Community Based therapeutic care for SAM

1. Global Health Fellowship Nutrition module Community Based therapeutic care for SAM

2. SAM • Defined • WFH < -3z scores • Visible severe wasting • Nutritional edema • 20 M children worldwide • Most in S. Asia + sub-Saharan Africa • 5-20 x higher risk death: directly or indirectly • ↑ CFR in children w/ diarrhea +/or pneumonia • Largely absent from international health agenda • Few countries have national SAM policies • CTC + Facility based approach

3. CTC - Definition • Community based model for delivering care to malnourished people • Fast, effective, cost efficient assistance • Manner that empowers affected communities • Creates platform for longer-term solutions

4. Main principlesBasic Public Health & Development & Flexibility • Coverage-decentralized • Good access to services • Engagement w/ & participation • Local communities & infrastructure • Appropriate levels of intervention • Simple protocols & supplies (RUTF local) • Commensurate w/ resources • Sectoral integration • Smooth transitions btw in-pt and out-pt • Capacity building • Local HCP + outreach/case finding, F/U • Timeliness • Early intervention to prevent progression

5. CTC classification of acute malnutrition • Moderate • WFH, HFA: -3< SD score <-2 • No edema • Treated as out-pt • Severe w/out complications • WFH, HFA: SD score <-3 • Edema • Treated as out-pt • Malnutrition w/ complications • WFH, HRA: SC score -3 < SC <-2 • Moderate or severe acute malnutrition • Anorexia • Life threatening clinical illness • Admitted to in-pt care

6. In-patient care • ↑ risks nosocomial infections • Mother separated from family • ↑ malnutrition in siblings • ↓ economic activity, food security household • Expensive • Low coverage • Overcrowding in-pt facilities • ↑ mortality & morbidity

7. Elements in CTC:Initial Stabilization • In-pt phase of treatment of SAM w/ complications • Identify/treat life threatening problems • Treat infections, electrolyte, specific micronutrient imbalances • Begin feeding • D/C to out-pt therapeutic program (OTP) • ASAP appetite returns • Major signs infection ↕ • Irrespective of wt gain or WFH • Lower Resource allocation priority than out-pt care • Once sufficient resources available for good out-pt coverage • Good community understanding & participation • Fundamental difference: prioritization of resources • 10-15% • Stabilization Centers: small, little infrastructure, 1-2 skilled staff

8. Elements of CTC: Outpatient Therapeutic Program (OTP) • Direct admissions • Severe malnutrition w/out complications • No period on in-pt stabilization • 85% of OTP admissions (coverage) • Important difference in CTC • Indirect admissions • Malnutrition w/ complications • Initial in-pt stabilization in SC • Transferred into OTP

9. Types of treatment for acutely malnourished children • Moderate acute malnutrition • Supplementary feeding program w/ take-home rations • FBF (micronutrient fortified mix of soya-cereal flour + vegetable oil + salt + sugar • Simple medicines (take at home) • Severe acute malnutrition w/out complications • RUTF • Simple medicines (take at home) • Weekly check-ups + resupply of RUTF • MAM & SAM w/complications • In-pt stabilization • When appetite + complications controlled → OTP

10. CTC w/ RUTF • Malnourished child > 6 mos age, with appetite • Standard dose of RUTF adjusted to wt • Consumed at home, directly from container • Minimal supervision • RUTF supplied q 2-4 wk at distribution site – take home ration • $3/kg if locally produced • 10-14kg or RUTF over 6-8wks

12. RUTF= Ready to Use Therapeutic Food • Energy dense mineral/vitamin enriched food • Peanuts, milk powder, sugar, oil + mineral/vitamin mix • Easily consumed by children > 6mo age • 23kJ/g (5.5 kcal/g)/ 500kcal/pk (92g) • BID x 4-6 wks • Equivalent in formulation to F100 • Promotes faster rate recovery from SAM • Oil based w/ low water activity • Microbiologically safe (pt w/ HIV, chronically ill) • Stores for several months • Eaten uncooked, soft/crushable • Ideal for micronutrient delivery (heat labile) • ↓ labor, fuel, water demands

13. RUFT=Therapeutic Food • Local production ↓ cost significantly • Local formulations: no milk/peanuts, but local grains + pulses, sesame oil • Range of protein content • Quality control, aflatoxin contamination • Vehicles for probiotics + prebiotics + antioxidants • Bind CTC w/ food security/agricultural interventions, local income generation + home based care for AIDS

14. CTC • SAM id: CHW or volunteers in community • MUAC < 115 • Nutritional edema • Children 6-59 mos • Full assessment following IMCI • Referral to in-pt or • CTC w/ regular visits to health centre • Early detection + decentralized treatment • prevent progression + complications

15. Coverage • Physical access, Understanding, Acceptance & Participation • Negative impact of poor coverage • Malnourished don’t receive care • In-pt services more visible, more demands • Essential steps • Distribution sites decentralized • Balance w/ access, cost, practicalities • Dialogue w/ local communities served • Negotiation w/ local communities • Central to success of CTC • Their concerns direct local program design

16. ParticipationVital • Local communities & local health infrastructures from the start • May slow down initial implementation • Ultimate benefits • ↓ local alienation • ↓disempowerment • ↓ undermining community spirit • ↑program impact • ↑ potential for successful handover

17. Protocols & Implementation • Core treatments protocols of OTP • Objective: physiological & medical requirements • Fixed • Short & simple: 3 pages • Easily taught to local HCP in 1 day • Implementation of OTP • Context specific • Flexibility required • Staffing, # & location of distribution sites • Frequency of distribution, selection of community nutrition workers • Links w/ local practitioners, MOH

18. Rights & Choices • CTC programs: uphold rights of pts w/ SAM to access OTP • CTC programs: ¾ of caregivers of children w/ SAM w/ complications accepted in-pt stabilization

19. Cost Effectiveness Core expenditures & economies of scale • TFC • Fixed capacity model: once center filled, others need to be built • Small economies scale: central offices, logistical support • CTC • High initial & fixed cost: recruit/train/equip transport mobile teams, decentralize food logistics, interact/mobilize community • Expansion to thousands pts w/ only extra cost of food & medicine

20. Limitations of CTC • Decentralization • Aim: >90% target pop live w/in 1 day t/f walk to site • Mobile teams to sites q wk/bi monthly • Access: roads, security • Pop confidence in mobile teams/RUFT delivery • Low density of malnutrition • Low prevalence malnutrition + highly dispersed pop • Cost/benefit diminishing returns • Fragmented/absent communities(relative) • Can reduce participation, mobilization • Absence of formal health infrastructure (relative) • Networks of HCP, traditional healers

21. Future Developments of CTC • Approach in areas of high insecurity, urban areas • “in situ” CTC w/ CHW • ↑community implementation responsibility • Implementation by local MOH/local actors on longer term basis • National growth monitoring program integrated into existing health programs • ↑ demand for CTC • New RUTF recipes, lower costs, locally made for supplemental feeding

23. Evidence • 80% of Children w/ SAM who have been identified through active case finding, or through sensitizing & mobilizing communities to access decentralized services themselves, can be treated at home • CFR 4.1% • Coverage ↑by 72% • Community based management of SAM. WHO, WFP, UN System Standing Committee on Nutrition, UN Children’s Fund

24. CTC • Preferred approach for emergency relief programs • Increasingly adopted for larger non emergency programs • WHO: larger-scale implementation