Community-based Approaches to Managing Severe Malnutrition

A three day meeting was held in Dublin hosted by Concern and Valid International between 8-10th of October, 2003 on community-based treatment¹ of the severely malnourished.

The objectives of the meeting were

• To compare lessons learnt after 3 years of experience of Community based1 Therapeutic Care (CTC).
• To describe substantive differences in protocol for noncentre based treatment of severe malnutrition between agencies.
• Focus on gaps in our knowledge of non- centre based treatment of severe malnutrition.
• Clear up misconceptions about CTC.

Day 1

Community based Therapeutic Care (CTC)

Steve Collins from Valid International began the meeting by describing a 'typical' CTC programme and explained the underlying principles and strategies.

The main principles of CTC are high coverage and good access, timeliness, sectoral integration, and capacity building.

A CTC programme comprised the following elements:

• Supplementary feeding programme (SFP)
• Stabilisation phase. This is the initial phase of treatment of severe malnutrition for children with complications.Here, life-threatening problems are identified and treated, specific deficiencies are corrected, metabolic abnormalties are reversed and Ready to Use Therapeutic Foods (RUTF) introduced.This is an inpatient phase and takes place in a stabilisation centre (SC), which may be located in a hospital or clnic.
• Outpatient Therapeutic programme (OTP). This provides specialised ready to use foods (RUTF) and simple medical protocols to severely malnourished children through existing health infrastructure.
• Community mobilisation. This component identifies traditional leaders, healers and other people within the community to maximise participation and engagement in the programme, leading to increased impact. Later, the programme identifies community resources, and works with community to develop other interventions, mother to mother mobilisations and follow-up case finding, etc.

Evolution of CTC

It is envisaged that a CTC programme will originate as an OTP attached to an SFP. This set-up may then evolve into a CTC. Initially, severely malnourished children will receive RUTF, and medicines will be administered following simple protocols. At this early stage, the critical strategy is to increase the impact of the programme by maximising coverage. An OTP attached to SFP can be established in days. This phase is followed by greater community mobilisation to increase the population's engagement, and development of stabilisation centres to improve individual care for very sick and malnourished children. The final phase in evolving to a 'full' CTC programme will involve improved follow up support to malnourished cases and active case finding. Efforts will also be made to embed the programme in food security and other sectoral programmes such as water and sanitation and health, as well as assisting in the development of local production of RUTF where appropriate.

New classification of malnutrition

The use of the CTC model of treatment of severe malnutrition may lead to a change in how we classify malnutrition, and a new classification and treatment schedule was suggested by Collins (see figure 1).

Notes on the classification:

1. When reviewing the meeting proceedings, several participants pointed out that the classification of malnutrition presented above does not match the WHO-IMCI protocol². WHO-IMCI does not have a protocol for the category of complicated moderate malnutrition (<80% weightfor- height). WHO-IMCI deals with children with a serious infection (all need treatment, regardless of their malnutrition status) and children with 'severe' malnutrition. WHO-IMCI takes the view that there is no need to stabilise children with moderate malnutrition, even if they have an infection. There is a need for agencies to discuss this classification with WHO further.
2. This classification does not take into account the different grades of oedema. Some agencies have treated children with grade I oedema (and no other medical complications) as having 'uncomplicated' malnutrition and children with grade II and III as having 'complicated' malnutrition. However, other agencies have also treated grade II oedema (and no other medical complications) as 'uncomplicated'. Further research is needed on this topic.

Field presentations on CTC and communitybased feeding

Presentations were made on eight programmes (Malawi³, Ethiopia , north Sudan⁴, south Sudan, Afghanistan⁵, Niger , and two randomised clinical trials (Senegal and Sierra Leone) employing non-centre based feeding as part of a protocol to treat severe malnutrition. There was considerable variation in both the context of the programmes and the protocols applied.

The protocols ranged from a compulsory stay in a stabilisation centre or traditional therapeutic feeding centre or hospital for all severely malnourished children, to no inpatient care at all. Most of the programmes, although not all, were attached to an SFP. Coverage rates varied from 19% to 70%. Defaulter rates were also very variable. However, the programmes all had at least two components in common.

First, when in-patient care was provided (either in stabilisation centres, hospitals or traditional TFCs) all programmes followed the WHO phase I protocol, with a few minor modifications according to national or agency protocols. Secondly, a RUTF - normally Plumpy'nut, or a locally produced equivalent - was provided during the non-centre based feeding phase of the protocol.

Analysis of the presentations and discussion of programme and clinical trial data found that during home-based treatment of this category of children:

• Mortality rates remained low (below SPHERE standards in all of the programmes).
• Rates of weight gains were generally not a high as in standard TFCs, but this was not considered to be a critical problem because once children are at home the risk of cross-infection is reduced.
• RTUF was acceptable to all the beneficiaries, though those who were most sick preferred milk-based formula.
• HIV+ beneficiaries can also recover, although their rates of weight gain were lower than other beneficiaries.

There was general agreement in the meeting that severely malnourished children with no medical complications, no oedema and an appetite could be safely treated for severe malnutrition in their homes using a non-centre based approach in phase II of the treatment of severe malnutrition. However, severely malnourished children with medical complications, or severe kwashiorkor cases (oedema grade III) or children with no appetite are best treated in an inpatient facility following standard WHO protocols for phase I until they have been stabilised.

Coverage was increased using a non-centre based approach because beneficiaries had to travel less distance to obtain treatment, and the treatment was less disruptive to their every-day life. Also, the approach is more likely to employ active case finding than traditional TFC models where large distances preclude such activities.

Based on the presentations there was no clear agreement on whether an initial phase of inpatient treatment was necessary in the treatment of severe (very low weight for height - <-3 z-scores or <70% median) and/or oedematous but uncomplicated malnutrition. There was also no agreement on the management of infants under 12 months, Presented protocols for this agegroup varied enormously, or those under 1 year were excluded from the interventions described. Anumber of points emerged in discussion following the presentations:

Flexibility

It was generally agreed that non-centre based treatment was another 'tool' to add to the box of implementation strategies to deal with severe malnutrition.

Sustainability of CTC programmes

CTC programme experience is still limited so that lessons regarding hand-over to the Ministry of Health (MoH) are still being learnt.

Cost-effectiveness

Better information on costs for both TFCs and CTC is required. This information is particularly important for Governments and donors.

Sectoral integration

The food security situation will affect non-centre based programmes' outcomes. Dependence on an existing SFP for rapid start-up of a CTC or home treatment programme raises questions about use of these approaches in situations where SFPs are absent.

Breastfeeding

There is no information to explain what will be the impact on breastfeeding, of giving RUTFs to infants and children who are currently being breastfed. This subject needs further research.

Day 2

Cultural and ethical considerations of CTC and home based approaches

The introduction by Johan Pottier stressed the importance, or primacy, of engagement with communities. When there is a good engagement with local communities, there is a better chance of programmes achieving good impact and results.

Following this, presentations on the cultural and ethical aspects of non-centre based treatment were made on the basis of studies in Malawi and Sierra Leone.

Use of anthropology to improve coverage of a CTC programme in Malawi

In the early stages of the Malawi CTC programme, rates of admission into the programme were lower than expected. Anthropological work, using structured interview and observations, were undertaken over a three week period to better understand the reasons for this. Two main reasons emerged from the study.

Firstly, mothers were unhappy with both the process and outcome of the project screening phase. They communicated this discontent back to other mothers who were therefore reluctant to attend the screenings. The discontent was mainly due to:

• Over-crowding and long hours waiting in the heat at the screenings.
• Anxiety about transfers to stabilisation centres (mothers' experience of stabilisation centres were influenced by earlier programmes which involved long stays in TFCs).
• The vast majority of people who had come to the screening were turned away. This was further complicated by the fact that routine growth monitoring was on-going in the area and many children who were low weight-for-age (and diagnosed as malnourished by the MoH staff) but not low weight-for-height (and therefore not eligible for the CTC programme) had expected to enter the programme but were in fact not admitted.

Secondly, a rich variety of ideas existed in the community related to causes of swelling and wasting. These are not encompassed by translation of the term "malnutrition". The community believed in a strong moral element in causation of 'swelling'. Moreover, many 'swollen' children probably were seeing a traditional practitioner before visiting the MoH or CTC project for assistance. The anthropological work suggested several ways to improve the situation. To begin with, the principles of screening and what the programme was actually looking for - thin and sick children - should be more clearly explained directly to the local leaders as well as the local growth monitoring staff. These measures were taken so that the local leaders were then able to pass on the message to potential beneficiaries. In addition, women were given some compensation for attending a screening even if their child was not admitted. The project also needed to explain the definition and causes of malnutrition, and refer specifically to local names of diseases of wasting and swelling. The project needed to try and enroll traditional practitioners as allies as they were probably seeing the malnourished children first - if the project could encourage the traditional practitioners to send the children to the OTP, it would increase coverage and access to treatment.

Anthropological studies looking at the acceptability of non-centre based treatment compared to traditional TFC models (Sierra Leone⁶ and Malawi)

The respective studies found that non-centre based treatments had the following advantages over traditional TFC approaches:

• There was less disruption to home life.
• Carers are able to fulfil their social responsibilities.
• Improved access.
• Carers felt a sense of empowerment because they were trusted to look after their own child and could make their child better.
• Non-centre based programmes tap into the community ethos of looking after each other.
• The need for a woman to make an important decision about whether or not to treat one child in a TFC and leave others behind has been reduced
• CTC makes use of, and influences, existing networks.

Discussions around these presentations raised a number of issues. First, the appropriateness of using local leaders to mobilise the community for nutrition programmes. Malnutrition is often associated with political and/or social exclusion. If this is so, local leaders may not always be the best people to help locate malnourished children.

The influence of social cohesion in communities was another key topic of discussion. High rates of severe malnutrition are often associated with, or caused by, population displacement. Displacement may lead to decreased social cohesion. It was queried whether the CTC model works in these circumstances. There was a recognised need in the meeting for guidelines or a decisionmaking tree to help planners assess most appropriate programme type for treatment of severe malnutrition in any given context.

Participants also considered what are the ethics of piloting new programmes such as CTC, when there are already reasonably efficacious models to treat severe malnutrition (standard TFCs)? International guidelines (Helsinki) give provision for this if efficacy improves, or cost decreases so that access will improve. CTC qualifies for this. However it is important to balance the risk of denying many people a new therapy against the risk of undermining a treatment that works.

The afternoon session was led by a number of presentations on Ready to Use Therapeutic Foods (RUTF).

Summary of Plumpy'nut (Andre Briend)

Plumpy'nut is the name given to the spread manufactured by Nutriset with almost identical ingredients to F100. The only difference is a 33% reduction in sodium and a reduction in sugar, with increased maltodextrin and whey powder (to ensure low osmolarity).

The advantages of Plumpy'nut are that:

• It has a straightforward production technology.
• It has a low surface area to volume ratio. This means a reduced exposure to oxygen and longer shelf life compared to high energy milks.
• A spread can be eaten without water. Bacteria need water to grow so that more bacteria grow in liquid F100 than in Plumpy'nut.
• Its osmolarity is very low. Plumpy'nut has a slower gastric emptying time than F100.
• Tests in Tchad and Senegal have shown that Plumpy'nut is very well accepted.

Local Production of RUTF in Malawi and Ethiopia (Peter Fellows)

Local production of RUTF has started in Malawi. Generally, the RUTF supply has been satisfactory after an initial settling down period, when routine Quality Assurance (QA) detected an increase in aflatoxin levels on one occasion. It was agreed that the factory would undertake a 100% inspection of peanuts to prevent recurrence. Also, there were some problems with the Sales/Accounts Department with incorrect charging and wrong quantities delivered. A future aim is to link groundnut supplies to the Concern Agricultural Extension programme.

Village level production has started in Nambuma. Set-up was very easy. However, the ingredients are still all produced in Lilongwe. This will be a problem for any village based production because QA testing cannot be done at this level. It will be necessary to determine whether or not it is cheaper to produce the RUTF centrally and then distribute it, or whether bringing the ingredients to the village and making up the product there is more cost-effective.

Valid International is looking at production of RUTF in Ethiopia.

Development of alternative RUTF formulations (Jeya Henry)

There are a number of issues around the local production of RUTF.

• Peanuts are highly susceptible to myctxins, and a fairly sophisticated technology is required to test for mycotoxins.
• In African countries, allergies to peanuts are relatively rare, but in other countries, e.g. Latin America and Asia, rates of allergies may be higher. Moreover, there are also issues of taboos around peanuts.
• There is a large variation in linoleic acid con tent in peanuts (13-43%).
• Milk powder still remains a relatively expensive commodity.

Hence there is a need to develop other formulations of RUTF. Work is on-going at Oxford Brookes University to develop alternative formulations and good headway has been made in achieving this.

Discussion about the RUTF presentations focused on a number of areas:

Cost-effectiveness for production at village level.

Participants felt it would be useful to have a breakdown of costs of different components of RUTF production (ingredients/labour etc) to assess whether or not it will be cost-effective to produce at village level.

Genetically modified (GM) foods.

GM foods are a big issue in Southern Africa, for example in Zambia. When designing new RUTFs there is a need to consider what products to use and ensure that they are acceptable to the community.

The need to change the mineral mix used in production of new RUTFs.

It was pointed out that calcium and phosphorous were left out in the design of the original mineral and vitamin mix⁷ because they were contained in the milk powder. There is a need for a different vitamin/mineral mix if excluding milk from a new RUTF.

The need to consider anti-nutrients in complementary infant foods.

An unpublished study measured anti-nutrients in approximately 130 situations where complementary infant foods were used in relief operations. High levels of anti-nutrients were found in many cases. However, anti-nutrients are not routinely tested in any relief programme. A need to set up quality control measures for antinutrients for infant feeding was identified, which the Oxford Brookes group offered to look into.

Day 3

Working group meetings

Six working groups were asked to review and vote on a series of proposals related to different aspects of non-centre based treatment of severe malnutrition⁸. The idea behind this was to air contentious issues, determine where there was consensus, and produce a snapshot of the views of participants on some of the more contentious recommendations which have been put forward as CTC programmes have developed.

This process was difficult for a number of reasons. Many participants attending the conference work for agencies, and agencies need to discuss their strategies internally. Many individuals felt that they could not support a given statement without discussion within their agency first. The individuals who took part in the conference have had very different experiences with non-centre based treatment of severe malnutrition.

All the working groups were given different statements. As any individual could only be in one working group, it was not possible for people to vote on all the statements. This was particularly problematic for the agencies from which only one or two individuals attended the meeting. It was also difficult for the reporters to accurately gauge the amount of consensus and disagreement for each statement within a working group, and thus claim that any one statement had been endorsed or even agreed by the group.

However, in spite of this difficult process and the general level of dissatisfaction with the process, each working group did make presentations to the plenary indicating which statements were accepted, rejected or modified⁹.

Donor presentations

The chairperson noted that donors' interest in the CTC / home based treatment model of managing severe malnutrition was reflected by the large number of both bilateral and multi-lateral donor agencies present at the meeting. The development of CTC projects in the field has been supported through operational research grants from FANTA(Food and Nutrition Technical Assistance) and the Development Cooperation of Ireland (DCI). The Office of US Foreign Disaster Assistance (OFDA) and European Commission Humanitarian Office (ECHO) have both provided funding for the implementation of CTC and home based projects.

The speakers were all supportive of the development of non-centre based feeding programmes to treat severe malnutrition. They expressed the hope that the approach could both improve the flexibility of emergency responses to severe malnutrition and increase coverage of current programmes. Several of the speakers stressed that they did not see the future of therapeutic feeding as either the TFC model or the CTC model. Instead, they viewed the development of homebased approaches as a way to expand choices/tools to alleviate malnutrition. The choice of which tool to use will be context specific.

Several other common themes emerged in the donors' presentations including funding/cost issues, the emergency/development continuum, treating malnutrition at an earlier stage, and the relationship between HIV/AIDS and malnutrition.

Funding/cost issues

Most of the US Agency for International Development's (USAID) budget for nutrition programmes is tied to food aid through the PL480 legislation. This could be problematic if largescale Plumpy'nut programmes are implemented because the legislation requires use of foods produced in the US. However, it may be possible to get around this by using US manufacturers to produce Plumpy'nut.

According to ECHO's calculations, the food costs for a CTC programme are in the same range as the food costs for a TFC (approximately 25-28 euro/child/month).

Treating malnutrition at an earlier stageA potential benefit of CTC programmes is that they offer the chance to treat malnutrition earlier in the community and 'address risk higher up the ladder'. However, if the programmes are only linked to emergency SFP programmes, then this benefit may be lost as guidelines for emergency SFP only advise their establishment when high levels of wasting are recorded.

HIV/AIDS and its relationship with severe malnutrition

Several of the donors noted that the HIV/AIDS epidemic will have important consequences in terms of how severe malnutrition is treated in the future. HIV/AIDS will result in more severely malnourished children and adults in places which are not accustomed to deal with severe malnutrition on a large scale. UNICEF undertook an analysis looking at the relationship between HIV/AIDS and malnutrition in Southern Africa in March 2003 and believe that a CTC model of treatment of severe malnutrition has a clear role to play in areas with a high prevalence of HIV/AIDS.

Considerations for the future

From the final panel discussion on day 3, a number of general recommendations emerged on certain themes:

Integration between CTC activities and MoH programmes to treat malnutrition

There is a need for people working in CTC and other home based programmes to be more sensitive to the skills and abilities available in the countries in which they work. Emergencies often re-occur and governments with a strong MoH will resent agencies that assume only they know how to treat malnutrition.

Choice between different types of programme to treat severe malnutrition

It is important to give people the choice between both non-centre based treatment and standard in-patient care because many people (such as orphans) may be unable to go home and receive treatment, or certain situations (such as wars or insecure refugee camps) may make it difficult to return home. Emergency situations, however, often occur with limited lead in time and organisations may be unable to scale up complex programmes very quickly so it may be difficult to provide individuals with choice in reality.

Use of Plumpy'nut for people living with HIV/AIDS

An unpublished study in Burundi found that adult HIV+ women had the same rate of weight gain and recovery weight as non-HIV patients in a TFC. HIV+ individuals can respond to this type of treatment. Hence, there is a need to integrate HIV+ individuals into these programmes. It is also important to distinguish between recovery rates of people with HIV and those with AIDS. The CTC model may be a useful entry point into the community for HIV/AIDS programmes because the programme's approach results in very close contact with the community relatively quickly. It may also be a useful way to locate HIV/AIDS patients.

Operational research on non-centre based programmes

There is a need to identify the top 10 operational research questions that have arisen around the development of CTC programmes. This will certainly include the treatment protocols for infants under 12 months and patients with oedema. There is not enough interaction between NGOs and academics around these topics (in the UK at least).

Terminology and definitions of non-centre based programmes to treat severe malnutrition There is some confusion over the terminology used in non-centre based treatment programmes. The CTC model has developed its own nomenclature but this is not the same as that used by agencies working on other home based programmes (partly because the strategies are not the same). UNICEF will take the lead on this, working with the key agencies involved, over the next few months. A report of the preliminary discussions will be presented at the emergencies working group at the next UN sub-committee on nutrition (SCN) meeting in New York (March 2004).

There is also a need to define, and if possible standardise, some of the programme outcomes and measurements used by different agencies to assess the impact of non-centre based treatment. The Sphere definitions are useful for some, but not all, impact measures.

The wider implications of RUTFs

Evidence presented at this conference has shown that children fed RUTFs have been able to achieve rapid weight gain and can recover from malnutrition. This finding has very wide implications for nutritional strategies in countries which consistently record high levels of malnutrition. For example, could RUTFs be used to help children to recover from diarrhoea or malaria? Is there a role for RUTFs as a transition food in resource poor environments? Could it be useful for mothers who are HIV+ and would like to wean early? Can we expand its use to assist these groups? Research on some of these questions is ongoing in different areas. The problem with all these ideas is that the RUTF will need to be much cheaper than is currently the case.

A full copy of the proceedings can be obtained from the ENN website, http://www.ennonline.net. Copies of the full presentations from the workshop are available online at http://www.fantaproject.org/ctc/workshop2003.shtml

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¹No standard nomenclature exists to describe this approach. Preferred nomenclature, which may or may not reflect differences in programming, varies between practitioners and researchers. Therefore the terms 'community-based', 'home-based', 'non-centre based' treatment or approaches are used interchangeably in this summary,

²Management of the Child with a Serious Infection or Severe Malnutrition: IMCI guidelines for care at the firstreferral level in developing countries (WHO/FCH/CAH/00.1)

³See this issue of Field Exchange. Home-based therapy with RTUF in Malawi. Field article. Dr. Mark Manary and Heidi Sandige

⁴Field Exchange 16. OTP: An evaluation of a new SCUK venture in N. Dafur, Sudan (2001). Evaluation. p26-27. August 2002

⁵See Field Exchange 19. Ambulatory treatment of severe malnutrition in Afghanistan. Field article. p14-15. July 2003.

⁶See this issue of Field Exchange. Socio-anthropological aspects of home recovery from severemalnutrition.Field artcle p24.

⁷CMV therapeutic

⁸Group 1: Admission, discharge and referral criteria; Group 2: Outpatient Medical protocols; Group 3: Nutritional Products and Protocols; Group 4: Community involvement, case finding, follow up and mobilisation; Group 5: Integration and Longer term issues; Group 6: Management of infants under 6 months.

⁹The statements that the groups were asked to comment on, and/or the modified versions/feedback produced by the working groups, could form the basis of a future agenda for operational research on the treatment of severe malnutrition in a non-centre based programme