Acute malnutrition is an underlying factor in almost 50% of the 10 to 11 million children under 5 years of age who die each year of preventable causes. Inpatient treatment for severe acute malnutrition is associated with high opportunity and economic costs for affected families and health service providers. Community-based therapeutic care attempts to address these problems and to maximize population-level impact through improving coverage, access, and cost-effectiveness of treatment.
The community-based therapeutic care model
Community-based therapeutic care programs provide effective care to the majority of acutely malnourished people as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. People with severe acute malnutrition without medical complications are treated in an outpatient therapeutic program with ready-to-use therapeutic food and routine medication. Those suffering from severe acute malnutrition with medical complications are treated in an inpatient stabilization center according to standard World Health Organization protocols until they are well enough to be transferred to the outpatient therapeutic program.
Impact of community-based therapeutic care programs
Twenty-one (21) community-based therapeutic care programs were implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005. These programs, which treated 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients. Initial data indicate that these programs are affordable, with the cost-effectiveness of emergency community-based therapeutic programs varying from US$12 to US$132 per year of life gained.
BlackREMorrisSSBryceJ. Where and why are 10 million children dying every year?Lancet2003;361:2226–34.
2.
CaulfieldLERichardSABlackRE. Undernutrition as an underlying cause of malaria morbidity and mortality in children less than five years old. Am J Trop Med Hyg2004;71:55–63.
3.
RiceALSaccoLHyderABlackRE. Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. Bull World Health Organ2000;78:1207–21.
4.
PelletierDLFrongilloEA. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr2003;133:107–19.
5.
UNICEF. The State of the World's Children2005. New York: UNICEF.
International Institute of Population Sciences and ORC Macro. National Family Health Survey (NFHS2), 1998–99. 2000. Mumbai, India: International Institute of Population Sciences.
ManaryMJNdkehaMJAshornPMaletaKBriendA. Home based therapy for severe malnutrition with ready-to-use food. Arch Dis Child2004;89:557–61.
11.
PelletierDL. The relationship between child anthropometry and mortality in developing countries: implications for policy, programs and future research. J Nutr1994;124:2047S–81S.
12.
ChenLCChowdhuryAHuffmanSL. Anthropometric assessment of energy-protein malnutrition and subsequent risk of mortality among preschool aged children. Am J Clin Nutr1980;33:1836–45.
13.
BriendAHasanKZAzizKMHoqueBAHenryFJ. Measuring change in nutritional status: a comparison of different anthropometric indices and the sample sizes required. Eur J Clin Nutr1989;43:769–78.
14.
BairagiR. On validity of some anthropometric indicators as predictors of mortality. Am J Clin Nutr1981;34:2592–4.
15.
SchofieldCAshworthA. Why have mortality rates for severe malnutrition remained so high?Bull World Health Organ1996;74:223–9.
16.
GoldenM. The effects of malnutrition in the metabolism of children. [Review]. Transactions of the Royal Society of Tropical Medicine & Hygiene1988;82:3–6.
17.
GoldenMHN. Severe Malnutrition. The Oxford Textbook of Medicine. Oxford: Oxford University Press1996:1278–96.
18.
AhmedTAliMUllahMM. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet1999; 353:1919–22.
19.
GoldenMHNBriendA. Treatment of severe child malnutrition in refugee camps. Eur J Clin Nutr1993;47.
20.
PrudhonCBriendALaurierDGoldenMHNMaryJY. Comparison of weight- and height- based indices for assessing the risk of death in severely malnourished children. Am J Epidemiol1996;144:116–23.
21.
CollinsSSadlerK. Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study. Lancet2002;360:1824–30.
22.
Sphere Project Team. The Sphere Project: Humanitarian charter and minimum standards in disaster response. Geneva: The Sphere Project, 2004.
23.
UNICEF. Strategy for improved nutrition of children and women in developing countries. 1990. Geneva: WHO.
24.
CollinsS. Community-based therapeutic care: A new paradigm for selective feeding in nutritional crises 48. 2004. London: Humanitarian Practice Network. Overseas Development Institute. Network Paper.
25.
KharaT and CollinsS. Community-based Therapeutic Care (CTC). Valid International. 2. 2004. Oxford, UK: Emergency Nutrition Network. Special Supplement Series.
26.
MyattMFelekeTCollinsSSadlerK. A field trial of a survey method for estimating the coverage of selective feeding programs. Bull World Health Organ2005;83:20–6.
27.
Van DammeW. Medical assistance to self-settled refugees. Guinea 1990–1996. 1–249. 1998. Antwerp, ITG Press.
28.
Van DammeW. Medical assistance to self-settled refugees. Guinea (letter). Lancet2002;359:260–1.
29.
JhaPBangouraORansonK. The cost-effectiveness of forty health interventions in Guinea. Health Policy Plan. 1998;13:249–62.
30.
WHO. Report of an informal consultation on the community-based management of severe malnutrition. 2006. Geneva: WHO.
31.
AshworthAKhanumS. Cost-effective treatment for severely malnourished children: what is the best approach?Health Policy Plan1997;12:115–21.
32.
MyattMKharaTCollinsS. A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food Nutr Bull2006;27(Suppl):S7–23.
33.
GuerreroS and MollisonS. Engaging communities in emergency response: the CTC experience in Western Darfur. Humanitarian Exchange30, 20–22. 2005. London, UK, Overseas Development Institute.
34.
GrelletyY. Management of severe malnutrition in Africa. 2000. Ph.D. Thesis. University of Aberdeen.
35.
CollinsSYatesR. The need to update the classification of acute malnutrition. Lancet2003;362:249.
36.
NabarroDMcNabS. A simple new technique for identifying thin children: a description of a wallchart which enables minimally trained health workers to identify children who are so thin, or wasted, that they require immediate nutritional help. J Trop Med Hyg1980;83:21–33.
37.
BandaweCRKabwaziN. Cultural and ethical considerations of Community Therapeutic Care (CTC). In: Report of an Interagency Workshop on community-based approaches to managing severe malnutrition. 2003. Oxford, UK: Emergency Nutrition Network.
38.
HendersonRHSundaresanT. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bull World Health Organ1982;60:253–60.
39.
BoelaertMDavisALe LinB. Nutrition guidelines. Paris: Medecins sans frontieres, 1995.
40.
ValadexJJ. Assessing child survival programs in developing countries - Testing Lot Quality Assurance Sampling. Boston, Mass, USA: Harvard University Press, 1991.
41.
SadreMDonosoG. Treatment of malnutrition. Lancet1969;2:112.
42.
LawlessJLawlessMMGardenAS. Admissions and mortality in a children's ward in an urban tropical hospital. Lancet1966;2:1175–6.
43.
CookR. Is hospital the place for the treatment of malnourished children?J Trop Pediatr Environ Child Health1971;17:15–25.
44.
KingKWFougereWWebbREBerggrenGBerggrenWLHilaireA. Preventive and therapeutic benefits in relation to cost: performance over 10 years of Mother-craft Centers in Haiti. Am J Clin Nutr1978;31:679–90.
45.
BeghinIDViteriFE. Nutritional rehabilitation centres: an evaluation of their performance. J Trop Pediatr Environ Child Health1973;19:403–16.
46.
Beaudry-DarismeMLathamMC. Nutrition rehabilitation centers—an evaluation of their performance. J Trop Pediatr Environ Child Health1973;19:299–332.
47.
KhanumSAshworthAHuttlySR. Controlled trial of three approaches to the treatment of severe malnutrition. Lancet1994;344:1728–32.
48.
PerraACostelloAM. Efficacy of outreach nutrition rehabilitation centres in reducing mortality and improving nutritional outcome of severely malnourished children in Guinea Bissau. Eur J Clin Nutr1995;49:353–9.
49.
RenemanLDerwigJ. Long-term prospects of malnourished children after rehabilitation at the Nutrition Rehabilitation Centre of St Mary's Hospital, Mumias, Kenya. J Trop Pediatr1997;43:293–6.
50.
PecoulBSoutifCHounkpeviMDucosM. Efficacy of a therapeutic feeding centre evaluated during hospitalization and a follow-up period, Tahoua, Niger, 1987–1988. Ann Trop Paediatr1992;12:47–54.
51.
HeikensGTSchofieldWNDawsonSGrantham-McGregorS. The Kingston project. I. Growth of malnourished children during rehabilitation in the community, given a high energy supplement. Eur J Clin Nutr1989;43:145–60.
52.
HeikensGTSchofieldWNDawsonSMWaterlowJC. Long-stay versus short-stay hopsital treatment of children suffering from severe protein-energy malnutrition. Eur J Clin Nutr1994;48:873–82.
53.
AshworthA. Efficacy and effectiveness of community-based treatment of severe malnutrition. Food Nutr Bull2006;27(Suppl):S24–48.
54.
BriendALacsalaRPrudhonCMounierBGrelletyYGoldenMHN. Ready-to-use therapeutic food for treatment of marasmus [letter]. Lancet1999;353:1767–8.
55.
Diop ElHIDossouNINdourMMBriendAWadeS. Comparison of the efficacy of a solid ready to use food and a liquid milk-based diet for the rehabilitation of severely malnourished children: a randomized trial. Am J Clin Nutr2003;78:302–7.
56.
FellowsP. Production of ready-to-use therapeutic food (RUTF) at rural centres in Malawi, a guide for producers. 2003. Oxford, UK, Valid International.
57.
SandigeHNdekhaMJBriendAAshornPManaryMJ. Home-based treatment of malnourished Malawian children with locally produced or imported ready-to-use food. J Pediatr Gastroenterol Nutr2004;39:141–6.
HenryCJKSeyoumTA. An alternative formulation of ready-to-use therapeutic food (RUTF) for use in supplementary feeding. 2004. Oxford, UK: Valid International.
