Severe Acute Malnutrition Strategy
in Oromiya Region, Ethiopia
Case Competition
Group 2
Achieving MDGs for Global Health Summer School
School of Public Health
Fudan University - 2014
Group 2 members
Supervisor: Dr. Jiang Hong (Fudan University)
Name
Institution
Anissa Rizkianti
University of Sydney
Qin Xianjing
Guangxi Medical University
Fang Liang
Central South University
Yang Wei
Fudan University
Xuan Xiuchen
Harbin Medical University
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Outline
• Severe acute malnutrition
– Introduction
– Definition of severe acute malnutrition
– Current situation in Oromiya region
– Prevention strategy
• Project proposal
– Study design
– Objectives
– Sample
– Outcomes
– Intervention
– Budget allocation
• Limitations and challenges
• Recommendations
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SEVERE ACUTE MALNUTRITION
IN OROMIYA, ETHIOPIA
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Oromiya, Ethiopia
• Total population: 28,067,000, with only 14 percent lives in
urban areas (Ethiopia Demography and Health, 2008).
• Economy:
– Major national income: agriculture
• Coffee (50-60% of total exports)
• Crops (cereal, pulses and oil crops)
– Vulnerable to food shortages due to natural disaster (flooding,
droughts)
• Education level:
– Literacy rate: 36% (2004), male > female, female literacy in rural
only 17%
– Education attainment: 66% of females with no education, with less
than 2% completed primary and secondary leve
• Health worker:
– Ratio of health workers: 3 per 10,000
– Ratio of public health workers: <0.5 per 10,000
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Life Expectancy of Ethiopia
Source: World Health Statistics 2009
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Trends of Childhood Mortality in Ethiopia
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Malnutrition among Under-five Children
in Ethiopia
Source: Ethiopia DHS Report, 2011
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Malnutrition
•
•
•
•
Malnutrition is commonly used as an
alternative to under-nutrition but also
refers to over-nutrition.
Malnourished: inadequate calories
and protein for growth and
maintenance or inability to fully utilize
the food due to illness (undernutrition).
Malnourished children are susceptible
to increased risk of infections (diarrhea
and Acute Respiratory Infection)
Anthropometric indicators of nutritional
status by WHO (WHO Child Growth
Standards) :
– Weight-for-age
– Height-for-age
– Weight-for-height
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Severe Acute Malnutrition
• Severe acute
malnutrition “wasting”
is defined as very low
weight for height (below
-3 SD of the median
WHO growth
standards)
Indicator
Measure
Severe wasting
Weight-for-height
< -3 SD
Severe wasting
Mid-upper-arm
circumference (MUAC)
< 110 mm
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Cut-off
Source: WHO Children Growth Standards, 2009
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The Prevalence of Acute Malnutrition
in East Africa Region
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Source: Ethiopia DHS Report, 2011
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Trends of Severe Acute Malnutrition
in Ethiopia
%
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Source: Ethiopia DHS Report, 2000, 2005, 2011
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Conceptual Framework
Causes of Malnutrition in Society
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Source: Unicef, 2009
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Prevention Strategy
Facility-based treatment (F-100)
• Advantages:
– Basic ingredients components
– WHO recommendation
• Disadvantages:
–
–
–
–
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Longer recovery time
Relatively expensive
Cooking required
Water-based food (bacterial
contamination)
• Challenges:
– The dearth of skilled health
workers and health
infrastructure
– Poor accessibility (physical
and economic) to these
facilities
– Opportunity and travel costs
incurred by the mother (or
caregiver) getting to staying at
the health center with her child
(more spending time)
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Prevention Strategy
Community-based treatment (RUTFs)
•
•
Advantages:
– Short time recovery
– Relatively cheap
– No cooking required
– Oil-based food (less bacterial
contamination)
– Fewer communicable illnesses
(through hospital transmission
with other patients)
Disadvantages:
– Patent issue
– Imported ingredients
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Challenges:
– Importing ingredients are not
available locally (particularly
dry skimmed milk and the
mineral–vitamin mix)
– Requires clinic nearby or
community health workers for
monitoring progress, treating
illnesses, and distributing
RUTF
– Limited evidence on the
efficacy
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RUTF
• Ready-to-Use Therapeutic Food (RUTF): homebased therapy for severe child malnutrition or
severe wasting
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• RUTF is a lipid rich
spread paste, contains
of a mixture of
ingredients
Typical Recipe for RUTF
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Project Proposal
RUTF DEVELOPMENT &
COMMUNITY-BASED TREATMENT
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Study Design
•
•
•
•
Study type: Randomized controlled trial
Research questions: Is RUTF more effective and cost-effective strategy to
treat severe acute malnutrition among under-five children in community-based
level compared to F-100?
Study hypothesis:
– Null hypothesis: RUTF is as effective and cost-effective as F-100 in the
treatment of severe acute malnutrition among under-five children in
community-based level
Study population: all under-five children aged 6-59 months suffering from
severe acute malnutrition, living in East Hararghe zone in Oromiya region (the
highest adjusted proportion of severe wasting)
– Inclusion criteria:
• Presence of severe wasting (WHO criteria: weight-for-height Z-score is
less than -3 SD)
• Ability of parents or guardians to provide informed consent
– Exclusion criteria:
• Presence of chronic diseases and not good appetite
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Objectives
• To compare the effectiveness of F-100 and
RUTF as the treatment of severe acute child
malnutrition among under-five children in
community-based level
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Sample
• Sample size is calculated by the sampling method of
comparing proportions for two independent samples.
• From the previous study, % mortality rates for the treatment of
RUTF and F-100 are 3.0% and 5.4%, respectively.1
Assuming 5% two-sided significance level and power of 80%,
we get the sample size of 1,096 for each group. So, total
sample for this study is 2,192 children.
1. Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home-based therapy with ready-to-use
therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled,
clinical eff ectiveness trial. Am J Clin Nutr 2005; 81: 864–70.
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Outcomes
• Primary outcomes:
– Rates of growth (% children with weight-forheight Z-scores >-2 SD)
• Secondary outcomes:
– Mortality (% death rate)
– Rates of normal weight-for-age and heightfor-age (Z-scores >-2 SD)
– Cost of treatment
– Length of recovery time (days)
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Intervention
• Intervention:
– Standard F-100 (control)
– Standard RUTF
• Sample is randomly assigned to each
intervention (n1 = n2 = 1,096) for 8 weeks
follow-up
• Each children who is assessed for
anthropometry and identified by the health
workers as severe acute malnutrition will be
allocated to the treatment
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Case Identification
• Anthropometric screening
for weight-for-height -3
SD (severe acute
malnutrition/wasting) by
the community health
workers
• Children are taken to the
nearest village health
posts to get measured on
weight and height
• Mothers are expected to
have additional transport
cost to the village health
post  incentives
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Budget Allocation
No
Allocation
Quantity
1
F-100 supply
60 days x 1,096 children
2
RUTF supply
10 kg x 1,096 children
3
Health workers training
4
Cost
Total cost
$2/day
$131,520
$3/kg
$32,880
30 health workers x 1 day
$30/person/day
$900
Mothers’ training
2,192 mothers x 1 day
$20/person/day
$43,840
5
Transport incentives for
mothers
2,192 mothers x 1 day-return
$20/person/dayreturn
$43,840
6
Incentives for health
workers
30 health workers x 2,192
children
$10/patient/day
$657,600
7
Incentives for volunteers
(transport)
30 volunteers x 60 days
$20/person/day
$36,000
8
Instruments
(standardized weight
and height scale)
15
$1,500
$22,500
9
Data management (data
collection, analysis)
1 package
$10,000
$10,000
10
Advocacy and media
1 package
$5,000
$5,000
TOTAL
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$984,080
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Next steps….
• Disseminate the results in policy brief
paper to encourage the government and
other stakeholders and persuade potential
industry to locally produce RUTF
• Ask for government support in providing
initial budget, raw ingredients and
technical assistance  building advocacy
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Long-term Development
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Discussion
CHALLENGES &
RECOMMENDATIONS
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Limitation and Challenges
• Study limitation:
– Blinding is not applied
– Conducted only in one area
– Measurement bias
• Challenges:
–
–
–
–
–
–
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Limited numbers of health workers and professionals
Inadequate health facilities
Low coverage of media and health information
Poor transportation system due to geographical condition
Limited funding
Legal ramification issue in RUTF patent and license 
long-term development
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Recommendations
• Community-based therapeutic care  scaled up in both
emergency and non-emergency settings
• Provide appropriate training included in medical, nursing
and primary health-care curricula
• RUTF  widely produced and distributed to decrease
barriers in access, reduce opportunity costs associated
with treatment and encourage compliance by patients
• Provide further study (qualitative) on the response or
perception from local people, government and
community leaders
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