Community case management of severe acute malnutrition in southern Bangladesh

Summary of study¹

Bangladesh has the fourth-highest number of children (approximately 600,000 at any one time) suffering from severe acute malnutrition (SAM) in the world. Currently, ongoing national programmes (such as the National Nutrition Programme) do not include an effective mechanism of identifying or treating young children who suffer from SAM.

Measuring MUAC

A recent prospective cohort study aimed to examine the effectiveness and feasibility of adding the diagnosis and treatment of SAM to the community case management (CCM) package delivered by community health workers (CHWs) outside health facilities in Barisal, Bangladesh. Research goals included:

• To compare the effectiveness (i.e. the rate of recovery) of treatment of SAM provided by CHWs with that provided by the standard of care for SAM in Bangladesh.
• To compare the cost effectiveness of CCM of SAM provided by CHWs with that of the standard of care for SAM in Bangladesh.
• To estimate the coverage of CCM of SAM provided by CHWs.
• To examine the quality of care (error-free case management) delivered by CHWs for cases of SAM.

Barisal Division in southern Bangladesh comprises six districts and with a population of about eight million people, is among the poorest in the country, with alarmingly high rates of acute malnutrition among children under five. Save the Children USA (SC US) have been working in the Division since June 2004 and between 2004 and 2010, have implemented a six-year Development Assistance Programme named ‘Jibon o Jibika’ (‘Life and Livelihoods’ in Bangla) in three Districts. As part of this programme, SC US employed a cadre of CHWs, all local women educated to grade eight, to deliver preventive and curative care to children in the target Districts. Interventions included CCM of basic childhood illnesses such as diarrhoea and acute respiratory infection (ARI), monthly growth monitoring and promotion (GMP) sessions, and household-level education and counselling around infant and young child feeding, health, and sanitation.

SC US and Feinstein International Centre (FIC) at Tufts University were given permission by the Government of Bangladesh (GoB) and the Institute of Public Health Nutrition (IPHN) to pilot the community case management of SAM (CCM of SAM) in Burhanuddin Upazila in one of the JoJ target Districts (Bhola District). In a neighbouring Upazila (Lalmohan) in the same District, the Upazila Health Complex (UHC) was supported to provide inpatient treatment for children with SAM according to National Guidelines and to compile monitoring data on referrals and outcomes of treatment. This Upazila received exactly the same support by the ‘Jibon o Jibika’ programme apart from support for the CCM of SAM.

In both Burhanuddin (the intervention Upazila) and Lalmohan (the comparison Upazila) a mid-upper arm circumference (MUAC) measure and an oedema check for all children <3 years old was introduced into all routine CHW activities. These included the monthly GMP sessions and household visits for counselling and treatment of sick children. CHWs also discussed SAM and its consequences with different groups of community members in ongoing counselling and mobilisation activities.

Method

The study ran between June 2009 and June 2010. All children more than six months in age that were identified as suffering from SAM by one of the 261 CHWs working under the SC US programme in Burhanuddin Upazila were eligible for the intervention. Any child identified with SAM with appetite and no medical complication was treated directly by the CHW with ready to use therapeutic food (RUTF). Any child with SAM with medical complications, such as the absence of appetite, was referred to the UHC to receive inpatient stabilisation care. In the comparison Upazila, all children identified with SAM by CHWs were referred to the UHC.

Informed consent was obtained from all participating caregivers before recruitment. This involved the CHW discussing a verbal consent form with groups of mothers before each growth monitoring session and with individual caregivers at household visits. This form explained the objective of the study and the procedures for any child identified with SAM.

Children were discharged from treatment as recovered once MUAC was assessed as more than 110 mm and they had gained at least 15% of their admission weight for two consecutive weeks. Children admitted with nutritional oedema were discharged once oedema was absent for two consecutive weeks and their MUAC was assessed as more than 110 mm.

All CHWs in the intervention and the comparison Upazilas participated in a two-day training which covered the causes and consequences of SAM, the standardised measurement of MUAC and how to check for nutritional oedema. CHWs in the intervention Upazila were also trained on the classification of SAM and the use of nutritional and medical protocols for its treatment. Subsequently, CHWs in the intervention Upazila met with their supervisors every month to discuss problems, submit monthly reports, and receive a new stock of therapeutic food and medicines.

At the UHC in both the intervention and the comparison Upazilas, core medical staff participated in a two-day training that covered the causes and consequences of SAM, the standardised measurement of MUAC and how to check for nutritional oedema, and the nutritional and medical protocols for the inpatient treatment of SAM. In both Upazilas, SC US supplied the equipment and all ingredients for therapeutic milk. In the comparison Upazila, SC US also provided one additional care assistant whose sole job was to care for children with SAM and counsel caregivers on child feeding and care practices.

In the intervention Upazila, CHWs were trained to use a simple algorithm that classified children into two groups: SAM with complications and SAM without complications. Any child with SAM with complications was referred to the UHC to receive one to four days of inpatient treatment with therapeutic milks and medication. Once complications were under control, children were referred back to the CHW to complete treatment. Any child with SAM without complications was seen weekly in their homes by a CHW and treated with RUTF.

All dietary treatment for any child admitted to the UHC was administered according to the Bangladesh National Guidelines for inpatient management of SAM. In the intervention Upazila, for children suffering from SAM with complications, this included an initial phase (phase 1) of treatment in the UHC. Locallyprepared Formula 75 (F75) containing 75 kcal/100 ml/day was given over 12 feeds per day. The child was discharged back to their CHW where treatment continued with RUTF at home when the following conditions were satisfied: good appetite, oedema reducing and infection under control.

For all children treated by the CHW, RUTF was provided as a weekly ration in proportion to a child’s weight. The CHW used a simple chart to calculate the correct ration size which provided 175-200 kcal/kg/day and 4-5g protein/kg/day.

All medical treatment followed protocols as specified in the National Guidelines for the Management of Severely Malnourished Children in Bangladesh. This includes a single oral dose of folic acid (5 mg) and the broad-spectrum antibiotic Cotrimoxazole oral (Trimethoprim 5 mg/kg and Sulphamethoxazole 25 mg/kg) given twice a day for five days. Albendazole and vitamin A were only given where there was no record of the child receiving these treatments during the twice yearly Vitamin A+ campaigns that are common in the target area. All medication was prescribed by the UHC staff during inpatient management and by the CHW during outpatient management.

For cases of SAM without complications in the intervention Upazila, the antibiotic was administered by the caregiver at home. The CHW instructed each caregiver on when and how to give the drug. For cases of SAM with mild pneumonia in either the intervention or the comparison Upazila, the trained CHW provided treatment with Cotrimoxazole following CCM of ARI and Diarrhoea guidelines.

Results

An informal group discussion

Results show that when SAM is diagnosed and treated by CHWs, a very high proportion of malnourished children can access care and they are very likely to recover. The main outcome measures including the high recovery rate (92%) and low mortality and default rates (0.1% and 7.5% respectively) are all considerably better than the Sphere international standards for therapeutic feeding programmes and compare favourably with other community-based management of acute malnutrition (CMAM) programmes across the world. The also compare favourably to previous work that has examined the outpatient rehabilitation of children suffering from SAM in Bangladesh. The level of coverage seen in this program,e was 89% (CI 78.0%-95.9%) by April 2010; this is one of the highest rates of coverage ever recorded for similar programmes. In contrast, monitoring data in a comparison Upazila (an administrative subdivision of a district), where the standard of care (facility-based treatment) was the only mechanism for treating SAM, showed that most children referred never made it to the facility or, if they did, they went home before completing treatment.

There are a number of reasons that explain these positive findings. First, results show that CHWs were able to identify and treat SAM very early in the course of the disease. This meant that children presented with fewer complications, were easier to treat and there was rarely a need to refer a child for inpatient treatment. The programme design supported this early identification of cases through decentralised and multiple pathways to treatment including the use of MUAC bands by CHWs at monthly growth monitoring sessions and during home visits to sick children and the use of a ‘watch-list’ of sick children by CHWs in their villages. In addition, study findings show that there was a good interface between the community and the programme. Mothers and community-level health practitioners, such as village doctors and other communitybased stakeholders, were aware of SAM, trusted CHWs to provide effective treatment, and referred their own children and others in their villages when they were sick or losing weight. Study findings also demonstrated a very high quality of care delivered by CHWs. When assessed against a treatment algorithm they achieved, on average, a rate of 100% errorfree case identification and management.

Cost effectiveness was also analysed as part of this study. The CCM of SAM in Bangladesh cost $165 per child treated and $26 per DALY (disability-adjusted life year) averted. This is a similar cost-effectiveness ratio to other priority child health interventions such as immunisation and treatment of infectious tuberculosis. It is also at a level considered ‘highly cost-effective’ according to WHO’s definition that defines an intervention as cost effective if it averts one DALY for less than the per capita GDP of a country.

This study has demonstrated that such a model of care in Bangladesh is feasible and could be an effective and cost-effective strategy to ensure timely and high quality treatment for a condition that is typically associated with high levels of mortality. This is an important finding in a country that has the fourth-highest number of children suffering from SAM in the world, yet to date has had no effective mechanism of identifying and treating them.

¹Sadler.K et al (2011). Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Save the Children and Feinstein International Centre. June 2011