1. Community Case Management of Severe Acute Malnutrition in Southern Bangladesh: an Operational Effectiveness Study Date : May 12, 2011 Presented by Eric Swedberg at the CORE Group Spring Meeting, Baltimore

2. 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

3. 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)

4. 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

5. 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)

6. 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 …”

7. 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

8. 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

9. 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

10. Program approach: identifying children with SAM 261 CHWs: monitoring of nutrition (using MUAC & oedema) & health status (clinical signs) during normal activities: GMP: 0-24 months Household visits of sick children: 0-36 months Identification of SAM: MUAC < 110mm and/or Nutritional oedema

13. Severe pneumonia or

14. Diarrhea with dehydrationOutpatient Care by the CHW Inpatient Care at the UHC Classification of SAM and treatment modality in our program Upazila

15. 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

16. 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

17. 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.pdffor more information

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

21. 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

22. ‘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’

23. 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)

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