1. Results Monitoring (B) - Tracking The PepsiCo Foundation Meeting March 31, 2008 The PepsiCo Foundation Community-based Management of Acute Malnutrition (CMAM) Toby Stillman Advisor, Emergency Health and Nutrition

2. Page 2 Measures of Undernutrition Development Contexts Stunting (Chronic) Underweight (Both)Wasting (Acute) IndexHeight for AgeWeight for Age Weight for Height or MUAC Moderate< -2 SD Severe< - 3 SD Is it possible to define upfront development vs. emergency context?

3. Page 3 Measures of Undernutrition Emergency Contexts Stunting (Chronic) Underweight (Both) Wasting (Acute) IndexH/AW/AW/H or MUAC Moderate< -2 SD Severe< - 3 SD Note: Cut off points for MUAC differ from agency to agency – these cut offs are consistent with MSF guidance

4. Page 4 Stunting (Chronic) Underweight (Both) Wasting (Acute) IndexH/AW/AW/H or MUAC Moderate< -2 SD Severe< - 3 SD Severe Acute Malnutrition (SAM) Measures of Undernutrition Emergency Contexts Note: Cut off points for MUAC differ from agency to agency – these cut offs are consistent with MSF guidance

5. Page 5 Measures of Undernutrition Severe Acute Malnutrition Marasmus (gross wasting) Kwashiorker (oedema) Case Fatality of 20% to 30% Case Fatality of 50% to 60% This page repeated later, but took it out

6. Page 6 Nutrition Emergencies Benchmarks and Thresholds WHO, Management of Malnutrition in Major Emergencies, 2000 SeverityPrevalence of Acute Malnutrition Acceptable< 5 % Poor5 – 9 % Serious10 – 14 % Critical> = 15 %

7. Page 7 SeverityPrevalence of Acute Malnutrition Acceptable< 5 % Poor5 – 9 % Serious10 – 14 % Critical> = 15 % Emergency Threshold (moderate + severe) Nutrition Emergencies Benchmarks and Thresholds WHO, Management of Malnutrition in Major Emergencies, 2000

8. Page 8 Screen the population Children with Moderate Malnutrition Supplementary Feeding Program Children with Severe Malnutrition Therapeutic Feeding Center (TFC) Recovered No Malnutrition Nutrition Emergencies Traditional Response

9. Page 9 Traditional Response Therapeutic Care Inpatient care in a –Pediatric ward –Nutrition rehabilitation unit (NRU), or –Therapeutic feeding center (TFC) Global standards call for: –No more than 50 beds per TFC –1 Nurse –2 trained health workers –1 nursing aid for every 10 children

10. Page 10 Phase I – Stabilization*Phase II – Rehabilitation TreatmentAntibiotic, Anti-malarial, Vitamin A, etc.** CareAttend to complications (e.g. shock, hypoglycemia)** FeedF-75 Therapeutic MilkF-100 Therapeutic Milk Quantity135ml/kg/day**200ml/kg/day** Length of Time1-7 Days,3 to 4 Weeks *ACF breaks treatment into 3 phases. **See WHO, Management of Severe Malnutrition, 1999 for further detail. Case Fatality of less than 10% Traditional Response Therapeutic Care…Cont’d

11. Page 11 Traditional Response Constraints: Labor Intensive Inpatient care in a –Pediatric ward –Nutrition rehabilitation unit (NRU), or –Therapeutic feeding center (TFC) Global standards call for: –No more than 50 beds per TFC –1 Nurse –2 trained health workers –1 nursing aid for every 10 children

12. Page 12 Inpatient care in a –Pediatric ward –Nutrition rehabilitation unit (NRU), or –Therapeutic feeding center (TFC) Global standards call for: –No more than 50 beds per TFC –1 Nurse –2 trained health workers –1 nursing aid for every 10 children Traditional Response Constraints: Cross Infection

13. Page 13 High Coverage Moderate Coverage/Mode rate mortality Low Coverage/High mortality TFC Health Post Traditional Response Constraints: Poor Coverage

14. Page 14 Evolution of a New Approach CMAM: 1998-99 Development of PlumpyNut–a Ready to Use Therapeutic Food (RUTF) equivalent to F-100 South Sudan

15. Page 15 UncomplicatedComplicated Evolution of a New Approach Additional Screening

16. Page 16 Screen the population Children with Moderate Malnutrition Supplementary Feeding Program Children with Severe Malnutrition Therapeutic Feeding Center (TFC) Recovered No Malnutrition Review Traditional Response

17. Page 17 Screening Children with Moderate Malnutrition Supplementary Feeding Program No Malnutrition Children with Severe Malnutrition No ComplicationsComplicationsOutpatient Therapeutic Care Inpatient Therapeutic Care Review: New Approach–CMAM

18. Page 18 CMAM Coverage TFC Health Post Moved this slide up

19. Page 19 Screening Children with Moderate Malnutrition Supplementary Feeding Program No Malnutrition Children with Severe Malnutrition No ComplicationsComplicationsOutpatient Therapeutic Care Inpatient Therapeutic Care 85% can be treated as outpatients CMAM Impact

20. Page 20 Screening Children with Moderate Malnutrition Supplementary Feeding Program No Malnutrition Children with Severe Malnutrition No ComplicationsComplicationsOutpatient Therapeutic Care Inpatient Therapeutic Care Time in hospital reduced considerably CMAM Impact…Cont’d

21. Page 21 Phase I – StabilizationPhase II – Rehabilitation TreatmentAntibiotic, Anti-malarial, Vitamin A, etc.** CareAttend to complications (e.g. shock, hypoglycemia)** FeedF-75 Therapeutic MilkRUTF Quantity100kcal/kg/day**200kcal/kg/day** Length of Time1-7 Days,3 to 4 Weeks **See WHO, Management of Severe Malnutrition, 1999, and CTC Field Manual for further detail. Outpatient Care CMAM Impact…Cont’d

22. Page 22 Better than traditional approach CMAM Outcomes from CTC 2000 - 2003, (n = 7,408), & TFCs 1992-1998 (n= 11,287) against SPHERE minimum standards 0% 25% 50% 75% 100% 77%5%11%7% SPHERE 75%10%15%0% TFC 65%12%18%5% recovereddieddefaultLTF CMAM Does it Work?

23. Page 23 CMAM (70%) Traditional (30%) Coverage Increases Dramatically CMAM Does it Work?...Cont’d

24. Page 24 WHO, Management of Malnutrition in Major Emergencies, 2000 SeverityPrevalence of GAM Acceptable< 5 % Poor5 – 9 % Serious10 – 14 % Critical> = 15 % Emergency Threshold CMAM Emergency to Development

25. Page 25 Rainer Gross, Patrick Webb Lancet 2006; 367: 1209–11 Static rates exceed emergency thresholds CMAM Emergency to Development

26. Page 26 Roll out CMAM protocols at national level across the globe –Technical support for revision of protocols and training –Cash for RUTF Conduct ongoing research –Alternative formulations of RUF –Local Production of RUF –Impact of RUF, and appropriate formulations for: HIV+ Moderate malnutrition Prevention of malnutrition CMAM Our Roll-Out Strategy Changed Header Here / Downplay research with Foundation

27. Page 27 CMAM Save the Children Portfolio Support national level guideline –Adaptation and roll out in: Mozambique, Pakistan, Bangladesh, and Haiti. –Need for adaptation and roll out in India, Nigeria, and Mali Pilot activities adapting protocols to address needs of HIV+ in: Uganda, Ethiopia, and Malawi – “Food by Prescription” Ongoing emergency programming: Ethiopia, Darfur, Pakistan and through SCUK in Niger Large scale effectiveness trial: Impact of Ready to Use Foods on chronic malnutrition in Malawi