1. Global Health Fellowship Nutrition module

2. SAM  Defined WFH < -3z scores Visible severe wasting Nutritional edema  20 M children worldwide Most in S. Asia + sub-Saharan Africa  5-20 x higher risk death: directly or indirectly ↑ CFR in children w/ diarrhea +/or pneumonia  Largely absent from international health agenda  Few countries have national SAM policies  CTC + Facility based approach

3. CTC - Definition  Community based model for delivering care to malnourished people  Fast, effective, cost efficient assistance  Manner that empowers affected communities  Creates platform for longer-term solutions

4. Main principles Basic Public Health & Development & Flexibility  Coverage-decentralized Good access to services  Engagement w/ & participation Local communities & infrastructure  Appropriate levels of intervention Simple protocols & supplies (RUTF local) Commensurate w/ resources  Sectoral integration Smooth transitions btw in-pt and out-pt  Capacity building Local HCP + outreach/case finding, F/U  Timeliness Early intervention to prevent progression

5. CTC classification of acute malnutrition  Moderate WFH, HFA: -3< SD score <-2 No edema Treated as out-pt  Severe w/out complications WFH, HFA: SD score <-3 Edema Treated as out-pt  Malnutrition w/ complications  WFH, HRA: SC score -3 < SC <-2  Moderate or severe acute malnutrition Anorexia Life threatening clinical illness Admitted to in-pt care

6. In-patient care  ↑ risks nosocomial infections  Mother separated from family ↑ malnutrition in siblings ↓ economic activity, food security household  Expensive  Low coverage  Overcrowding in-pt facilities ↑ mortality & morbidity

7. Elements in CTC: Initial Stabilization  In-pt phase of treatment of SAM w/ complications Identify/treat life threatening problems Treat infections, electrolyte, specific micronutrient imbalances Begin feeding  D/C to out-pt therapeutic program (OTP) ASAP appetite returns Major signs infection ↕ Irrespective of wt gain or WFH  Lower Resource allocation priority than out-pt care Once sufficient resources available for good out-pt coverage Good community understanding & participation  Fundamental difference: prioritization of resources 10-15% Stabilization Centers: small, little infrastructure, 1-2 skilled staff

8. Elements of CTC: Outpatient Therapeutic Program (OTP)  Direct admissions Severe malnutrition w/out complications No period on in-pt stabilization 85% of OTP admissions (coverage) Important difference in CTC  Indirect admissions Malnutrition w/ complications Initial in-pt stabilization in SC Transferred into OTP

9. Types of treatment for acutely malnourished children  Moderate acute malnutrition Supplementary feeding program w/ take-home rations FBF (micronutrient fortified mix of soya-cereal flour + vegetable oil + salt + sugar Simple medicines (take at home )  Severe acute malnutrition w/out complications RUTF Simple medicines (take at home) Weekly check-ups + resupply of RUTF  MAM & SAM w/complications In-pt stabilization When appetite + complications controlled → OTP

10. CTC w/ RUTF  Malnourished child > 6 mos age, with appetite Standard dose of RUTF adjusted to wt Consumed at home, directly from container Minimal supervision  RUTF supplied q 2-4 wk at distribution site – take home ration $3/kg if locally produced 10-14kg or RUTF over 6-8wks

12. RUTF= Ready to Use Therapeutic Food  Energy dense mineral/vitamin enriched food  Peanuts, milk powder, sugar, oil + mineral/vitamin mix Easily consumed by children > 6mo age 23kJ/g (5.5 kcal/g)/ 500kcal/pk (92g) BID x 4-6 wks  Equivalent in formulation to F100  Promotes faster rate recovery from SAM  Oil based w/ low water activity Microbiologically safe (pt w/ HIV, chronically ill) Stores for several months  Eaten uncooked, soft/crushable Ideal for micronutrient delivery (heat labile) ↓ labor, fuel, water demands

13. RUFT=Therapeutic Food  Local production ↓ cost significantly  Local formulations: no milk/peanuts, but local grains + pulses, sesame oil  Range of protein content  Quality control, aflatoxin contamination  Vehicles for probiotics + prebiotics + antioxidants  Bind CTC w/ food security/agricultural interventions, local income generation + home based care for AIDS

14. CTC  SAM id: CHW or volunteers in community MUAC < 115 Nutritional edema Children 6-59 mos  Full assessment following IMCI Referral to in-pt or CTC w/ regular visits to health centre  Early detection + decentralized treatment prevent progression + complications

15. Coverage  Physical access, Understanding, Acceptance & Participation  Negative impact of poor coverage Malnourished don’t receive care In-pt services more visible, more demands  Essential steps Distribution sites decentralized ○ Balance w/ access, cost, practicalities ○ Dialogue w/ local communities served Negotiation w/ local communities ○ Central to success of CTC ○ Their concerns direct local program design

16. Participation Vital  Local communities & local health infrastructures from the start  May slow down initial implementation  Ultimate benefits ↓ local alienation ↓ disempowerment ↓ undermining community spirit ↑ program impact ↑ potential for successful handover

17. Protocols & Implementation  Core treatments protocols of OTP Objective: physiological & medical requirements Fixed Short & simple: 3 pages Easily taught to local HCP in 1 day  Implementation of OTP Context specific Flexibility required Staffing, # & location of distribution sites Frequency of distribution, selection of community nutrition workers Links w/ local practitioners, MOH

18. Rights & Choices  CTC programs: uphold rights of pts w/ SAM to access OTP  CTC programs: ¾ of caregivers of children w/ SAM w/ complications accepted in-pt stabilization

19. Cost Effectiveness Core expenditures & economies of scale  TFC Fixed capacity model: once center filled, others need to be built Small economies scale: central offices, logistical support  CTC High initial & fixed cost: recruit/train/equip transport mobile teams, decentralize food logistics, interact/mobilize community Expansion to thousands pts w/ only extra cost of food & medicine

20. Limitations of CTC  Decentralization Aim: >90% target pop live w/in 1 day t/f walk to site Mobile teams to sites q wk/bi monthly Access: roads, security Pop confidence in mobile teams/RUFT delivery  Low density of malnutrition Low prevalence malnutrition + highly dispersed pop Cost/benefit diminishing returns  Fragmented/absent communities (relative)  Can reduce participation, mobilization  Absence of formal health infrastructure (relative) Networks of HCP, traditional healers

21. Future Developments of CTC  Approach in areas of high insecurity, urban areas “in situ” CTC w/ CHW ↑community implementation responsibility  Implementation by local MOH/local actors on longer term basis National growth monitoring program integrated into existing health programs  ↑ demand for CTC  New RUTF recipes, lower costs, locally made for supplemental feeding

23. Evidence  80% of Children w/ SAM who have been identified through active case finding, or through sensitizing & mobilizing communities to access decentralized services themselves, can be treated at home  CFR 4.1%  Coverage ↑by 72%  Community based management of SAM. WHO, WFP, UN System Standing Committee on Nutrition, UN Children’s Fund

24. CTC  Preferred approach for emergency relief programs  Increasingly adopted for larger non emergency programs  WHO: larger-scale implementation