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Field Article60%, hence, 200 severely and 800 moderatelymalnourished were expected at the TFC-HTand SFPs, respectively. At the end of its sixmonth programme life, the TFC-HT exceededthe expected beneficiary case load, havingadmitted 259 children under five years of ageand three adults. This is equivalent to programmecoverage of 78% of all severely malnourishedchildren based upon the Decembernutritional survey and the February rapidassessment.ACF South Sudan TFC-HT protocolACF-USA’s protocol for the treatment of severelymalnourished individuals is divided into differentphases: Phase I or the Intensive CarePhase, Transition Phase, and Phase II or theRapid Weight Gain/Rehabilitation Phase.Admission criteria are as follows:• For children 6-59 months, a weight for heightratio of less than 70% and/or bilateral oedema(kwashiorkor) and/or MUAC (Mid-Upper Arm Circumference) less than 11.0 cmfor children with height above 75 cm.• Children or adolescents from 5 years to 18years, a weight for height less than 70% ofthe median and/or bilateral oedema.• Adults with body mass index less than 16and/or bilateral oedemaPhase I (Intensive Care) is carried out in theTFC where the patients receive systematic medicaltreatment, and daily medical follow-up,with specific treatment if indicated. Nutritionaltreatment is based on a F75 therapeutic milkdiet that provided 135 ml/kg per kg bodyweight per day. The average stay is 4 to 7 days.Patients move to the Transition Phase when:• they are recovering their appetite• in kwashiorkor cases, when the oedema hasbegun to disappear• they are no longer fed by naso-gastric tube(if this was necessary during phase I)• they are no longer seriously ill.In the transition phase, the energy intake isincreased and the proportion of energy-providingnutrients modified, allowing the patient toadapt progressively to a diet expresslydesigned to produce a rapid gain in weight.Hence, F100 milk is introduced at 100ml/kg toprovide the same energy value as phase I, i.e.100 kcal/day. This phase lasts 2-4 days and isalso carried out in the TFC.Following the transition phase, the patientwithout problems is transferred to Phase II(Rapid Weight Gain) of treatment (for patientswith kwashiorkor, complete disappearance ofoedema signals this transfer). The treatment consistsof medical check-up every two days andfull F100 diet (i.e. 200 kcal/kg/day plus porridge)to obtain optimal increase in weight. Theaverage stay is 2 to 4 weeks. This phase is carriedout either at the TFC or as Home Treatment.The Home Treatment option is offered to caretakerswhose children fit the following criteria:• Older than 12 months• Acute medical complication/illness havebeen controlled and no need for further medicaltreatment• Absence of nutritional oedema on admission• The child has successfully passed throughphase 1, transition phase and spent 2 days inrehabilitation phase within the TFC itself• The mother/caretaker fully understands thefeeding protocols• The patient/caretaker lives in the catchments areas delimited for Home Treatment.The patients on Home Treatment are not consideredas cured, and medical and nutritionalfollow up continues through weekly attendanceat the identified HT Centre/s and through regularmonitoring by home visitors. In case oftreatment failure or relapse (loss of weight,medical complication (such as primary complextuberculosis (PTB)), the beneficiary is readmittedand continues treatment in the centre. Thosewho do not fit the HT eligibility criteria completePhase II of treatment at the TFC.The discharge criteria for the TFP are:• an ascendant weight gain curve and no diseasepresent, and• reached target weight for height of 80% ofmedian and MUAC > or = 12 cm for twoconsecutive measurements, and• for kwashiorkor cases, at least 15 days sincethe disappearance of oedema.All severely malnourished patients admitted tothe therapeutic programme are discharged tothe SFP for the Consolidation Phase. Patientsare reviewed during the scheduled distributionsof the SFP to receive follow-up care (medicalmonitoring and supplemental feeding) toavoid relapse.ResultsBased on all programme records, the cure ratein the TFC-HT programme was high at 81%(this compares well with the SPHERE minimumstandard of 75%). The mean length of stayfor the children who recovered was 48 days,averaging a weight gain of 9 g/kg/day. Seventytwo percent of those children that recoveredunderwent home treatment, while 28%remained at the centre throughout. Of the 28%who were managed in the TFC, 10% did so dueto persistent medical complication or becausethey were aged under 11 months. The remaining18% were actually eligible for home treatmentbut opted to stay at the centre, eitherbecause of distance from their homes or due toflooding that would have impeded follow-up.A Fundi, ACF-USA, S Sudan, 2004Weight gainDuring the second phase of treatment whererapid weight gain is meant to occur, children atthe TFC spent an average of 22 days gaining16g/kg per day to reach the desired weight. Athome, it took about 18 days longer to reach targetweights with a slower weight gain of7g/kg/day. Ninety two percent of the childrenon HT completed the treatment until full recovery,while only 82% did so at the TFC. The childrenwho recovered on the HT regime spent 4-5 days in phase 1 and 4 days in transition at thestabilisation centre where they adapted to theuse of RUTF (Plumpy’nut).Medical assessment as partof the TFC-HT programmeLength of staySome of the children had medical complicationsthat could not be controlled or reversed at theTFC. Four and a half percent were thereforereferred to specialised clinics, although themortality rate at the TFC was still minimal at2.5%. These specialised clinics (currently tenwith another under construction) come in theform of PHCUs (Primary Health Care Units),run by Norwegian Church Aid (NCA). Theseprovide primary health services for the entirecounty of West Gogrial, and are available forthe referral of medical complication cases.DefaultingOverall, defaulter rates were low at 12%, with15% defaulting among those who stayed at theTFC and 7% amongst those on HT. Generally,the shorter stay at the centre (average of 8-9days) as well as the readiness to use RUTF athome improved receptivity to, and acceptabilityof, the HT programme among mothers andchildren. There were no cases of relapse amongHT children that compelled their return to thecentre. An ongoing study of this treatment protocoland its results across different AAH missionsis being undertaken and it is anticipatedthat the duration of stay at TFCs may be evenshorter elsewhere than found in this programme.ConstraintsAlthough largely successful, certain programmeconstraints operated. As with mostareas in south Sudan where ACF-USA operates,homesteads and villages are widely dispersedamidst difficult terrain, which frequently experienceswidespread flooding. Without internalmeans of transport in the field or the capacity tomatch the number of centres with the numberof villages, the strategy is highly reliant on anetwork of locally based ‘home visitors’. Theircritical role involves screening and referrals atthe community and household level, monitoringthe children (particularly those on hometreatment) and tracing defaulters. Given thephysical arduousness of the work and shortagesof home visitors, programme effectivenesscan easily be compromised. Given this and thegeneral economic marginalisation and growingneeds of the south Sudanese community, especiallyfollowing the peace accord with theNorth, there are many challenges still to betackled if we are to achieve full coverage andmaximum impact of HT.For further information, contact Adalbert MenaFundi, email: med@aahssd.org, or Marie-SophieSimon, ACF-USA, email: mss@aah-usa.org1A training module for National Staff in the TFC/SFP wasdeveloped by ACF-USA and was employed in Alek.18