Community Based therapeutic care for SAM
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Transcript Community Based therapeutic care for SAM
Global Health Fellowship
Nutrition module
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
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
Main principles
Basic 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
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
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
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
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
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
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
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
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
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
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
Participation
Vital
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
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
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
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
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
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
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
CTC
Preferred approach for emergency relief
programs
Increasingly adopted for larger non
emergency programs
WHO: larger-scale implementation