Zambia efforts in prevention, early detection and treatment of wasting during COVID-19

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Getinet Babu, Agnes Aongola, Colleen Emary, Phyllis Oyugi, Claire Beck and Chansa Tembo.

Getinet Babu is a Senior Humanitarian Nutrition Advisor with World Vision International (WVI).

Agnes Aongola is a Senior Nutrition Officer who has worked with the Ministry of Health in Zambia.

Colleen Emary is a health and nutrition Senior Technical Advisor with WVI, based in Canada.

Phyllis Oyugi is a Nutrition Specialist with UNICEF in Zambia.

Claire Beck is Director of Humanitarian Health and Nutrition for WVI.  

Chansa Nakazwe is the Nutrition Specialist for World Vision Zambia.

Background

Zambia faced a serious food insecurity and nutrition crisis prior to the COVID-19 pandemic. In August 2019, 60 out of 116 districts were projected to be classified as integrated phase classification phase 3 (crisis) or phase 4 (emergency) and severe acute malnutrition levels were set to increase in 24 districts. On the basis of these projections, 36 districts were prioritised for the scale-up of malnutrition prevention and treatment services through the national integrated management of acute malnutrition (IMAM) programme led by the Ministry of Health (MoH) with support from UNICEF, World Vision, People in Need and PLAN International. This article describes the efforts to support the continuation of the scale-up process to prevent and treat child malnutrition in these priority districts in the context of the COVID-19 pandemic.

Scale-up and continuity of nutrition services during COVID-19

The coordination of the scale-up of nutrition services was provided by the Zambia MoH. This included the provision of guidance and tools for health workers and the chairing of online meetings for nutrition partners. In collaboration with the MoH and UNICEF, three non-governmental organisation partners (World Vision, People in Need and PLAN International) jointly developed a plan to guide the scale-up of services. As a result, wasting treatment services were initiated in an additional 366 health facilities in the 36 target districts, thereby covering 647 of the 659 health facilities. A gap analysis conducted by UNICEF, MoH and partners in the 36 target districts revealed the limited capacity of health workers and volunteers for acute malnutrition treatment due to infrequent trainings and a lack of practical experience. Capacity building of health workers was subsequently prioritised.  

Continuation and scale-up of essential nutrition services in the context of COVID-19 were enabled through funds already designated for the 36 target districts as well as additional funds from the Scaling-Up Nutrition Movement Pooled Fund and the Foreign, Commonwealth and Development Office.[1] The UNICEF funds initially assigned to the emergency response were reprogrammed to include COVID-19 prevention activities within nutrition services. This enabled the following immediate programme adaptations to take place in April 2020 to allow essential services to continue:

Introduction of COVID-19 measures: Community health workers (CHWs) and clinical staff received immediate training in infection prevention control (IPC) protocols. The MoH, in coordination with UNICEF and other partners, also provided personal protective equipment (PPE) to all health facilities as well as for CHWs to use during outreach activities. In addition, caregivers were instructed to bring their own cloths to use as weighing pants and mid-upper arm circumference (MUAC) tapes were disinfected between measurements. 

Adjusting the IMAM guidelines: Rapid and temporary adjustments were made to wasting treatment protocols in the Zambia IMAM guidelines including adaptations to the ration schedule for ready-to-use therapeutic food (RUTF). This minimised the frequency of caregivers’ visits to nutrition sites and reduced the risk of overcrowding.  

Introducing Family MUAC: Health workers and volunteers were trained to take MUAC measurements and they then trained caregivers in wasting screening (Family MUAC). The rollout of Family MUAC began in December 2020 (later than anticipated due to initial shortages of MUAC tapes) to facilitate the timely and early referral of children with acute malnutrition while reducing the risk of COVID-19 transmission.

Resuming outreach services: Initially during the pandemic, referrals to nutrition centres dropped, the frequency of follow-up decreased and defaulting rose due to outreach services being suspended between March and June 2020 as well as widespread fear among caregivers of attending health facilities. When PPE became available, outreach services resumed and caregivers gained confidence to attend health centres again. The district health office acted to strengthen outreach and monitoring activities by providing transport to facilities with remote outreach locations, paying a stipend to volunteers and offering increased training, supervision and mentoring to CHWs. During 2020, over 300 health workers and 721 CHWs were trained on programme adaptations as a result.

Remote field monitoring: To support field monitoring in this challenging context, remote methods were adopted. In areas with good internet access, an online form was used. Where internet access was poor, information was collected through phone calls made by the district nutritionist to facility-based staff. A WhatsApp group provided a feedback mechanism for those experiencing network issues. Key challenges were delays in the submission of monitoring information and poor network coverage in some districts.

Ensuring a functional supply chain: Efforts were made to supply sufficient RUTF via the effective pre-positioning of stocks in all districts. Health facilities were encouraged to monitor and report on their RUTF stock levels to help prevent stock-outs.

Ensuring continuity of the child health week campaign: In spite of the challenges of movement restrictions, the planned child health week campaign was successfully implemented in June 2020 to ensure the provision of major life-saving services including micronutrient supplementation, growth monitoring, infant and young child feeding promotion and counselling and vaccinations. All activities were conducted with COVID-19 prevention measures in place.

Achievements

The rapid adaptations made to IMAM protocols at the start of the COVID-19 pandemic were critical to ensuring continued access to wasting treatment services in this challenging context.  The provision of PPE and supplies brought confidence to facility-based health workers and CHWs, increased training and supervision for CHWs allowed the scaling up of outreach services and early transportation of RUTF meant that treatment could continue without stock-outs. 

As a result, between January and October 2020, a total of 105,185 children were screened for wasting and 6,361 children were admitted for wasting treatment across the 36 priority districts. This reflects a 188% increase in admissions compared to the same period in 2019. The defaulter rate also reduced from 12% pre-June 2020 to 3% since outreach activities resumed.

Maintaining implementation of the child health week demonstrated continuity in health and nutrition service delivery while ensuring the safety of health workers and communities in the context of COVID-19. Coverage during this national campaign exceeded its target, with 178% of the two million targeted beneficiaries being reached.

Conclusions

The rapid integration of COVID-19 prevention activities into nutrition programming, enabled by flexible funding arrangements, allowed the scale-up of life-saving nutrition services in the Zambia context. The continuity of this level of service provision requires further funding investments to cover the full-service packages, all health facilities and all required outreach services. Supervision and data management challenges must also be addressed.

For the most vulnerable households, loss of income and increased food insecurity, exacerbated by the socio-economic impacts of COVID-19, threatens access to affordable, nutritious food for mothers and adequate complementary feeding for young children. To address this challenge, government, development partners and the donor community should continue to invest in livelihood programming in the priority areas of Zambia while maintaining wasting treatment services for those in need. The MoH should work with nutrition partners to strengthen the implementation of essential nutrition actions for preventing malnutrition including the promotion, protection and support of infant and young child feeding.

For more information, please contact Getinet Babu at: Getinet_amenu@wvi.org