Highlights from MSF-hosted meeting on outpatient and community based therapeutic care

By Kirsti Lattu, MSF Programme Officer and Caroline Grobler-Tanner, Independent Nutrition Advisor

Examining an infant in the TFC. Maradi, Niger

In 2005, Médecins Sans Frontières (MSF) treated more than 60,000 severely malnourished children during the crisis in Niger. Over 70% of the children were cared for on an outpatient basis, using Ready to use Therapeutic food (RUTF)¹. In light of this experience, MSF hosted an informal technical meeting on 'New Perspectives in Responding to Nutritional Emergencies: Ambulatory and Community-Based Therapeutic Care (CTC)' on November 1, 2005 in New York. The forum provided an opportunity to exchange operational experiences in the treatment of severe malnutrition in emergencies. Discussions centred on programme implications and challenges raised by outpatient and community-based therapeutic care in emergency settings.

The meeting focused on three areas:

• New developments in community-based care and medical protocols
• Operational challenges faced in Niger
• Intervention strategies across differing emergency contexts.

Presentations by Valid International, Concern Worldwide, Save the Children-US and MSF provided technical and contextual programme overviews from recent field experiences in Niger, Darfur, Ethiopia, Chad and Nigeria. The following key points emerged:

There is a general consensus, based on experience in different settings, that community based approaches (outpatient and CTC) using RUTF (Plumpy'nut and locally produced RUTF) are effective in treating severe acute malnutrition. Unlike traditional centre based care, they provide the opportunity for reaching very large numbers of children without incurring substantial additional costs.

There is consensus regarding the use of the revised classification for acute malnutrition². This classification based on CTC experience distinguishes between those requiring inpatient stabilisation care (acute malnutrition with complications) and those who can be treated directly on an outpatient basis (acute malnutrition without complications). This classification allows agencies to achieve high coverage while maintaining quality of care for those who require it.

There is agreement that we need to "do more and do it better." In other words, quantity does not have to come at the sacrifice of quality of care. Protocols and terminology now need to be clarified so that all can benefit from the experiences of organisations that are already engaged in ambulatory care and CTC interventions.

MSF's experience in treating more than 60,000 severely malnourished in Niger during the 2005 crisis demonstrates the enormous possibility of emergency programme scale-up using outpatient care, while maintaining excellent programme outcomes compared to SPHERE (cure rates >90%, mortality <5% and defaulting < 5%). Overall, 70%³ of the caseload was treated directly in an outpatient programme. This extended reach (coverage) has profound implications for all involved in caring for and preventing severe acute malnutrition.

In Niger, there were a number of international non-governmental organisations (NGOs) working on development focused food and nutrition-related programmes. The 2005 nutritional crisis highlighted tensions and constraints in shifting from development to an emergency programme, as well as the need for a more proactive response independent of media attention.

Treatment for severe acute malnutrition is the same whether in an emergency or nonemergency setting. CTC should therefore, in principle, facilitate easier transitions between development and emergency response, given that the programme elements are the same.

Discussion points of interest

Programme experiences

Programme presentations from Niger, Darfur, Ethiopia, Chad, and Nigeria provided insights into outpatient care and CTC approaches in various emergency contexts. These contexts included functional, semi-functional, or nonfunctional health systems; areas of limited access due to insecurity or, by contrast (in the case of Katsina, Nigeria), programme operations in an area with neither security nor apparent food availability problems⁴. The CTC framework aims to maximise the comparative advantages of different agencies and is flexible enough to adapt for all of these contexts. As more agencies implement CTC in non-emergency settings, existing CTC programmes can facilitate emergency scale up. Proximity of services to beneficiaries is key to early presentation and early treatment. Other suggestions raised that might speed the transition to emergency scale response included:

• Loose or informal interagency agreements to share responsibilities according to agency strengths.
• Moving towards specialisation to avoid overlap and to cover a range of needed programmatic responses.

However if we are seeing a trend towards specialisation, are there any organisations other than MSF ready to provide medical management of stabilisation centres? Once MSF has established emergency context stabilisation centres, their handover presents yet another challenge. In Niger, 18,000+ of the severely malnourished required inpatient care. In MSF's experience, due in part to the sheer caseload volume, handover of stabilisation centres was an issue because of limited or non-existent potential handover partners.

To improve patient outcomes in Niger, MSF distributes a 'protection ration' each time a child comes for outpatient care follow-up. The idea behind this is to prevent sharing by providing food for other members (particularly other children) in the household, as well as to promote the concept of RUTF as a medicine for the malnourished child.

In responding to the Niger crisis, MSF revived the concept of blanket feeding in operational areas. Efforts to 'blanket' feed all under fives by distributing locally available food offered another mechanism with which to inject food into households with young children.

Due to insufficient staffing or other programme obstacles, active case finding of malnourished children may not be feasible in every situation. For example, MSF enrolled 60,000 children in Niger without community outreach activities beyond active participation by mothers (caretakers) themselves.

Grey areas

Mothers line up with their children, all under five years old, at an MSF TFC in Maradi, Niger.

Discussions revealed several grey areas where there are gaps in information and understanding. For example:

In Niger and Nigeria, the majority of severely malnourished children are younger than 24 months. It was noted that if children survive past weaning age, they are less likely to relapse. Some sites admitted children of mothers who walked 20-30 kilometres, while other sites didn't attract parents (caretakers) who lived very nearby.

It is unclear why in some areas, selected families or even certain children, are more affected than others.

In Nigeria (population 150 million), where the measles vaccination coverage is less than 10%, there is a measles epidemic every two years resulting in malnutrition prevalence rate peaks corresponding with measles outbreaks. Emergency threshold levels for global acute malnutrition may not be reached in high population density settings such as Nigeria, but the overall number of severely acute malnourished children can be very high. Is this an emergency or chronic situation? Furthermore, how do we define nutritional emergencies? Given little or sometimes no nutritional surveillance data, it is challenging to differentiate between seasonal variations, normal and emergency levels from year to year. MSF's programme in Katsina State, Nigeria treated over 12,000 cases of malnutrition in 2005, initially in a post-measles epidemic response. At the time of the meeting, MSF's programme in Katsina State recorded 10.5% global acute malnutrition (GAM), 2.3% severe acute malnutrition (SAM) and had 10,104 admissions over 18 weeks. There were no epidemics at the time - is this a nutritional emergency or 'normal'? Who is responsible for responding to severe acute malnutrition, if the government does not?

Issues for further exploration

• Should we continue aiming for weight gains above 10g/kg/day (SPHERE) as indicated for inpatient treatment? Do we need to "stuff them like fois gras?" asked one presenter. MSF's experience shows that even older children receiving only two Plumpy'nut a day showed reasonable weight gain.
• Do caregivers and their malnourished children admitted to an outpatient programme need to return for weekly consultations at outpatient sites? Concern Worldwide's experience in Ethiopia suggests the possibility of check-up consultations on a bi-weekly basis without detriment to patient progress. Thus we need to further explore when it would be appropriate to extend the time between check-ups.
• Continuing to explore other alternatives to Plumpy'nut for children that do not like or who cannot eat peanut-based products should be a priority in deveoping alternative RUTF formulations.
• It is time to renew clinical research to determine the best protocols for treatment of severely malnourished children. We've done well in decreasing some causes of mortality and need to now turn attention to finding the most effective treatment for sepsis, colitis, etc. If there are no evident classical signs and symptoms (Integrated Management of Childhood Illnesses (IMCI) approach), we risk under diagnosing illnesses such as acute respiratory infections. Additionally, we need to revisit the best antibiotic combinations for effective treatment of these pathologies.
• In an effort to improve patient care, MSFFrance is raising the level of care available to those admitted into intensive care units within stabilisation centres. All intensive care units include oxygen, blood banking, and powerful, appropriate antibiotics.
• There needs to be greater standardisation of anthropometry measurement (e.g. MUAC, weight for height measurements and per cent of the median versus z scores) in order to facilitate sharing of programme information, coordination across intervening organisations and evaluation.

Priorities for next steps

Inpatient care in the MSFTFC, Maradi, Niger

Since community based approaches using RUTF are an accepted effective treatment for severe malnutrition, it will be important to develop clear guidelines and standards. The guidelines should note the similarities and differences between the different types of interventions (outpatient care, CTC), where they may be appropriate and expected programmes outcomes. Organisations considering implementing community based programmes and their donors need easy access to these guidelines and standards.

WHO and UNICEF leadership must work to quickly introduce and facilitate acceptance of community based approaches within national Ministries of Health. The role of UNICEF in both a coordination role and in ensuring sustainable supplies of RUTF in emergencies and beyond must be clearly defined.

One devil's advocate queried, "As many actors step up to undertake CTC or ambulatory care, will these types of programmes become another endless effort to alleviate chronic food and other nutrition-related issues, rather than addressing underlying root causes of malnutrition?" Hopefully not. However, acutely malnourished children need effective treatment. The good news is that for cases without complications, this treatment has now been radically simplified and thus is available to far more children than ever before.

For further information, contact, Caroline Tanner, email: cgroblertanner@yahoo.com or Christophe Fournier, MD/MSF Director of Programmes, email: Christophe.Fournier@newyork.msf.org

¹Plumpy'nut (Nutriset) was the RUTF used in Niger by all organisations involved in treatment of severe acute malnutrition.

²Collins S, Yates R. The need to update the classification of acute malnutrition. Lancet 2003; 362(9379):249. See also ENN special supplement no.2 Community Based Approaches to Managing Severe Malnutrition. Available from the EEN and online at http://www.ennonline.net

³70% represents the uncomplicated cases. The other 30%, or some 18,000 cases, were complicated severe acute malnutrition requiring inpatient care.

⁴Although abundant food was available in local markets, due to price, food was inaccessible to many Katsina State residents.