Treating Acute Malnutrition Seriously

Treating Acute Malnutrition Seriously Kate Sadler Senior Researcher, FIC Contents 1. Types of malnutrition 2. Global importance of acute malnutrition – Severe Acute Malnutrition (SAM) 3. Inattention paid to SAM – Problems with the clinical model of care 4. New community-based approaches (CTC) – – Public health principles Impact Definition of Severe Acute Malnutrition (SAM)  Weight-for-height <70% or < -3SD of the median NCHS reference values ("wasted")  Bilateral pitting oedema of nutritional origin ("oedematous malnutrition")  Middle Upper Arm Circumference (MUAC) < 110mm in children between 6 – 59 months of age Oedematous Wasted Differences between acute and chronic malnutrition  Different aetiologies  Different diagnostic indicators – Chronic malnutrition/stunting (height for age) – Underweight & stunting (weight for age) – Acute malnutrition/wasting (MUAC or weight for height)  Different treatment approaches – Type of programme  Chronic malnutrition – Preventative, nutritional supplements  Acute malnutrition - Treatment , complete therapeutic diet – Duration of programme  Chronic malnutrition - years  Acute malnutrition – 1-2 months Importance of acute malnutrition Prevalence of SAM Regions┼ Under-5 population 2000 (000's)┼ 106,394 44,478 166,566 159,454 54,809 30,020 50,655 546,471 110,458 707,584 wasting prevalence (% )┼ moderate & severe 10 7 15 4 2 4 9 10 wasting numbers (000's) <-2 z <-3 z scores scores WFH total WFH total 10,639 3,113 24,985 6,378 1,096 1,201 3,192 890 3,331 300 severe 3 2 2 0 1 2 2 Sub-Saharan Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS and Baltic States Industrialized countries Developing countries Least developed countries Total 49,182 11,046 10,929 2,209 60,228 13,139 ┼ UNICEF global database on child malnutrition. UNICEF 2001 (using NCHS reference data) Mortality associated with SAM Regions┼ Under-5 population 2000 (000's)┼ wasting numbers (000's) <-2 z scores WFH total annual mortality numbers < -3 z scores WFH** < -2 z-scores total <-3 z scores between -2 & -3 zWFH total scores WFH * Sub-Saharan Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS and Baltic States Industrialized countries Developing countries Least developed countries Total 106,394 44,478 166,566 159,454 54,809 30,020 50,655 546,471 110,458 707,584 10,639 3,113 24,985 6,378 1,096 1,201 3,192 890 3,331 300 565,768 168,942 1,644,950 484,528 83,273 68,416 - 421,767 117,546 440,201 39,668 1,444,214 291,918 987,535 286,489 2,085,151 484,528 83,273 108,084 4,350,164 963,208 49,182 11,046 60,228 10,929 2,209 13,139 2,905,951 671,290 3,577,241 1,736,132 5,313,373 Lancet 2006; 368, 9551 * Moderate mortality rate = 76/1000/year for children with <80% WFH or -2 z scores (Pelletier DL 1994) ** Severe mortality rate = 132/1000/year for children with MUAC <110 (Pelletier DL 1994) Acute malnutrition has been ignored  Child survival community has not addressed acute malnutrition – Focus on underweight (weight for age) – Recent lancet series on child survival made no mention of acute malnutrition  WHO did not recognise the term “acute” malnutrition  Growth monitoring programs contain no indicator of acute malnutrition  IMCI has no anthropometric indicator – Relies upon clinical signs – shown to be insensitive and non-specific Where and why are 10 million children dying every year? Robert E Black, Saul S Morris, Jennifer Bryce Lancet 2003; 361: 2226–34 Acute malnutrition has been ignored  Child survival community has not addressed acute malnutrition – Focus on underweight (weight for age) – Recent lancet series on child survival made no mention of acute malnutrition  Growth monitoring programs contain no indicator of acute malnutrition  IMCI has no anthropometric indicator – Relies upon clinical signs – shown to be insensitive and non-specific Why has SAM been ignored?  Clinical, medicalised approach with focus on nutritional & medical protocols – 24 hour monitoring; parenteral antibiotics – successful at rehabilitating individuals BUT  hasn’t delivered wide-scale benefits – Low coverage of cases - <10% – High CFRs – 20-30% - same as 1950s  Exclusive inpatient approach “un-doable” – Insufficient bed capacity – Too few skilled staff 1 1. Arch Dis Child 2006; 91(8):706-710 Why has SAM been ignored?  Clinical approach with focus on nutritional & medical protocols hasn’t delivered wide-scale benefits – Low coverage of cases - <10% – High CFRs – 20-30% - same as 1950s  Exclusive inpatient approach “un-doable” – Too few skilled staff – Insufficient bed capacity  Exclusive inpatient approach unpopular with patients – Poor access to centralised services – High costs of 30 day inpatient regime to carers  SAM remains hidden – No indicators for acute malnutrition in GMP Response to these failings  Greater focus on clinical treatment protocols  Updated WHO manual – Training in use of WHO protocols  Proliferation of inpatient protocols – Various national guidelines  Some success: – Ashworth A, Chopra M, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363(9415):1110-1115 The relationship between coverage, cure rate and impact in the treatment of SAM Clinical protocols are now NOT the main factors limiting impact Main factors determining impact are the Public Health considerations –Coverage –Access to care –Early case-finding & treatment –Providing simple quality service within resource constraints COMMUNITY-BASED MANAGEMENT OF SEVERE ACUTE MALNUTRITION A Joint Statement by the WHO, WFP, UN SSCN and UNICEF MAY 2007  “The community-based approach involves timely detection of severe acute malnutrition in the community and provision of treatment for those without medical complications with ready-to-use foods (cut)… at home. If properly combined with a facility-based approach (cut) community-based management of severe acute malnutrition could prevent the deaths of hundreds of thousands of children. “ www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html Acute malnutrition 1. Economic deprivation – Poverty – Poor public health – High work loads (esp. Women) 2. Social exclusion – Clustered in poorest families – Malnourished siblings 3. Re-occurring – Chronic vulnerability 4. Individual pathological changes – Reductive adaptation – Immunosupression Principles behind community-based management (CTC) 1. Intensity of care is appropriate to medical and nutritional needs 2. 3. Maximise early presentation and access Maximise compliance & minimise resource requirements 1. Intensity of care is appropriate to medical and nutritional needs Traditional classification Acute Malnutrition Severe Acute Malnutrition Inpatient care Moderate Acute Malnutrition Outpatient care Severe Acute Malnutrition With Complications Without Complications 1. Bilateral pitting oedema grade 3* (severe oedema) OR 2. MUAC < 110mm AND bilateral pitting oedema grades 1 or 2 (marasmic kwashiorkor) OR 3. MUAC < 125mm OR bilateral pitting oedema grades 1 or 2 AND one of the following: MUAC < 110 mm OR Bilateral pitting oedema grades 1 or 2* AND: Appetite Clinically well Alert Anorexia Lower Respiratory Tract Infection** Severe palmar pallor High fever Severe dehydration Not alert Inpatient Care IMCI/WHO Protocols Outpatient Care OTP Protocols OTP protocols  Extremely simple – Can be implemented by clinic worker after a one day training  Weekly visits to clinic  200Kcal/Kg/day Ready to use therapeutic food (RUTF) Plus initial provision of: – Vitamin A – Amoxycillin – Folic acid – Mebendazole – Measles vaccination: if required – Anti Malarial Ready to Use Therapeutic Food (RUTF)  Oil based paste nutritionally equivalent to WHO F100  Very low water activity so resists bacterial contamination – Lasts for 3-6 months at home un-refrigerated  Local production easy & cheaper – Using local crops  One of a range of Ready to Use Foods (RUF) – RUSF, RUCF, RUHF 2. Design programs to maximise early presentation  Severity at presentation directly related to lead time to presentation – Cases that present early easier to treat – Decentralisation of outpatient units  Invest to develop understanding & participation amongst target population  Decreases barriers to access Dowa district, Malawi NRU Inpatient care CTC access point using HP or clinic 50 kms 2. Design programs to maximise early presentation  Severity of presentation directly related to lead time to presentation – Cases that present early usually much easier to treat  Invest to develop understanding & participation amongst target population Coloured MUAC tape • No numbers – Suitable for use by uneducated people • Facilitates work of community-based case-finders in the non formal health sector => sustainable case finding & referral 3. Design programs to maximise compliance & minimise resource requirements  Early discharge from inpatient facilities – As appetite returns  Reduces resource constraints – Decreases staff and bed demands – Decongests & improves quality of inpatient care – Decrease risk of acquired infection  Decreases costs to mothers and families – Increase compliance & decrease default Impact of Community-based Therapeutic Care Outcome from unselected cases of SAM presenting to emergency CTC programs N recovered default dead 23,511 79% 11% 4% 3.3% transferred & 2.3% non-recovered 78% exclusive outpatient care Average coverage 74% (11 programs) 21 programs implemented in Malawi, Ethiopia Sudan & Niger between 2001 – 2005 Food Nutr Bull 2006; 27(3):S49-S82 , Study Objective  To describe the impact on treatment outcomes of triaging cases of SAM according to this classification: – Treating those without complications exclusively as outpatients & – those with complications initially as inpatients followed by outpatient care. Methods Aug-Dec 2002 Non Triaged N=343 Inpatient Care Aug-Dec 2003 Triaged N=347 Inpatient Care n=234 Outpatient care n=315 Outpatient care n=226 Outpatient care n=113 Primary outcomes by group N Dead Recovered Non responder Defaulted Non-triaged Aug-Dec 02 343 11.2% 71.4% 12.0% 7.6% Triaged Aug-Dec 03 347 6.1% 79.8% 5.5% 9.5% * * * * p < 0.05 Potential confounders Non-triaged Aug-Dec 02 343 26 -2.0 11.1 m 150 yes 31 sev 81 good 226 f 191 no 310 mild 113 poor 117 Triaged Aug-Dec 03 347 25 -1.9 11.9 m 190 yes 26 sev 62 good 241 f 155 no 319 mild 192 poor 106 N Median Age (months) Mean Admission WFH (Z score) Mean Admission MUAC (cm) Sex Maras-Kwash Admission oedema grade Admission appetite * * * * p < 0.05 Multivariate analysis of independent risk factors for recovery Dependant variable Recovered (n=538) Independent Adjusted risk factors 95% CI p value OR (at admission) MUAC ≤ 11cm 0.39 0.23-0.66 < 0.0001 Anorexia 0.61 0.39-0.94 0.03 Independent Dependant Adjusted risk factors 95% CI variable OR (at admission) Recovered Odema +++ 1.06 0.56-1.99 (n=538) WHZ ≤ -3 0.69 0.41-1.18 Triaged 1.36 0.87-2.10 p value 0.86 0.17 0.18 Multivariate analysis of independent risk factors for mortality Dependant variable Dead (n=458) Independent Adjusted risk factors 95% CI OR (at admission) MUAC ≤ 11cm 2.64 1.12-6.21 Odema +++ 2.37 0.98-5.74 p value 0.03 0.06 Anorexia Triaged 1.29 0.52 0.64-2.59 0.26-1.06 0.48 0.07 Conclusions: impact of triage on outcomes Triage does not reduce recovery  Triage may reduce mortality  Reduced mortality could be due to:  – less overcrowding in inpatient units – a reduction in acquired infection – less opportunity costs promoting earlier presentation Conclusions: role of communitybased management  The use of triage to refer cases of SAM with complications to inpatient care and without to outpatient care could help address SAM worldwide and meet the MDG 1 & 4: – Increasing coverage: current inpatient capacity not enough – Improving outcomes Advocacy & clear messages to policy makers The global importance of SAM as a major cause of avoidable mortality must be better communicated  Communicate the fact that high impact, highly cost effective interventions exist to treat SAM  – Need for more cost effectiveness data Acknowledgements  Dr Steve Collins of Valid International for lending slides and title to this presentation.  Concern Worldwide, Ireland Aid and DfID for funding the CTC research and development program.