Will COVID-19 increase the death rate among severe acute malnourished children? A context of Humanitarian Emergency, India

Laxman Sharma, Assistant Professor, IIHMR University, Jaipur talks about how the government has made the right call to ensure food security during lockdown and how it can be sustained in the long term with appropriate nutrition responses

The global and national agenda is to fight against virulent COVID-19 which is exponentially infecting thousands and lakhs of people day by day. Prime minister Narendra Modi on March 24, 2020, announced a national lockdown for 21 days as an unprecedented drastic measure, as the number of corona virus  cases crossed 500 in India. During the 21-day lockdown, Indian government had assured that essentials such as food and medicines will be available. Further central government had announced a 1.7 lakh crore Prime Minister Gareeb Kalyan Yojana which would include direct benefit cash transfers, free LPG, grains and pulses for the poor while the middle class would be able to withdraw funds from their Employee Provident Fund (EPF) account. So far, the measures taken by the government seems to address food insecurity, except for a missing picture of nutritional needs.

During a humanitarian emergency – COVID 19, India has made a right call to ensure food security through Prime Minister Gareeb Kalyan Yojana and other schemes. To tackle the situation in a long term, it is also essential to design appropriate nutrition responses along with food security measures. It is necessary to identify the type, degree and extent of undernutrition, those most at risk and the appropriate response. In Indian context, the nutrition response is especially recommended for the children under five years, pregnant and lactating women. According to the National Family Health Survey (NFHS) – 4, 2015-16, India has 38.4 per cent stunted, 35.8 per cent underweight, 21 per cent wasted, 7.5 per cent severely wasted children aged less than five years. In the last decade, severe acute malnutrition has increased from 6.4 per cent (NFHS-3, 2005-06) to 7.5 per cent (NFHS -4, 2015-16) in India. The severe acute malnutrition ranges from 2.2 per cent (Manipur) to 11.4 per cent (Jharkhand) in India (NFHS 4). Most importantly, states like Punjab (5.6 per cent), Haryana (9 per cent), Sikkim (5.9 per cent), Karnataka (10.5 per cent), Uttrakhand (9 per cent), Goa (9.5 per cent), Gujarat (9.5 per cent), Kerala (6.5 per cent), Assam (6.2 per cent), Chattisgarh (8.4 per cent) has shown exponential increase (≥50 per cent) in prevalence of severe acute malnutrition in the last decade. Indian Council of Medical Research (ICMR) study on Global Burden of Disease (GBD) reports that 68.4 per cent of child deaths are due to various forms of malnutrition.

With this back ground, and in an emergency callout of COVID-19, it is very much important to conduct a rapid assessment using national, state health authorities and frontline health workers (ASHA, ANM) to identify the high-risk pockets of malnutrition for under five children in India. The rapid assessment should include screening of children using MUAC and Infant Young Child Feeding practices in Emergencies (IYCF-E) to assess the nutritional situation at this time of crisis. Even if rapid assessments could not be conducted at a large scale (due to limited resources) secondary data sources such as National Family Health Survey (NFHS-4) 2015-16, Comprehensive National Nutrition Survey (CNNS), admission rates and coverage in existing programmes / facilities (National Rehabilitation Centre / Malnutrition Treatment centre, Poshan Abhiyaan) for managing malnutrition could be analysed to identify the high risk geographies in India. Once the high-risk regions / groups who are in greatest need for nutritional support are identified, appropriate response should be implemented based on the nutritional context and emergency. The appropriate response may include both prevention and treatment options. One of the treatment options to address severe acute malnutrition in humanitarian emergencies is Community based Acute Malnutrition (CMAM). In 2000, CMAM was first tested as a pilot study in humanitarian emergencies. (1) Later in 2007, it was supported and recommended by United Nations (UN) agencies that CMAM could be used as a standard procedure for treating and managing severe acute malnutrition in emergency and developmental contexts. CMAM is an evidence-based model, adopted in more than 70 countries to treat medically uncomplicated severe acute malnourished children.

In 2009, CMAM was first introduced as an emergency response to manage SAM children in Bihar during Kosi floods. (2) Later, Madhya Pradesh, Maharashtra, Rajasthan and Odisha implemented CMAM on a small scale to treat SAM children through facility-based and community-based approach. (2–6) In 2015, National Health Mission of Government of Rajasthan implemented CMAM by adopting POSHAN (Proactive and Optimum care of children through Social Household Approach for Nutrition) strategy to treat severely malnourished children without medical complication using Medical Nutrition Therapy (MNT) Kit [1]. The CMAM POSHAN-I was implemented in 2015-16 covering 10 High Priority Districts (HPD) and three tribal districts of Rajasthan. Around 234,404 children aged 6-59 months were screened and 9640 children were enrolled under the programme for treatment using ‘Energy Dense Nutrient Supplement’ (EDNS) at the community level. (7, 8) EDNS was supplied to the caretaker or mother according to the weight of the child. Also, ANM counselled the mother / caretaker on the importance of feeding EDNS, adequate feeding practices, hygiene, hand-washing and immunisation. The ASHA, called as POSHAN Pahari in CMAM, made home visits to monitor and counselled the mother /caretaker on feeding EDNS, adequate dietary intake, hygiene and hand-washing practices. After 12 weeks of intervention using EDNS, 88 per cent children recovered from severe acute malnourished nutrition status. (7, 8) With this internationally comparable success rate, the second phase of POSHAN-II was implemented in December 2018, covering 20 districts of Rajasthan. (7) In Integrated Management of Acute Malnutrition (IMAM) POSHAN-II around 375,533 children were screened and 10,344 children with severe acute malnutrition were enrolled for the 1 Medical Nutrition Therapy (MNT) kit consist of Energy dense Nutritional Supplement (EDNS), antibiotics and albendazole which is used for the treatment of SAM children in POSHAN-II.(7) intervention. (7,9) The IMAM POSHAN-II achieved high survival rates (the death among SAM children was only 0.1 per cent) comparable with international standards (< 10 per cent child deaths). (10) The high survival rate is one of the major achievements of the large-scale community-based programme, as one of the primary objectives is to reduce the fatality rates among SAM children. The IMAM programme in Rajasthan (POSHAN-II) reported a cure rate of 70.4 per cent, which is comparable with international standards ( > 75 per cent). (10) In India, CMAM interventions have reported cure rates between 53 to 68 per cent. (5, 6) Although, the cure rate (70.4 per cent)in Rajasthan under POSHAN 2 is slightly less than the international standards, it is still the highest cure rate achieved nationally among such interventions tried out on a scale. The frontline health workers ANM and ASHA acted as a pillar for the success of the intervention.

CMAM is a key child survival intervention, initially designed only for emergency context later adopted for developmental context too. In the wake of COVID-19, and as a long-term measure, central and state government must think of key child survival intervention like CMAM, to save the severely wasted children from the verge of death. This could address the nutritional needs of children under five years, along with food security. The experiences of CMAM intervention in Rajasthan at a large scale reconfirms that it is a feasible and low-cost evidence-based intervention to address the severe acute malnutrition. In addition, moderate acute malnourished children should be provided with supplementary nutrition through Anganwadi Centres regularly and must be checked frequently for the nutritional status. During this phase of fighting the Corona Virus, Indian government must take a call to address the nutritional needs of the country along the food security.

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