After becoming proficient in methods of detecting and educating, these local teams will disperse into their respective neighborhoods and will begin teaching mothers there utilizing the Hearth Model

• These mothers will then be capable of recognizing SAM and knowing what to do and where to go

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PHASE II: Action

Intervention Flow Chart

1⁰ and 2⁰Rapid screening

Complicated SAM

Referred

Uncomplicated SAM Weekly Supply Weekly

Checkup

Education

Not SAM

Parents at home screening

prevention

education and check for improvement

Not improved within 3 weeks

Referred 17

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At Home Screening

YesMUAC <110 mm OR

edema

SAM:2° Screening

No

MUACSurveillance

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2° ScreeningSAM

1: Grade 3 pitting edemaOR

2: MUAC <110 & Grade 1/2 edemaOR

3: MUAC <110 & one of the following:

• Anorexia• Lower Respiratory

Tract Infection• Severe palmar pallor

• High fever• Severe dehydration

• Not alert

Complicated Non-complicated

1: MUAC < 110

OR

2: MUAC 110 w/ Grade 1/2 edema

AND:• Appetite

• Clinically well• Alert

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– Non-complicated cases:• Weight assessment • Give weekly supply of prophylactic antibiotics, RUTF’s

(purchased from local manufacturers), & food ration for family• Detailed instructional component• Set up weekly follow-up for monitoring

2° Screening

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PHASE III: Follow Up

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Monitoring

• Will consist of 4 procedures:– Weekly recorded measurements– Screening for potential complications– Deferment to MSF for treatment of complicated SAM– Providing the next week’s provisions

• Will occur at all 4 centers in Arsi Nigele 5 days a week (with an estimated child load of 300 children/day)

• If fewer designated days are desired by mothers, we will accommodate them

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Monitoring: Weekly Progress1) Weight gain: WHO Standards of Weight Gain:

2) Pitting Edema:

-reduction or disappearance

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Monitoring: Screening for Complications

• For those that are failing to improve, determine the etiology:– Inappropriate administration– Non-compliance– Underlying Infection– Missed complication

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Reporting and Outcome Evaluation

• Send out weekly progress reports to the Phil and Linda Bates Foundation, as well as local consensus agencies, UN, etc.– Weight changes– Presence and grade of edema– Complication rates

• Outcome evaluation– DALYs– Mortality & morbidity

rates

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Phase IV: Sustainability

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Local RUTF Production

• Use of locally grown crops to produce RUTF• Crop growth will occur concurrently with

purchased RUTF treatment• Additional crops will be grown to fund RUTF

components not immediately available

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Components of RUTF

• Sugar and oil are made locally within the region• Peanuts are made in Addis Ababa • Soy production will soon begin locally via an Indian manufacturer Ruchi Soya ***Due to the high cost of milk, soy products will be substituted

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Local Production• Production specifics will reflect those

outlined in Manary’s article in Food and Nutrition Bulletin

• Quality control will be maintained based on the protocols outlined

Manary. 2006. Local production and provision of ready-to-use therapeutic food (RUTF) spread for the treatment of severe childhood malnutrition. Food and Nutrition Bulletin, vol 27; 3.

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Collaboration Efforts

• Doctors Without Borders:– Referral Clinic(s)

• GAVI government partnerships:– Incentive for families to participate (receive food AND

vaccinations)– Share resource costs

• UNICEF/UN WFP:– Partnership for food distribution to families

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$1.0 million Budget

$200,000Salaries (Director, ADs, CHWs, Local Outreach Workers)

$300,000 Treatment (RUTFs, supplemental medications/therapies, food for families)

$200,000Transportation, Housing, Rent, Medical supplies, MUACs, Other

$300,000Agriculture Sustainability measures (industrial mixers, seeds, etc)

BenefitsPHASE I:

• Location

• Replicable

• Education of women

PHASE II:

• Cost effective

• Save lives

• Community investment

PHASE III:

• Adequate monitoring

• Preventative measures

• Increased compliance

PHASE IV:

• Sustainability

• Decreased incidence of SAM

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LimitationsPHASE I:

• Lack of participation

• Noncompliance to screeningprocedures

PHASE II:

• Opportunity costs to parents referred to clinical facilities

• Underlying complications

PHASE III:

• Accuracy of outcome data

• Long term follow up

PHASE IV:

• RUTF Manufacturing: need to buy vitamin supplements

• Transport costs

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References• World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, 1999.

• RE Black, LH Allen, ZA Bhutta et al. and for the Maternal and Child Undernutrition Study Group, Maternal and child undernutrition: global and regional exposures and health consequences, Lancet 371 (2008), pp. 243–260.

• Bhutta Z, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS, Shekar M, Maternal and Child Undernutrition Study Group: What works? Interventions for maternal and child undernutrition and survival. Lancet 2008, 371:417-440.

• Bahwere P, Binns P, Collins S, Dent N, Guerrero S, Hallam A, Khara T, Lee J, Mollison S, Myatt M, Saboyo M, Sadler K, Walsh A: Community Based Therapeutic Care. A Field Manual. Oxford, Valid International; 2006.

• Prudhon C, Prinzo Z, Briend A, Daelmans B, Mason J. Proceedings of the WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children. Food and Nutrition Bulletin 2006; 27(3):S99-S108.

• Nutrition Working Group, Child Survival Collaborations and Resources Group (CORE), Positive Deviance / Hearth: A Resource Guide for Sustainably Rehabilitating Malnourished Children, Washington, D.C: December 2002.

• Humanitarian Bulletin. UN Office for Coordination of Humanitarian Affairs. 18 May 2009.

• http://www.doctorswithoutborders.org/news/article.cfm?id=2727

• http://www.gavialliance.org/resources/Ethiopia_GAVI_Alliance_country_fact_sheet_June_2008_ENG.pdf

• http://www.unicef.org/infobycountry/files/ETHIOPIA_UNICEF_HAU_12_March_2009.pdf

• World Health Organization. Management of the child with a serious infection or severe malnutrition: Guidelines for care at the first referral level in developing countries. 2000. Accessed February 19, 2010. http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.1.pdf

• Collins, Steve, et Al., (2005). Key issues in the success of community-based management of sever malnutrition. ValidInternational Ltd.

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Appendix

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DALY’s: Disability Adjusted Life Years• Measures overall disease burden• Combines mortality and morbidity into one measurement• DALY = YLL +YLD

– YLL: years of life lost• YLL = N * L N: # deaths L: Standard Life Expectancy • YLD = I * DW * L I: Incidence Cases

DW: Disability Weight ( 0 = perfect health 1 = equivalent to death

-disease severityL: avg duration of case until remission or

death

Distribution Weights

Wasting: 0.053Stunting: 0.002

Develop. Disability: 0.024Cretinism (Iodine Deficiency): 0.804

Corneal Scar (Vit. A deficiency): 0.277Severe Iron deficiency anemia : 0.090

Cognitive Impair.: 0.024WHO & Global Burden of Disease 2004