Home treatment for severe malnutrition in South Sudan

By Josephine Querubin, ACF-USA

Josephine Querubin is a medical doctor who has been working in humanitarian work for the past 12 years. Beginning in her home country, the Philippines, she moved to international work with the EU, MSF-CH, and then ACF-USA. She began working with ACF-USA in South Sudan in August 2003 becoming Medical and Nutrition Coordinator, and finished in March 2006.

TFCThe author would like to acknowledge the work of the local staff and ACF team in South Sudan reflected here. In particular, the author would like to mention Mark Wamalwa, Veronica Natesiro, Edna, and Samson Ekale who have displayed immense dedication and hard work in running the programmes in south Sudan, caring for the children in more ways than drugs and food alone ever could. The author would also like to acknowledge the support of Marie Sophie Simon, HQ nutritionist with ACF-USA, who has been with the team throughout and taught us how to do things right, yet enjoy at the same time.

Waiting to be weighed in the HT programme

This article details the largely positive experiences of ACF-USA in using home treatment as an integral part of their programme to manage severe malnutrition in South Sudan.

Many parts of South Sudan, especially in Upper Nile and Bahr-el Ghazal regions, experienced a prolonged pre-harvest hunger period in 2005 following the delayed rains that had adversely affected crop production in the previous year. Given the poor access to water and health services in the area, in conjunction with a large influx of returnees, the nutritional situation became even more precarious than usual. ACF-USA had a strong presence in Upper Nile since 2001 and was therefore able to extend programming in Bahr-el Ghazal in response to the emerging nutritional emergency in Twic and Gogrial counties in 2005.

Both Twic and Gogrial counties are situated in Warab State in the northern section of the Upper Nile region, North East of South Sudan. Warab State lies in the flood plains agro-ecological zone and receives extensive seasonal flooding from the tributaries of the River Nile. With a vast land area, the villages and homesteads are scattered and far apart. The population is predominantly from the Dinka tribe, which comprise approximately 5% of southern Sudan's estimated population of about 8.9 million. Crops and livestock production are the main sources of livelihood.

Background to treatment for severe malnutrition

It is common practice among the communities of the south for women to tend to every member in the family, as well as perform most of the household and farm labour. At the same time, mothers are the principal caretakers of any severely malnourished child admitted to a treatment centre. Conventional Therapeutic Feeding Centres (TFCs), especially in open settings with widely dispersed populations and where the beneficiary and caretaker must stay in for 24 hours for an average of one month, have always been faced with low coverage or a high default rate or both. Following various studies to improve the management of the severely malnourished and increase the impact of therapeutic feeding programmes, Action Contre le Faim (ACF) has, in recent years, employed the Home Treatment (HT) approach. In this approach, once medical complications have been controlled, the child continues nutritional rehabilitation with Ready-to-Use Therapeutic Food (RUTF) at home and comes for scheduled follow-up at the centre until the desired weight is reached. Piloted by ACF-USA in Upper Nile in 2004, the HT protocol was subsequently implemented in Gogrial county last year.

TFC-HT programme

The programme was designed to cover at least four Payams in the county (West Gogrial). One Therapeutic Feeding Centrebased Home Treatment Programme (TFC-HT) was established in Alek, with the capacity to treat 200 severely malnourished, along with one Supplementary Feeding Programme (SFP), designed for a capacity of 800 moderately malnourished children. Health Education and Gardening programmes were also implemented alongside. These programmes ran over a six-month period.

Initial activities of the team focused on linking with the SRRC (Sudan Relief and Rehabilitation Commission) counterparts, local authorities, and other agencies on the ground, on community orientation and mobilisation, and on preparing for both the logistics and technical requirements of the programme. ACF-USA designed and implemented this phase within a three-week period. During this period, Sudanese national staff received training that covered general subjects like the organisation's charter and Staff Rules and Regulations, as well as technical topics like nutrition/malnutrition, and the objectives and functioning of the TFC-HT and SFP. In addition, each category of staff received specific training following a standard module and according to their duties and responsibilities as detailed in their job descriptions.

From experience and analysis of the context, ACF-USA consider the minimum standard acceptable in south Sudan for feeding programmes coverage is 50% of the acutely malnourished children as estimated from a baseline nutritional survey in the targeted area. For its programmes in Alek, Gogrial West in 2005, ACF-USA targeted coverage of 60%, hence, 200 severely and 800 moderately malnourished were expected at the TFC-HT and SFPs, respectively. At the end of its six month programme life, the TFC-HT exceeded the expected beneficiary case load, having admitted 259 children under five years of age and three adults. This is equivalent to programme coverage of 78% of all severely malnourished children based upon the December nutritional survey and the February rapid assessment.

ACF South Sudan TFC-HT protocol

ACF-USA's protocol for the treatment of severely malnourished individuals is divided into different phases: Phase I or the Intensive Care Phase, Transition Phase, and Phase II or the Rapid Weight Gain/Rehabilitation Phase.

Admission criteria are as follows:

• For children 6-59 months, a weight for height ratio of less than 70% and/or bilateral oedema (kwashiorkor) and/or MUAC (Mid- Upper Arm Circumference) less than 11.0 cm for children with height above 75 cm.
• Children or adolescents from 5 years to 18 years, a weight for height less than 70% of the median and/or bilateral oedema.
• Adults with body mass index less than 16 and/or bilateral oedema

Phase I (Intensive Care) is carried out in the TFC where the patients receive systematic medical treatment, and daily medical follow-up, with specific treatment if indicated. Nutritional treatment is based on a F75 therapeutic milk diet that provided 135 ml/kg per kg body weight per day. The average stay is 4 to 7 days.

Patients move to the Transition Phase when:

• they are recovering their appetite
• in kwashiorkor cases, when the oedema has begun to disappear
• they are no longer fed by naso-gastric tube (if this was necessary during phase I)
• they are no longer seriously ill.

In the transition phase, the energy intake is increased and the proportion of energy-providing nutrients modified, allowing the patient to adapt progressively to a diet expressly designed to produce a rapid gain in weight. Hence, F100 milk is introduced at 100ml/kg to provide the same energy value as phase I, i.e. 100 kcal/day. This phase lasts 2-4 days and is also carried out in the TFC.
Following the transition phase, the patient without problems is transferred to Phase II (Rapid Weight Gain) of treatment (for patients with kwashiorkor, complete disappearance of oedema signals this transfer). The treatment consists of medical check-up every two days and full F100 diet (i.e. 200 kcal/kg/day plus porridge) to obtain optimal increase in weight. The average stay is 2 to 4 weeks. This phase is carried out either at the TFC or as Home Treatment.

The Home Treatment option is offered to caretakers whose children fit the following criteria:

• Older than 12 months
• Acute medical complication/illness have been controlled and no need for further medical treatment
• Absence of nutritional oedema on admission
• The child has successfully passed through phase 1, transition phase and spent 2 days in rehabilitation phase within the TFC itself
• The mother/caretaker fully understands the feeding protocols
• The patient/caretaker lives in the catch ments areas delimited for Home Treatment.

The patients on Home Treatment are not considered as cured, and medical and nutritional follow up continues through weekly attendance at the identified HT Centre/s and through regular monitoring by home visitors. In case of treatment failure or relapse (loss of weight, medical complication (such as primary complex tuberculosis (PTB)), the beneficiary is readmitted and continues treatment in the centre. Those who do not fit the HT eligibility criteria complete Phase II of treatment at the TFC.

The discharge criteria for the TFP are:

• an ascendant weight gain curve and no disease present, and
• reached target weight for height of 80% of median and MUAC > or = 12 cm for two consecutive measurements, and
• for kwashiorkor cases, at least 15 days since the disappearance of oedema.

All severely malnourished patients admitted to the therapeutic programme are discharged to the SFP for the Consolidation Phase. Patients are reviewed during the scheduled distributions of the SFP to receive follow-up care (medical monitoring and supplemental feeding) to avoid relapse.

Results

Based on all programme records, the cure rate in the TFC-HT programme was high at 81% (this compares well with the SPHERE minimum standard of 75%). The mean length of stay for the children who recovered was 48 days, averaging a weight gain of 9 g/kg/day. Seventy two percent of those children that recovered underwent home treatment, while 28% remained at the centre throughout. Of the 28% who were managed in the TFC, 10% did so due to persistent medical complication or because they were aged under 11 months. The remaining 18% were actually eligible for home treatment but opted to stay at the centre, either because of distance from their homes or due to flooding that would have impeded follow-up.

Weight gain

During the second phase of treatment where rapid weight gain is meant to occur, children at the TFC spent an average of 22 days gaining 16g/kg per day to reach the desired weight. At home, it took about 18 days longer to reach target weights with a slower weight gain of 7g/kg/day. Ninety two percent of the children on HT completed the treatment until full recovery, while only 82% did so at the TFC. The children who recovered on the HT regime spent 4- 5 days in phase 1 and 4 days in transition at the stabilisation centre where they adapted to the use of RUTF (Plumpy'nut).

Length of stay

Some of the children had medical complications that could not be controlled or reversed at the TFC. Four and a half percent were therefore referred to specialised clinics, although the mortality rate at the TFC was still minimal at 2.5%. These specialised clinics (currently ten with another under construction) come in the form of PHCUs (Primary Health Care Units), run by Norwegian Church Aid (NCA). These provide primary health services for the entire county of West Gogrial, and are available for the referral of medical complication cases.

Defaulting

Medical assessment as part of the TFC-HT programme

Overall, defaulter rates were low at 12%, with 15% defaulting among those who stayed at the TFC and 7% amongst those on HT. Generally, the shorter stay at the centre (average of 8-9 days) as well as the readiness to use RUTF at home improved receptivity to, and acceptability of, the HT programme among mothers and children. There were no cases of relapse among HT children that compelled their return to the centre. An ongoing study of this treatment protocol and its results across different AAH missions is being undertaken and it is anticipated that the duration of stay at TFCs may be even shorter elsewhere than found in this programme.

Constraints

Although largely successful, certain programme constraints operated. As with most areas in south Sudan where ACF-USA operates, homesteads and villages are widely dispersed amidst difficult terrain, which frequently experiences widespread flooding. Without internal means of transport in the field or the capacity to match the number of centres with the number of villages, the strategy is highly reliant on a network of locally based 'home visitors'. Their critical role involves screening and referrals at the community and household level, monitoring the children (particularly those on home treatment) and tracing defaulters. Given the physical arduousness of the work and shortages of home visitors, programme effectiveness can easily be compromised. Given this and the general economic marginalisation and growing needs of the south Sudanese community, especially following the peace accord with the North, there are many challenges still to be tackled if we are to achieve full coverage and maximum impact of HT.

For further information, contact Adalbert Mena Fundi, email: med@aahssd.org, or Marie-Sophie Simon, ACF-USA, email: mss@aah-usa.org

¹A training module for National Staff in the TFC/SFP was developed by ACF-USA and was employed in Alek.