COMMUNITY ASPECTS
AND
PASSIVE & ACTIVE
SCREENING
Module 2
© Michael Golden & Yvonne Grellety
Version 2012 _ based upon protocol version 6.6.2
The moral rights of the authors have been asserted. The authors retain the copyright to this
material. It cannot be abstracted, divided or used to teach fee-paying students. It must not
be changed or altered without reference to the authors. It can be used without charge for
teaching UNICEF staff and Ministry of Health Staff in developing countries.
1
THE DIFFERENT STEPS
1- Importance of involvement of the community
2- Active screening at community level
3- Passive screening at health centre level
2
IMPORTANCE OF COMMUNITY
INVOLVEMENT
1st Part
4
IMPORTANCE OF ACCESS
• It is critical to have treatment available as close to
the patient’s home as possible.
• This allows OTP to function with weekly visits made
by the patient + caretaker
• More IPFs allow easy transfer, transport to IPF is
less traumatic, visits by husband easy
• Admission to IPF is difficult for most mothers
– Cost of transport, meals, etc
– Loss of earning capacity and work at home
– The other children need looking after
– The family is disrupted – husbands often want their wives
to be in the household. 5
DISPERSION INCREASES
COVERAGE
Coverage (OTP) Coverage (IPF only)
74% 28%
Image/data © Valid International
Dowa district, Malawi
TFC
OTP
50 kms
Data/image © Valid international
North Darfur
2001
Tina
Karnoi & Malha
Tina
Um Barow
Kutum
Mellit
Fata Barno Koma
El Sayah
Serif Korma
Kebkabiya El Fasher
Um Keddada
Tawila & Dar el Saalam
100 kms
Hospital TFC
Taweisha
OTP distribution point
Other TFC El Laeit
© Valid international
ORGANISATION OF THE
COMMUNITY ASPECT
1. At national level, the National Nutrition Department
(NND) should
Coordinate with community IMCI, Maternal & child
health services and agriculture, food security
Standardise the training-of-trainers modules for
active screening, finding defaulters and home visits
Facilitate the coordination within the DHMT (District
Health Management team)
Coordinate/determine the type and amount of
incentives /payment/ recognition given by ALL
agencies. 9
ORGANISATION OF THE COMMUNITY
ASPECT
At District Level, the DNO At the health centre, the
should nurse should
Coordinate within the
DHMT for all the activities Recruit & train the Community
of community mobilisation Health Workers (CHW)
Coordinate on a monthly
Deliver the training-of- basis the CHW & be in charge
trainers at district level of their conditions of work
Collaborate with the different
Collect and collate the agencies and programs
screening data and (incentives offered,
determine the frequency subsistence, travel
and areas to be screened allowances for meetings.)
10
ORGANISATION OF THE COMMUNITY
ASPECT
At community level, the Community Health Worker
Pre requisite: honest & trusted by the community, both males and
females, able to read, write and see (test of vision)
Recruit male and female volunteers from the villages – and a focal
point within each village.
S/he has to:
• Sensitize the community, visit the village periodically and more
frequently where there appears to be a problem
• Inform the community leaders, traditional and modern health
practitioners, etc. about the program
• Maintain a link between the OTP and the village elders
• Identify, train, and motivate volunteers at village level and other
workers living in the community.
• Screen actively all the children and refer the MAM/SAM to
OTP/SFCP 11
ORGANISATION OF THE COMMUNITY
ASPECT
The volunteers (recruited by the
CHW)
Pre requisite: Honest & trusted by the
community, both males and females,
able to read & write if possible -
They have to
. Hold village meetings to sensitize
the community about the program
with the CHW (outreach worker)
. Be familiar with all the villagers
. Visit each house and measure
MUAC and look for oedema
. Do home visits to look for
defaulters and failures-to-respond
with the CHW.
. Link with OTP (with the CHW) 12
ACTIVE SCREENING
AT COMMUNITY LEVEL
2nd Part
13
14
ACTIVE CASE FINDING: MUAC
• Screening all children for acute malnutrition using
MUAC tapes
• Be careful to use the correct criteria and refer all
SAM children to the OTP
15
Take the MUAC for children of 6
month of age or more
16
ACTIVE SCREENING:
BILATERAL OEDEMA
Check for bilateral oedema
Teach the CHW and the volunteers in an IPF if
possible – so that they see positive cases
17
SCREENING , REFERRAL, FOLLOW-UP,
EDUCATION
• Refer cases of SAM/MAM to the
nearest OTP/SFP site.
• Record the SAM – MAM –
Normal – oedema and give the
screening sheet to the district
(DNO)
• Follow up at home of cases that
have been: 1) absent
2) discharged from IPF & have
not enrolled at an OTP
3) failed-to-respond to treatment
• Promote good health practices –
Essential Nutrition Actionss18
PASSIVE SCREENING WITHIN
THE HEALTH STRUCTURES
3rd part
Screening is called passive when the patients present to
a health structure and active when it is house-to-house
in the community
19
PASSIVE SCREENING:
WHERE?
It should be routine in all hospitals &
health centres,
– Hospital level: OPD, Emergency Ward , IPF
– Health centre during immunisation, IMCI –
Growth Monitoring, etc.
– Campaign: Vitamin A / deworming campaigns,
etc.
20
PASSIVE SCREENING: WHERE?
WHO?
• Use MUAC
• All doctors and nurses should carry a MUAC
tape with them as they work!
For children of 6 months and over with MUAC
<125mm, and older children who appear
malnourished, weight-for-height should also be
taken
• Use MUAC and W/H for adolescents & MUAC
for adults
• Examine for bilateral oedema and it’s degree
21
“WASTING”
Weight for Height/Length reflects
recent weight loss or gain
Height-for-Age (HFA) reflects
“STUNTING”
skeletal growth
Weight-for-Age (WFA) is a
WASTING
composite index and is used as a AND
measure of ‘underweight’ STUNTING
The 3 children have the same age
Same Same
height
weight
23
Normal Wasted Stunted Stunted & Obese
WfA = 0 Z WfA < -3 Z WfA < -3 Z WfA = 0 Z
WfH = 0 Z WfH < -3 Z WfH < 0 Z WfH > +3 Z
HfA = 0 Z HfA = 0 Z HfA < -2 Z HfA < -2 Z 24
CLASSIFICATION OF ACUTE
MALNUTRITION
INDICATORS CLASS of AGE Moderate Acute Severe Acute
MALNUTRITION MALNUTRITION
Bilateral All No Yes
Oedema
W/L(H) Children <-2 to – 3 Z-score < - 3Z-score
WHO2006
W/H % NCHS Adolescents 70 to <80% <70%
BMI Adults 16 to 17 <16
MUAC Children: >6 mo 115 to <125mm <115 mm
Adults 180 to <210 mm* <160 mm*
With recent weight
PW <210mm loss
LM <210mm
* Provisional cut off 25
MEASURE THE LENGTH/HEIGHT
26
Feet here
Chi
ld st a
>87 nding
cm
Ch
i ld
l yin
g
<8
7cm
27
80.0= 80
80.1 = 80
If you take the length
80.2 = 80
or height in cm
80.3=80.5
It is rounded to the
80.4=80.5
nearest decimal to
80.5=80.5
look up in the chart
of weight-for-height. 80.6=80.5
80.7=80.5
80.8=81
80.9=81
81.0=81
TAKE THE WEIGHT
For infants < 8kg: scale with 5 - 10g precision (e.g. SECA)
For children ≥ 8kg: scale with 100g precision (e.g. SALTER)
For patients > 15kg:UNISCALE/electronic scale
29
TO WEIGH A PATIENT OF MORE
THAN 8KG, PLEASE DO THE
FOLLOWING:
For the hanging SALTER scale
- Use a basin which is more hygienic, practical, less
traumatic and with which the child is familiar.
- Put 2 ropes underneath the basin, cross them and
pass the 4 rope-ends through holes in the basin’s rim at
equal distance from each other and tie the 4 ends
together to hang on the scale’s hook.
- The basin should be no more than 10cm height from
the floor (but not touching the floor!)
- Tare the basin to zero the scale.
30
For the infant scale (SECA), 1- you have first to tare the
scale using the lower black weight – fix it tightly with the screw.
2- Move the upper sliding
weights to the anticipated
weight of the child using
the small and big cursor.
3- Put the child on the
scale and adjust the
cursor, first in kg and
31
then in g.
Boys and girls mortality rates
SAM children admitted to therapeutic feeding
centres using a UNISEX table (NCHS) shows that
using exactly the same anthropometric admission
criteria for boys and girls leads to a non-significant
difference in mortality rate: albeit girls have a
slightly higher CFR. DO NOT DISCRIMINATE
against girls.
female male total
alive 3883 4211 8094
death 492 489 981
total 4375 4700 9075
Case Fatality rate 11.2 10.4 10.8
Chi-squared P 0.197 NS
Boys and girls WHZ
• If a girl and boy are the same weight a girl needs
to loose more weight to be classified as SAM
When you have the weight in kg and g and the height/length
rounded to the nearest half-cm, look first to the height/length row
and then in/between which columns the child’s weight lies.
Use for both boys and girls
Length
Length Weight Kg – Z-score Weight Kg – Z-score
very severe moderate discharge very severe moderate discharge
median media
severe SAM MAM IMAM severe SAM MAM IMAM
cm -4.0 -3 -2 -1.5 -1 0 cm -4.0 -3 -2 -1.5 -1 0
Use Length for less than 87 cm
45 1.73 1.88 2.04 2.13 2.23 2.44 66 5.5 5.9 6.4 6.7 6.9 7.5
45.5 1.79 1.94 2.11 2.21 2.31 2.52 66.5 5.6 6 6.5 6.8 7 7.6
46 1.85 2.01 2.18 2.28 2.38 2.61 67 5.7 6.1 6.6 6.9 7.1 7.7
46.5 1.91 2.07 2.26 2.36 2.46 2.69 67.5 5.8 6.2 6.7 7 7.2 7.9
47 1.97 2.14 2.33 2.43 2.54 2.78 68 5.8 6.3 6.8 7.1 7.3 8
47.5 2.04 2.21 2.40 2.51 2.62 2.86 68.5 5.9 6.4 6.9 7.2 7.5 8.1
48 2.10 2.28 2.48 2.58 2.70 2.95 69 6.0 6.5 7 7.3 7.6 8.2
48.5 2.17 2.35 2.55 2.66 2.78 3.04 69.5 6.1 6.6 7.1 7.4 7.7 8.3
49 2.23 2.42 2.63 2.75 2.87 3.13 70 6.2 6.6 7.2 7.5 7.8 8.4
49.5 2.31 2.50 2.71 2.83 2.96 3.23 70.5 6.3 6.7 7.3 7.6 7.9 8.5
50 2.38 2.58 2.80 2.92 3.05 3.33 71 6.3 6.8 7.4 7.7 8 8.6
50.5 2.46 2.66 2.89 3.01 3.14 3.43 71.5 6.4 6.9 7.5 7.8 8.1 8.8
51 2.54 2.75 2.98 3.11 3.24 3.54 72 6.5 7 7.6 7.9 8.2 8.9
51.5 2.62 2.83 3.08 3.21 3.34 3.65 72.5 6.6 7.1 7.6 8 8.3 9
52 2.70 2.93 3.17 3.31 3.45 3.76 73 6.6 7.2 7.7 8 8.4 9.1
52.5 2.79 3.02 3.28 3.41 3.56 3.88 73.5 6.7 7.2 7.8 8.1 8.5 9.2
34
53 2.88 3.12 3.38 3.53 3.68 4.01 74 6.8 7.3 7.9 8.2 8.6 9.3
Use for both boys and girls
Height Weight Kg – Z-score Height Weight Kg – Z-score
very dischar very
severe moderat media sever moderat discharg media
seve ge seve
SAM e MAM n e SAM e MAM e IMAM n
re IMAM re
cm -4.0 -3 -2 -1.5 -1 0 cm -4.0 -3 -2 -1.5 -1 0
Use Height for more than or equal to 87 cm
87 9.0 9.6 10.4 10.8 11.2 12.2 104 12.0 13 14 14.6 15.2 16.5
87.5 9.0 9.7 10.5 10.9 11.3 12.3 104.5 12.1 13.1 14.2 14.7 15.4 16.7
88 9.1 9.8 10.6 11 11.5 12.4 105 12.2 13.2 14.3 14.9 15.5 16.8
88.5 9.2 9.9 10.7 11.1 11.6 12.5 105.5 12.3 13.3 14.4 15 15.6 17
89 9.3 10 10.8 11.2 11.7 12.6 106 12.4 13.4 14.5 15.1 15.8 17.2
89.5 9.4 10.1 10.9 11.3 11.8 12.8 106.5 12.5 13.5 14.7 15.3 15.9 17.3
90 9.5 10.2 11 11.5 11.9 12.9 107 12.6 13.7 14.8 15.4 16.1 17.5
90.5 9.6 10.3 11.1 11.6 12 13 107.5 12.7 13.8 14.9 15.6 16.2 17.7
91 9.7 10.4 11.2 11.7 12.1 13.1 108 12.8 13.9 15.1 15.7 16.4 17.8
91.5 9.8 10.5 11.3 11.8 12.2 13.2 108.5 13.0 14 15.2 15.8 16.5 18
92 9.9 10.6 11.4 11.9 12.3 13.4 109 13.1 14.1 15.3 16 16.7 18.2
92.5 9.9 10.7 11.5 12 12.4 13.5 109.5 13.2 14.3 15.5 16.1 16.8 18.3
93 10.0 10.8 11.6 12.1 12.6 13.6 110 13.3 14.4 15.6 16.3 17 18.5
93.5 10.1 10.9 11.7 12.2 12.7 13.7 110.5 13.4 14.5 15.8 16.4 17.1 18.7
94 10.2 11 11.8 12.3 12.8 13.8 111 13.5 14.6 15.9 16.6 17.3 18.9
94.5 10.3 11.1 11.9 12.4 12.9 13.9 111.5 13.6 14.8 16 16.7 17.5 19.1
95 10.4 11.1 12 12.5 13 14.1 112 13.7 14.9 16.2 16.9 17.6 19.2
95.5 10.4 11.2 12.1 12.6 13.1 14.2 112.5 13.9 15 16.3 17 17.8 19.4
96 10.5 11.3 12.2 12.7 13.2 14.3 113 14.0 15.2 16.5 17.2 18 19.6
96.5 10.6 11.4 12.3 12.8 13.3 14.4 113.5 14.1 15.3 16.6 17.4 18.1 19.8
97 10.7 11.5 12.4 12.9 13.4 14.6 114 14.2 15.4 16.8 17.5 18.3 20
97.5 10.8 11.6 12.5 13 13.6 14.7 114.5 14.3 15.6 16.9 17.7 18.5 20.2
98 10.9 11.7 12.6 13.1 13.7 14.8 115 14.5 15.7 17.1 17.8 18.6 20.4
98.5 11.0 11.8 12.8 13.3 13.8 14.9 115.5 14.6 15.8 17.2 18 18.8 20.6
99 11.1 11.9 12.9 13.4 13.9 15.1 116 14.7 16 17.4 18.2 19 20.8
99.5 11.2 12 13 13.5 14 15.2 116.5 14.8 16.1 17.5 18.3 19.2 21
100 11.2 12.1 13.1 13.6 14.2 15.4 117 15.0 16.2 17.7 18.5 19.3 21.2
100.5 11.3 12.2 13.2 13.7 14.3 15.5 117.5 15.1 16.4 17.9 18.7 19.5 21.4
101 11.4 12.3 13.3 13.9 14.4 15.6 118 15.2 16.5 18 18.8 19.7 21.6
101.5 11.5 12.4 13.4 14 14.5 15.8 118.5 15.3 16.7 18.2 19 19.9 21.8
35
102 11.6 12.5 13.6 14.1 14.7 15.9 119 15.4 16.8 18.3 19.1 20 22
Exercise 1: Calculate the WfH in Z-scores
1- Shana, a girl of 63 cm length and 5.0 kg
weight
2- Rico, a boy of 101cm height and 11.8 kg
weight
3- Kareem, a boy of 82 cm length and 8.5 kg
weight
Answers Exercise 1
Calculate the WfH in Z-scores
1. Shana, WfH = - 4 Z score
2. Rico WfH between -4 Z and -3 Z score
3. Kareem, WfH = -3 Z score
THE TRAINING OF THE
STAFF
• They should be aware of the importance of the
passive screening
• Each staff member should carry a MUAC
• It is ESSENTIAL to practice and then complete
the standardisation test
• If the test is not good, the staff should be
retrained
38
STANDARDISATION TEST
• First explain to the mothers what you are doing
• After their consent, take 10 children from 6 months to 5
years of age (use IPF or out-patients, infant school etc).
• Give each subject a number - one to ten –
• Tell each participant to measure the MUAC of the 10
children and to note the results on a sheet of paper.
• Collect the results and wait for about half to one hour.
• Mix up the children so they are sitting in a different order,
but keep their numbers.
• Repeat the measures on the same 10 children without
knowing the first measurements
• Analyse the results using software from SMART (ENA)
Training module ([Link] 39
THE STANDARDISATION TEST’S
SHEET
Measurer nº:........... Name:………………….…………………….
1st round / 2nd round Time.........................
Child nº MUAC (mm) Weight (kg.g) Height/length([Link])
1
2
3
4
5
6
7
8
9
10
40
ENA - SMART
41
REPORT OF THE
STANDARDISATION TEST ON
ENA
MUAC Precision: Accuracy: N° +/- N° +/-
Sum of squares Sum of squares Precision Accuracy
MUAC2 - MUAC1 (Superv. (MUAC1+MUAC2) -
Observor (MUAC1+MUAC2)
Supervisor 1.00 0/1
Observer 1 2.00 OK 3.00 OK 2/0 0/3
Observer 2 24.00 WEAK 63.00 WEAK 5/0 3/1
Observer 3 8.00 WEAK 25.00 WEAK 1/4 3/3
Observer 4 1.00 OK 0.00 OK 0/1 0/0
Observer 5 8.00 WEAK 17.00 WEAK 0/5 4/2
42
BILATERAL
OEDEMA
Formally test for oedema with finger
pressure
43
RECORD OF PASSIVE
SCREENING
Where there is no active
screening in the
community (yet).
• Maintain a screening
register in the health
centre for numbers of
SAM, MAM and normal
children seen.
• During campaigns use
screening tally sheets.
45
Mortality risks of different
diagnostic criteria
• MUAC <115 has the lowest mortality risk
• Children with both have about twice the
mortality
• Kwashiorkor has about the same mortality as
WHZ<-3 AND MUAC <115
• MUAC <115 does not increase kwash mortality
• WHZ < -3 dramatically increases kwash mortality
46
Both WHZ and MUAC should be used
• Some countries are moving to MUAC-only programs.
This is unethical as it omits many children at high risk
of death.
• Only 16% of SAM children have SAM by both WHZ and
MUAC criteria. This varies by country and within
countries.
• The mortality risk for WHZ<-3 is higher than for MUAC
<115mm
• Although MUAC is easy to take in the community for
passive screening use both.
47
SUMMARY OF MODULE 2
• Community aspect
• Importance of active and passive screening
• Taking anthropometric measurements
• Use of unisex WHO chart
• Checking for Oedema
• Classification by No anthropometric malnutrition –
Moderate Acute Malnutrition – Severe Acute
Malnutrition according to the admission criteria
• This will allow to target the worst areas at high risk
before deterioration of their nutritional status 48
