Predictors of recovery in children aged 6-59 months with uncomplicated severe acute malnutrition: a multicentre study.

OBJECTIVE: To identify predictors of recovery in children with uncomplicated severe acute malnutrition (SAM). DESIGN: This is a secondary data analysis from an individual randomised controlled trial, where children with uncomplicated SAM were randomised to three feeding regimens, namely ready-to-use therapeutic food (RUTF) sourced from Compact India, locally prepared RUTF or augmented home-prepared foods, under two age strata (6-17 months and 18-59 months) for 16 weeks or until recovery. Three sets of predictors that could influence recovery, namely child, family and nutritional predictors, were analysed. SETTING: Rural and urban slum areas of three states of India, namely Rajasthan, Delhi and Tamil Nadu. PARTICIPANTS: In total, 906 children (age: 6-59 months) were analysed to estimate the adjusted hazard ratio (AHR) using the Cox proportional hazard ratio model to identify various predictors. RESULTS: Being a female child (AHR: 1·269 (1·016, 1·584)), better employment status of the child's father (AHR: 1·53 (1·197, 1·95)) and residence in a rental house (AHR: 1·485 (1·137, 1·94)) increased the chances of recovery. No hospitalisation (AHR: 1·778 (1·055, 2·997)), no fever, (AHR: 2·748 (2·161, 3·494)) and ≤ 2 episodes of diarrhoea (AHR: 1·579 (1·035, 2·412)) during the treatment phase; availability of community-based peer support to mothers for feeding (AHR: 1·61 (1·237, 2·097)) and a better weight-for-height Z-score (WHZ) at enrolment (AHR: 1·811 (1·297, 2·529)) predicted higher chances of recovery from SAM. CONCLUSION: The probability of recovery increases in children with better WHZ and with the initiation of treatment for acute illnesses to avoid hospitalisation, availability of peer support and better employment status of the father.

Childhood diarrhoeal deaths in seven low- and middle-income countries.

OBJECTIVE: To investigate the clinical characteristics of children who died from diarrhoea in low- and middle-income countries, such as the duration of diarrhoea, comorbid conditions, care-seeking behaviour and oral rehydration therapy use. METHODS: The study included verbal autopsy data on children who died from diarrhoea between 2000 and 2012 at seven sites in Bangladesh, Ethiopia, Ghana, India, Pakistan, Uganda and the United Republic of Tanzania, respectively. Data came from demographic surveillance sites, randomized trials and an extended Demographic and Health Survey. The type of diarrhoea was classified as acute watery, acute bloody or persistent and risk factors were identified. Deaths in children aged 1 to 11 months and 1 to 4 years were analysed separately. FINDINGS: The proportion of childhood deaths due to diarrhoea varied considerably across the seven sites from less than 3% to 30%. Among children aged 1-4 years, acute watery diarrhoea accounted for 31-69% of diarrhoeal deaths, acute bloody diarrhoea for 12-28%, and persistent diarrhoea for 12-56%. Among infants aged 1-11 months, persistent diarrhoea accounted for over 30% of diarrhoeal deaths in Ethiopia, India, Pakistan, Uganda and the United Republic of Tanzania. At most sites, more than 40% of children who died from persistent diarrhoea were malnourished. CONCLUSION: Persistent diarrhoea remains an important cause of diarrhoeal death in young children in low- and middle-income countries. Research is needed on the public health burden of persistent diarrhoea and current treatment practices to understand why children are still dying from the condition.

Food Insecurity in Tribal High Migration Communities in Rajasthan, India.

BACKGROUND: The COVID pandemic and subsequent lockdown has disrupted food supplies across large parts of India, where even prior to the pandemic, food insecurity and malnutrition were widely prevalent. Tribal populations in southern Rajasthan, India, live in extreme scarcity, rely mainly on outward migration for sustenance, and have been significantly affected by the pandemic. In this study, we assess the availability of foodstuffs at the household level and community experiences about satiety and hunger during lockdown. METHODOLOGY: We conducted a rapid assessment of food security in rural southern Rajasthan, India, using a structured questionnaire. Trained interviewers conducted telephonic interviews using KoBoToolbox, an open-source tool. A total of 211 respondents including community volunteers, family members of tuberculosis patients and malnourished children, pregnant women, and influential members in the villages participated in the study. RESULTS: A cereal was reported to be present by 97% of the respondents, two-thirds had pulses, and nearly half had milk. The amount of cereals available was adequate for about 5 months and that of pulses, oil/ ghee, and sugar for about 1 to 2 weeks. Two-thirds of the respondents reported that food in their households was sometimes not sufficient for the amount they wanted to eat, and 97% of these mentioned not having money to buy food as the reason for not having sufficient food. CONCLUSION: This study highlights widespread food insecurity among tribal communities in southern Rajasthan, and the scenario is likely to be similar in other tribal migration dependent areas of the country.

Financing primary healthcare for rural areas.

CONTEXT: Primary healthcare in India is provided by both public and private providers. However, access to good quality primary healthcare is lacking in underserved populations such as communities in rural and remote areas and families in low income quartiles. While there are government programs on comprehensive primary healthcare, stagnant investments restrict their reach and quality. At the same time, there are several for-profit and not-for-profit primary healthcare providers that fill the gap, but are limited in scale and geographical reach. They also often find it challenging to provide affordable comprehensive primary healthcare. AIMS: The Consultation on Financing Primary Healthcare was organized to draw lessons for financial sustenance of comprehensive and equitable primary healthcare initiatives. Eighteen academicians and practitioners, representing different institutions from across India, presented and engaged in discussions around the theme of financing primary healthcare. METHODS AND MATERIAL: The Consultation proceedings were recorded, transcribed, analyzed, and synthesized to bring out the key insights. RESULTS: The Consultation drew insights from the experiences and evidence shared by the participants on the ways to finance primary healthcare services sustainably, especially for underserved populations. The financing models discussed include public-private partnership, user fees, community financing, subscription and cross-subsidy. Cost-reduction strategies such as task-shifting and use of appropriate technology were also identified as key to improving efficiency in service delivery.

Communicable or noncommunicable diseases? Building strong primary health care systems to address double burden of disease in India.

Between 1990 and 2016, India has seen an epidemiological transition in disease burden and deaths, with a steady rise in noncommunicable disease (NCD) burden. This has led to a tussle for policy attention and resources between proponents of communicable diseases such as tuberculosis, and of NCDs, such as cardiovascular diseases and diabetes. Review of evidence from global burden of diseases studies and from our own field data from rural south Rajasthan reveals that communicable-malnutrition- maternal-newborn diseases (CMNND), injuries, and NCDs are major causes of disease burden and deaths in childhood, youth and older age group, respectively. Risk factors related to diet, nutrition, and air pollution contribute significantly to communicable as well as NCDs. Many NCDs in adults have origins in malnutrition during pregnancy and early childhood; similarly, certain NCDs are caused by a communicable disease. We argue that the binary of communicable and NCD is incorrect, and that resources and policy attention be focused on strengthening primary health care systems that address CMMNDs as well as NCDs; and reduce the underlying risk factors.

Costing of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition from a randomised trial in India.

TRIAL DESIGN: Three feeding regimens-centrally produced ready-to-use therapeutic food, locally produced ready-to-use therapeutic food, and augmented, energy-dense, home-prepared food-were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6-59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks. METHODS: Costs were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting. RESULTS: No significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (<3500 rupees). CONCLUSION: Home-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM. TRIAL REGISTRATION NUMBER: NCT01705769; Pre-results.

Mid upper arm circumference as a predictor of risk of mortality in children in a low resource setting in India.

OBJECTIVE: In this secondary analysis of data from an intervention trial, we assessed the performance of Mid Upper Arm Circumference (MUAC) as a predictor of mortality in children aged 6-59 months from Delhi, India, one year after their initial MUAC measurements were taken. Additionally, we assessed MUAC as an absolute value and MUAC z-scores as predictors of risk of mortality. METHODS: In the trial, children were screened using MUAC prior to referral to the study clinic. These children were revisited a year later to ascertain their vital status. Baseline MUAC and MUAC z-scores were used to categorize children as severely (MUAC <115 mm, MUAC z-score <-3SD) or moderately (MUAC 115 to <125 mm, MUAC z-score <-2SD) malnourished. The proportion of malnutrition, risk of mortality, relative risk estimates, positive predictive value and area under the curve (AUC) by MUAC and MUAC z-scores were calculated. RESULTS: In the resurvey, the first 36159 children of the 48635 in the initial survey were contacted. Of these, vital status of 34060 (94.2%) was available. The proportion of severe malnutrition by MUAC (<115 mm) was 0.5% with an associated mortality of 4.7% over a one year period and an attributable mortality of 13% while the proportion of the severe malnutrition by MUAC z-score (<-3SDwas 0.9% with an associated mortality of 2.2%. CONCLUSIONS: MUAC is a significant predictor of subsequent mortality in under-five children. In settings where height measurement is not feasible, MUAC can be used as a screening tool for identifying severely malnourished children for management.

Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India.

OBJECTIVE: To assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group). METHODS: In an individually randomised multicentre trial, we enrolled 906 children aged 6-59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥-2 SD and absence of oedema of feet). RESULTS: Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >-2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ<-2 and ≥-3; adjusted OR 1.46, 95% CI 1.02 to 2.08; p=0.039), and lower for those with SAM (adjusted OR 0.58, 95% CI 0.40 to 0.85; p=0.005) in the RUTF-L when compared with the A-HPF group. CONCLUSIONS: This first randomised trial comparing options for home management of uncomplicated SAM confirms that RUTF-L is more efficacious than A-HPF at home. Recovery rates were lower than in African studies, despite longer treatment and greater support for feeding. TRIAL REGISTRATION NUMBER: NCT01705769; Pre-results.