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    Team one case Team one case Presentation Transcript

    • 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 1
    • 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) 2
    • Severe Acute MalnutritionSevere Acute Malnutrition (SAM) is an urgent, life-threatening condition characterizedby 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. 3 http://www.savethechildren.org.uk/en/9245.htm
    • Two ApproachesInpatient Treatment Community-based Management• Hospital care for SAM has a • Care for non-complicated significantly reduced cases of SAM in the child’s mortality for children. With community/home with the treatment including use of RUTFs therapeutic diet and care • Outcomes comparable to for any co-morbidities inpatient care• Limited usefulness due to • Drawbacks: lack of facilities, man-power – Complicated Cases and high cost – Education – Screening 4
    • Location of Intervention 5
    • 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.” 6
    • Director MD/MPH Assistant Directors Finance and Awareness and Medical Officer Logistics Public Relations CRNP/BSN MBA MPH Recruiter Community Community Community Community RUTFHealth Worker Health Worker Health Worker Health Worker Production 1 2 3 4 Manager Women Women Women Women Farmers worker(s) worker(s) worker(s) worker(s) 7
    • Phases of Action Sustainability Follow Up (continuous) Action (2 mos) (2 mos)Preparation(1-2 mos) 8
    • Phase I – Preparation  Recruitment  CHW Training Community Assessment  Promotion Teams  Local Teams  Educate Mothers 9
    • 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 10
    • 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 11
    • 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 12
    • 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 13
    • 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 14
    • 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 15
    • PHASE II: Action 16
    • Education Intervention Flow Chart Complicated Referred 1⁰ and 2⁰ SAMRapid screening Uncomplicated Weekly Weekly Supply SAM Checkup education and check for improvement Not SAM Not improved within 3 weeksParents at home Referred screening prevention 17
    • At Home ScreeningMUAC <110 mm Yes SAM: OR 2 Screening edema No MUAC Surveillance 18
    • 2 Screening Non- Complicated SAM complicated 1: Grade 3 pitting edema OR 1: MUAC < 1102: MUAC <110 & Grade 1/2 edema OR OR 3: MUAC <110 & one of the following: 2: MUAC 110 w/ •Anorexia Grade 1/2 edema •Lower Respiratory AND: Tract Infection •Appetite •Severe palmar pallor •Clinically well •High fever •Alert •Severe dehydration •Not alert 19
    • 2 Screening– 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 20
    • PHASE III: Follow Up 21
    • 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 22
    • Monitoring: Weekly Progress1) Weight gain: WHO Standards of Weight Gain:2) Pitting Edema: -reduction or disappearance 23
    • Monitoring: Screening for Complications• For those that are failing to improve, determine the etiology: – Inappropriate administration – Non-compliance – Underlying Infection – Missed complication 24
    • 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 25
    • Phase IV: Sustainability 26
    • 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 27
    • 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 28
    • 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 outlinedManary. 2006. Local production and provision of ready-to-use therapeutic food (RUTF) spreadfor the treatment of severe childhood malnutrition. Food and Nutrition Bulletin, vol 27; 3. 29
    • 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 30
    • $1.0 million Budget$200,000 Salaries (Director, ADs, CHWs, Local Outreach Workers) $300,000 Treatment (RUTFs, supplemental medications/therapies, food for families) $200,000 Transportation, Housing, Rent, Medical supplies, MUACs, Other $300,000 Agriculture Sustainability measures (industrial mixers, seeds, etc) 31
    • Benefits PHASE I: PHASE II: • Location • Cost effective • Replicable •Save lives•Education of women •Community investment PHASE III: PHASE IV:•Adequate monitoring • Sustainability•Preventative measures • Decreased incidence of SAM• Increased compliance 32
    • Limitations PHASE I: PHASE II: • Lack of participation • Opportunity costs to parents referred to clinical facilities• Noncompliance to screening procedures • Underlying complications PHASE III: PHASE IV: • Accuracy of outcome data • RUTF Manufacturing: need to buy vitamin supplements • Long term follow up • Transport costs 33
    • 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. Valid International Ltd. 34
    • Appendix 35
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    • 38
    • 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 Distribution Weights death -disease severity Wasting: 0.053 L: avg duration of case until remission or Stunting: 0.002 death Develop. Disability: 0.024 Cretinism (Iodine Deficiency): 0.804Corneal Scar (Vit. A deficiency): 0.277Severe Iron deficiency anemia : 0.090 Cognitive Impair.: 0.024 WHO & Global Burden of Disease 2004