Community Case Management of Severe Acute Malnutrition in Southern

Bangladesh: an Operational Effectiveness Study

Date : May 12, 2011Presented by Eric Swedberg at the CORE Group Spring

Meeting, Baltimore

Study Team & Acknowledgements

• Co-investigator Committee - Prof. Fatima Parveen Chowdhury, Prof. Sayed Zahid Hossain, Dr. Rokeya Sultana and Dr. Syed Khairul Anam

• Investigators- Kate Sadler, Chloe Puett, Golam Mothabbir and Mark Myatt

• Others – Iman Nahil, Hasan Ali, Osman Gani Siddique, Dr. Sohel Rana, Kelly Stevenson, Margarita Clarke, Paige Harrigan and Hanqi Luo

• Funding – GAIN and PepsiCo Foundation

Child Malnutrition in Bangladesh

• Acute malnutrition is the severest form of undernutrition with the highest risk of mortality and morbidity

• Severe acute malnutrition (SAM) is defined by wasting (a low MUAC or weight for height measurement) and/or nutritional oedema

• Bangladesh has the fourth highest number in the world of children suffering from severe acute malnutrition (approx 500,000 annually)

Nutrition Programming in Bangladesh

– Nutrition programs over the last 20 years have been large community-based projects that have focused on

– Behaviour Change Communication – Growth monitoring and Promotion– Defining undernutrition with weight for age i.e.

no mechanism for identifying SAM at community level.

– Severe acute malnutrition treated as a rare problem for inpatient settings (doctors) only

– This probably means that a lot of SAM has gone unidentified and untreated

National Strategy for SAM in Bangladesh

– This has focused on using the facility-based management protocol/adopted WHO protocol. In other countries there have been challenges with this:

• Inpatient units often resource constrained » Number of children with SAM exceed inpatient

capacity• Opportunity costs for patients are high• Patients present late, often very sick with

complications• Risky environment (ie risk of acquiring

infection is high)

Community-based Management of Acute

Malnutrition • Community-based Management of Acute

Malnutrition (CMAM) has been developed and tested (largely across Africa) over the past 8 years to address these problems.

• It combines – Inpatient management of cases of SAM with

complications– Outpatient management of cases of SAM without

complications and – Uses new ready-to-use foods, for cases that have no

complications

– WHO, WFP, UNSCN and UNICEF gave their strong support to the approach in 2007 with a joint statement on CMAM

“ …. If properly combined with a facility-based approach <cut> community-based management of severe acute malnutrition could prevent the deaths of hundreds of thousands of children …”

Community-based Management of Acute

Malnutrition • Bangladesh wanted to

assess the effectiveness of such an approach in this context and how it might best be integrated into current health service delivery.

• Through the Director General of Health Services:– A team of co-investigators was

formed from the Institute of Public Health and Nutrition in Bangladesh; the Research and Planning Unit of the Directorate General Health Services; the Regional Medical College (Barisal) and the District Health Authority.

– Provided support to the study implementers; Tufts and Save the Children

CCM of SAM: a new approach• Community Health Workers (CHWs)

– Not just screening and referral but..– Effective assessment and treatment of SAM– Package that integrated identification/treatment of SAM with

CCM of illness• Feasible in the context of poor access to clinics and

hospitals by the poor• Feasibly scaled up• Complement and improve the recently endorsed

national guidelines for management of severely malnourished children

Study Objective & Research Questions

• To examine the operational effectiveness of enabling existing CHWs to identify and treat children over the age of 6 months suffering from uncomplicated severe acute malnutrition (SAM) without the need for referral to facility-based inpatient health services.

– Examine the effectiveness (i.e. the rate of recovery) and cost effectiveness of treatment of SAM provided by CHWs and of that provided by the standard of care for SAM in areas that are not yet delivering CCM of childhood illness.

– Evaluate coverage of the intervention– Evaluate the quality of care delivered by the CHW

Program approach: identifying children with SAM

• GMP: 0-24 months• Household visits of sick

children: 0-36 months

Identification of SAM:• MUAC < 110mm and/or• Nutritional oedema

Participants practicing edema assessment during the training program

261 CHWs: monitoring of nutrition (using MUAC & oedema) & health status (clinical signs) during normal activities:

Classification of SAM and treatment modality in our program Upazila

SAM with NO complications SAM WITH complications

Age ≥ 6 monthsMUAC < 110mm and/or bilateral edema

Good Appetite

AND

Clinically well.If infection is present it is mild. For example:·Pneumonia that is not classified as severe· Diarrhoea with no dehydration

Poor Appetite

AND/OR

Clinically unwell. For example:· Any of the IMCI general danger signs or·Severe pneumonia or· Diarrhea with dehydration

Outpatient Care by the CHW Inpatient Care at the UHC

Management of children with SAM

Community-based management• SAM with complications:

– Inpatient phase 1 according to national guidelines – F75 100 kcal/kg/day

– Gradual introduction of RUTF and discharge to the CHW to complete treatment

• SAM with no complications managed by CHW– RUTF 200 kcal/kg/day– Counsel on feeding and caring practices– Follow up weekly at home

• Discharged cured at 15% weight gain

Facility based management• Inpatient dietary management according to

national guidelines

Effectiveness: data collection

• Monthly monitoring database– Recovery, mortality etc

• Interviews and FGDs with carers of SAM children

• Child card data:– Demographic and nutritional

characteristics at admission– MUAC and weight gain for

different levels of malnutrition– Length of stay

Coverage: data collectionSQUEAC (semi quantitative evaluation of access & coverage)

• A two-stage assessment in April 2010:– STAGE 1 : Using routine

program monitoring data, already available data and qualitative data to hypothesize level of program coverage

– STAGE 2 : Test hypothesis using small-area surveys.• See

http://www.brixtonhealth.com/SQUEAC.Article.pdf for more information

Preliminary Results (1): Community Case Management of SAM (Jun09-10)

Preliminary Results (2): Community Case Management of SAM(Jun09-10)

Exits Intervention area n=724 SPHERE International

StandardsNo. Percentage

Successfully discharged (cured)

665 91.9% >75%

Defaulter 54 7.5% <15%Death 01 0.1% <10%Non-responder 04 0.6%

Weight gain (g/kg/day) 6.7 (SD = 0.1) >5g/kg/dayLength of stay (days) 37.4 (SD=0.6)

Overall coverage 89.0% (95% CI = 78.0% - 95.9%)

>50%

• Total children (6-36 months) in study : 724 (711 children with MUAC <110mm, and 13 children with edema )

Exploring high recovery and low mortality

• Early identification and early treatment of SAM and early & appropriate treatment of Illness– Less complications– Easier to treat– Very few referrals to

inpatient care

Distribution of MUAC at admission for the period June 09-June 10 (n=718)

Exploring early presentation and high coverage

• Multiple pathways to treatment– Very decentralized CHW network using MUAC tapes

during daily activities• GMP• Home visits to sick children• Watch-list

– Good interface between the community, community level health practitioners and the program• CHWs recruit carers to find cases• Health assistants, village doctors and TBAs refer children to the

CHW

‘I am very happy to have this program. We can treat the SAM children. Before this we had no idea. We used to go to the health assistant but he also had no proper idea. We all thought it was a strange disease. No knowledge. No prevention. No treatment. Now we prevent SAM and now we treat SAM’

Exploring early presentation and high coverage (2)

• Community mobilization around SAM– Etiologies understood by carers matched program

messages– Able to recognize SAM

• SAM as a treatable condition

• Program quality– CHWs trusted by community– No drug or RUTF stockout– Small caseloads (2-4 cases on average)

Preliminary Results (3): Facility-based Care of SAM (Aug09-Apr10)

  Referred (n=633) Treated (n=61) % (n) % (n)OutcomeCure 1.4% (9) 14.8% (9)Defaulter 7.9% (50) 82.0% (50)Non responder 0.3% (2) 3.2% (2)Refused Hospital Referral 52.9% (335) -Outpatient treatment only 37.4% (237) -

In the second phase of the CCM of SAM rollout all children identified with SAM in this Upazila are now eligible for treatment by CHWs with RUTF.

Exploring low uptake and high default

Aspect Sl.# Description 1 No one to carry on and look after household activities 2 Husband was not present at home 3 Husband did not give permission to go to hospital

Social and cultural

4 Faith in traditional healer and treatment

5 No adequate money to meet the transport expenses 6 No money for purchasing medicine Economic 7 Hospital was far away from household

8 Hospital does not provide adequate treatment 9 Dirtiness of the hospital 10 No bed facilities 11 Doctors and Nurses do not behave well 13 Hospital does not provide hygienic food (Quality) 14 Hospital does not provide adequate food (Quantity) 15 Low quality medicine are provided

Governance & Management

16 Doctors and Nurses are not available in time

Others 17 Do not know the way to hospital

• Bed and staff capacity

• Carer perception of hospital-based treatment

Summary• In this context a purely facility-based approach for the treatment of

SAM is not feasible nor acceptable to participants • Community-case management of SAM, that combines outpatient and

inpatient treatment, can be an extremely effective strategy to ensure timely treatment to a very high proportion of cases.

• Several aspects of program design are important for effectiveness including:– Very decentralized CHW network and multiple pathways to treatment that

supported early identification and treatment of cases– A very small number of cases that require inpatient treatment– Use of a CHW cadre supported a good interface between program and

community and a high level of mobilization around SAM– Quality of program and of care delivered by CHWs ….