Menu ENN Search

Community care: addressing the management of severe malnutrition

Summary of published paper1

Bedessa TFC, Ethiopia (May 2000)

The long-held traditional approach to treating severely malnourished individuals in emergencies is challenged in a recent 'viewpoint' article published in the Lancet. Dr. Steve Collins argues that a therapeutic feeding (TF) centre's huge requirement for resources, skilled staff and imported therapeutic products makes the operation very expensive and highly dependent upon external support. Furthermore, the centralised approach to care with its high staff requirements undermine local health infrastructure, dis-empower communities, and promote the congregation of people and resulting centre-acquired infection. In addition, admission of a patient into a TF centre requires that the carer, usually a mother, leaves the family for about 30 days. Absence of a mother would be particularly damaging for younger siblings left at home.

Current practice and limitations

In Collin's considerable experience over the past 10 years, coverage of TF programmes is often low thereby limiting their overall impact. In a recent trip to Ethiopia where out of a population of 400,000 there were approximately 16,000 severely malnourished children (20% severe wasting), it would have been necessary to establish 40 TF centres based on international standards of 100 per feeding centre. This would have necessitated employing 40 skilled centre managers, at least 20 logisticians, 160 nurses and 400 carers. In the event, the TF centre programme took several months to become operational and never reached this sort of scale. There was a similar picture elsewhere in Ethiopia with coverage limiting impact of many agency TF programmes. By September 2000 many agencies had finally started programmes (2 months after the peak of the nutritional crisis). The article also points out that SPHERE standards do not include indicators for programme coverage nor indicators to assess the negative impacts on health infrastructure and communities. Collins advocates Community Based Therapeutic Care (CBTC) as an alternative.

The components of CBTC

CBTC aims to treat the majority of people with severe acute malnutrition in their homes. This type of care combines the management of malnourished children using outreach workers and the 'Hearth' method of home-based nutrition education and support. The author asserts that the Hearth method has been very successful in rehabilitating children with chronic malnutrition in several less developed countries. The approach uses mothers from the community who are selected on the basis of their ability to raise well-nourished children even in the face of poverty. CBTC would combine these two features and in addition utilise the newly developed Ready to Use Therapeutic Food (RUTF), specially designed to treat severe malnutrition in the community. RUTF is nutritionally equivalent to F100 but is a paste that patients can eat directly from the packet. Trials have shown RUTF to be popular and highly resistant to contamination. It is prepared from peanuts, dried skimmed milk, sugar and a specially formulated mineral and vitamin premix (CMV). All the ingredients apart from the CMV are available in the vast majority of less developed countries.

Phasing in CBTC

The article states that during the first few weeks of an emergency, there is usually little choice but to try to manage the severely malnourished in the community. Once therapeutic feeding centres become operational, CBTC would then become appropriate for patients in the rehabilitation phase of treatment. This normally lasts from day 7 until discharge and includes about 75% of patients. During rehabilitation a patient's metabolism has stabilised, appetite has returned and any infections are under control. Treating the stabilised cases through CBTC would greatly reduce need for TF centres allowing them to be smaller and therefore quicker to establish.

Experience in Ethiopia shows that a form of CBTC centre can evolve from dry Supplementary Feeding Programmes (SFPs) and can then be set up within a matter of days. Currently, in the early stages of an emergency before TF centres are established people identified as severely malnourished at SFPs will be given a dry supplementary ration and single dose of Vitamin A, the minimum for clinical management of a moderately malnourished individual. In Ethiopia it was relatively easy to provide additional nutritional support, education and systematic medical treatment to the severely malnourished right from the outset. The severely malnourished were identified by a red wrist band and given a ration of RUTF in addition to the usual ration for supplementary feeding. Increasing the numbers of staff allowed sufficient capacity to provide soap and additional medication, e.g. a single dose of mebendazole and measles vaccination for children. In a full CBTC facility (intensive first phase with community care for rehabilitation phases) they could also be given a single dose of long acting antibiotic such as chloramphenicol in oil.

Role of the carer

Although not fully explored in an emergency, transition from the 'intensive SFP' piloted in Ethiopia into full CBTC would require identification of 'successful' mothers, around whom a structured community treatment and education programme could be constructed. The mothers of those children who respond well i.e. 'successful mothers' could be used as a focus to promote behavioural change in other carers. As in the Hearth method, programme staff could work with these successful mothers to establish a simple treatment plan based on the behaviours that the mothers have already used successfully. These mothers could then educate other mothers at daily meetings. Initially RUTF would have to be imported but eventually could be made locally.

Using local clinics and health posts

Ideally, CBTC could operate alongside a therapeutic feeding centre to which complicated cases could briefly be admitted for initial rehydration, antibiotics and to re-establish appetite. Initial experience in Ethiopia suggests that with appropriate support, local clinics and health posts can provide this function. Small decentralised stabilisation centres, based in local health posts, would reduce the transport problems associated with centralised feeding centres and help to 'embed' the programme within local communities. This intervention would also help ensure that some of the emergency funding went into supporting existing health infrastructure.

Mortality rates

Collins acknowledges the reality that given the usual delays before implementation and consistent low coverage of current TF centres, it is likely that CBTC will often operate without associated feeding centres. When such centres are not available, people who require TF care will be treated through CBTC and will be exposed to a higher risk of mortality than if treated in a TF centre. Currently, due to limited coverage and people's inability to access centralised TF centres the majority of severely malnourished tend to die in their homes and are not recorded in statistics, at best only appearing as defaulters from SFPs. Therefore when emergency CBTC is operating in the absence of 'stabilisation centres', reporting statistics may indicate higher mortality rates than is normally reported in therapeutic feeding programmes, particularly at the initial stages of an emergency.

Research needs

A final point made in the article is that rigorous research to compare the impact of CBTC and TF centre programmes should accompany the introduction of emergency CBTC programmes and initially it will be necessary to start with small pilot programmes.

For further information contact Dr. Steve Collins at email: steve@validinternational.org

Show footnotes

1Collins.S (2001): Changing the way we address severe malnutrition during famines: The Lancet, Vol 358, August 11th, pp 498-501.

More like this

FEX: Community-based Therapeutic Care (CTC)

Malnourished Child being fed with ready-touse therapeutic food (RUTF) Summary of published research1 Bedawacho Woreda is a district in Ethiopia, 350 km south of Addis Ababa,...

FEX: Ambulatory treatment of severe malnutrition

Severely malnourished child with father Commentary by Dr. Steve Collins Dr. Steve Collins is a medical doctor with a doctorate in nutrition during emergency operations. He is...

FEX: To TFC or to CBTF

Summary of published letter* The last issue of Field Exchange carried a summary of a published article by Steve Collins on community based therapeutic feeding (CBTF). The...

FEX: Letter on nomenclature used in malnutrition programmes, by Mike Golden

Nomenclature used in programs for tackling malnutrition Dear Editor, The following terms, inter alia, have been used in describing programs/centres. CTC Community...

FEX: Community-based Approaches to Managing Severe Malnutrition

One nutrition worker's solution to childcare at a busy feeding distribution! A three day meeting was held in Dublin hosted by Concern and Valid International between 8-10th of...

FEX: World Vision programme for severe acute malnutrition in SNNPR

By Dr. Sisay Sinamo and Dr. Gedion Tefera Dr Sisay Sinamo is Coordinator for the Health and Nutrition Coordination Unit with World Vision Ethiopia. A medical graduate from...

FEX: Technical and Management issues within CTC (Special Supplement 2)

4.1 CTC from Scratch - Tear Fund in South Sudan By Ed Walker (Tearfund) Beneficiaries collecting their general ration in South Sudan. Tearfund has been working in Northern...

FEX: Outpatient therapeutic programme (OTP): an evaluation of a new SC UK venture in North Darfur, Sudan (2001)

Summary of internal evaluation1 by Anna Taylor (headquarters nutrition advisor for SC UK) North Darfur experienced a severe drought in 1999 and 2000. This caused widespread...

FEX: ACC/SCN Working Group on Nutrition in Emergencies

The annual UN ACC/SCN meeting was held in Nairobi, Kenya between 2-5 April 2001. The Working Group on nutrition in Emergencies meeting was held on the 5th. Highlights of the...

FEX: Ethics of use of ready-to-use-therapeutic foods

Dear Editor, I have been following the debate on the ethics surrounding the research on Community Therapeutic Care (CTC) and Ready to Use Therapeutic Foods (RUTFs), and was...

FEX: Valid Nutrition

Name Valid Nutrition Address CuibĂ­n Farm, Derry Duff, Bantry, Co. Cork, Ireland Chief Executive Officer: Derek Staveley Phone +353 86 7809541 Chair of Trustees...

FEX: Introduction (Special Supplement 2)

Glossary ACF Action Contre la Faim CHA Community Health Assistant CHAM Christian Health Association of Malawi CNW Community Nutrition Worker CTC Community Therapeutic...

FEX: Ambulatory treatment of severe malnutrition in Afghanistan

By Emmanuelle Lurqin Emmanuelle is a paediatric nurse and since 2000, has worked with MSF Belgium on nutrition programmes in Angola, Burundi, and Afghanistan. She is currently...

FEX: An Ongoing Omission: Adolescent and Adult Malnutrition in Famine Situations

By Peter Salama and Steve Collins. (December '98) A boy sits under a tree awaiting a distribution by the UN World Food Programme in the southern village Acum Cum. The food is...

FEX: The Risks of Wet Feeding Programmes

The author of this article, Steve Collins is a medical doctor. During the autumn of 1996 he was Oxfam's health team leader in Liberia. This article is based upon his...

FEX: Integration of CTC with strategies to address HIV/AIDS (Special Supplement 2)

By Paluku Bahwere, Saul Guerrero, Kate Sadler & Steve Collins (Valid International) The district health officer of Dowa, Malawi, briefs clinic and community workers about the...

FEX: CTC from Scratch - Tear Fund in South Sudan (Special Supplement 2)

By Ed Walker (Tearfund) Beneficiaries collecting their general ration in South Sudan. Tearfund has been working in Northern Bahr el Ghazal, southern Sudan, in the nutrition...

FEX: CTC Approach (Special Supplement 2)

by Steve Collins (Valid International) 2.1 Main principles of CTC Community Therapeutic Care (CTC) is a community-based model for delivering care to malnourished people. CTC...

FEX: Effectiveness of Integrated Outpatient Care of Severe Acute Malnutrition in Ethiopia

By Martin Eklund and Tsinuel Girma Martin Eklund holds an MSc in Clinical Nutrition from the University of Copenhagen. His specialisation is community-based management of...

en-net: Treatment of malnourished adults and the elderly

Could anyone provide references on treatment of severely malnourished adults and/or the elderly? I'm particularly looking for evidence of the impact of programmes on a large...

Close

Reference this page

Community care: addressing the management of severe malnutrition. Field Exchange 14, November 2001. p3. www.ennonline.net/fex/14/community

(ENN_3539)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.