Administration of MANA Ready-to-Use Therapeutic...

Administration of MANA Ready-to-Use Therapeutic Food for Children Suffering from Severe Acute Malnutrition without Complications A Case Study of Observed Changes over Six Weeks at Rwaza Health Center, Musanze District, January – March 2011

RUTF Study at Rwaza April 2011

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TABLE OF CONTENTS Abbreviations......................................................................................................................... 2 Acknowledgements ............................................................................................................... 3 Executive Summary............................................................................................................... 4 Introduction............................................................................................................................ 5 Objectives.............................................................................................................................. 5 Methodology, Sample, and Materials .................................................................................... 5 Calendar of Key Activities...................................................................................................... 6 Findings ................................................................................................................................. 6 Characteristics of the Participant Group................................................... 7 Weight and MUAC Measurements ........................................................... 7 Nutritional Status by Age Group ............................................................... 8 Weekly Interview with the Mother............................................................. 9 Organoleptic Qualities .............................................................................. 9 Home Visits .............................................................................................. 9 Conclusion........................................................................................................................... 10 Recommendations............................................................................................................... 10 References .......................................................................................................................... 11 Annexes............................................................................................................................... 12 Project Proposal ..................................................................................... 12 Intake Form for Child with Severe Acute Malnutrition ............................ 14

Weekly Form for Interview of Mother or Caregiver about the Health Status of the Child (recall of the past 7 days) ....................... 18

Photos from the Study ............................................................................ 20 ! 2011 MANA Foods Rwanda Ltd. All rights reserved. MANA Foods Rwanda Ltd. PO Box 2319 Kigali, Rwanda Tel. 250.785.748.314 www.mananutrition.org


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ABBREVIATIONS CHW Community Health Workers CMAM Community Management of Acute Malnutrition GoR Government of Rwanda MAM Moderate Acute Malnutrition MANA Mother Administered Nutritive Aid MINISANTE Ministry of Health MUAC Middle Upper Arm Circumference RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition UN United Nations UNICEF United Nations International Children’s Emergency Fund WHO World Health Organization


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ACKNOWLEDGMENTS MANA would like to thank the Ministry of Health, including the Hon. Minister Dr. Robert Sezibera, the Hon. Permanent Secretary Dr. Agnes Binagwaho, Dr. Fidele Ngabo (Coordinator of Maternal and Child Health), and Alphonsine Nyirahabineza (Head of Nutrition Desk) for the approval and guidance of this project. MANA would also like to thank the staff at the Rwaza Health Center for their willing participation and assistance during this project, including Protais Sibomana (Head of Health Center), Leopold Nirere (Deputy Head), and Josephine Ntawukigiruwe (Social Worker). MANA also expresses its gratitude to the following Community Health Workers for their valuable contributions to their communities and during this project, including: Consolee Dukuzumuremyi, Claudien Basigarirakubona, Jean Nizeyimana, Christine Akimanizanye, Concilie Hategekimana, Genevieve Akimanizanye, Eurelie Uwizeyimana, Williphram Uwimana, and Christine Nizeyimana. MANA is also grateful for the kindness and hospitality of Father Bonaventure, parish priest in Rwaza, and the other priests at the parish who shared generously with us. MANA is also extremely grateful for the involvement of Aphrodis Ndagiyimfura who served as a consultant to MANA during this project. Mr. Ndagiyimfura was highly recommended by the Nutrition Desk, and without his leadership, this project would not have been possible. Finally, MANA would like to thank the mothers of the children who participated in this project. Their love for their children is immeasurable, and their commitment to this project was invaluable.


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EXECUTIVE SUMMARY The efficacy of RUTF in the treatment of severe acute malnutrition throughout sub-Saharan Africa is well documented. The quantitative results for weight and MUAC gains (see Table 1 below) achieved during this study are consistent with results reported in similar studies, demonstrating the efficacy of MANA’s RUTF product for the treatment of severe acute malnutrition. Additional qualitative results also confirm MANA’s efficacy. Table 1: Summary Weight and MUAC results Number of Children in Each Group Weight for Age Red

<-3z Yellow

>-3z & <-2z Green

>-2z Beginning of Study 14 0 0 End of Study 3 8 3 MUAC Red Yellow Green Beginning of Study 6 4 4 End of Study 0 2 12 Further, MANA’s RUTF product achieved excellent results in terms of acceptability among health care workers, mothers, and children. Acceptability is often a strong indicator of compliance and therefore success. Community Health Workers play a critical role in the identification of severe acute malnutrition and in the follow up necessary to ensure compliance with treatment. The Government of Rwanda and Ministry of Health are to be commended for their investment in these front line resources. The staff at the Rwaza Health Center with whom MANA worked on this project were informed, courteous, and helpful at all times. They treated the mothers with great respect and the children with gentleness. They sincerely appreciated the work that MANA is doing in Rwanda. RUTF is an important component of Rwanda’s strategies, policies, and plans to reduce severe acute malnutrition. The Government of Rwanda and the Ministry of Health have been supportive of the establishment of a factory to produce RUTF in Rwanda. MANA is pleased to be able to serve in this role. Going forward, MANA would recommend further efficacy studies for RUTF to evaluate recovery rates across age groups, as well as comparative acceptability studies for the various RUTF products in use in Rwanda.

Dominique

20 January 2011 4.7 kg

Dominique 03 March 2011

6.9 kg


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INTRODUCTION The Government of Rwanda and the Ministry of Health (MINISANTE) have adopted a proactive and aggressive stance toward malnutrition in the country. Rwanda’s Vision 2020, the National Nutrition Policy (2005), the Economic Development and Poverty Reduction Strategy (2008-2012), and the President’s emergency initiative to end malnutrition (2009) all demonstrate a serious, long-term commitment to combat malnutrition. MANA Foods Rwanda Ltd. (MANA) is establishing operations in Rwanda to produce Ready-to-Use Therapeutic Food (RUTF). RUTF is part of the global protocol for the Community Management of Severe Acute Malnutrition (CMAM) adopted by the World Health Organization, World Food Programme, UNICEF, and the UN System Standing Committee on Nutrition in 2007 (see Annex 1). MINISANTE also includes RUTF as part of the protocol for the treatment of severe acute malnutrition in Rwanda. In November 2010, MANA submitted a proposal to MINISANTE to provide MANA’s RUTF product to ten to fifteen children suffering from severe acute malnutrition and to observe and document the changes in health among these children. This proposal was officially approved by the Minister of Health in December 2010, and MANA was assigned by the Nutrition Desk to work with the health center at Rwaza, Musanze District. The Nutrition Desk made official introductions to the Rwaza Health Center staff, and the work began on 14 January 2011. The project officially concluded on 03 March 2011. OBJECTIVES The primary purpose of the work was to observe and document the changes in health for children who have been diagnosed with severe acute malnutrition and who receive the standard course of treatment of MANA’s Ready-to-Use Therapeutic Food (RUTF) over a six-week period of time. Additionally, MANA purposed to observe and quantify the acceptability of the RUTF product among the caregivers and children. METHODOLOGY, SAMPLE, AND MATERIALS The methodology included selection, measurement (quantitative), interview (qualitative), education, visual, and distribution.

• Selection – MANA requested that selected participants be between the ages of six months and thirty-six months. The participants must have been clinically diagnosed with severe acute malnutrition (based on weight for age per the child’s health card; i.e., the child’s weight for age would plot in the red area of the graph on the health card) without complications and in need of RUTF treatment. Each identified child must have a parent or guardian who would ensure that the child would be brought to the Health Center every week for monitoring and evaluation during the course of the work. After meeting with health center staff, it was decided that all participants must be HIV negative and must not be receiving other nutritional therapy from the health center. Also, all children one year of age and older must have been dewormed.

o Community Health Workers (CHW) identified the children who qualified using the above criteria. Health center staff confirmed the selections. Fifteen children were enrolled in the project; one child withdrew after the first week as the father went to the Eastern Province for work. CHW participation in this project was critical.

o Initial enrollment forms were completed for each enrolled child (see Annex 2). • Measurement – Every week, weight and middle upper arm circumference

measurements were taken for each child by the health center staff. Measurements were carefully documented by health center staff and MANA personnel. Each measurement was double-checked and confirmed (or corrected, if necessary) by health center staff and MANA personnel (see Annex 3).

• Interview – Every week, MANA personnel conducted an interview with the mother of the child. The purpose of the interview was to discuss changes in health, acceptability, challenges, and other issues as necessary (see Annex 3). Also, MANA visited the home of each child (with one exception) with a CHW during the course of the project to obtain additional qualitative information.


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• Education – Every week, MANA and/or health center staff discussed concepts of nutrition with the mothers, reinforced teaching regarding proper administration of RUTF, and answered questions and addressed concerns that may have become known.

• Visual – Every week, a photo was taken of the mother and child to document visible changes in appearance (see Annex 4).

• Distribution – Every week for six weeks, health center staff distributed the appropriate number of packets of MANA to the mother of each child. On average, the mother received twenty one packets of MANA per week.

CALENDAR OF KEY ACTIVITIES

• November 2010 – MANA submits proposal to MINISANTE • December – MINISANTE approves proposal; assigns MANA to Rwaza • 14 January 2011 – MANA meets District Hospital director and nutrition director to

inform them about the project; MANA meets with Rwaza Health Center staff (Titulaire, nurse, social worker) to discuss project, review selection criteria, and revise intake and interview forms

• 20 January – First meeting with mothers and children; take starting measurements; first distribution of MANA

• 24-25 January – Home visits (seven of fifteen children) • 27 January – Second distribution of MANA; one child withdraws from program • 3 February – Third distribution of MANA • 10 February – Fourth distribution of MANA • 17 February – Fifth distribution of MANA • 23 February – Home visits (six of fourteen children) • 24 February – Sixth (final) distribution of MANA • 3 March – Final measurements; awarding of certificates to mothers • 17 March – Awarding of certificates to health center staff and CHW

FINDINGS Summary Eleven of the fourteen children recovered from severe acute malnutrition (based on weight for age measurements). When considering MUAC measurements, there were no children in the red by the conclusion of the project.

• Average Weight Gain: 19% (6.7kg ! 8.0kg) • Average MUAC Gain: 16% (11.8cm ! 13.7cm)

Table 1: Summary Weight and MUAC results Number of Children in Each Group Weight for Age Red

<-3z Yellow

>-3z & <-2z Green

>-2z Beginning of Study 14 0 0 End of Study 3 8 3 MUAC Red Yellow Green Beginning of Study 6 4 4 End of Study 0 2 12


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Details • Characteristics of the Participant Group

The average age of the participants was 17.3 months (beginning of study) and 18.8 months (end of study). The group was evenly distributed between male (50%) and female (50%) participants.

Table 2: Age/Gender Distribution of Participants

Beginning of Study End of Study Age (months) Male Female Age (months) Male Female 6-12 4 1 6-12 2 1 13-24 2 4 13-24 4 4 25-36 1 2 25-36 1 2 Total 7 7 Total 7 7

• Weight and MUAC Measurements There were seven total measurements (baseline and end of week for six weeks) for weight and MUAC. The average for each is shown in the graph below. With regard to Week 5 for weight, it should be noted that the health center staff member who took the weight measurements is not skilled in this; the measurements for every other week were done by the health center staff member who is skilled in this area. Over the course of the six week treatment period, weight increased by an average of 19% (6.7kg ! 8.0kg) per child and the MUAC measurement increased by an average of 16% (11.8cm ! 13.7cm) per child.

Table 3: Weight and MUAC by Week, Average

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(")$ ("%$ ("%$

&&"($&)"*$

$&)"($$&*"&$

&*"!$ &*"#$ &*"#$

6.0

7.0

8.0

9.0

10.0

11.0

12.0

13.0

14.0

15.0

1 2 3 4 5 6 7

Weight (kg) MUAC (cm)


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As evidenced by the following tables, the 6-12 month old children recorded the greatest gains in both weight and MUAC, followed by the 13-24 month old children and finally by the 25-36 month old children.

Table 4: Weight Gain by Age Group Age at Beginning of Study (months)

Number of Children

Avg Starting Weight (kg)

Avg Weight Gain (kg)

Avg Weight Gain (%)

6-12 5 5.36 1.84 34.3% 13-24 6 7.07 0.97 13.8% 25-36 3 8.17 0.93 11.4% Total 14 6.69 1.27 19.0%

Table 5: MUAC Gain by Age Group Age at Beginning of Study (months)

Number of Children

Avg Starting MUAC (cm)

Avg MUAC Gain (cm)

Avg MUAC Gain (%)

6-12 5 10.80 2.54 23.5% 13-24 6 12.05 1.63 13.6% 25-36 3 12.77 1.50 11.7% Total 14 11.76 1.93 16.4%

• Nutritional Status by Age Group

All children in the study recorded gains in weight. At the beginning of the study, fourteen children were diagnosed with severe acute malnutrition based on weight for age. At the conclusion of study, three of fourteen children recovered from acute malnutrition, eight of fourteen improved from severe to moderate acute malnutrition, and three of fourteen remained in area of severe acute malnutrition. The children with severe acute malnutrition will continue with RUTF therapy, whereas the eight children who improved to moderate acute malnutrition will be admitted to a supplementary feeding program. The three children who recovered from acute malnutrition will be discharged, and the families will receive continuing nutritional education. All children in the study recorded gains in MUAC. At the beginning of the study, six children had a MUAC of 11.5cm or less (mortality index, red). By the conclusion of the study, there were no children with a MUAC of 11.5cm or less.

Table 6: Nutritional Status based on Weight for Age (health card graph) Beginning of Study End of Study

Age (months) Red <-3z

Yellow >-3z & <-2z

Green >-2z

Age Red <-3z

Yellow >-3z & <-2z

Green >-2z

6-12 5 - - 6-12 1 1 1 13-24 6 - - 13-24 2 4 2 25-36 3 - - 25-36 - 3 - Total 14 0 0 3 8 3

Table 7: Nutritional Status based on MUAC

Beginning of Study End of Study Age (months) Red Yellow Green Age Red Yellow Green 6-12 4 1 - 6-12 - 1 4 13-24 2 2 2 13-24 - 1 5 25-36 - 1 2 25-36 - - 3 Total 6 4 4 0 2 12


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• Weekly Interview with the Mother Each week, the mother of each child was interviewed to gain information about the child’s progress, product acceptability, and any challenges faced in the child’s treatment. A summary of collective qualitative observations from the mothers is presented below.

Table 8: Observations by the Mothers during the Study Before the study During and after the study

The child is weak and apathetic The child has energy The child does not have an appetitie The child has a good appetite The child is unhappy and cries a lot The child plays with energy and smiles The child’s skin is dry The child’s skin is soft and healthy The child’s hair tended to be red The child’s hair is now black The child was losing weight The child is gaining weight The child could not stand The child is walking The child was not sleeping well The child sleeps very well The mother is very tired The mother is well rested The mother’s breast milk is not enough There is more breast milk

• Organoleptic Qualities

Based on the survey results, mothers and children alike showed great appreciation for the taste of MANA’s RUTF and found it easy to use. Mothers also found the smell and texture quite enjoyable. Although not represented in this survey, one health center staff member commented that MANA’s RUTF is far better in taste and texture than the two other RUTF products (Plumpy’nut and Nutty Butta) that have been used at the health center. Importantly, mothers reported that the product is easy to use and does not have any undesirable or harmful effects such as allergy, diarrhea, or prurit for either the mother or the child. The weekly interviews conducted by the health center staff and MANA, as well as observations of the children at the health center and in the home, confirm this information.

Table 9: Organoleptic Survey Results

• Home Visits The home visits played an important role in the successful treatment of the children. At least once per week, the CHW visited the mother and child to follow up on the instruction and advice provided at the health center and to evaluate (and correct when necessary) compliance with the treatment protocol for severe acute malnutrition. MANA also visited the home of every child (with one exception). MANA’s purpose was to reinforce the education provided at the health center, inquire about compliance, and gain a deeper understanding about the complexity of factors that influence recovery rates.


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CONCLUSION The efficacy of RUTF in the treatment of severe acute malnutrition throughout sub-Saharan Africa is well documented. The quantitative results for weight and MUAC gains achieved during this study are consistent with results reported in similar studies, demonstrating the efficacy of MANA’s RUTF product for the treatment of severe acute malnutrition. Additional qualitative results also confirm MANA’s efficacy. Further, MANA’s RUTF product achieved excellent results in terms of acceptability among health care workers, mothers, and children. Acceptability is often a strong indicator of compliance and therefore success. Community Health Workers play a critical role in the identification of severe acute malnutrition and in the follow up necessary to ensure compliance with treatment. The Government of Rwanda and Ministry of Health are to be commended for their investment in these front line resources. The staff at the Rwaza Health Center with whom MANA worked on this project were informed, courteous, and helpful at all times. They treated the mothers with great respect and the children with gentleness. They sincerely appreciated the work that MANA is doing in Rwanda. RUTF is an important component of Rwanda’s strategies, policies, and plans to reduce severe acute malnutrition. The Government of Rwanda and the Ministry of Health have been supportive of the establishment of a factory to produce RUTF in Rwanda. MANA is pleased to be able to serve in this role. RECOMMENDATIONS The sample size for this project does not facilitate strong recommendations. However, observations during the project and a review of the data point to a few areas for recommended follow up.

1. It is noted from the data that the youngest age group (6-12 months) achieved the greatest gains in terms of weight and MUAC. An expanded efficacy study measuring recovery rates across age groups may be beneficial to further refine the methods in place for identifying children with severe acute malnutrition. The data would seem to indicate that treating children when they are younger (>6 and <12 months) has the greatest benefit.

2. There are currently two RUTF products in use in Rwanda. With MANA to start local production soon, that will make three RUTF products in Rwanda. A comparative acceptability study may be beneficial as acceptability is often a predictor of success.

Clarisse


Clarisse 03 March 2011

5.9 kg


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REFERENCES Community Management of Severe Acute Malnutrition: A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund, 2007. Rwanda National Nutrition Policy, October 2005. Rwanda National Protocol for the Management of Protein Energy Malnutrition, 2008 Edition. Rwanda Ministry of Health Child Health Card. World Health Organization, Management of Severe Malnutrition: A manual for physicians and other senior health workers, WHO, Geneva, 1999.


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PROJECT PROPOSAL


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INTAKE FORM FOR CHILD WITH SEVERE ACUTE MALNUTRITION


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16


17


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WEEKLY FORM FOR INTERVIEW OF MOTHER OR CAREGIVER ABOUT THE HEALTH STATUS OF THE CHILD (RECALL OF THE PAST 7 DAYS)


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PHOTOS FROM THE STUDY

Jean Marie


Jean Marie 03 March 2011

8.3 kg

Elissa


Elissa 03 March 2011

7.8 kg

Egide

+1.2 kg over six weeks


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