Results Monitoring (B) - Tracking

The PepsiCo Foundation MeetingMarch 31, 2008

The PepsiCo Foundation

Community-based Management of Acute Malnutrition (CMAM)

Toby Stillman

Advisor, Emergency Health and Nutrition

Page 2

Measures of Undernutrition Development Contexts

Stunting (Chronic)

Underweight (Both) Wasting (Acute)

Index Height for Age Weight for Age

Weight for Height or MUAC

Moderate < -2 SD < -2 SD < -2 SD

Severe < - 3 SD < - 3SD < - 3SD

Is it possible to define upfront development vs. emergency context?

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Measures of Undernutrition Emergency Contexts

Stunting (Chronic)

Underweight

(Both) Wasting (Acute)

Index H/A W/A W/H or MUAC

Moderate < -2 SD < -2 SD < -2 SD

Severe < - 3 SD < - 3SD < - 3SD

Note: Cut off points for MUAC differ from agency to agency – these cut offs are consistent with MSF guidance

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Stunting (Chronic)

Underweight

(Both) Wasting (Acute)

Index H/A W/A W/H or MUAC

Moderate < -2 SD < -2 SD < -2 SD

Severe < - 3 SD < - 3SD < - 3SD

Severe Acute Malnutrition

(SAM)

Measures of Undernutrition Emergency Contexts

Note: Cut off points for MUAC differ from agency to agency – these cut offs are consistent with MSF guidance

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Measures of Undernutrition Severe Acute Malnutrition

Marasmus (gross wasting)

Kwashiorker (oedema)

Case Fatality of 20% to

30%

Case Fatality of 50% to

60%

This page repeated later, but took it out

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Nutrition EmergenciesBenchmarks and Thresholds

WHO, Management of Malnutrition in Major Emergencies, 2000

Severity Prevalence of Acute Malnutrition

Acceptable < 5 %

Poor 5 – 9 %

Serious 10 – 14 %

Critical > = 15 %

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Severity Prevalence of Acute Malnutrition

Acceptable < 5 %

Poor 5 – 9 %

Serious 10 – 14 %

Critical > = 15 %

Emergency Threshold

(moderate + severe)

Nutrition Emergencies Benchmarks and Thresholds

WHO, Management of Malnutrition in Major Emergencies, 2000

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Screen the population

Children with Moderate

Malnutrition

Supplementary Feeding Program

Children with Severe

Malnutrition

Therapeutic Feeding Center

(TFC)Recovered

No Malnutrition

Nutrition Emergencies Traditional Response

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Traditional ResponseTherapeutic Care• Inpatient care in a

– Pediatric ward

– Nutrition rehabilitation unit (NRU), or

– Therapeutic feeding center (TFC)

• Global standards call for:– No more than 50 beds per

TFC

– 1 Nurse

– 2 trained health workers

– 1 nursing aid for every 10 children

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Phase I – Stabilization*

Phase II – Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**

Care Attend to complications (e.g. shock, hypoglycemia)**

Feed F-75 Therapeutic Milk F-100 Therapeutic Milk

Quantity 135ml/kg/day** 200ml/kg/day**

Length of Time

1-7 Days, 3 to 4 Weeks

*ACF breaks treatment into 3 phases.

**See WHO, Management of Severe Malnutrition, 1999 for further detail.

Case Fatality of less than

10%

Traditional ResponseTherapeutic Care…Cont’d

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Traditional ResponseConstraints: Labor Intensive• Inpatient care in a

– Pediatric ward

– Nutrition rehabilitation unit (NRU), or

– Therapeutic feeding center (TFC)

• Global standards call for:– No more than 50 beds per

TFC

– 1 Nurse

– 2 trained health workers

– 1 nursing aid for every 10 children

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• Inpatient care in a– Pediatric ward

– Nutrition rehabilitation unit (NRU), or

– Therapeutic feeding center (TFC)

• Global standards call for:– No more than 50 beds per

TFC

– 1 Nurse

– 2 trained health workers

– 1 nursing aid for every 10 children

Traditional ResponseConstraints: Cross Infection

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High Coverage Moderate

Coverage/Moderate

mortality

Low Coverage/High

mortality

TFC

Health Post

Health Post

Health Post

Health Post

Health Post

Traditional ResponseConstraints: Poor Coverage

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Evolution of a New ApproachCMAM: 1998-99

Development of PlumpyNut–a Ready to Use Therapeutic Food (RUTF) equivalent to F-100

South Sudan

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Uncomplicated Complicated

Evolution of a New ApproachAdditional Screening

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Screen the population

Children with Moderate

Malnutrition

Supplementary Feeding Program

Children with Severe

Malnutrition

Therapeutic Feeding Center

(TFC)Recovered

No Malnutrition

Review Traditional Response

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Screening

Children with Moderate

Malnutrition

Supplementary Feeding Program

No Malnutrition

Children with Severe Malnutrition

No Complications Complications

Outpatient Therapeutic Care

Inpatient Therapeutic Care

Review:New Approach–CMAM

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CMAM Coverage

TFC

Health Post

Health Post

Health Post

Health Post

Health Post

Moved this slide up

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Screening

Children with Moderate

Malnutrition

Supplementary Feeding Program

No Malnutrition

Children with Severe Malnutrition

No Complications Complications

Outpatient Therapeutic Care

Inpatient Therapeutic Care

85% can be treated as

outpatients

CMAM Impact

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Screening

Children with Moderate

Malnutrition

Supplementary Feeding Program

No Malnutrition

Children with Severe Malnutrition

No Complications Complications

Outpatient Therapeutic Care

Inpatient Therapeutic Care

Time in hospital reduced

considerably

CMAM Impact…Cont’d

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Phase I – Stabilization Phase II – Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**

Care Attend to complications (e.g. shock, hypoglycemia)**

Feed F-75 Therapeutic Milk RUTF

Quantity 100kcal/kg/day** 200kcal/kg/day**

Length of Time 1-7 Days, 3 to 4 Weeks

**See WHO, Management of Severe Malnutrition, 1999, and CTC Field Manual for further detail.

Outpatient CareCMAM Impact…Cont’d

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Better than traditional approach

CMAM

Outcomes from CTC 2000 - 2003, (n = 7,408), & TFCs 1992-1998 (n= 11,287) against SPHERE minimum standards

0%

25%

50%

75%

100%

77% 5% 11% 7%

SPHERE 75% 10% 15% 0%

TFC 65% 12% 18% 5%

recovered died default LTF

CMAMDoes it Work?

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CMAM (70%) Traditional (30%)

Coverage Increases

Dramatically

CMAMDoes it Work?...Cont’d

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WHO, Management of Malnutrition in Major Emergencies, 2000

Severity Prevalence of GAM

Acceptable < 5 %

Poor 5 – 9 %

Serious 10 – 14 %

Critical > = 15 %

Emergency Threshold

CMAMEmergency to Development

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Rainer Gross, Patrick Webb Lancet 2006; 367: 1209–11

Static rates exceed

emergency thresholds

CMAMEmergency to Development

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• Roll out CMAM protocols at national level across the globe– Technical support for revision of

protocols and training– Cash for RUTF

• Conduct ongoing research– Alternative formulations of RUF– Local Production of RUF– Impact of RUF, and appropriate

formulations for: HIV+ Moderate malnutrition Prevention of malnutrition

CMAMOur Roll-Out Strategy

Changed Header Here / Downplay research with Foundation

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CMAMSave the Children Portfolio

• Support national level guideline

– Adaptation and roll out in: Mozambique, Pakistan, Bangladesh, and Haiti.

– Need for adaptation and roll out in India, Nigeria, and Mali

• Pilot activities adapting protocols to address needs of HIV+ in: Uganda, Ethiopia, and Malawi – “Food by Prescription”

• Ongoing emergency programming: Ethiopia, Darfur, Pakistan and through SCUK in Niger

• Large scale effectiveness trial: Impact of Ready to Use Foods on chronic malnutrition in Malawi