Critical appraisal of the management of severe acute Malnutrition in Malawi: a case of two hospitals in Zomba

Transcription

1 UNIVERSITY OF MALAWI College of Medicine Critical appraisal of the management of severe acute Malnutrition in Malawi: a case of two hospitals in Zomba By Maggie Pempho Chiwaula BSc in Agriculture (Human Nutrition Food Science & Management) A Dissertation Submitted in Partial Fulfillment of the Requirements of the Master of Public Health Degree April 2011 i

2 CERTIFICATE OF APPROVAL The Thesis of Maggie Pempho Chiwaula is approved by the Thesis Examination Committee (Chairman, Post Graduate Committee) (Supervisor) (Internal Examiner) (Head of Department) i

3 DECLARATION I, Maggie Pempho Chiwaula hereby declare that this thesis is my original work and has not been presented for any other awards at the University of Malawi or any other University. Name of Candidate: Maggie Pempho Chiwaula Signature: Date: ii

4 ACKNOWLEDGEMENTS I wish to express my heartfelt gratitude to all individuals and groups of people too numerous to mention for their various support rendered to me throughout my research and the whole Master of Public Health studies. The following deserve to be mentioned: Dr John Phuka my Thesis supervisor, for his support, guidance and encouragement during this critical stage of my studies. I appreciate your commitment and assistance despite your tight schedules; Dr Maureen Chirwa my Academic supervisor for her encouragement and support throughout my studies, you were like a mother to me and I sincerely thank you; I should also thank Dr Susanna Woodd, Symon Langisi, Lone Maloya, Chrissie Black of St Lukes Hospital and Tracy Chinula, Eunice Kangunga and Tinenenji Chigumula of Domasi Hospital for your collaboration during my study, without you this study would have been difficult; I am also grateful to all Department of Community Health Staff as well as my MPH colleagues for their varied support. I cannot forget to thank Ministry of Health, Zomba District Health Office in particular for the assistance rendered to me; I would also like to thank Mervis Kamanga and Pumula Saka, for their assistance in editing my write up, I appreciate. May I also take this opportunity to thank Chrispine Musicha for his input on statistics without your help the whole analysis was a headache. Finally, I cannot forget to acknowledge Levi, Caleb, and Yankho, for your tolerance, support and encouragement throughout my studies. I love you all. To God be the Glory. iii

5 ABSTRACT Introduction: Undernutrition is the leading cause of child mortality and morbidity in developing countries. The problem remains a major challenge in Malawi and it contributes to high morbidity and mortality among under-five children and other vulnerable groups such as pregnant and lactating women. In Malawi, 48% of children under-five years of age are stunted while 22% are underweight and 5% are wasted. Objectives: To conduct a critical appraisal of the management of severe acute malnutrition at two hospitals in Zomba district where Community Therapeutic Care programme had not been fully introduced. Methods: Data was collected retrospectively from hospital records for a period of three years, January 2006 to December The data was then entered and analyzed in a computer. The main focus was on Nutrition Rehabilitation Units outcomes cure, death and default rates which were computed and compared across months and between the NRUs. Results: The overall cure rate for the two NRUs was 77.6%. NRU A had a higher cure rate (79.9) than NRU B (68.1) (p-value =<0.001). Children with a known HIV seropositivity stayed longer days (25.2) before being discharged as cured than their HIV seronegativity counterparts (22.7). Children who were diagnosed as having marasmus on admission, stayed longer before recovery than their kwashiorkor counterparts. Survival analysis showed that, the longer the time the children stays in the NRU, the slimmer the chance of getting cured. Conclusion: Over the years, admissions are increasing in the two NRUs. The mean length of stay of the admissions depended on HIV status, diagnosis and some institutional factors. iv

6 TABLE OF CONTENTS CERTIFICATE OF APPROVAL... I DECLARATION... II ACKNOWLEDGEMENTS... III ABSTRACT... IV LIST OF TABLES... VII LIST OF FIGURES... VIII CHAPTER ONE: INTRODUCTION BACKGROUND PROBLEM STATEMENT LITERATURE REVIEW Epidemiology of malnutrition Consequences of malnutrition Management of severe acute malnutrition Challenges in the management of severe acute malnutrition JUSTIFICATION OF THE STUDY CHAPTER TWO: OBJECTIVES OF THE STUDY BROAD OBJECTIVES OF THE STUDY SPECIFIC OBJECTIVES CHAPTER THREE: METHODOLOGY STUDY SITES STUDY DESIGN AND SAMPLING DATA COLLECTION ETHICAL CONSIDERATIONS DATA ANALYSIS CHAPTER FOUR: RESULTS INTRODUCTION PATIENT FACTORS THAT MIGHT HAVE CONTRIBUTED TO PATIENT OUTCOME Age of the patient Patient diagnosis HIV Status OUTCOME INDICATORS LENGTH OF STAY SURVIVAL ANALYSIS CHAPTER FIVE: DISCUSSION PATIENT FACTORS THAT MIGHT HAVE CONTRIBUTED TO PATIENT OUTCOME INSTITUTIONAL FACTORS THAT MIGHT HAVE AFFECTED PATIENT OUTCOME STUDY LIMITATIONS CONCLUSION RECOMMENDATIONS v

7 REFERENCES APPENDICES APPENDIX 1: WHO TREATMENT GUIDELINES FOR THE MANAGEMENT OF SEVERE ACUTE MALNUTRITION APPENDIX 3: LETTER OF ACCEPTANCE TO CONDUCT THE STUDY AT DOMASI RURAL HOSPITAL APPENDIX 4: LETTER OF ACCEPTANCE TO CONDUCT THE STUDY AT ST LUKES HOSPITAL vi

8 LIST OF TABLES TABLE 1: AGE DESCRIPTION OF SAMPLE TABLE 2: OVERALL OUTCOME INDICATORS (N= 934) TABLE 3: LENGTH OF STAY UNDER DIFFERENT CONDITIONS WHEN OUTCOME IS CURED TABLE 4: LENGTH OF STAY UNDER DIFFERENT CONDITIONS WHEN OUTCOME IS DEATH (N=61) vii

9 LIST OF FIGURES FIGURE 1: DISTRIBUTION OF CASES BY OUTCOME FIGURE 2: NUTRITIONAL DIAGNOSIS OF THE CASES FIGURE 3: HIV STATUS OF BOTH NRUS FIGURE 4: TRENDS IN ADMISSIONS IN BOTH NRUS FIGURE 5: SURVIVAL ANALYSIS FOR LENGTH OF STAY FOR THE WHOLE SAMPLE BEFORE GETTING CURED FIGURE 6: SURVIVAL ANALYSIS FOR LENGTH OF STAY BEFORE GETTING CURED BY NRU viii

10 ABBREVIATIONS AND ACRONYMS CAS CHAM CI CTC DHO H.S.A HIV MOH NRU OPC OTP ReSoMal RUTF SFP UNICEF WFP WHO Community therapeutic care Advisory Services Christian Health Association of Malawi Confidence Interval Community-based Therapeutic Care District Health Office/officer Health Surveillance Assistants Human Immunodeficiency Virus Ministry of Health Nutrition Rehabilitation Unit Office of the President and Cabinet Outpatient Therapeutic Programme Rehydrated Salt for the Malnourished Ready-to Use Therapeutic Food Supplementary Feeding Programme United Nation Children s Fund World Food Programme World Health Organization ix

11 CHAPTER ONE: INTRODUCTION 1.1 Background Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it also refers to over-nutrition. In this study the term malnutrition refers to under-nutrition. Malnutrition and malnourishment are synonyms of under-nutrition and undernourishment, respectively [1]. Under-nutrition is often a consequence of low dietary intake of various nutrients and diseases. The effects of malnutrition especially in young children are overwhelming although often times these effects may not be attributable to malnutrition because people may not know about the link [2]. Malnutrition is the leading cause of child mortality in developing countries especially in Sub-Saharan Africa [3], Malawi is not spared, being one of the poor countries in the sub- Saharan Africa where under-nutrition is common. Besides, malnutrition is one of the public health concerns in Malawi. In 2003, malnutrition was among the first top ten causes of NRU admissions and causes of mortality in health facilities. In fact it was number 4 and number 5 respectively from the top [4]. The same has been the experience for Zomba District and there has been no much improvement for the past decade. For instance, it is estimated that 48% of children under five are stunted while 22% are underweight and 5% 1

12 are wasted in Malawi [5]. The rates of malnutrition have been almost similar for the past two decades. According to the 2000 Demographic and Health Survey (DHS), stunting was estimated at 49%, underweight was estimated at 25% while wasting was estimated at 6% for the under five population [6]. The levels of acute malnutrition in under five children are high and a large proportion of the cases become severe with complications due to delays in case detection and care-seeking [7]. Although community based treatment of severe acute malnutrition (SAM) has been advocated for in recent years, facility based treatment of severe acute malnutrition is still required in Malawi. However, this is derailed by a number of factors, which include high case fatality rates. Unfortunately, adequate information is not available to assist government and relevant stakeholders to improve the provision of treatment to severe acute malnutrition. This study, therefore, aims at supporting government s efforts to improve the provision of malnutrition treatment by generating information that explains the factors responsible for better outcomes in malnutrition treatment. Poor nutrition has both short and long term effects on children and the nation as a whole. Children who are malnourished tend to have increased morbidity and mortality and also are prone to suffer from delayed mental development, poor school performance and reduced intellectual achievement [2]. The effects of malnutrition may not attract urgent attention but are of economic importance both to the individuals and the nation as a whole. Poor nutrition severely hinders personal, social and nation development [8]. 2

13 In Malawi, management of severe acute malnutrition has mostly been facility-based in NRUs or pediatric wards. However, it is currently being complemented by Communitybased Therapeutic Care (CTC). Under the CTC programme, severely malnourished children with medical complications are managed at the NRUs as in-patients while those severely malnourished without complications are managed as outpatients [1]. In Malawi there are about 95 (NRU) where management of severely malnourished children is done. In an NRU, a family member stays with the child, creating camp like conditions while receiving care and this has been viewed negatively as an opening for cross infection of various diseases, depriving siblings at home of care and undermining already fragile livelihoods [9]. Ministry of Health in conjunction with other partners like United Nations Children s Fund (UNICEF) and World Food Programme (WFP) provide appropriate nutritional and systematic treatment for the malnourished children in the NRUs while CTC Advisory Services provides technical support in CTC. Management of these cases in the Nutrition Rehabilitation Units is divided into 3 phases; initial, rehabilitation and follow-up. During the initial phase, life-threatening problems are identified and treated in a hospital or a residential care facility, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun. During the rehabilitation phase, intensive feeding is given to recover most of the lost weight, emotional and physical stimulation are increased, the mother or care giver is trained to continue care at home and preparations are made for discharge of the child. Follow-up phase is done after discharge, the child and the child s family is followed to prevent relapse and assure continued physical, mental and emotional development of the child [1]. 3

14 The Community-based Therapeutic Care approach is intended to complement facility-based management of severe malnutrition, and to facilitate community capacity development in order for communities to be responsible for identifying and managing malnourished children [7]. There are 4 components of CTC approach and these include: Community outreach, Outpatient Therapeutic Programme (OTP), Nutrition Rehabilitation Unit (NRU) and Supplementary Feeding Programme (SFP). NRUs act as stabilization centers for severely malnourished children with complications. When the complications have been stabilized, the children are discharged to OTP. On the contrary, in NRUs where OTP and Community outreach are not well established (no CTC programme), children are discharged when they have achieved nutritional recovery (>85% weight for height and no oedema) [10]. Malawi still has high case fatality rates for malnutrition mainly in central hospitals. For example, Zomba district experiences a high death rate (22%) in the NRUs [11]. This is very high as compared to the acceptable rate of less than 10% [12]. We still have high malnutrition case fatality rates in Malawi, and it is not known whether critical appraisal was ever conducted to know possible causes in Zomba. It was against this background that this clinical audit had been proposed in order to come up with ways of improving the current situation in the district. Out of the four NRUs in Zomba district, two were audited during this study. 4

15 1.2 Problem statement As is the case in most NRUs in Sub-Saharan Africa, high case fatality rates in Malawian NRUs as are still worrisome. As stated earlier, Zomba as a district has not been spared from this experience. In 2007 the average death rate for Zomba NRUs was about 22% as opposed to the acceptable rate of less than 10% [11-12]. However, in Zomba, not much has been done as far as NRU appraisal is concerned. 1.3 Literature review Epidemiology of malnutrition Malawi is faced with an endemic malnutrition problem whose major contributing factors are low availability and access to food in terms of quantity, quality and diversity; poor child care practices, poor hygiene and sanitation, as well as low availability and access to optimal health care services [13]. Intrauterine period and the first 6 months of life are critical for the development of stunting whereas the subsequent year is more critical for the development of underweight and wasting [14]. Malnutrition remains one of the major public health problems throughout the developing world and is an underlying factor of over 50% of the million children under five years of age who die each year from preventable causes [15]. Acute malnutrition is an extremely common condition associated with high rates of mortality and morbidity and requires specialized treatment and prevention interventions. Malnutrition is globally the most important risk factor for illness and death affecting hundreds of pregnant women and 5

16 young children [16]. In many poor countries like Malawi, severe acute malnutrition is the commonest reason for pediatric NRU admission [15]. In Malawi, it was found that severe and global acute malnutrition rates were 3.1% and 6.6%, respectively for children 6-59 months old and this is above the 2% reported for developing countries. The global acute malnutrition rate in Zomba, one of the districts in the southern region of Malawi was estimated at 4.9%, and severe acute malnutrition was estimated at 2.7% in children 6-59 months of age [17] Consequences of malnutrition Poor nutrition during pregnancy reduces physical development that may lead to miscarriages, low birth weight or worse still, still birth, perinatal death and irreversible brain damage to the unborn child. Low birth weight babies have a high risk of frequent infections and deaths. Furthermore, a child with poor nutritional status is highly susceptible to frequent illnesses due to an impaired immune system that reduces child survival, physical and mental development could lead to poor school performance. Malnutrition in children affects mental and physical development resulting in poor learning outcomes and professional capabilities. It also weakens one s immunity and affects the economic development of a nation [13]. Every year some 10.6 million children die before they reach their fifth birthday. Seven out of every ten of these deaths are due to diarrhea, pneumonia, measles, malaria or 6

17 malnutrition. Malnourished children are much more likely to die with or without complications than their well nourished counterparts. Malnourished children do not respond to medical treatment in the way they do when well nourished [8]. Although data is imprecise, it is known that the risk of mortality in acute malnutrition is directly related to severity with moderate wasting associated with a mortality of between per children per year and severe wasting associated with a mortality rate of between per 1000 children per year [18]. More than 10 million children under the age of 5 die each year of whom 1.5 million are severely malnourished [19] Management of severe acute malnutrition It is known that children with severe acute malnutrition must be treated differently from other children because their physiology is seriously affected. This makes management of severe acute malnutrition in developing countries like Malawi very important. Ministry of Health (MOH) in collaboration with UNICEF, WHO and other key partners developed National Guidelines for the management of severe acute malnutrition in Malawi, in order to standardize and improve the quality of care for severely malnourished children across the country [12]. In these National Guidelines, the 10 WHO steps for the management of severe acute malnutrition were adopted (Appendix 1). One of the ways of assessing the quality of NRU management is by looking at outcome indicators. Some of the indicators include; cure or recovery rate, death rate and defaulter 7

18 rate which are assessed monthly. Outcome of malnourished children may be poor if not handled with care even within the hospitals Challenges in the management of severe acute malnutrition Nutrition Rehabilitation Units are faced with a lot of challenges in handling cases of severe acute malnutrition. Some of the challenges include; limited in-patient capacity, lack of enough skilled staff in the hospitals to treat the large numbers needing care, the centralized nature of hospitals promotes late presentations and high opportunity cost for carers, serious risk of cross infections for immunosupppressed children with severe acute malnutrition and mortality rates before and after discharge [18]. One of the challenges faced in the management of severe acute malnutrition is the poor outcome of malnourished children in many NRUs as seen from high death rate. The causes of high case fatality rates for malnutrition vary from hospital to hospital and from one patient to another. The rates may reflect not only the quality of health care but also the severity of the cases admitted. A number of factors can contribute to this experience. For instance, some parents only bring their children to the hospital when they are almost moribund [9]. A Malawian study showed that central hospitals admit children with high severity of illness and could be the best explanation for high case fatality in central hospitals than mismanagement [20]. Besides, other studies have shown that the quality of care provided to children in health institutions is frequently compromised by shortages of staff and resources. 8

19 Successful management of malnourished children requires that each child be treated with special care and affection. It was also reported that case mortality for severely malnourished children almost doubled as a result of changing staff [21]. Other studies have ascribed failure to improve outcome of malnourished children to HIV infection, lack of maternal participation in the feeding programme, inadequate care and prescription errors and over prescription of intravenous therapies and blood transfusion [22]. The mortality risk of malnourished children is thought to relate to several factors. Another study reported that weight, height, oedema, pallor, anorexia, apathy and fever were risk factors for mortality in malnourished children [23]. Another study also reported HIV as having a significant impact on the mortality of malnourished children [24]. HIV complicates the severity of the illness in malnourished children. In Sub-Saharan Africa, countries with the highest case fatality of malnutrition, AIDS and tuberculosis have led to an epidemic of secondary severe malnutrition related to these co morbidities [19]. In Sub-Saharan Africa and increasingly India, an additional concern is that many patients with severe malnutrition are also infected with HIV [16]. A high proportion of severely malnourished children admitted in NRUs are HIV positive [18]. In Malawi, there is high prevalence of HIV infection in severely malnourished children attending NRUs [25], and HIV increases mortality of malnourished children. A Malawian study revealed that severely malnourished children with HIV infection have an increased risk of mortality compared with their uninfected counterparts [10]. 9

20 A study in Colombia reported that low mortality rates were achieved in children with severe acute malnutrition in class 1 hospitals after the implementation of the WHO Guidelines in the management of severe acute malnutrition [26]. However, failure is likely to occur regardless of the use of these treatment steps. Muller and Krawinke [16] (p281) noted that although the effectiveness of the WHO 10 steps scheme for the treatment of severe acute malnutrition is proven, there are still pitfalls for certain patients, such as those with extreme anemia and those who are close to cardiac failure. A study by Maitland found that, death rate among malnourished children was very high even though WHO guidelines were used to guide management [22]. In South Africa, inadequate knowledge and lack of resources were the most common barriers for the implemented 10 treatment steps [27]. 1.4 Justification of the study Reducing malnutrition and its effects is both a global and development goal as presented by the Millennium Development Goals (MDGs) and the Malawi Growth and Development Strategy (MGDS). Reduction of malnutrition entails prevention of malnutrition and treatment of the undernourished children. This study targets the latter by generating information that will assist to improve provision of facility based treatment of severe malnutrition. The results of the study will be used to inform local practitioners as well as policy makers on best practices in management of severe malnutrition cases at NRUs. The results of this study are therefore expected to be used by the Ministry of Health, the Department of HIV/AIDS and Nutrition in the Office of President and Cabinet (OPC), the Christian Health Association of Malawi (CHAM), and other private practitioners. The 10

21 results may also be used by other relevant stakeholders such as UNICEF, World Food Programme, and Concern Worldwide. These organisations have special interest in the health of children, and the results may be used as part of evidence for coming up with strategies that would help to come up with better interventions on how management of malnourished children can be improved and maintained. Therefore, the significance of this study cannot be overemphasized. 11

22 CHAPTER TWO: OBJECTIVES OF THE STUDY 2.1 Broad objectives of the study The main objective of the study was to conduct a critical appraisal of the management of severe acute malnutrition at two hospitals where Community Therapeutic Care programme had not been fully introduced. 2.2 Specific objectives The following were the specific objectives of the study: 1. To assess patient factors (e.g. HIV status, nutritional diagnosis, and length of stay between admission and death) that may have contributed to patient outcome 2. To assess institutional factors (e.g. number of admissions, type of therapeutic food used), that might have contributed to patient outcomes. 3. To assess the trends in outcomes in the two NRUs 4. Draw recommendations for the management of the two NRUs. 12

23 CHAPTER THREE: METHODOLOGY 3.1 Study sites The two NRUs that were involved in this study are from Zomba district which is situated in the southern region of Malawi. The two NRUs were chosen because of their unique characteristics that may be influencing their activities. Both NRUs have similar target population but have different characteristics as they are owned by different institutions (MOH and CHAM). At the two NRUs, CTC had not yet been introduced and it was assumed that they both follow the NRU protocols as stipulated by Malawi Government guidelines which have been adopted from WHO. The two sites were referred to as NRU A and B in this study. NRU A is under Ministry of Health and it is on a separate block. The NRU receives referrals from surrounding health facilities and it refers the complicated cases to Zomba Central hospital. In their treatment for severely malnourished children both therapeutic milks (F75 and F100) and plumpy nuts were used. Even though NRU A uses RUTF, treatment of children with severe acute malnutrition was still centralized and the majority of the patients were treated as inpatients. During the study period, the unit had one Community Health nurse, one Home Craft Worker, three HSAs and a hospital maid who were responsible for day and night activities at the NRU. 13

24 NRU B is a Christian Health Association of Malawi NRU and is located close to the pediatric ward, where malnourished children have a separate block. NRU B does not have Out-patient Therapeutic Programme and Community outreach components for CTC; therefore, children were discharged from the unit when they have nutritionally recovered. Nurses and clinicians who visit the pediatric ward also visited the NRU. During the study period, nurses who were on night duty at the pediatric ward also visited the NRU and were responsible for night feeds as well. For day time feeding, Home Craft Workers were responsible for preparation of feeds. 3.2 Study design and sampling The study was a clinical audit and data was collected by looking over the NRU practice. The advantage of the design was that it was faster to implement and it provided a baseline. No sampling was done; any child admitted at the NRU during the study period was included in the sample. However, those children with some variables not recorded were excluded from the study. 3.3 Data collection A checklist was developed and used to isolate the required individual information from the relevant documents. Monthly data was collected retrospectively from hospital records for a period of three years, January 2006 to December The following were the targeted documents where data was collected: 14

25 NRU registers: number of admissions, death, defaulters, date of admission and discharge, age, sex, admission criteria, HIV status, NRU monitoring cards (multicharts): medication given, time of death, cause of death. Monthly report forms: number of admissions, deaths, and defaulters. 3.4 Ethical considerations First consent was sort from the NRU Administrator and Hospital In -charge for the NRU A and NRU B respectively, before getting some data from the NRU records. They were told in advance about the intention to do this study at their hospitals (Appendices 3 and 4). In this study there was no direct contact with patients and secondary data was used anonymously by using identity numbers instead of names in order to protect patient identity. 3.5 Data analysis Data was entered into Microsoft Excel 2007 but most of the analysis was done in STATA for windows (Version 9.0). Data analysis involved calculations of indicators like cure, death and defaulter rates. Survival analysis was also applied to survival data (death and cure). Number of admissions was used to explore the trends in severe malnutrition cases between years and between months. The trend analysis helped to assess if severe malnutrition cases 15

26 are increasing or declining over time. Seasonal changes in severe malnutrition cases were also assessed by the use of trend analysis. A number of NRU outcome indicators were estimated to assess the performance of the two NRUs and these indicators included cure rate, death rate, defaulter rate, and transfer rate [12]. In this section, analysis for number of admissions at a specified period was done for each NRU mainly to explore the trends in severe malnutrition cases between years and between months; this helped to explore how busy the unit was. Outcome indicators were also calculated by NRU, to assess whether they were in line with the minimum requirement by WHO. Mean length of stay was also calculated by adding the total number of days that each child discharged as cured stayed in the NRU and this was divided by the number of children cured for a specific month [13]. Mean length of stay between admission and death for those patients who had died in the NRU was also calculated to assess the relative contribution of institutional factors and patient factors to death rate. Patient survival data was analyzed using the Kaplan-Meier method which helped in calculating the probabilities of surviving and dying at different times. Regression analysis was done to test the significance of the factors that affect survival (or hazard rates). Following WHO guidelines, which MOH has adopted, the following formulae were used to calculate cure rate, death rate, defaulter rate and transfer out rates. 16

27 Total cured Cure rate Total exists x 100 (1) Death Total deaths rate x 100 Total exists (2) Default Total defaults rate Total exists x 100 (3) Transfer Total transfers rate x 100 Total exists (4) The following indicators were then compared over time, HIV status of the child, age of the child, sex of the child, diagnosis (whether marasmus or kwashiorkor). The comparisons were also made between the hospitals. 17

28 CHAPTER FOUR: RESULTS 4.1 Introduction Data was collected from all the cases (1105) that were admitted into the NRUs during the chosen period. However, it was noted, during data cleaning and analysis, that 171 cases had some variables missing and these were excluded from the sample. As a result, the study had a total sample of 934 cases (see Figure 1). Out of these 752 and 182 were from NRU A and B respectively. Out of the total sample, 49% (458) were boys the rest were girls. Figure 1 below shows the distribution of cases by their outcome, the other category refers to total number of cases who did not respond to treatment and those who requested to be discharged from the NRUs before being cured cases found Cases dropped: 171 Cases used: 934 Defaulted: 17 Transferred: 99 Died: 72 Cured: 725 Other: 21 Figure 1: Distribution of cases by outcome 18

29 4.2 Patient factors that might have contributed to patient outcome Age of the patient Table 1 below presents the mean age of cases for the two hospitals in months. The mean age (SD) for all cases during the study period was 25.5(18.7). Table 1: Age description of sample NRU Mean Std Dev NRU A 24.0 (n=726) 15.0 NRU B 31.6 (n=192) 28.8 Overall 25.5 (n=918) Patient diagnosis Figure 2 below presents the results of the nutritional diagnosis of the cases. The results show that 201(21.5%) of the cases were diagnosed as having marasmus, while 551(59%) had kwashiorkor and 182(19.5%) had both marasmus and kwashiorkor at the same time (marasmic kwashiorkor). 19

30 Figure 2: Nutritional diagnosis of the cases HIV Status Figure 3 below presents the HIV status of the cases. Out of the whole sample 100(10.7%) were HIV infected, 155(16.6%) were not infected, 671(71.8%) had unknown HIV status and 8 (0.9%) were exposed. 20

31 Percentage HIV status for both NRUs Reactive Nonreactive Unknown Exposed HIV status Figure 3: HIV status of both NRUs Figure 4 below presents the trends in admissions of severe malnutrition cases in the two NRUs. The figure also shows the seasonal variations in the number of admissions. There are more admissions in the months of January and February when the number of admitted cases was higher than the rest of the months in all the three years. Least number of cases was admitted in the months of July, August and September. 21

32 Figure 4: Trends in admissions in both NRUs 22

33 4.3 Outcome indicators The study used cure rate, death rate, default rate and transfer rate as summary outcome indicators. These are summarized in Table 2 below. Overall cure rate for the two NRUs was 77.6%. Overall death rate was 7.7%, and overall defaulter rate was 1.8%. Details of the rates have been outlined in Table 2 below. Table 2: Overall outcome indicators (n= 934) Variable NRU A NRU B Overall Cured Death Transfer Defaulted Other (p=<0.001) 4.4 Length of stay By adding the total number of days that each child discharged as cured stayed in the NRU and dividing this by the number of children cured for a specific month, the mean length of stay was calculated. Table 3 below presents the summary of the mean length of stay when the outcome is cured. 23

34 The average number of days that children stayed in the NRUs before being discharged as cured was significantly lower at NRU A than at NRU B ( p= <0.001). There were also differences in the length of stay for cases that were in different health conditions. Overall, HIV positive children seemed to stay longer before being discharged as cured as opposed to their HIV negative children. At NRU B, HIV positive children stayed for a longer period before they were cured than at NRU A (p = 0.01). For HIV negative children, they stayed longer at NRU B (32.7days) than at NRU A (21.0days) before being discharged as cured p=< (Table 3). Children that were diagnosed with kwashiorkor on admission seemed to have stayed for shorter periods before they were discharged as cured than children that were diagnosed with marasmus at both hospitals. There were also statistical differences in mean length of stay for kwashiorkor and marasmic children at NRU A and B which were higher at NRU B than at NRU A (Table 3). Table 3: Length of stay under different conditions when outcome is cured Condition NRU A NRU B P value Overall HIV positive 22.9(n=49) 29.5(n=25) (n=74) HIVnegative 21.0(n=121) 32.7(n=21) (n=142) Kwashiorkor 18.7(n=369) 24.3(n=84) (n=453) Marasmus 21.5(n=102) 30.3(n=36) (n=138) 24

35 Table 4 presents the summary of the mean length of stay when the outcome is death. For the children who died in the NRUs, their average days of being treated before they died were not statistically different (Table 4). For the children who died in the NRUs, the average days of being treated before they died were not significantly different for NRU A (9.6 days) and NRU B (9.4 days) p = 1.0 Table 4: Length of stay under different conditions when outcome is death (n=61) Condition NRU A NRU B P value Overall Kwashiorkor 7.4 (n =14) 8.8 (n = 25) (n = 39) Marasmus 8.0 (n = 8) 11.1 (n =14) (n = 22) 4.5 Survival analysis Figure 5 below shows the survival analysis for the children in both NRUs. The overall median length of stay was 20.0 days and the results seem to show that, the children that stayed longer in the NRU had slimmer the chance of getting cured. 25

36 Figure 5: Survival analysis for length of stay for the whole sample before getting cured Figure 6 below shows the chance of surviving when a child is admitted at the two NRUs. The trend in the chance of being cured in the two NRUs are similar in that time of stay is affecting the outcome i.e. the longer the children stayed in the NRU the slimmer the chance of surviving. The median length of stay at NRU A was around 28.0 days while that at NRU B was around 20.0 days. The results show that children had a higher chance of getting cured when admitted at NRU A than when admitted at NRU B, p = <

37 Figure 6: Survival analysis for length of stay before getting cured by NRU 27

38 CHAPTER FIVE: DISCUSSION 5.1 Patient factors that might have contributed to patient outcome It was noted that most of the children admitted were edematous (had kwashiorkor). This is in agreement with what other studies found that most of the sample had kwashiorkor followed by marasmus then marasimic-kwashiorkor [23, 24] on admission. This was one of those variables that were collected on admission in the NRUs; some errors might have been encountered especially on deciding whether one really had both kwashiorkor and marasmus at the same time. This may be particularly difficult if the one taking the variable was not trained. Those children who were diagnosed with marasmus on admission, stayed longer before recovery than their kwashiorkor counterparts. This was in line with the findings of another study where edematous children stayed fewer days than their marasmic counterparts in the NRU before being discharged as cured [23]. The trend was almost similar even when outcome was death. As already noted earlier on, the average days stayed by the children either before being discharged as cured or dead while in the NRU was significantly higher for NRU B than for NRU A. Marasmic children stayed a bit longer in the NRU than their kwashiorkor counterparts regardless of outcome and HIV status. This means that, HIV had no effect on the length of stay for children who had either marasimus or kwashiorkor. Although HIV testing for malnourished children in any nutrition programme is one of the 28

39 requirements by the government of Malawi as adopted from WHO guidelines, not many children were being tested for HIV as revealed by this study. The main cause was not known as data on this was not collected. However, other studies [25] have shown that most guardians are willing to undergo HIV testing and counseling and it could be possible that in the two NRUs guardians were not receiving adequate information on the importance of HIV testing especially for malnourished children. On the other hand, it could also be possible that priority was not given to these children to be tested due to inadequate HIV test kits at the hospitals. HIV infected children stayed longer than their uninfected counterparts in both NRUs before being discharged as cured. For HIV infected children, they stayed a bit longer before recovering at NRU B than at NRU A. However, the mean length of stay in both NRU is a bit higher when HIV positive than when HIV negative. This is related to what Fergusson [10] (p.7) found that HIV infected children had a longer stay in the NRU than their uninfected counterparts, and also Sadler [24] (p.8) found out that the length of stay for confirmed HIV-seropositive children was longer than that for HIV-seronegative children. This could be because of other medical complications that HIV infected children usually have. 5.2 Institutional factors that might have affected patient outcome During the study period, there were more admissions at NRU A than at NRU B this meant that NRU A would be busier than NRU B. As said earlier on, NRU B is under CHAM, where most services are paid for; and some people may not have adequate information that the NRU services were free. The other reason could be that NRU B is allocated on the 29

40 border with another district, and patients could be accessing the services from other facilities in the other district. Mean Cure rate at NRU A was above the national minimum standards of >75% as opposed to that at NRU B which was below the accepted standards. Looking at the overall, mean cure rate was within the accepted levels. NRU A had a death rate below the national minimum standards of <10% while NRU B had death rate above the national minimum standards for NRU performance. In most developing countries, case fatality rates in hospitals treating SAM remain at 20-30% [28] (Collins, p.8). However, the overall death rate for the NRUs was within the acceptable rates. This means that overall death rate may not give a good picture of the individual NRU performance and it is important to analyze death rate by NRU. Both NRUs had mean defaulter rates which were within the accepted levels of <15% and the overall rate was not affected. From the look of things, it was seen that performance at NRU B was not very good looking at cure and death rates. A number of factors may have affected the outcome indicators at different levels; some factors could be individual or institutional. For instance, at NRU A in addition to the therapeutic milks, they also used RUTF for the treatment of malnutrition which was not used at NRU B and this might have contributed to the different outcomes. On the same note other studies have shown that RUTF promotes a faster rate of recovery from SAM than standard F100 and that it is associated with high cure rates [29, 30]. On the other hand, staffing could as well play a role, i.e. whether the staffs handling the 30

41 children were specifically trained in the management of malnourished children or not. This is in line with a study by Collins [18] (p.12), who found out that one of the challenges that NRUs are faced with is lack of enough skilled staff to treat the large numbers needing care. The issue of night feeds is also important because if night feeds are not given to the children they may die either in the early hours of the following day due to complications like hypoglycemia. As described earlier on, NRU B relied on nurses who were on night duty in the pediatric ward to be providing night feeds to the malnourished children on the other side of the ward. It was not clear whether this strategy indeed worked for the NRU but it was feared that the nurses who were also responsible for the non malnourished sick children would be very occupied at night and making feeds would be a challenge and supervision of the children taking feeds at night might be questionable. During the study period, NRU A had a team of health workers who were rotating for night duty and this could have been one of the positive areas as preparation and giving of night feeds was one of their primary responsibilities. This meant that some complications like hypoglycemia would be rare. The other challenge was that there was missing data on time of death and causes of death for those children who died in the NRU, and it is difficult to relate the causes of death to other relevant factors. Case-load, staffing, training, quality of and availability of supplies might have affected the outcome of the NRUs under study [27] (Puoane, p.7), and this would be the case even in this study. The other possible cause of the high death rate could be that as a hospital, NRU B rarely referred their patients who were very sick to other centres, which would not be the case 31

42 with NRU A as it referred their complicated cases to Zomba Central hospital. This issue might not be overlooked as it would be possible that the unit would be referring complicated cases who might have died within their Unit, hence the lower rates. Data on number of referrals to Central NRU and what happened afterwards was not collected hence difficult to conclude. It was also discovered that the average days of being treated, for the children who died in both NRUs, were not significantly different. This means that some institutional factors had a hand on the death of the children in the NRUs because staying in the wards for about 10 days, before dying, could not only be associated with late reporting of patients to the centers, but may also be associated with some institutional factors, as well as severity of the cases. Overall, the average number of days that children stayed in the NRUs before being discharged as cured was significantly lower at NRU A than at NRU B. This was regardless of whether one had kwashiorkor or marasmus, HIV status, outcome and his/her sex. This may be due to a number of factors which include, time of reporting to the NRU by clients, shortage of supplies, inadequate knowledge by responsible staff on how the children should be managed, ward rounds not being made regularly by clinicians or protocols were not being followed consistently as it would take long for the malnourished child to recover. Survival analysis showed that there was a higher chance of recovering at NRU A than at NRU B. Overall, there was a lower chance of surviving as the children stayed longer in 32

43 both NRUs, with the situation being worst when one was admitted at NRU B. Regardless of HIV status, the chance of surviving was decreasing when one stayed longer in the NRUs as already observed earlier on. Although, the picture on effects of HIV on survival of the malnourished children could be clearer if most of the children underwent HIV counseling and testing, those children who were HIV infected had a lower chance of surviving compared to their uninfected counterparts. This is in line with the findings of another study where HIV infection increased case fatality of malnourished children. [18]. 5.3 Study limitations The study was faced with some shortfalls. These included missing of some patient variables from the records such as time of death, and cause of death for those patients who died within the units. Therefore it was not possible to analyze such data even though it was planned earlier on to include such data. The study was also faced with a limitation in precision of diagnosis since records and registers were used. Another limitation of this study was that most children admitted in the NRUs were not being tested for HIV hence the discussions made in this report on HIV was based on the small numbers tested. The other limitation was that the methodology used in the study did not include in depth interviews with key informants. It was realized during data analysis and reporting that this was necessary 33

44 CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion In conclusion, HIV status of the malnourished children affected the number of days that malnourished children stayed in the NRUs. The HIV infected children stayed longer than their uninfected counterparts, and overall, the picture is the same for NRU A and NRU B. So it can easily be concluded that HIV status affected the average number of days that children with malnutrition could be treated. It was also noted that, the chance of getting cured when admitted in the NRUs was reduced by being HIV infected. On average, children who were marasmic stayed longer before being discharged as cured, than their kwashiorkor counterparts and following this, it can be concluded that having kwashiorkor or marasmus could determine how long one would take to be discharged from the NRU, thus patient diagnosis may affect outcome. Most of the children stayed for some days in the NRUs before dying, and it could be possible to prevent some of the deaths in the NRUs provided extra care was taken. One had a lower chance of surviving when at NRU B as opposed to when one was at NRU A. Again when admitted at NRU B, patients were staying a little longer than when admitted at NRU A, and this was irrespective of HIV status as well as diagnosis. 34

45 6.2 Recommendations The District Health Officer (DHO) should intensify supportive supervision in all NRUs to make sure that protocols are being followed and also to make sure that all relevant records are up to date so that areas that need improvement should be seen clearly. The introduction of CTC as an approach is also recommended in both centres as there is evidence that use of RUTF is associated with good outcome indicators. The DHO in liaison with Ministry of Health Nutrition Unit should make sure that the NRUs have all the necessary supplies needed in the treatment of malnourished children, e.g. therapeutic milks, Reseal, routine drugs especially antibiotics. The Hospital Management Team of NRU B should consider allocating members of staff specifically for night shifts at the NRU so that they should be responsible for preparation of night feeds for the malnourished children. For instance, the Home Craft Workers can be deployed for this task since they have a number of them. This may help to allay fears that children may not be given night feeds if the hospital is mainly to rely on nurses who are in most cases occupied in the ever busy pediatric wards, and feed preparation may not be a priority to them. 35

46 NRU in-charges in both hospitals should ensure that guardians are well informed of the importance of HIV testing for their children so that they receive necessary services in order to improve their outcome. On the same, malnourished children should be among those patients prioritized for HIV testing even in the event when they have few test kits, because knowing their status will facilitate referral to appropriate services while receiving nutrition care. I also recommend that a study be done that may include interviews with key informants like programme managers and focus group discussion to come up with strategies that may help to improve the outcome. 36

47 REFERENCES 1. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO; Poel EV, Hosseinpoor AR, Jehu-Appiah C, Vega J, Speybroeck N. Malnutrition and the disproportional burden on the poor: the case of Ghana. Int. J. Equity Health. 2007;6: Pongou R, Ezzati M, Salomon JA. Household and community socioeconomic and environmental determinants of child nutritional status in Cameron. BMC Public Health. 2006;6: Malawi Government. Ministry of Health and Population Planning Department Health Management Information Bulletin. Lilongwe: Malawi Health Management Information Unit; National Statistical Office (Malawi), ORC Macro. Malawi demographic and health survey Zomba: NSO ; Calverton, Maryland: ORC Macro; National Statistical Office (Malawi), ORC Macro. Malawi demographic and health survey Zomba: NSO; Calverton, Maryland: ORC Macro; Government of Malawi / UNICEF, Ministry of Health. Interim guidelines for the management of severe acute malnutrition through community-based therapeutic care. Lilongwe, Malawi; (Unpublished). 8. Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for the inpatient treatment of severely malnourished children. Geneva: WHO; Latham MC. Human nutrition in the developing world. Food and Nutrition Series. 37