2010 team 1

1. 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

2. 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

3. 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.
3

4. 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
4

5. Location of Intervention
5

6. 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

7. Director
MD/MPH
Medical Officer
CRNP/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
7

8. Preparation
(1-2 mos)
Action
(2 mos)
Follow Up
(2 mos)
Sustainability
(continuous)
Phases of Action
8

9. Phase I – Preparation
 Recruitment
 CHW Training
 Community Assessment
 Promotion Teams
 Local Teams
 Educate Mothers
9

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. PHASE II: Action
16

17. Intervention Flow Chart
1⁰ and 2⁰
Rapid 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

18. At Home Screening
YesMUAC <110 mm
OR
edema
SAM:
2° Screening
No
MUAC
Surveillance
18

19. 2° Screening
SAM
1: Grade 3 pitting edema
OR
2: MUAC <110 & Grade 1/2 edema
OR
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
19

20. – 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
20

21. 21
PHASE III: Follow Up

22. 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

23. Monitoring: Weekly Progress
1) Weight gain: WHO Standards of Weight Gain:
2) Pitting Edema:
-reduction or disappearance
23

24. Monitoring: Screening for
Complications
• For those that are failing to improve,
determine the etiology:
– Inappropriate administration
– Non-compliance
– Underlying Infection
– Missed complication
24

25. 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

26. 26
Phase IV: Sustainability

27. 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

28. 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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29. 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.
29

30. 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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31. $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

32. Benefits
PHASE 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
32

33. Limitations
PHASE I:
• Lack of participation
• Noncompliance to screening
procedures
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
33

34. 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

35. Appendix
35

36. 36

37. 37

38. 38

39. 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 severity
L: avg duration of case until remission or
death
Distribution Weights
Wasting: 0.053
Stunting: 0.002
Develop. Disability: 0.024
Cretinism (Iodine Deficiency): 0.804
Corneal Scar (Vit. A deficiency): 0.277
Severe Iron deficiency anemia : 0.090
Cognitive Impair.: 0.024
WHO & Global Burden of Disease 2004