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The PepsiCo Foundation Meeting March 31, 2008

Toby Stillman Advisor, Emergency Health and Nutrition. The PepsiCo Foundation Meeting March 31, 2008. The PepsiCo Foundation. Community-based Management of Acute Malnutrition (CMAM). Measures of Undernutrition Development Contexts.

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The PepsiCo Foundation Meeting March 31, 2008

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

  2. Measures of Undernutrition Development Contexts Is it possible to define upfront development vs. emergency context?

  3. Measures of Undernutrition Emergency Contexts Note: Cut off points for MUAC differ from agency to agency – these cut offs are consistent with MSF guidance

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

  6. Nutrition EmergenciesBenchmarks and Thresholds WHO, Management of Malnutrition in Major Emergencies, 2000

  7. Nutrition Emergencies Benchmarks and Thresholds Emergency Threshold (moderate + severe) WHO, Management of Malnutrition in Major Emergencies, 2000

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

  9. Traditional ResponseTherapeutic 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. Traditional ResponseTherapeutic Care…Cont’d Case Fatality of less than 10% *ACF breaks treatment into 3 phases. **See WHO, Management of Severe Malnutrition, 1999 for further detail.

  11. Traditional ResponseConstraints: 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. Traditional ResponseConstraints: Cross Infection • 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

  13. Traditional ResponseConstraints: Poor Coverage Health Post TFC Health Post Low Coverage/High mortality High Coverage Health Post Moderate Coverage/Moderate mortality Health Post Health Post

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

  15. Evolution of a New ApproachAdditional Screening Uncomplicated Complicated

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

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

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

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

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

  21. CMAM Impact…Cont’d Outpatient Care **See WHO, Management of Severe Malnutrition, 1999, and CTC Field Manual for further detail.

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

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

  24. CMAMEmergency to Development Emergency Threshold WHO, Management of Malnutrition in Major Emergencies, 2000

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

  26. CMAMOur Roll-Out Strategy • 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 Changed Header Here / Downplay research with Foundation

  27. CMAMSave 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

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