Cmam t ph1_v1

HANDOUTS
& EXERCISES
COMMUNITY-B ASED MANAGEMENT OF ACUTE MALNUTRITION
Module 1: Overview of Community-Based Management of Acute Malnutrition (CMAM)
HANDOUTS
& EXERCISES
COMMUNITY-BASED MANAGEMENT OF ACUTE MALNUTRITION
MODULE ONE
Overview of Community-Based Management of Acute
Malnutrition (CMAM)

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
LEARNING OBJECTIVES HANDOUTS AND EXERCISES
Introduce Participants, Training
Course, Modules, and Course
Objectives
Handout 1.1 Abbreviations and Acronyms
Handout 1.2 Terminology for CMAM
Handout 1.3 References and Further Reading
PowerPoint: Overview of Community-Based Management of
Acute Malnutrition (CMAM)
1. Discuss Acute Malnutrition
and the Need for a Response
Handout 1.4 Key Information on Undernutrition
2. Identify the Principles of
CMAM
Handout 1.5 CMAM Principles
3. Describe Recent Innovations
and Evidence Making CMAM
Possible
Handout 1.6 Classiﬁcation of Acute Malnutrition for CMAM
Handout 1.7 Screening and Admission Using MUAC
RUTF packets
Coloured MUAC tapes (designed for use in community-based
programmes)
4. Identify the Components of
CMAM and How They Work
Together
Handout 1.8 CMAM Components and How They Work Together
5. Explore How CMAM Can
Be Implemented in Different
Contexts
Handout 1.9 Case Studies
Handout 1.10 Implementing CMAM in Different Contexts
Handout 1.11 Factors to Consider in Seeking to Provide Services for
the Management of SAM
Handout 1.12 Integrating CMAM into Routine Health Services at the
District Level
6. Identify Key National and
Global Developments and
Commitments Relating to
CMAM
WHO, WFP, the UN/SCN and UNICEF. 2007. Community-based
management of severe acute malnutrition: A joint statement.
Video 1. Concern Worldwide Ethiopia Video
Wrap-up and Module Evaluation Handout 1.13 Essentials of CMAM
Field Visit to Outpatient Care Site Handout 1.14 Field Visit Checklist

1.1
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
HANDOUT 1.1
ABBREVIATIONS AND ACRONYMS
ACF Action Contre La Faim
ACT artemisinin-based combination therapy
AED Academy for Educational Development
ARI acute respiratory infection
ART antiretroviral therapy
ARV antiretroviral
AWG average daily weight gain
BCC behaviour change communication
CBO community based organisation
CCC Community Care Coalition
CDC Centers for Disease Control
CHC child health card
CHP community health promoter
CHPS Community-Based Health Planning and Services Initiative
CHPS-TA Community-Based Health Planning and Services Initiative – Technical Assistance
CHW community health worker
CMAM Community-Based Management of Acute Malnutrition
CMV combined mineral and vitamin mix
CRS Catholic Relief Services
CSAS centric systematic area sampling
CSB corn-soy blend
CTC community-based therapeutic care
DHMT district health management team
DHS Demographic Health Survey
DSM dry skim milk
EBF exclusive breastfeeding
EDL Essential Drug List
ENA Essential Nutrition Actions
ENN Emergency Nutrition Network
EPI expanded programme of immunisation
FANTA Food and Nutrition Technical Assistance Project
FAO Food and Agriculture Organisation of the United Nations
FBF fortiﬁed blended food
GAM global acute malnutrition
GHS Ghana Health Services

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
GI gastrointestinal
GMP growth monitoring and promotion
GSHP Ghana Sustainable Health Project
HBC home-based care
HEW health extension worker
HFA height-for-age
HIRD High Impact and Rapid Delivery
HIV human immunodeﬁciency virus
HMIS health management information system
IEC information, education and communication
IFE Infant Feeding in Emergencies
IMCI integrated management of childhood illness
INAAM Integrated Nutrition Action Against Malnutrition
ITN insecticide treated net
IU international units
IYCF infant and young children feeding
KCAL kilocalories
LNS lipid-based nutrient supplement
LOS average length of stay
LRTI lower respiratory tract infection
M&E monitoring and evaluation
MAM moderate acute malnutrition
MAMI Management of Acute Malnutrition in Infants Project of the Institute of Child Health
MCH maternal and child health
MCHN maternal and child health and nutrition
MDG Millenium Development Goal
MICS Multiple Indicator Clause Survey
MOH Ministry of Health
MSF Médecins Sans Frontièrs
MUAC mid-upper arm circumference
NCHS National Centre for Health Statistics
NFDM non-fat dry milk
NGO nongovernmental organisation
NRC nutrition rehabilitation centre
NRU nutrition rehabilitation unit
OI opportunistic infection
OICI Opportunities Industrialization Centers International
OPD outpatient department
OTP outpatient therapeutic programme
1.1

1.1
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
OVC orphans and vulnerable children
PD Positive Deviance
PHC primary health care
PLHIV people living with HIV
PMTCT prevention of mother-to-child transmition of HIV
PRA Participatory Rural Appraisal
QHP Quality Health Partners
ReSoMal Rehydration Solution for Malnutrition
RRA Rapid Rural Appraisal
RUSF ready-to-use supplementary food
RUTF ready-to-use therapeutic food
SAM severe acute malnutrition
SC stabilisation centre
SC-USA Save the Children USA
SD standard deviation
SFP supplementary feeding programme
SMART Standardised Monitoring and Assessment for Relief and Transition
SNNPR Southern Nations, Nationalities, and People’s Region
SQUEAC semi-quantitative evaluation of access and coverage
SST supplementary suckling technique
SWOT strengths, weaknesses, opportunities and threats
TB tuberculosis
TF task force
TFC therapeutic feeding centre
UN United Nations
UNICEF United Nations Children’s Fund
UN/SCN United Nations System Standing Committee on Nutrition
USAID United States Agency for International Development
VCT voluntary counselling and testing
WFA weight-for-age
WFH weight-for-height
WFP World Food Programme
WHO World Health Organization
WSB wheat-soy-blend

HANDOUTS
& EXERCISES

1.2
HANDOUTS
& EXERCISES
HANDOUT 1.2
TERMINOLOGY FOR CMAM
Acute
Malnutrition
Acute malnutrition is a form of undernutrition. It is caused by a decrease in food
consumption and/or illness resulting in bilateral pitting oedema or sudden weight loss.
It is defined by the presence of bilateral pitting oedema or wasting (low mid-upper arm
circumference [MUAC] or low weight-for-height [WFH]).
Note: The MUAC indicator cutoffs are being debated (see “Mid-Upper Arm Circumference
[MUAC] Indicator” below). The WFH indicator is expressed as a z-score below two
standard deviations (SDs) of the median (or WFH z-score < -2) of the World Health
Organization (WHO) child growth standards (WHO standards), or as a percentage of
the median < 80% of the National Centre for Health Statistics (NCHS) child growth
references (NCHS references).
Anthropometry Anthropometry is the study and technique of human body measurement. It is used to
measure and monitor the nutritional status of an individual or population group.
Appetite Appetite is the decisive criteria for participation in outpatient care. The test is done at
admission and at all outpatient care follow-on sessions to ensure that the child can eat
ready-to-use therapeutic food (RUTF). If the child has no appetite, s/he must receive
inpatient care.
Bilateral Pitting
Oedema
Bilateral pitting oedema, also known as nutritional oedema, kwashiorkor or oedematous
malnutrition, is a sign of severe acute malnutrition (SAM). It is defined by bilateral pitting
oedema of the feet and verified when thumb pressure applied on top of both feet for
three seconds leaves a pit (indentation) in the foot after the thumb is lifted. It is an
abnormal infiltration and excess accumulation of serous fluid in connective tissue or in a
serous cavity.
The categories of bilateral pitting oedema are:
Mild : Both feet (can include ankles), Grade +
Moderate: Both feet, lower legs, hands or lower arms, Grade + +
Severe: Generalized bilateral pitting oedema including both feet, legs, hands, arms
and face, Grade + + +
Centre-Based
Care for SAM
Centre-based care for SAM refers to the management of SAM with or without medical
complications in inpatient care until weight recovery is achieved.
Before the development of CMAM or in the absence of the CMAM approach, children with
SAM were exclusively managed as inpatients receiving medical treatment and nutrition
rehabilitation until weight recovery is achieved.
Community-
Based
Management
of Acute
Malnutrition
(CMAM)
CMAM refers to the management of acute malnutrition through: 1) inpatient care
for children with SAM with medical complications and all infants under 6 months old
with SAM; 2) outpatient care for children with SAM without medical complications; 3)
community outreach; and 4) services or programmes for children with moderate acute
malnutrition (MAM) that may be provided depending on the context.
CMAM evolved from Community-Based Therapeutic Care (CTC), which is a community-
based approach for the management of acute malnutrition in emergency settings,
and comprises the key components of community outreach, supplementary feeding
programmes (SFPs), outpatient care programmes (OCPs) and stabilisation centres (SCs).
Other variants of CMAM include ambulatory care or home-based care (HBC) for SAM.

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.2
CMAM
Programmes
versus CMAM
Services
Implementing agencies manage CMAM programmes. The Ministry of Health (MOH) or
private health care providers at health facilities (or in the communities) provide CMAM
services.
Community
Outreach
Community outreach for CMAM includes community assessment, community mobilisation,
active case-finding and referral, and case follow-up.
Community
Referral
Community referral is the process of identifying children with acute malnutrition in the
community and sending them to the health facility for CMAM services.
Community
Volunteer
A community volunteer is a person who conducts outreach for community mobilisation,
screening, referral and follow-up in the community. He or she can receive an incentive
but no remuneration.
Coverage Geographical coverage refers to the availability of CMAM services (i.e. geographical
access) through the decentralisation and scale-up of CMAM services. Service or
programme coverage refers to the uptake of CMAM services (service access and use).
Geographical coverage can be defined by the ratio of health facilities with CMAM
services to health facilities per district, or by the ratio of children with SAM in treatment
to children with SAM in the community (estimated with direct methods or indirect
methods).
Geographical coverage, defined by the ratio of children with SAM in treatment to the
total number of children with SAM identified in the community at a particular time, is
measured by a population survey in the study population (i.e., cluster survey; the study
population is living in an area that can be larger than the catchment area of the health
facilities with CMAM services).
Service or program coverage, defined by the ratio of children with SAM in treatment
to the total number of children with SAM identified in the community at a particular
time, is measured by a population survey (e.g., centric systematic area sampling [CSAS]
method, semi-quantitative evaluation of access and coverage [SQUEAC] method, the
study population is living within the catchment area of the health facilities with CMAM
services).
Coverage Ratio Coverage ratio is expressed as the ratio of children with SAM under treatment (a) to the
total number of children with SAM identified in the community at a particular time (a+b).
Children with SAM identified in the community are calculated as children with SAM under
treatment (a) plus children with SAM who are not under treatment (b). [Coverage ratio =
a/(a+b)].
Essential Health
Care Package
Essential health care package refers to the set of services provided at health facilities, as
mandated by the national health policy. The package varies based on the health facility
type (e.g., health centre versus health post).
F75 Formula 75 (75 kcal/100ml) is the milk-based diet recommended by WHO for the
stabilisation of children with SAM in inpatient care.
F100 Formula 100 (100 kcal/100ml) is the milk-based diet recommended by WHO for the
nutrition rehabilitation of children with SAM after stabilisation in inpatient care and
was used in this context before RUTF was available. Its current principal use in CMAM
services is for children with SAM who have severe mouth lesions and cannot swallow
RUTF, and who are being treated in inpatient care.
Diluted F100 is used for the stabilisation and rehabilitation of infants under 6 months of
age in inpatient care.
Global Acute
Malnutrition
(GAM)
GAM is a population-level indicator referring to overall acute malnutrition defined
by the presence of bilateral pitting oedema or wasting defined by WFH < -2 z-score
(WHO standards or NCHS references). GAM is divided into moderate and severe acute
malnutrition (GAM = SAM + MAM).

1.2
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
Hand-Over of
CMAM
Hand-over refers to the actual transfer of roles and responsibility for CMAM services
from the nongovernmental organisation (NGO) to the MOH. While the NGO or other
partner may continue to provide some financial or technical support following the hand-
over (e.g., purchase and transport of supplies, provision of training), MOH staff conducts
CMAM planning and provides CMAM services.
Health Care Health care is the prevention, treatment and management of illness and the preservation
of mental and physical well-being through the services offered by health care providers.
Health care embraces all the goods and services designed to promote health, including
preventive, curative and palliative interventions, whether directed to individuals or to
populations.
Health Care
Provider
Health care provider refers to the medical, nursing and allied health professionals,
including community health workers (CHWs).
Health Care
System
A health care system refers to the organised delivery of health care.
Health System A health system consists of all structures, resources, policies, personnel, services and
programmes involved in the promotion, restoration and maintenance of health.
Height-for-Age
Index
(HFA)
The HFA index is used to assess stunting. It shows how a child’s height compares to the
height of a child of the same age and sex in the WHO standards. This index reflects a
child’s past nutritional status.
Inpatient
Care for the
Management
of SAM with
Medical
Complications
Inpatient care is a CMAM service treating children with SAM with medical complications
until their medical condition is stabilised and the complication is resolved (usually four
to seven days). Treatment then continues in outpatient care until weight recovery is
achieved. Inpatient care for SAM with medical complications is provided in a hospital or
health facility with 24-hour care capacity.
In-Service
Training
In-service training prepares health professionals to provide CMAM services by developing
specific knowledge and skills according to their job qualifications while accounting for
prior learning and work experience. It includes theoretical and practical training (e.g., on-
the-job training, tutoring or mentoring, refresher training sessions).
Integration of
CMAM or CMAM
Services
Integration of CMAM refers to the incorporation of CMAM into the national health system.
Integration of CMAM services refers to the incorporation of the CMAM services of
inpatient care, outpatient care and community outreach into the national health care
system. It assumes that the health care system has the capacity and competence for
providing, strengthening, adapting, and maintaining quality and effective CMAM services
with minimal external support.
Minimal external support refers to financial and technical support to the MOH for capacity
strengthening and access to supplies.
Kwashiorkor See Bilateral Pitting Oedema.
Management of
Illness
Management of a specific illness is the prevention, detection, referral for treatment,
treatment, follow-up, and prevention of relapse of the illness.
Marasmic
Kwashiorkor
Marasmic kwashiorkor is the simultaneous condition of severe wasting (marasmus) and
bilateral pitting oedema (kwashiorkor).
Marasmus See Severe Wasting.

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.2
Medical
Complications in
the Presence of
SAM
The major medical complications in the presence of SAM that indicate the need for
referral of a child to inpatient care are: anorexia or no appetite, convulsions, high
fever, hypoglycaemia or hypothermia, intractable vomiting, lethargy or not alert, lower
respiratory tract infection (LRTI), severe anaemia, severe dehydration, unconsciousness.
(Other cases needing inpatient care besides severe bilateral pitting oedema, marasmic
kwashiorkor, SAM with medical complications and infants under 6 months with SAM
include: infants 6 months or older with SAM and a weight below 4 kg, children with SAM
in outpatient care and weight loss for three weeks or with static weight for five weeks, or
upon mother/caregiver’s request.)
Micronutrient
Deficiencies
Micronutrient deficiencies are a consequence of reduced or excess micronutrient intake
and/or absorption in the body. The most common forms of micronutrient deficiencies are
related to iron, vitamin A and iodine deficiency.
Mid-Upper Arm
Circumference
(MUAC)
Indicator
Low MUAC is an indicator for wasting, used for a child that is 6 to 59 months old.
MUAC < 110 mm indicates severe wasting or SAM. MUAC ≥ 110 mm and < 125 mm
indicates moderate wasting or MAM. MUAC cutoffs are being debated; for example, new
suggestions could be MUAC < 115 mm for SAM and ≥ 115 and <125 for MAM.
MUAC is a better indicator of mortality risk associated with acute malnutrition than WFH.
Moderate Acute
Malnutrition
(MAM)
Moderate
Wasting
MAM, or moderate wasting, is defined by a MUAC ≥ 110 mm and < 125 mm (the
cutoff is being debated) or a WFH ≥ -3 z-score and < -2 z-score of the median
(WHO standards) or WFH as a percentage of the median ≥ 70% and < 80% (NCHS
references).
MAM can also be used as a population-level indicator defined by WFH ≥ -3 z-score and <
-2 z-score (WHO standards or NCHS references).
Nutritional
Oedema
See Bilateral Pitting Oedema.
Oedematous
Malnutrition
See Bilateral Pitting Oedema.
Outpatient
Care for the
Management of
SAM Without
Medical
Complications
Outpatient care is a CMAM service treating children with SAM without medical
complications through the provision of routine medical treatment and nutrition
rehabilitation with RUTF. Children attend outpatient care at regular intervals (usually
once a week) until weight recovery is achieved (usually two months).
Outreach
Worker for
CMAM
An outreach worker is a CHW, health extension worker (HEW) or community volunteer
who identifies and refers children with acute malnutrition from the community to the
CMAM services and follows up with the children in their homes when required.
Pre-Service
Training
Pre-service training is conducted at a teaching institution as part of the curriculum for
a professional qualification. It can be at the pre-graduate, post-graduate or diploma
level (e.g., in medical or nursing schools). It includes theoretical and practical training.
Practical training sessions can be simulations, demonstrations, on-the-job training,
mentoring, etc.
Ready-to-Use
Therapeutic
Food (RUTF)
RUTF is an energy-dense, mineral- and vitamin-enriched food specifically designed to
treat SAM. RUTF has a similar nutrient composition to F100. RUTF is soft, crushable
food that can be consumed easily by children from the age of 6 months without adding
water. Unlike F100, RUTF is not water-based, meaning that bacteria cannot grow in
it and that it can be used safely at home without refrigeration and in areas where
hygiene conditions are not optimal. It does not require preparation before consumption.
Plumpy’nut® is an example of a commonly known lipid-based RUTF.

1.2
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
Referral A referral is a child who is moved to a different component of CMAM (e.g., from
outpatient care to inpatient care for medical reasons) but has not left the program.
Routine Health
Services
Routine health services refer to those services provided at health facilities depending
on staff capacity and facility resources. These services include the essential health care
package and other services.
Scale-Up Scale-up involves the expansion of services (e.g., from the pilot phase to the program
phase, as part of a strategy to expand geographical coverage to the targeted area or
nationally).
Self-Referral Self-referral occurs when mothers/caregivers bring children to the outpatient care or
inpatient care site without a referral from outreach workers (e.g., CHWs, volunteers).
Severe Acute
Malnutrition
(SAM)
SAM is defined by the presence of bilateral pitting oedema or severe wasting (MUAC <
110 mm [cutoff being debated] or a WFH < -3 z-score [WHO standards] or WFH < 70%
of the median [NCHS references]).
A child with SAM is highly vulnerable and has a high mortality risk.
SAM can also be used as a population-based indicator defined by the presence of
bilateral pitting oedema or severe wasting (WFH < -3 z-score [WHO standards or NCHS
references]).
Severe Wasting Severe wasting is a sign of SAM. It is defined by a MUAC < 110 mm (cutoff being
debated) or a WFH < -3 z-score (WHO standards) or WFH < 70% of the median (NCHS
references).
Severe wasting is also called marasmus. The child with severe wasting has lost fat and
muscle and appears very thin (e.g., signs of “old man face” or “baggy pants” [folds of
skin over the buttocks]).
Sphere Project
or Sphere
Standards
The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response
is a voluntary effort to improve the quality of assistance provided to people affected
by disaster and to enhance the accountability of the humanitarian agencies in disaster
response. Sphere has established Minimum Standards in Disaster Response (often
referred to as Sphere Standards) and indicators to describe the level of disaster
assistance to which all people have a right. www.sphereproject.org
Stunting Stunting, or chronic undernutrition, is a form of undernutrition. It is defined by a height-
for-age (HFA) z-score below two SDs of the median (WHO standards). Stunting is a
result of prolonged or repeated episodes of undernutrition starting before birth. This
type of undernutrition is best addressed through preventive maternal health programmes
aimed at pregnant women, infants, and children under age 2. Programme responses to
stunting require longer-term planning and policy development.
Transition of
Programmes
Transition refers to the process leading up to hand-over, including planning and
preparation for the gradual transfer of roles and responsibilities for CMAM services from
the NGO to the MOH, until hand-over is complete.
Undernutrition Undernutrition is a consequence of a deficiency in nutrient intake and/or absorption
in the body. The different forms of undernutrition that can appear isolated or in
combination are acute malnutrition (bilateral pitting oedema and/or wasting), stunting,
underweight (combined form of wasting and stunting), and micronutrient deficiencies.
Underweight Underweight is a composite form of undernutrition including elements of stunting and
wasting and is defined by a weight-for-age (WFA) z-score below 2 SDs of the median
(WHO standards). This indicator is commonly used in growth monitoring and promotion
(GMP) and child health and nutrition programmes aimed at the prevention and treatment
of undernutrition.

1.2
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
Wasting Wasting is a form of acute malnutrition. It is defined by a MUAC < 125 mm (cutoff being
debated) or a WFH < -2 z-score (WHO standards) or WFH < 80% of the median (NCHS
references).
Weight-for-Age
Index
(WFA)
The WFA index is used to assess underweight. It shows how a child’s weight compares to
the weight of a child of the same age and sex in the WHO standards. The index reflects
a child’s combined current and past nutritional status.
Weight-for-
Height Index
(WFH)
The WFH index is used to assess wasting. It shows how a child’s weight compares to
the weight of a child of the same length/height and sex in the WHO standards or NCHS
references. The index reflects a child’s current nutritional status.

1.3
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
HANDOUT 1.3
REFERENCES AND FURTHER READING
MODULE ONE: OVERVIEW OF COMMUNITY-BASED MANAGEMENT OF ACUTE
MALNUTRITION
 Caulfield, L., M. de Onis, M. Blössner and R. Black. 2004. “Undernutrition as an underlying cause of
child deaths associated with diarrhea, pneumonia, malaria, and measles,” American Journal of Clinical
Nutrition 80:193-8.
 Collins, S. 2004. “Community-based therapeutic care: A new paradigm for selective feeding in
nutritional crisis,” Humanitarian Practice Network Paper 48, ODA. www.validinternational.org.
 Collins, S. et al. 2006. “Management of severe acute malnutrition in children,” Lancet 368: 1992-2000.
www.validinternational.org.
 Collins, S. and Yates, R. 2003. “The need to update the classification of acute malnutrition,” Lancet
362: 249.
 Diop, E. et al. 2003. “Comparison of the efficacy of a solid ready to use food and liquid milk based
diet for the rehabilitation of severely malnourished children: a randomized trial,” American Journal of
Clinical Nutrition 78: 302-7.
 Emergency Nutrition Network (ENN) et al. 2004. Module 2 in Infant Feeding in Emergencies
(December). www.ennonline.net.
 Gatchell, V., V. Forsythe and P. Rees Thomas. The sustainability of Community-based Therapeutic Care
(CTC) in non-acute emergency contexts. WHO Technical Background Paper.
 http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/CBSM/tbp_5.pdf
 Gross, R. and P. Webb. 2006. “Wasted time for wasted children: severe child undernutrition must be
resolved in non-emergency settings,” Lancet 367: 1209-1211. www.thelancet.com.
 Save the Children US, Concern Worldwide and FANTA/AED. 2005. Inter-agency meeting Feb 28-March
2. Presentations and ENN report on the meeting. www.fantaproject.org/focus/emergency.
 WHO, WFP, UN/SCN and UNICEF. 2006. “Informal consultation on the community-based management
of severe malnutrition in children,” Food and Nutrition Bulletin, Vol. 27, No. 3 (supplement). www.
fantaproject.org.
 WHO, WFP, the UN/SCN and UNICEF. 2007. Community-based management of severe acute
malnutrition: A joint statement.
MODULETWO: DEFINING AND MEASURING ACUTE MALNUTRITION
 WHO Department of Health and Development. 2002. Training Course on the Management of Severe
Malnutrition. Geneva: WHO.
 WHO. 1983. Measuring Change in Nutritional Status. Geneva: WHO.
 WHO. 2000. Management of Nutrition in Major Emergencies. Geneva: WHO.

1.3
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
 Young, Helen and Susanne Jaspars. 2006. “The meaning and measurement of acute malnutrition
in emergencies. A primer for decision-makers,” ODI, Humanitarian Practice Network Paper No. 56,
November.
 Reference material on weight and height equipment, where to purchase equipment and available kits:
http://www.fantaproject.org/downloads/pdfs/anthro_4.pdf
 WHO Child Growth Standards. http://www.who.int/childgrowth/standards/
MODULETHREE: COMMUNITY OUTREACH
 Valid International. 2006. Community-based Therapeutic Care (CTC) A Field Manual. Oxford: Valid
International. www.validinternational.org
 Emergency Nutrition Network (ENN). 2005. Operational Challenges of Implementing Community
Therapeutic Care, ENN Report on an Interagency Workshop (Washington: February 28-March 2).
 Saul Guerrero. 2007. “Impact of non-admission on CTC program coverage,” Field Exchange 31: 28-30,
September.
MODULE FOUR: OUTPATIENT CARE ANDTHE MANAGEMENT OF SAM WITHOUT
MEDICAL COMPLICATIONS
 Valid International. 2006. Community-based Therapeutic Care (CTC): A Field Manual. Oxford: Valid
International.
 WHO. 2008. Draft guidelines for health managers (not yet released).
 National guidelines for CMAM
 WHO or national guidelines for Integrated Management of Childhood Illness (IMCI)
MODULE FIVE: INPATIENT CARE FORTHE MANAGEMENT OF SAM WITH MEDICAL
COMPLICATIONS INTHE CONTEXT OF CMAM
 Collins, S, A. Dufﬁeld and M. Myatt. 2000. Adults: “Assessment of nutritional status in emergency
affected populations,” RNIS Supplement, ACC/SCN (July).
 ENN, IBFAN, Terre des Hommes, UNHCR, UNICEF, WFP, WHO. 2004. The Young Severely
Malnourished Infant (chapter 8) in Infant Feeding in Emergencies, Module 2, version 1.0 for health
and nutrition workers in emergency situations. www.ennonline.net
 The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response. 2004
edition. www.sphereproject.org
 WHO. 2003. Guidelines for the inpatient treatment of severely malnourished children. Geneva.
 WHO/UNICEF. 2000. Management of the Child with Serious Infection or Severe Malnutrition: Guidelines
for Care at the First-Referral Level in Developing Countries. www.who.int/child-adolescent-health/
publications/CHILD_HEALTH/WHO_FCH_CAH_00.1.htm
 WHO. 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health
Workers. Geneva. www.who.int/nut/publications
 WHO. 2004. Report on a consultation to review current literature on severe malnutrition. Geneva.

1.3
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
 WHO. 2002. Training Course on the Management of Severe Malnutrition. Geneva.
 Woodruff, B. and A. Dufﬁeld. 2000. “Adolescents: Assessment of nutritional status in emergency
affected populations.” RNIS Supplement, ACC/SCN (July). www.unsystem.org/SCN/publications
 Indicates document is included in the Supplemental Reference Packet
MODULE SIX: SERVICES OR PROGRAMMES FORTHE MANAGEMENT OF MODERATE
ACUTE MALNUTRITION (MAM) INTHE CONTEXT OF CMAM
 WHO. 2000. The Management of Nutrition in Major Emergencies. Geneva.
 Médecins Sans Frontières (MSF). 2004. Nutrition Guidelines (revised), draft.
 WFP/UNHCR. 1999. Guidelines for Selective Feeding in Emergencies.
 The Sphere Project. 2004. Humanitarian Charter and Minimum Standards in Disaster Response. www.
sphereproject.org
 WFP/UNHCR. 2000. Food and Nutrition Needs in Emergencies.
 USAID, Commodities Reference Guide. www.usaid.gov/our_work/humanitarain_assistance/ffp/grg
 WHO/UNICEF. 2000. Management of the Child with Serious Infection or Severe Malnutrition: Guidelines
for Care at the First-Referral Level in Developing Countries. www.who.int/child-adolescent-health/
publications/CHILD_HEALTH/WHO_FCH_CAH_00.1.htm
MODULE SEVEN: PLANNING CMAM SERVICES ATTHE DISTRICT LEVEL
 Valid International. 2006. Community-based Therapeutic Care (CTC): A Field Manual. Oxford: Valid
International. www.validinternational.org.
 Standardised monitoring and assessments for relief and transition (SMART), “Measuring mortality,
nutritional status and food security in crisis situations (interpretation).” www.smartindicators.org.
 The Sphere Project. 2004. Humanitarian Charter and Minimum Standards in Disaster Response. www.
sphereproject.org.
 UNICEF. 1990. Strategy for Improved Nutrition of Children and Women in Developing Countries. New
York: UNICEF Program Division.
 WHO. 2007. Reference manual for policy makers and programme managers. Draft, December.
MODULE EIGHT: MONITORING AND EVALUATION OF CMAM
 Valid International. 2006. Community-based Therapeutic Care: A Field Manual. Oxford: Valid
International. Chapters 9 & 10.

1.4
HANDOUTS
& EXERCISES
HANDOUT 1.4
KEY INFORMATION ON UNDERNUTRITION
1
Caulfield, L., M. de Onis, M. Blössner and R. Black. 2004. “Undernutrition as an underlying cause of child deaths associated with
diarrhea, pneumonia, malaria, and measles,” American Journal of Clinical Nutrition 80:193-8.
WHAT IS UNDERNUTRITION?
Undernutrition is a consequence of a deficiency in nutrient intake and/or absorption in the body and can
take the form of:
 Acute malnutrition (bilateral pitting oedema and/or wasting)
 Stunting
 Underweight
 Micronutrient deficiencies
Note: Malnutrition comprises both overnutrition (obesity) and undernutrition, but the term
malnutrition is often used for forms of undernutrition (e.g., acute malnutrition).
Undernutrition in all its forms is a significant public health concern and an underlying factor in over 50
percent of the 10 million deaths from preventable causes among children under 5 each year.1
All four
types of undernutrition can overlap in the same child.
Undernutrition Indicators
Acute Malnutrition Stunting Underweight
Micronutrient
Deficiencies
Indicators Low mid-upper arm circumference
(MUAC) or low weight-for-height
(WFH, wasting)
or
Presence of bilateral pitting
oedema
Low height-for-
age (HFA)
Low weight-
for-age (WFA),
combining
wasting and
stunting
Clinical signs
and biochemical
markers
WHAT IS ACUTE MALNUTRITION?
 Acute malnutrition is caused by a decrease in food consumption and/or illness resulting in bilateral
pitting oedema or sudden weight loss. It is defined by the presence of bilateral pitting oedema or
wasting (low MUAC or low WFH).
 Acute malnutrition comprises both severe acute malnutrition (SAM) and moderate acute malnutrition
(MAM) and can have the following indicators (with cutoffs):

1.4
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
Bilateral
Pitting
Oedema
MUAC*
WFH z-score
(WHO standards or
NCHS references)
WFH as a percentage of the
median (NCHS references)
SAM: Present < 110 mm* < -3 < 70%
MAM: Not present
> 110 mm* and
< 125 mm*
≥ -3 and < -2 ≥ 70% and < 80%
*cutoffs being debated
WHY FOCUS ON ACUTE MALNUTRITION?
 The World Health Organization (WHO), the World Food Programme (WFP), the UN Standing
Committee on Nutrition (UN/SCN), and the United Nations Children’s Fund (UNICEF) estimate that
nearly 20 million children suffer from SAM worldwide and that SAM contributes to more than one
million deaths of children under 5 every year.
 The importance of underweight (low WFA) and stunting (low HFA) in contributing to child illness
and mortality is well accepted. As such, development programmes (e.g., growth monitoring
and promotion [GMP], integrated management of childhood illnesses [IMCI]) and child survival
interventions have focused on these forms of undernutrition in health and nutrition prevention and
treatment programmes. Until recently, acute malnutrition has not been given much recognition
beyond humanitarian emergency interventions.
 Since the 1990s a very effective SAM treatment protocol with low case fatality has been developed
and made available. The availability of ready-to-use therapeutic food (RUTF) and the CMAM approach
in the early 2000s made large-scale management of SAM possible with improved access and
coverage.
 A larger number of children are affected by underweight and stunting than are by acute malnutrition,
which demonstrates that a higher mortality risk is associated with acute malnutrition. Addressing
acute malnutrition with an effective treatment at large scale will have a significant impact on mortality
at the population level (see the Lancet's 2008 "Maternal and Child Undernutrition" series for further
information).
 Acute malnutrition occurs in both emergency and non-emergency settings, but it is sometimes
difficult to draw the line between the two:
- Many countries experience protracted emergencies (e.g., South Sudan, Democratic Republic
of Congo).
- Some non-conflict settings like India have high general acute malnutrition (GAM) because of
poverty.
- The SAM/MAM case load in a country is determined by both prevalence and total population.
Both are high in Pakistan and India. Therefore, a large concentration of cases can occur
outside high-profile emergencies.
 Children have a right to treatment for acute malnutrition, as they do for other illnesses (e.g., malaria,
pneumonia), regardless of where they live. It is vital to find ways to reach them over the short,
medium and long term.
 Other factors, like HIV, can lead to high SAM levels even when GAM is low (e.g., Malawi).

1.5
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
HANDOUT 1.5
CMAM PRINCIPLES
1. MAXIMUM ACCESS AND COVERAGE
Goal: Bring treatment close to where people live and make it less costly to access by having many
decentralised sites and regular (weekly or biweekly) outpatient services.
 Outpatient care can be managed by health care providers with a variety of expertise. This reduces
the need for highly trained clinical staff.
 Bringing care into the home reduces opportunity costs and disruption to the family.
2.TIMELINESS
Goal: Start treatment before the onset of life-threatening illnesses.
 Strong community outreach allows for early detection of severe acute malnutrition (SAM), ensuring
that children are found, referred and treated on a timely basis.
 Decentralized services allow for early presentation because families can be referred to health facilities
with outpatient care close to home.
3.APPROPRIATE MEDICAL CARE AND NUTRITION REHABILITATION
Goal: Provide the right treatment to children in need.
 CMAM recognises that the severity of illness in children with SAM can range widely. Those with
medical complications or no appetite are referred to inpatient care. Those with no medical
complications and an appetite are referred to outpatient care.
 Once children are identiﬁed with acute malnutrition, they must be seen by a health care provider with
the skills to assess them.
4. CARE AS LONG AS IT IS NEEDED
Goal: Reduce barriers to access and prevent relapse.
 Programmes are designed to minimise default to ensure that children stay in the programme until
they recover.
 Strong community outreach helps to identify and reduce barriers to access.
 Strong health service capacity ensures that treatment can be offered on an ongoing basis and is
available as long as there is a need and supplies are present.

1.6
HANDOUT 1.6
CLASSIFICATION OF ACUTE MALNUTRITION FOR CMAM
HANDOUTS
& EXERCISES
*Medical complications include severe bilateral pitting oedema, marasmic kwashiorkor,
anorexia, intractable vomiting, convulsions, lethargy or not alert, unconsciousness,
lower respiratory tract infection (LRTI), high fever, severe dehydration, severe anaemia,
hypoglycaemia, and hypothermia.
**Others admitted to inpatient care are: infants less than 6 months with SAM (bilateral
pitting oedema or visible wasting), children over 6 months of age who weigh less than
4 kg, and children with SAM in outpatient care who are losing weight or have static
weight for ﬁve weeks.
*** Children with MAM and medical complications are admitted to supplementary
feeding services or programmes (known as SFPs in the emergency context) and receive
supplementary food rations, but are referred for medical treatment and return to
supplementary feeding when medical complications are resolved.
Acute Malnutrition
Severe acute
malnutrition (SAM) without
medical complications
OUTPATIENT CARE
Moderate acute
malnutrition (MAM) without
medical complications***
SUPPLEMENTARY
FEEDING
Severe acute
malnutrition (SAM) with
medical complications*
INPATIENT CARE*
Appetite test

1.7
HANDOUT 1.7
SCREENING AND ADMISSION USING MUAC
HANDOUTS
& EXERCISES
MID-UPPER ARM CIRCUMFERENCE (MUAC)TAPE
MUAC ONLY FOR REFERRAL AND ADMISSION
For children 6-59 months:
RED SAM MUAC < 110 mm and/or bilateral pitting oedema
YELLOW MAM MUAC > 110 mm and < 125 mm
GREEN Normal MUAC > 125 mm
 MUAC is recommended as the best tool for effective CMAM services. The World Health Organization
(WHO, 2005) has endorsed MUAC as an independent criterion for referral and admission to treatment
services for severe acute malnutrition (SAM). However, national guidelines may also require the use
of weight-for-height (WFH) in addition to MUAC.
 MUAC < 110 mm indicates severe wasting in children age 6-59 months. MUAC ≥ 110 mm and < 125
mm indicates moderate wasting (cutoffs being debated).
 Children age 6-59 months who are referred from the community with a red MUAC (<110 mm) are
automatically admitted to outpatient care if they have an appetite and no medical complications.
 In some situations, cutoffs may be adjusted to accommodate available resources. For example,
several countries, such as Ethiopia, use MUAC < 120 mm as the cutoff for admission to services to
manage moderate acute malnutrition (MAM).
SCREENING AND ADMISSION USING MUAC
 MUAC is simple, quick, accurate and inexpensive, and colour-coded tapes are suitable to be used by
people who are illiterate/innumerate but trained.
 Identifying SAM with MUAC tapes can help people in the community better recognize which children
need treatment: those who are very thin (a red MUAC).
 MUAC automatically selects younger children, those who are most at risk.

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.7
 MUAC is a better indicator of mortality risk associated with undernutrition than WFH.1
 MUAC involves only one measurement, while WFH requires two measurements and one calculation.
As a result, there are fewer chances for error with MUAC and the process takes less time.
 MUAC-only admission reduces the chance that children will be rejected at an outpatient care site
because a referral based on MUAC is an automatic entitlement for admission.
CONSIDERATIONS IN USING MUAC
 MUAC and WFH will identify slightly different groups of children as having SAM. Some children with
MUAC < 110 mm can have a WFH z-score > -3 (WHO standards) or WFH > 70% of the median
(National Centre for Health Statistics [NCHS] references) and vice versa. Therefore, different
discharge criteria are applicable depending on the means of admission, which also includes bilateral
pitting oedema.
 If a young infant’s age is unknown, the age is estimated by the mother/caregiver. If this is not
possible, the ready-to-use therapeutic food (RUTF) appetite test can be used. If the infant can
swallow the RUTF, then s/he can be safely treated in outpatient care if identiﬁed with SAM. No
lower cutoff proxy based on length is applicable, neither for the use of MUAC nor for admission to
outpatient care for SAM without medical complications.
 Health care providers must be trained and regularly monitored for the standardisation of MUAC
measurements.
1
See Myatt et al (2007), FNB or www.who.int/child_adolescent_health/New_Publications/nutrition/CBSM/tbp_1.pdf.

1.8
HANDOUT 1.8
CMAM COMPONENTS AND HOWTHEY WORKTOGETHER
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
CORE COMPONENTS: COMMUNITY-BASED MANAGEMENT OF ACUTE MALNUTRITION
1. Community Outreach involves:
 Community assessment and mobilisation
 Active case-ﬁnding to ensure early detection, early presentation and referral
 Education and sensitisation of the community so that they know how and where to bring their
children for screening and treatment
 Case follow-up
To establish the most effective outreach, CMAM makes it a priority to:
 Understand local barriers to access and service uptake
 Explain acute malnutrition and the objectives of the services in readily understandable local terms
 Engage a broad array of local institutions and community outreach systems and initiatives
2. Outpatient Care is provided to children 6-59 months with severe acute malnutrition (SAM) and
appetite but no medical complications. The following services are provided through outpatient care
follow-on sessions to the health centre:
 Medical assessment and anthropometric monitoring
 Nutrition rehabilitation with ready-to-use therapeutic food (RUTF)
 Basic medical treatment
Medical assessment, anthropometric monitoring and treatment are based on simple protocols.
Services and/or programs to prevent
undernutrition
C
O
MMUNITY-BASE
D
M
A N AG E M E N T
O
F
ACUTEMALNUTRI
TIO
N(CMAM)
Community
Outreach
Services &
programs
addressing
MAM
Outpatient
care for SAM
without
complications
Inpatient
care for SAM
with
complications

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.8
3. Inpatient Care is provided to infants below 6 months of age with SAM and to children 6-59 months
with SAM and medical complications and/or no appetite.
 Medical treatment and nutrition rehabilitation is provided according to World Health Organization
(WHO) and/or national protocols
 Children 6-59 months return to outpatient care when the medical complication is resolved and
appetite returns
 Infants receive specialised treatment until full recovery
4. Management of Moderate Acute Malnutrition (MAM) can occur through supplementary
feeding services or programmes. Where such services do not exist, linkages can be created with other
prevention and treatment programmes, such as community nutrition programmes, aimed at moderately
malnourished children.
REFERRALSTO AND BETWEEN CMAM COMPONENTS
Referrals to CMAM services are fuelled by strong community outreach resulting in active case-ﬁnding and
self-referrals by community members. Admission criteria determine which service component a child is
admitted to initially.
Referrals between CMAM service components follow established criteria. Children initially admitted to
inpatient care will move to outpatient care as soon as their medical complication is resolved and their
appetite returns. After discharge from outpatient care, the children are referred to nutrition programmes
in the community (e.g., PD Hearth, GMP) or, in emergency contexts, to SFPs.
Effective and smooth referrals between the components are essential. This is facilitated by:
 The action protocol
 The use of referral slips, which ensure that full information on the child including reason for referral is
available
 Good communication between staff in inpatient care and outpatient care
REFERRALSTO AND BETWEEN CMAM SERVICE COMPONENTS
WORSENING
CONDITION
IMPROVING
CONDITION
INPATIENT C ARE
OUTPATIENT C ARE
SUPPLEMENTARY FEEDING
SERVICES OR PROGRAMMES
COMMUNITY NUTRITION
PROGRAMMES
Community
outreach
resulting in
active case-
ﬁnding and
self-referrals

1.9
HANDOUT 1.9
CASE STUDIES
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
CASE STUDY 1: LIFE-SAVING INTERVENTION IN NIGER
(NGO-implemented, sustainability not a stated goal)
In 2005, working at a scale unthinkable ﬁve years ago, Médecins Sans Frontières (MSF) reached over
60,000 children with acute malnutrition in Niger through a mobile outpatient care programme and use of
ready-to-use therapeutic food (RUTF). Children requiring inpatient care were transported to the inpatient
care site. The intervention achieved good results (mortality < 5 percent) in six to 12 months. This
intervention saved many lives, but was focused on the emergency response rather than the capacity to
treat severe acute malnutrition (SAM) in the long term, as it was not integrated into the health system. In
addition, the programme did not incorporate active case-ﬁnding; the service was promoted by reputation.
MSF’s CMAM approach is referred to as “ambulatory care” and is a component within MSF’s emergency
health and nutrition response model.
CASE STUDY 2: CMAM INTEGRATION IN ZAMBIA
In 2005, based on experiences in Ethiopia and Malawi, Valid International worked with the district
Ministry of Health (MOH) in Lusaka, Zambia, to design and develop an integrated programme for
management of SAM. The MOH implemented the programme directly from the outset, with Valid
providing technical and managerial support. MOH health facility staff were trained to provide outpatient
care alongside other primary health care (PHC) activities at health facilities. Hospital staff were trained to
discharge children to outpatient care after they stabilised and regained appetite. Community volunteers
were recruited for outreach activities and assistance with outpatient care days.
At the time of setup, some nongovernmental organisations (NGOs) were running supplementary feeding
programmes (SFPs) in some health centres. The outpatient care linked directly with the SFPs in these
centres, referring discharged cases to the SFP, while the SFP referred severe cases to outpatient care. The
programme opened in a phased approach, slowly expanding from 5 to 13 health centres across Lusaka.
The district MOH’s commitment to the programme was crucial to its implementation and integration. The
MOH created a position on its district staff for leading CMAM activities. This person is involved in daily
implementation, supervision and planning, with technical support from Valid International.
While the programme is running in the health centres, there have been and continue to be challenges in
programme development and implementation, including:
 Establishing low-cost local production of RUTF (now in operation)
 Ensuring links between hospitals with inpatient care and health facilities with outpatient care
 Keeping community volunteers motivated when the programme does not offer monetary incentives
(other “volunteer” activities in the health system offer per-diem pay)
 Distributing RUTF (currently, Valid International transports it to the MOH central stores and
sometimes to health centres directly)
 Limited nursing and nutrition staff availability on outpatient care days due to overall staff shortages
 Inpatient care situated in a national hospital: many people treated there do not live near an
outpatient care programme, so they stay in inpatient care at the hospital until weight recovery is
achieved; if there were an outpatient care programme near their homes, they could be discharged to
it as soon as they were stabilised and regained their appetite
 Funding for the programme, currently from an external donor, must be integrated into national plans

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.9
Note: It is recognised that integration from the onset is a much more sustainable way to develop a CMAM
programme. However, experience demonstrates that the process of integration and the provision of
technical, logistical and, in some cases, managerial support to strengthen capacity for sustainable long-
term service provision takes years; this must be considered during the planning stage.
CASE STUDY 3: EMERGENCY ANDTRANSITION IN ETHIOPIA
(NGO start-up with plan to transfer most responsibility to MOH and integrate into health system)
Concern Worldwide’s community-based therapeutic care (CTC) programme in Wollo, Ethiopia, began in
2003 as a high-input response to emergency levels of general acute malnutrition (GAM) and SAM. The
programme was established in health clinics and hospitals with existing staff. The MOH began assuming
responsibility for certain activities in 2004. Concern Worldwide and the MOH established a plan in which
Concern Worldwide would continue its support but in a more supervisory and mentoring role, and would
facilitate supply of RUTF, when necessary, over time. Recognising the need to strengthen the MOH’s
health services in Wollo so that it could take on the outpatient care programme, Concern Worldwide
opened a PHC programme and now indirectly supports the outpatient and inpatient care programmes
through that. Published data through May 2005 indicate that recovery and coverage rates have
remained high. Similar results were achieved in Malawi, where the MOH had taken on many activities
and programme outcomes still exceeded Sphere Standards two years after the peak of the emergency.
Concern Worldwide still assists with ﬁnancial and logistical support for the procurement and delivery of
RUTF, training, and low-level supervision/mentoring.
The experience in Ethiopia showed that the MOH’s post-emergency takeover of programme activities
will be smoother if the MOH is involved in initial planning and activities, and supervision and monitoring
systems are integrated into the MOH system from the beginning. The experience also showed that the
hand-over is a gradual process that requires an effective, functioning health system in which to integrate
activities and a reliable source of RUTF.

1.10
HANDOUT 1.10
IMPLEMENTING CMAM IN DIFFERENT CONTEXTS
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
EMERGENCY AND POST-EMERGENCY SETTINGS
 CMAM services have been implemented in emergency settings since 2001. More recently, outpatient
care for the management of acute malnutrition has occurred in non-emergency and high HIV
prevalence settings.
 For CMAM programmes that were started by nongovernmental organisations (NGOs) in an emergency
context and handed over to the Ministry of Health (MOH), initial performance results after hand-
over are encouraging. Longitudinal data on outcome indicators are necessary to better judge the
performance and sustainability of quality of the integrated CMAM services over time.
 In an emergency, CMAM interventions follow a hierarchy of interventions. The needs of the
greatest number should be a priority. In practice, this means that securing a general ration for the
whole population takes priority over setting up services for target groups within the population.
 In an emergency, large numbers of children can be reached through decentralised and/or mobile
outpatient care sites.
 To date, there are three scenarios for emergency CMAM interventions:
- Short-term, life-saving intervention with little or no attempt to hand over CMAM services to
the MOH or integrate them into routine health services (Handout 1.9 Case Study 1)
- Integrated CMAM services in a development context (Handout 1.9 Case Study 2)
- Emergency CMAM intervention that evolves into post-emergency services that are handed
over to the MOH and integrated into routine health services (Handout 1.9 Case Study 3)
 External agencies often start their involvement during a crisis but ideally will continue to support the
health system during the post-crisis transition to establish basic CMAM capacity. This will prepare the
local health services for future seasonal or sudden increases in severe acute malnutrition (SAM), and
if another crisis occurs, the country will require fewer external resources because local capacity will
have been maintained.

1.11
HANDOUT 1.11
FACTORSTO CONSIDER IN SEEKINGTO PROVIDE SERVICES FORTHE
MANAGEMENT OF SAM
HANDOUTS
& EXERCISES
ENABLING ENVIRONMENT
 Effective Ministry of Health (MOH) leadership and coordination mechanisms are essential to
ensure that various agencies, including government and nongovernmental organisations (NGOs)
running programmes for children with acute malnutrition, collaborate. Technical task forces and/or
coordination meetings at various levels should be put in place.
 Prevention of undernutrition should be the first policy priority, but treatment is needed for children
with SAM because they have a high mortality risk.
 National guidelines must be in place to standardise treatment protocols and monitoring tools. The
guidelines should describe the community-based approach to manage SAM that builds upon and links
with existing inpatient care, nutrition programmes and primary health care (PHC).
 Free treatment for malnourished children must be ensured.
 District health managers should develop a contingency plan to meet and manage additional needs if
the number of children requiring CMAM services exceeds capacity.
ACCESSTO SERVICES
 Centralised inpatient care for SAM with medical complications should be provided in a health facility
with 24-hour care.
 Decentralised outpatient care for SAM without medical complications should be provided in health
facilities. One health care provider can manage 10-15 children a day in outpatient care as part of
routine health services. In emergencies, services could be further decentralised in the community and
provided by mobile teams. Outpatient care sites should be set up within a day’s walk from and back
to a settlement.
 Adequate referral mechanisms must be ensured so that once children with SAM are identified, they
can access appropriate care.
 Qualified health care providers (i.e. qualified to perform a medical assessment, refer or treat children
with SAM) must be available in adequate numbers.
 Community outreach for community assessment, community mobilisation and active case-finding and
referral should be in line with existing formal and informal health and community outreach systems
and initiatives.
 Management of SAM as a routine health service means that a child presented at the health facility
at any time should be assessed and treated for SAM, receive health and nutrition education for
prevention of undernutrition, and be referred to other health services and initiatives as needed
(e.g., integrated management of childhood illness [IMCI], growth monitoring and promotion [GMP],
voluntary counselling and testing [VCT]). IMCI diagnostic tools and GMP programmes should include
the use of MUAC so that SAM can be identified and appropriate referral to CMAM can occur.

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.11
 Links with other community services and programmes should be made as necessary (e.g., with food
security, agriculture and livelihood programmes to ensure increased access to high-quality foods).
SUPPLIES
 Adequate resources and supplies for effective management of SAM must be provided to all health
facilities providing inpatient care and outpatient care for the management of SAM. This includes
ready-to-use therapeutic food (RUTF), F75, F100, ReSoMal, essential drugs, mid-upper arm
circumference (MUAC) tapes, scales and height boards, treatment cards, and monitoring cards.
 Regular transportation of supplies should be secured.
QUALITY OF SERVICES
 Having national CMAM guidelines with standardised treatment protocols fosters adherence.
 Support and supervision on clinical case management and organisation of services improve
performance.
 Standardised monitoring and evaluation (M&E) systems and tools compatible with the national health
information system enhance quality of services and reporting.
COMPETENCIES
 Opportunities to integrate pre-service and in-service training for CMAM should be maximised.
 Internships at learning sites and learning visits provide real-time learning and rapid transfer of skills.
 In-service training for improved management of SAM must be provided to health care providers at
all levels (i.e. district health managers, health care providers at health facilities, community outreach
workers) so there is an effective integrated approach that links management and supervision,
inpatient care, outpatient care, and other health services with one another.
 In-service training and support must be provided to community outreach workers (e.g., community
health workers [CHWs], volunteers) who identify and refer children with SAM in the communities.
 Capacity development strategies should account for high staff turnover.
 A positive work and learning environment empowers and motivates health care providers (control
workload).
 CMAM should become part of health care providers’ roles, responsibilities and job descriptions, and
health care providers should be accountable for meeting those responsibilities.
 Sharing information and experiences with peers and experts is essential for continually learning good
practices.
 Formative research is critical for improving the effectiveness of services, promoting good practices,
learning lessons and fostering programme integration and scale-up.

1.12
HANDOUT 1.12
INTEGRATING CMAM INTO ROUTINE HEALTH SERVICES ATTHE DISTRICT
LEVEL
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
 Existing health services and initiatives should be mapped and the programme planned with the
relevant authorities and agencies to prevent duplication, build upon and strengthen existing
structures and systems, and ensure that referral pathways, roles and responsibilities are clear.
 Health facilities with existing inpatient care for severe acute malnutrition (SAM) (e.g., therapeutic
feeding centre [TFC], nutrition rehabilitation unit [NRU], hospital ward) can be adapted to also
establish outpatient care for the management of SAM without medical complications in their
outpatient department (OPD). This takes the burden off the inpatient care staff, which will continue
to treat children with SAM and medical complications until they are stabilised and can be referred to
outpatient care.
 Good communication between health care providers managing inpatient care and outpatient care is
important for strong links and referral between those services.
 Existing community outreach networks can provide a platform for the community outreach work
required for successful CMAM implementation. Assessing what is already in place and identifying
potential links to those services are key to making the best use of resources available.
 CMAM can be integrated into child health and nutrition services at ﬁrst-level health facilities. Bilateral
pitting oedema and mid-upper arm circumference (MUAC) checks can be added to IMCI diagnostic
tools so that children with SAM can be identiﬁed at any contact point within the health care system
and be referred for appropriate treatment.
 CMAM can also be linked with other health services such as malaria prevention, voluntary
counselling and testing (VCT), family planning, and provision of relevant information, education and
communication (IEC) materials.

1.13
HANDOUT 1.13
ESSENTIALS OF CMAM
HANDOUTS
& EXERCISES
ESSENTIALS OF CMAM
1. Acute malnutrition is a significant public health concern. It is estimated that 20 million children
around the world suffer from severe acute malnutrition (SAM). Children suffering from SAM have an
increased mortality risk. Current estimates suggest that SAM contributes to about 1 million deaths of
children under 5 every year.
2. CMAM is a new approach to treating SAM. The principles of CMAM are maximum coverage and access
(reaching as many children with acute malnutrition as possible), timeliness (early identification and
referral before medical complications develop) and appropriate care (outpatient care for children with
SAM without medical complications as long as needed and inpatient care only for those with SAM
and medical complications). Evidence from emergency contexts has shown that about 80 percent of
children with SAM can be treated as outpatients.
3. To reach the maximum number of children with acute malnutrition, trained health care providers
must be able to reach the majority of these children in their communities, where they can access
health facilities as outpatients and continue treatment in their homes. Coverage and access are
achieved by providing CMAM outpatient care in decentralised health facilities or by establishing mobile
outpatient care sites (in the case of emergencies). This differs from the centre-based approach,
where all children with SAM are treated as inpatients for both stabilisation and rehabilitation until
weight recovery is achieved.
4. Recent innovations have made CMAM possible:
- Ready-to-use therapeutic food (RUTF), which can be used safely at home without refrigeration and
in areas where hygiene conditions are not optimal, meaning children can be treated at home
- Using an acute malnutrition classification that divides SAM into two categories--SAM with medical
complications and SAM without medical complications--to determine treatment (see below)
- Screening and admission using mid-upper arm circumference (MUAC) which is simple, accurate
and inexpensive, and makes active case-finding, referral and admission transparent
5. Treatment for SAM differentiates between SAM with medical complications and SAM without medical
complications:
- Children with SAM without appetite or with medical complications are treated in inpatient care
- Children with SAM and appetite and no medical complications are treated in outpatient care
- Infants under 6 months with SAM are treated in inpatient care
Children with moderate acute malnutrition (MAM) with appetite and no medical complications are
treated in services or programmes that manage MAM, such as supplementary feeding), if available.
6. CMAM has four essential components: community outreach, outpatient care for children with SAM
without medical complications, inpatient care for children with SAM with medical complications and
for infants under 6 months with SAM, and supplementary feeding for children with MAM (depending
on the context). In some cases, supplementary feeding may not be available. Effective and smooth
referral among the components is essential. Using an action protocol helps health care providers
determine which children require inpatient care and follow-up at home. To date, the protocols used in
outpatient care are aimed at children 6 to 59 months old.

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.13
7. Evidence from emergency programmes has demonstrated that the community-based approach works
very well. Recovery rates, mortality rates and default rates are all within Sphere Standards. Coverage
ratios are much higher than those seen in centre-based services.
8. CMAM can be implemented in a variety of contexts (e.g., emergency, non-emergency, high HIV
prevalence). The CMAM components should complement existing services.
9. CMAM should be integrated into existing health facilities and run as a component of primary health
care (PHC) where possible. Linkages can be made to other child health services (e.g., integrated
management of childhood illness [IMCI], HIV services, prevention services).
10. In recent years, there have been several key developments and commitments at the global level
regarding the acceptance of CMAM.

1.14
HANDOUT 1.14
FIELDVISIT CHECKLIST
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
Complete the following activities during the CMAM ﬁeld visit.
OBSERVE THE FOLLOWING ACTIVITIES, IF POSSIBLE:
Admission of children with severe acute malnutrition (SAM)
Discharge of children with SAM
Outpatient care follow-on sessions
-Anthropometric measurement
-Medical assessment
-Supply of ready-to-use therapeutic food (RUTF)
DISCUSS WITH STAFF THE FOLLOWING:
What do they like and dislike about the CMAM service?
How does this programme affect their overall workload?
What shortcomings or problems do they see with the service?
How do they work with volunteers?
How do they link with other health services (e.g., expanded programme of immunisation [EPI],
voluntary counselling and testing [VCT])?
What type of support is provided to the child’s family after the child is discharged (e.g., micro-
credit support, agricultural support, IYCF counselling)?
DISCUSS WITH MOTHERS/CAREGIVERS THE FOLLOWING:
How did they ﬁnd out about the service?
What do they like and dislike about the service?

1.15
HANDOUT 1.15
POWERPOINT PRESENTATION SLIDE IMAGES
HANDOUTS
& EXERCISES
1
Overview of Community-
Based Management of
2
Module 1. Learning Objectives
• Discuss acute malnutrition and the need for a
response.
• Describe the principles of CMAM.
• Describe recent innovations and evidence
making CMAM possible.
• Identify the components of CMAM and how
they work together.
• Explore how CMAM can be implemented in
different contexts.
• Identify global commitments related to CMAM.
3
What is undernutrition?
• A consequence of a deficiency in nutrients in the
body
• Types of undernutrition?
– Acute malnutrition (wasting and bilateral pitting
oedema)
– Stunting
– Underweight (combined measurement of stunting and
wasting)
– Micronutrient deficiencies
• Why focus on acute malnutrition?
What is undernutrition?
5
Undernutrition and
Child Mortality
Diarrhea
12%
Measles
5%
Perinatal &
Newborn
22%
All other
causes
29%
HIV/AIDS
4%
Pneumonia
20%
Malaria
8%
• 54% of child mortality is
associated with underweight
• Severe wasting is an
important cause of these
deaths (it is difficult to
estimate)
• Proportion associated with
acute malnutrition often
grows dramatically in
emergency contexts
Malnutrition
54%
Caulfied, LE, M de Onis, M Blossner, and R Black, 2004
6Source: Webb and Gross, Wasted time for wasted children, The Lancet April 8, 2006
Magnitude of ‘Wasting’ Around the
World – not only in emergencies
Photo Credit: Mike Golden

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.15
7
• Traditionally, children with SAM are treated in
centre-based care: paediatric ward,
therapeutic feeding centre (TFC), nutrition
rehabilitation unit (NRU), other inpatient care
sites.
• The centre-based care model follows the
World Health Organization (WHO) Guidelines
for Management of Severe Malnutrition.
Recent History in the Management of
Severe Acute Malnutrition (SAM)
8
Centre-Based Care for Children with
SAM: Example of a Therapeutic
Feeding Centre (TFC)
• What is a TFC?
• What are the advantages and disadvantages of
a TFC?
• What could be changed about the TFC model to
address these challenges?
9
El Fasher
Um Keddada
Mellit
Kutum
Taweisha
El Laeit
Malha
Tawila & Dar el Saalam
Karnoi &
Um Barow
Koma
KormaSerif
Kebkabiya
Fata Barno
Tina
N Darfur
2001
Hospital TFC
El Sayah
100 kms
10
12
Centre-Based Care for Children
with SAM: Challenges
• Low coverage leading to late presentation
• Overcrowding
• Heavy staff work loads
• Cross infection
• High default rates due to need for long stay
• Potential for mothers to engage in high risk
behaviours to cover meals

1.15
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
13
What is Community-Based
Management of Acute
Malnutrition (CMAM)?
14
CMAM
• A community-based approach to treating SAM
– Most children with SAM without medical
complications can be treated as outpatients at
accessible, decentralised sites
– Children with SAM and medical complications are
treated as inpatients
– Community outreach for community involvement and
early detection and referral of cases
• Also known as community-based therapeutic
care (CTC), ambulatory care, home-based care
(HBC) for the management of SAM
15
Core Components of CMAM (1)
16
1. Community Outreach:
• Community assessment
• Community mobilisation and involvement
• Community outreach workers:
- Early identification and referral of children with SAM
before the onset of serious complications
- Follow-up home visits for problem cases
• Community outreach to increase access and
coverage
17
2. Outpatient care for children with SAM
without medical complications at
decentralised health facilities and at home
• Initial medical and anthropometry assessment
with the start of medical treatment and nutrition
rehabilitation with take home ready-to-use
therapeutic food (RUTF)
• Weekly or bi-weekly medical and
anthropometry assessments monitoring
treatment progress
• Continued nutrition rehabilitation with RUTF at
home
ESSENTIAL: a good referral system to inpatient care, based on
Action Protocol
18
3. Inpatient care for children with SAM with
medical complications or no appetite
• Child is treated in a hospital for stabilisation of
the medical complication
• Child resumes outpatient care when
complications are resolved
ESSENTIAL: good referral system to outpatient care

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.15
19
4. Services or programmes for the
management of moderate acute
malnutrition (MAM)
• Supplementary Feeding
20
• Response to challenges of centre-based care for the
management of SAM
• 2000: 1st pilot programme in Ethiopia
• 2002: pilot programme in Malawi
• Scale up of programmes in Ethiopia (2003-4
Emergency), Malawi (2005-6 Emergency), Niger
(2005-6 Emergency)
• Many agencies and governments now involved in
CMAM programming in emergencies and non-
emergencies
– E.g., Malawi, Ethiopia, Niger, Democratic Republic of
Congo, Sudan, Kenya, Somalia, Sri Lanka
• Over 25,000 children with SAM treated in CMAM
programmes since 2001 (Lancet 2006)
Recent History of CMAM
21
Principles of CMAM
• Maximum access and coverage
• Timeliness
• Appropriate medical and nutrition care
• Care for as long as needed
Following these steps ensure maximum
public health impact!
22
Population
level impact
(coverage)
Individual level
impact
(cure rates)
Maximise Impact by Focussing on
Public Health
CLINICAL FOCUS
Early presentation
Access to services
Compliance with treatment
Efficient diagnosis
Effective clinical protocols
Effective service delivery
SOCIAL FOCUS
23
Key Principle of CMAM
Maximum access and coverage
24
El Fasher
Um Keddada
Mellit
Kutum
Taweisha
El Laeit
Malha
Karnoi &
Um Barow
Koma
KormaSerif
Kebkabiya
Fata Barno
Tina
N Darfur
2001
Hospital TFC
El Sayah
100 kms

1.15
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
25
El Fasher
Um Keddada
Mellit
Kutum
Taweisha
El Laeit
Malha
Karnoi &
Um Barow
Koma
KormaSerif
Kebkabiya
Fata Barno
Tina
N Darfur
2001
Hospital with inpatient care
El Sayah
Outpatient care site
100 kms
Inpatient care site 26
Bringing Treatment Into the Local
Health Facility and the Home
27
Timeliness
28
Timeliness: Early Versus Late
Presentation
29
Timeliness (continued)
• Find children before
SAM becomes serious
and medical
complications arise
• Good community
outreach is essential
• Screening and referral
by outreach workers
(e.g., community
health workers
[CHWs], volunteers)
30Inpatient care Outpatient Care SFP
Catching Acute Malnutrition Early

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.15
33
Care as long as it is needed
34
Care For as Long as Needed
• Care for the management of SAM is
provided as long as needed
• Services to address SAM can be
integrated into routine health services of
health facilities, if supplies are present
• Additional support to health facilities can
be added during certain seasonal peaks or
during a crisis
35
New Innovations Making
CMAM Possible
• RUTF
• New classification of acute malnutrition
• Mid-upper arm circumference (MUAC)
accepted as independent criteria for the
classification of SAM
31
Appropriate medical care
and nutrition rehabilitation
32
Appropriate Medical Treatment
and Nutrition Rehabilitation
Based on Need

1.15
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
37
RUTF (continued)
• Nutriset France produces ‘PlumpyNut®’ and
has national production franchises in Niger,
Ethiopia, and Zambia
• Another producers of RUTF is Valid Nutrition
in Malawi, Zambia and Kenya
• Ingredients for lipid-based RUTF:
– Peanuts (ground into a paste)
– Vegetable oil
– Powdered sugar
– Powdered milk
– Vitamin and mineral mix (special formula)
• Additional formulations of RUTF are being
researched
38
Local production-RUTF
Malawi and Ethiopia
39
Effectiveness of RUTF
• Treatment at home using
RUTF resulted in better
outcomes than centre-
based care in Malawi
(Ciliberto, et al. 2005.)
• Locally produced RUTF is
nutritionally equivalent to
PlumpyNut®
(Sandige et al. 2004.)
40
Acute Malnutrition
Severe Acute Malnutrition Moderate Acute Malnutrition
Therapeutic Feeding Centre Supplementary Feeding
WHO Classification for the
Treatment of Malnutrition
41
Classification for the Community-
Based Treatment of Acute
Malnutrition
Acute Malnutrition
Severe acute malnutrition
with medical complications*
Severe acute malnutrition
without medical complications
Moderate acute malnutrition
without medical complications**
Inpatient Care Outpatient Care
Supplementary
Feeding
*Complications: anorexia or no appetite, intractable vomiting, convulsions,
lethargy or not alert, unconsciousness, lower respiratory tract infection (LRTI),
high fever, severe dehydration, severe anaemia, hypoglycaemia, or hypothermia
**Children with MAM with medical complications are admitted to supplementary
feeding but are referred for treatment of the medical complication as appropriate 42
Mid-Upper Arm Circumference
(MUAC) for Assessment and
Admission
• A transparent and understandable
measurement
• Can be used by community-based outreach
workers (e.g., CHWs, volunteers) for case-
finding in the community

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.15
45
Components of CMAM
1. Community outreach
2. Outpatient care for the management of
SAM without medical complications
3. Inpatient care for the management of
SAM with medical complications
4. Services or programmes for the
management of MAM
46
Key individuals in the
community:
• Promote CMAM services
• Make CMAM and the
treatment of SAM
understandable
• Understand cultural
practices, barriers and
systems
• Dialogue on barriers to
uptake
• Promote community case-
finding and referral
• Conduct follow-up home
visits for problem cases
1. Community Outreach1. Community Outreach
47
Community Mobilisation
and Screening
48
2. Outpatient Care
• Target group: children 6-59 months with SAM
WITHOUT medical complications AND with
good appetite
• Activities: weekly outpatient care follow-on visits
at the health facility (medical assessment and
monitoring, basic medical treatment and nutrition
rehabilitation)
43
Screening and Admission Using
MUAC
• Initially, CMAM used 2 stage screening process:
– MUAC for screening in the community
– Weight-for-height (WFH) for admission at a health facility
= Time consuming, resource intense, some negative
feedback, risk of refusal at admission
• MUAC for admission to CMAM (with presence of
bilateral pitting oedema, with WFH optional)
= Easier, more transparent, child identified with SAM in the
community will be admitted, thus fewer children are
turned away
44
MUAC: Community Referral

1.15
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
49
Clinic
Admission for
Outpatient Care
50
Outpatient Care:
Medical Examination
51
Outpatient Care:
Routine Medication
• Amoxycillin
• Anti-Malarials
• Vitamin A
• Anti-helminths
• Measles
vaccination
52
Outpatient Care: Appetite Test
53
• Ensure
understanding of
RUTF and use of
medicines
Provide one week’s
supply of RUTF and
medicine to take at
home
Return every week
to outpatient care to
monitor progress and
assess compliance
RUTF Supply
54
3. Inpatient Care
• SAM with medical
complications or no
appetite
• Medical treatment
according to WHO and/or
national protocols
• Return to outpatient care
after complication is
resolved, oedema
reduced, and appetite
regained
• All infants under 6
months with SAM receive
specialised treatment
until full recovery

HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
1.15
57
Relationship Between Outpatient
Care and Inpatient Care
• Complementary
– Inpatient care for the management of SAM with
medical complications until the medical condition is
stabilised and the complication is resolving
• Different priorities
– Outpatient care prioritises early access and
coverage
– Inpatient care prioritises medical care and
therapeutic feeding for stabilisation
58
21 programmes in Ethiopia, Malawi, Sudan, Niger. 23,511
children with SAM treated and documented.
(results for combined outpatient and inpatient)
80%
11%
4%
2%3%
Cured
Defaulted
Died
Transferred
Non-cured
Programme Outcomes for 21
Inpatient and Outpatient Care
Programmes – 2001 to 2006
59
CMAM in Different Contexts
• Extensive emergency experience
– Some transition into longer term programming, as in
the cases of Malawi and Ethiopia
• Growing experience in non-emergency or
development contexts
– e.g., Ghana, Zambia, Rwanda, Haiti, Nepal
• Growing experience in high HIV prevalent areas
– Links to voluntary counselling and testing (VCT) and
antiretroviral therapy (ART)
55
4. Services or Programmes for the
Management of MAM
• Activities
– Routine medication
– Dry supplementary ration
– Basic preventive health
care and immunisation
– Health and hygiene
education; infant and
young child feeding
(IYCF) practices and
behaviour change
communication (BCC)
56
Components of CMAM

1.15
HANDOUTS
& EXERCISES
HANDOUTS
& EXERCISES
63
Global Commitment for CMAM (2)
• Collaboration on joint trainings between WHO,
UNICEF, United Nations High Council for
Refugees (UNHCR), and United States Agency
for International Development (USAID)
• Donor support for CMAM development,
coordination and training
• Several agencies supporting integration of
CMAM into national health systems
61
When Rates of SAM Increase:
Emergency Levels
GAM and SAM above seasonal norms
e with increased numbers
Transition
Non-Emergency
Capacity to manage severe acute
malnutrition strengthened in ongoing
health and nutrition programs within
existing health system
Community based prevention based
nutrition programs. SAM identified in
GM and screening through MUAC
Emergency Levels
(Exceed MoH capacity)
Facilitate MOH to cope with
increased numbers
(in-country rapid response)
Shock/crisis
Post emergency
High numbers reducing
MoH resumes normal
programming within
existing health system
Link outpatient and
inpatient care with
health/nutrition community
based programming
62
Global Commitment for CMAM (1)
• WHO consultation (Nov 2005) – agreement by WHO
to revise SAM guidelines to include outpatient care and
endorse MUAC as entry criterion for programmes
• United Nations Children’s Fund (UNICEF)
accepted CMAM globally (2006)
• United Nations (UN) Joint Statement on
Community-Based Management of Severe Acute
Malnutrition (May 2007) – support for national policies,
protocols, trainings, and action plans for adopting
approach: e.g., Ethiopia, Malawi, Uganda, Sudan, Niger

Cmam t ph1_v1

More Related Content

Cmam t ph1_v1