1. Use Of RUTF in Maradi, Niger 2001 – 2007 From treatment to prevention of acute severe malnutrition

2. Context The programme strategies have evolved over time –2001 – 2005 : ambulatory care for severely malnourished children –2006 and 2007 : prevention (and treatment) of severe malnutrition

3. Guidan Roumji, Niger Algeria Mali Burkina Faso Benin Nigeria Tchad Libya Niger Population in Guidan Roumji about 400 000

4. Guidan Roumji, Maradi region High prevalence and high incidence of malnutrition ( Maradi region : Stunting : 62.2%, wasting 11.6%, underweight : 54%, MICS III, February 2006) High mortality among children less than 5 years old ( under 5 mortality rate :198 % o, MICS III, 2006 )

5. Seasonality severe malnutrition

6. Young children are affected

7. 2002-2004: growing knowledge on the use of RUTF in the treatment of severely malnourished 2005: major crisis year, validates use on large population Management of severe malnutrition

8. Management of SAM with RUTF –Allows much more patients to be treated –Significantly reduces lethality in program –Only co-morbid patients are admitted in hospital: better use of medical resources

9. Management of SAM with RUTF Remaining problems –High number of severe malnourished children to take in charge every year –Still a significant number of deaths in the program –Many deaths not taken in charge within moderately malnourished? Better strategy? Treatment of moderate malnourished Prevention of SAM

10. Passive recruitment Admission criteria : NCHS : W/H < 80% All children are managed by medical personnel –Clinical screening (+ syst. RT for malaria) –Vitamin supplementation –No systematic antibiotics All malnourished children receive RUTF (184 g Plumpynut  per day ) All sick children hospitalized Others are sent home Treatment of moderately affected

11. Moderate malnutrition Niger 2006 High incidence 32 262 admissions all over the year ( estimation of 65 000 under 3 children in Guidan Roumji) Results 32,254 discharged, all screened by medical personnel Exit criteria : 2 consecutive weeks, W/H > 80% Cured rate : 95.5% Weight gain ( g/kg/day) : 5.3 ( 5.25 ;5.32) Mean length of stay ( days) : 31.4 (31.3;31.6)

12. Moderate malnutrition Niger 2006 Too much for a health system to run –Lacking medical HR –Difficult supervision No obvious need for individual medical follow-up for all children Not the solution for a region with so high incidence  New strategy to give low dose RUF to non- malnourished children to prevent malnutrition

13. Systematic distribution in 2007 Screening of all under 3 children organized before hunger gap period (over 62,000) Systematic distribution of RUF (46 g of Plumpydoz  / day ) every month for 6 months All severely malnourished treated as previous years Admission criteria WHO 2005 W/H < -3Zscore

15. Preventive distribution in 2007 62 878 children 6 months to 3 years, not severly malnourished received RUF 7258 admited to therapeutic program (severe WHO 2005) –Cure rate : 90% –1532 were severly malnourished according to NCHS

16. Preventive distribution The beneficiaries had to walk about 7km each way (14km) with their children in order to access the RUSF each month. The best way to evaluate the value placed upon this intervention by the population is to examine the drop-out rate from month to month as the program proceeded.

17. BeneficiariesDrop out Month##% May62,92200.0 June62,902200.0 July62,865570.1 August62,7561660.3 September62,6802420.4 October61,9619611.6 Defaulter rate in the distribution

18. Cases and new cases of SAM MonthTOTALNormalSevereNew severe 2007##%#%#% May49,24833,737692000.42000.41 June56,17240,784732040.41360.24 July60,60547,089781250.2300.05 Aug61,50647,646771080.2120.02 Sept61,85845,472741290.2180.03 OCT60,55642,529701470.2370.06

19. Cluster randomised trial RUSF vs no prevention Looking objectively into the reduction of incidence of wasting ( + effect on stunting) Mike Golden’s initial analysis Observational datas from the program : –Reduction in number of severely malnourished children admitted with increased operational capacity –Reduction in need for hospitalisation Does prevention work?

20. W/H<60%

21. Relative severity of SAM (% complicated cases)

22. Analysis Sources of data to evaluate the impact 1.The village study 2.The MUAC values of the intervention group 3.The Admissions for treatment

23. The village study 12 villages were selected in 2006 6 were intervention villages and 6 control 3 of the intervention and 3 of the control were in Guidan Roumdji, the remainder were in Madarounfa Zones of Maradi region.

24. The village study The children in the intervention villages received one sachet of RUTF (Plumpy’nut) each day over the latter part of the “hungry season”: August, September and October. The teams took, inter alia, anthropometric data each month from all the children in each village Any child with malnutrition was referred for treatment. In April 2007 the 3 “control” villages in the Guidan Roumdji received another intervention (RUSF)

25. The village study The children of 6 to 36 months from each group were selected for analysis The weight-for-height, height-for-age and weight-for-age were computed using the NCHS standards. Less than <-2 Zscore was defined as global malnutrition and <-3 Zscore as severe malnutrition for this analysis. The mean and SD of the monthly data for each village and group used to compute the global and severe wasting prevalence, after checking that the data were normally distributed (Wilks Shapiro test).

26. Longitudinal prevalence of Global wasting in

28. The groups were comparable at the start of the intervention The expected peak in GAM and SAM were ameliorated by intervention The prevention of malnutrition during the “hunger season” resulted in a prolonged improvement of the status of the intervened population

29. Stunting prevalence was not the same at baseline in the two groups of villages

30. The effect was more pronounced for severe stunting which improved significantly. The lag in the peak of stuting vs the peak in wasting is frequently seen and is clearly illustrated here

31. The Community Study Guidan Roumdji

32. Data from Guidan Roumdji In Guidan Roumdji all the children of over 60 cm who were less than 3 years old were enrolled in a mass- intervention. They were each given 4 pots of RUSF (Plumpy’Doz) each month for 4 months over the hungry season. This amounted to an intake of about 42g/d

34. Village study data - GAM

36. There was a marked reduction in wasting and severe wasting in the villages that received the RUSF distribution each month. There was no change in the prevalence of stunting or severe stunting. The level of underweight mirrored that of low weight-for-height.

37. What happened in the whole of the Intervention area (of which the study villages were a part)? Guidan Roumdji

40. Costs per patient

41. Costs and feasibility

42. Conclusion RUTF is very efficient in treating SAM –Increased number of patients –High cure rate RUF prevent the appearance of SAM –Reduction of total number of severe cases –Reduction of the complicated cases ( admissions that require hospital stay) RUF preventive distribution could have an impact on the under 5 mortality

43. Conclusion In our opinion : enough evidence today to increase the use of fortified spread Especially in high burden areas Need more research : –Comparison of products and dosage –Demonstrate the impact on the under 5 mortality Cost reduction of RUTF? New cheaper products with same effectiveness! Increased funding !