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