1. Global burden of acute malnutrition and the latest innovations in the field From the classical approach to the latest innovations in the field: Community-based Theurapetic Care (CTC) Eleni kakalou, MD MSc International Health-Health Crises Management 5 th Medical Department, Evangelismos General Hospital

2. FOOD IS NOT ENOUGH Without essential nutrients millions of children will die “Eating millet porridge every day is the equivalent of living off bread and water. With luck, toddlers here might have milk once or twice a week. Young children are so susceptible to malnutrition because what they eat lacks essential vitamins and minerals to help them grow, remain strong and fight off infections.” 200 million malnourished children 20 million severely malnourished children 50% of deaths attributable to malnutrition for <5yrs Dr. Susan Shepherd, MSF Medical Coordinator for the nutritional programme in Maradi, Niger

4. Causes of death in children under 5 years Source: WHO, based on C.J.L. Murray and A.D. Lopez, The Global Burden of Disease, Harvard University Press, Cambridge (USA), 1996; and D.L. Pelletier, E.A. Frongillo and J.P. Habicht, ‘Epidemiological evidence for a potentiating effect of malnutrition on child mortality’, in American Journalof Public Health, 1993:83.

5. The vicious cycle

6. Latin America and the Caribbean

7. Sub-Saharan Africa

8. Equitable growth

9. The success story

10. CTC-Pilot project 2000, Ethiopia : TFC prohibition lead to out-patient treatment Clinical outcome and effectiveness equal or better Collins and Sadler, 2002

11. CTC-development 2001 Darfur, Sudan: 25,000 pts treated 2002 Valid International, Concern FANTA/AED: formalization and 3yr research 2004-5: Maradi, Niger: MSF treated 60,000 pts with outcome that surpassed the classical approach

12. CTC principles Maximum coverage and access Timeliness Appropriate care

13. Ready–to-Use Therapeutic Food (RUTF) Late 1990’s by researcher Andre Briend and Nutriset a private company making (nutritional products for humanitarian relief) RUTF is an energy-dense mineral/vitamin-enriched food, specifically designed to treat severe acute malnutrition (Briend et al.,1999) Equivalent in formulation F100, WHO recommenede treatment of malnutrition (WHO, 1999/a) RUTF promotes a faster rate of recovery from severe acute malnutrition than standard F100 (Diop et al., 2003)

14. New classification of malnutrition Collins and Yates, 2003

15. Screening and Admission by MUAC

16. Decision chart for SPF programmes (CTC manual, Valid, 2006)

17. Community mobilization (CTC manual, Valid, 2006)

18. Admissions, exits and total number in OTP in Malawi, 2002-3 (CTC manual, Valid, 2006)

19. Health impact of malnutrition Physical growth Morbidity and mortality (Infection etc) Mental capacity Child bearing potential Chronic heart disease Diabetes Hypertension

20. Stunting and mental capacity

21. Malnutrition as a disease

22. Malnutrition: from one to generation to the next

23. Maradi, Niger 2005 MSF treated over 60,000 severely malnourished children using RUTF 38,000 severely malnourished children were treated Cure rate > 90% 4 hospitals and 17 emergency outpatient feeding centres Field Exchange. Emergency Nutrition Network. Scaling up the treatment of acute childhood malnutrition in Niger. Issue 28; July 2006

24. Scaling up to moderately malnourished children, 2006 65,000 malnourished children treated 11 Out-patient treating centers 92,5% acute moderate malnutrition in OTP (recovery rate 95.5%) 7,5% acute severe malnutrition in SC (recovery rates 81.3%) Gain weight 5.8g/Kg/day vs 3g/Kg/day Defaulter’s rate 3.4% 1. Field Exchange. Emergency Nutrition Network. Management of moderate acute malnutrition with RUTF in Niger. Issue 31; September 2007 2. A Retrospective Study of Emergency Supplementary Feeding Programmes. Dr. Carlos Navarro-Colarado. June 2007. ENN and SC UK. Available at http://www. ennonline.net/research

25. A mother’s experience “I prefer to come here once a week rather than staying in a treatment centre, because I have to take care of the fields and my other children – I have three other children at home.” “I have no-one to look after my other kids, my oldest girl is only 10 years old, I have no-one to help me. Without this place I wouldn’t have sought help, even if my child was very sick, because I can’t leave my other children alone for weeks.” Mothers of children receiving therapeutic RUF outpatient care in Magari, Niger

26. Funding At a current cost of €3 per kilo, total product cost would amount to €750 million to treat the 20 million children that WHO estimates have severe acute malnutrition. However, considering that raw materials account for at least 50% of locally produced product and that the most significant cost is powdered milk, the future cost will be higher

27. Rising price of milk

28. Cost for SAM MSF estimate based on RUTF needed to treat all cases of Severe Acute Malnutrition (258,000 tons for 20 million children at an average of 12.9 kilos per child Price per treatment: 38.7 euros, Jan 2008

29. During the emergency in Darfur in 2004, six different NGOs implemented the various components of the CTC programme in El Geneina TFC interventions were run by MSF-France and MSFSwitzerland; medical care was provided through clinics operated by MSF-Switzerland and Medair OTC was provided by Concern, Tearfund and SC-US and outreach by Medair, Concern and MSF-Switzerland Collaboration between the NGOs for coherent protocols and referral was facilitated by Valid and United Nations International Children’s Emergency Fund (UNICEF) This cooperation resulted in the decongestion of inpatient care and the more efficient use of resources. It enhanced case-finding, case follow-up and hygiene promotion Case fatality rates for severely malnourished individuals fell and programme coverage increased dramatically Source: (Walsh and Faroug, 2004) Case study 2: Collaboration in Darfur, 2004