Activity Performance of Stabilization Center

Transcription

1 h RELIEF PAKISTAN Activity Performance of Stabilization Center Stabilization Center serving malnourished children in DHQ, Timergara, Lower Dir, KPK A UNICEF and Relief Pakistan Joint Venture 2011 R ELIEF P AKISTAN

2 Stabilization C enter Performance Booklet Table of Contents S.No Contents Page. No 1 Nutrition Status in Pakistan 2 Stabilization Center importance and performance 3 Administration and Management 4 Equipments and Medicines Provided 5 SAM patient Referral to Stabilization Center 5.1 Self Referral 5.2 Through OPD 5.3 Through CMAM SFP/OTP Center 5.4 Through Committees 5.5 Through others UNICEF supported Organization 6 Admission Process of Severe Acute Malnutrition Children with Medical Complications 7 Care of SAM children in Stabilization Center 8 Reports and Record Keeping 9 Procedure adopted after recovery from stabilization center 10 Maintaining Hygiene at Stabilization Center 11 Annexture-1. Updated Stabilization Center Admission records 12 Annexture-2. DHQ, Timergara SC performance 13 Annexture-2. Activities Pictures

3 Abbreviation RP Relief Pakistan UNICEF United Nation s Education Fund KPK Khyber Pukhtoon Khuwa SC Stabilization Center WHO World Health Organization DHQ District Headquarter Hospital SFP Feeding Program OTP Outpatient Therapeutic Program SAM Severe Acute Malnutrition MAM Moderate Acute Malnutrition CERD Center for excellence Rural Development FATA Federally Administrated Tribal Area LHV Lady Health Visitor NA Nutrition Assistant CD Civil Dispensory BHU Basic Health Unit RHC Rural Health Center CMAM Community Based Management of Acute Malnutrition MUAC Mid Upper Arm Circumference OPD Outpatient Department UC Union Council SD Standard Deviation SHC PLW Pregnant and Lactating Women

4 Preface This booklet had been prepared with aim to evaluate Stabilization Center, importance in dealing children of Severely Acute Malnourished with medical complications. This is a fact that poor malnutrition has direct impacts over economy of the country especially under developed countries. Poor and disadvantaged populations are most susceptible to the risk. In development Countries an Estimated 50.6 million* Children under the age of five years are malnourished. Death rate recorded is almost 30-50% even after hospitalization. The booklet is provided with details of Severely Acute Malnourish Children with medical complication admitted and Cured in stabilization Center under Community Based Management of Acute Malnutrition Program, lower dir. The program is implemented by Relief Pakistan with support of UNICEF and Government of Pakistan. The booklets included brief analysis of malnutrition in Pakistan, Project overview and its component, Stabilization Center establishment and its output. *guidelines for the inpatient treatment of severely malnourish children-who

5 Nutrition Status in Pakistan The level of socioeconomic development is low in Pakistan; human development index is 142 nd in the world and 24% of the population lives below poverty line with 17% earning less than a dollar a day. The health profile of Pakistan is characterized by high population growth rate, high infant mortality and child mortality rates of 78 and 97 respectively, a high maternal mortality ratio of 320 per 100,000 live births1 and a high burden of communicable diseases. In Pakistan three levels of which causes of child malnutrition are: Child malnutrition, death and disability are the manifestation of a problem; The underlying causes are insufficient access to food, inadequate maternal and child-care practices, poor water/sanitation and inadequate health services. Located between Swat district and FATA on the west side of KPK province, Lower Dir district has been heavily affected in the by the conflict, resulting in massive displacement of population and increased constraints on food security and livelihoods. This, along with recent floods, is compounded by the underlying vulnerability that already characterized remote mountain areas prior to the crisis. This causes severe food insecurity in the areas and thousands of children and women have been suffered. UNICEF launched project on Community Based Management of Acute Malnutrition with support of government of Pakistan. UNICEF has selected Relief Pakistan along with others Non Governmental Organizations are selected to handle malnutrition issues at community level. Relief Pakistan implemented the project as per CMAM protocols and guidelines. SFP and OTP center have been established at community level. Basic Health Facilities, CD center, RHCs were selected to achieve maximum coverage and reach maximum malnourished children and PLWs. Children with Moderate Acute Malnutrition and Severe Acute Malnutrition with no medical complication were treated in SFP and OTP centers established at community level. Where Severe Acute Malnourished children with Medical complications are referred to Stabilization Center established at District Headquarter Timergara, Lower Dir. Stabilization Center Children, who are acutely malnourished and have medical complications, are treated in an inpatient stabilization centre (SC) until they are well enough to continue with outpatient care. Relief Pakistan with Support of UNICEF established SC setup at District Headquarter Hospital where 24 hour care is provided to the unstable severely malnourished patients. Patients are admitted for minimal number of days for stabilization, they are referred back to their OTP for further management after they are stabilized. The best of UNICEF supported Stabilization center is the financial support to poorest families, who are suffered from severe acute malnutrition with medical complications.

6 Up to date performance of stabilization Center shows total of 42 admissions, whereas 42 Case have been cured. 100% of cases have been cured and referred to concerned areas OTP center for further follow-up and treatments. SC performance ( Jan June 2011) Number of patients admitted and cured JAN FEB MARCH APRIL Month MAY JUNE GRAND ADMITTED CURED Administration and Management Stabilization Center required well experienced and technical staff in the field of health. Relief Pakistan hired services of quality doctor, Nutrition Assistants and LHVs as per CMAM protocols and guidelines. Doctor is providing services to the children suffered from malnutrition with medical complications. Nutrition Assistants and LHVs providing 24 hrs services to admitted malnourish children. They are responsible for recordkeeping as well. Relief Pakistan also hired services of well known pediatrician. Pediatrician has regular visits to stabilization center. In case of emergency pediatrician are providing services on emergency basis. Cook providing services to ensure proper diet preparation on regular basis. Quality hygiene is needed in stabilization center. Sweeper play important role in maintaining hygiene regularly. A Focal person is responsible for daily routine visits and maintaining proper coordination at community level. Health Department contributes and had provided five beds to deal with malnourished patients. They are also supporting stabilization center, when and where support required.

7 Equipments and medicine provided Relief Pakistan with support of UNICEF provided following technical equipments for proper anthropometry of children during admission and follow-up. Height Board which is use for children height Weight Machine use for weight purposes MUAC tape use for initial anthropometry Thermometer provided, measure body temperature of malnutrition children Staiticiscope which is use for respiratory rate Besides these mentioned above, other emergency equipments such as scissors, trays, cups, plates and spoons etc are present in stabilization center. SAM Patients Referral to Stabilization Center DHQ, Timgeraga, Lower Dir Relief Pakistan, stabilization Center received patients of SAM with Medical Complications from different groups and others organizations working in CMAM supported by UNICEF in Lower Dir. These patients handled with extra care and every possible support like financial and logistic support was provided prior, during and after treatment. Category wise SAM patients were admitted from following groups. 1. Through Self Referral Stabilization Center received some cases by self referral. On asking, the patient care taker told that most of the time they heard from other sources and effectiveness of CMAM program and child had brought their children to SC. Ms. Hameera mother came along with another women to stabilization Center. When she saw the care and treatment provided to other children, she willing to diagnose her daughter. On diagnosis, Ms. Humeera was found severely malnourish along with severe medical complications. She was referred to OPD, where Pediatrician checked and referred back to stabilization Center.

8 Ms. Hummera daughter of Mashal Khan and Qandi Gula, were totally bottle feeds belong to a poor family. She is an afghan refugees and living in camp-1, timergara, Lower Dir. She is 6 months old. Mashal Khan is labor and working on daily wages. Due to unbalance food intake she became malnourished. At the time of admission Ms. Humeera has 8 cm MUAC, 3 kg weight and 54 cm height. On <-4 SD z-score was recorded. She has loose motion, loss of appetite and vomiting at the time of admission. She had also severely dehydrated. At the time of discharge 8.2 cm, weight recorded was 3.3 and Z-score on <-3. She was admitted for two days and care as per CMAM protocols and guidelines were provided. At the time of discharge loose and vomiting was control and she had became good appetite. After recovery in SC she is admitted in Relief Pakistan OTP center timergara for further treatments in OTP center. The family is happy now and satisfied with treatment provided. Through Outpatient Department There is hundreds of children coming to OPD in DHQ hospital Timergara for checkup. These children belong to the poorest families and mostly severely affected by Malnutrition with medical complications. Pediatrician and doctors who are providing services in OPD, meanwhile checking the children and in case of SAM with medical complications, children were referred to Stabilization Center. These patients were screened by nutrition assistants and 24 hrs inpatient cares was provided. After recovery and sensitization of care taker these children were sent to the nearest OTP centers or admitted in OTP center located in DHQ hospital Timergara, Lower Dir. For example a case of Ms. Aisha,

9 who was checked and referred by OPD pediatrician. She is the daughter of Nazar Muhammad and belongs to yousufzai tribe living in Bajawar Nawagai. During admission her age was 3 months. The mother was very anemic and weak before delivery. Due to unbalance food intake during pregnancy she suffered from vomiting and nausea. She had no appetite and low B.P at time of birth. Family is financially very weak. Ms. Aisha has 5 brothers and 1 sister. She was totally bottle feed and goat milk was served after birth. Her mother got typhoid after Ms. Aisha delivery. Her father is driver and cannot handle household expenses. Delivery of Aisha took place with the help of Trained Birth Attendant. Delivery was normal. When Ms. Aisha was brought to Stabilization Center, she had loose motion with intractable vomiting, mild palmer pallor, and oral thrash and fever 39 Centigrade. At the time of admission Ms. Aisha had no edema, MUAC was 8cm, weight 2.8kg and 54 cam height. ZScore recorded was <h-4 SD. She was admitted for 5 consecutive days and inpatient care was provided. All treatment was provided as CMAM protocol and guidelines. At the time of discharge her MUAC 8.2 cm, weight 3 kg and height 54 cm. Her Z-Score recorded was the child was referred back to CERD center for further treatment in OTP and SFP center. Follow up plan was prepared and mother was sensitized to take care of child properly. The child parents were satisfied with the treatment provided and improved health condition of Ms. Aisha. Maaz S/O of Mr. Zahid Khan is another case admitted in SC through OPD referral. He was 6 months was old at the time of admission and belongs to Char Bagh Rabat. Family background is financially very weak as he has four sisters and one brother. He was bottle feed and mostly feed with cow milk. Delivery took place in home. Maaz received only few drops. Immunization was not done on proper time. Family hygiene condition is not good and even bottle used for feeding was unhygienic. The father is farmer. Maaz mother had back pain and anorexia before

10 delivery. No check had been made during pregnancy and delivery took place at with without any Trained Birth Attendant. Mother has no balance diet from the time of pregnancy till date. Maaz was brought to OPD due to weak appetite, Severe dehydration, loose motion with intractable vomiting. Pediatrician referred Maaz to Stabilization Center. At the time of admission anthropometry had taken which showed no edema, MUAC 9.5 cm, weight 4.4 kg, height 59 cm. Z-Score recorded was <-3SD. Relief Pakistan Team provided intensive treatment and feeding during his stay in stabilization center. CMAM protocols were followed and F-75 was given every 2 hrs. 6 feed of f-100 was given along with other routine and prescribed medicines. Maaz recovered within 4 days. Appetite was good. Vomiting and dehydration subsided. Child parents were satisfied with treatment provided. Anthropometry was taken at the time of discharge and child was referred to CD Rabat after sensitization of his parents. CMAM OTP/ SFP centers Relief Pakistan and Other UNICEF supported organizations working at CDs, BHUs, RHC level providing treatments to children with SAM and MAM. Those children, who have grade +++ odema or other medical complications including hypoglycemia, hypothermia, infection and dehydration, and micro nutrition s deficiencies or anemic children were referred to Stabilization Center. Logistic support was almost provided to all those SAM children with medical complication and was admitted in stabilization Center. There are many examples of such cases which were brought to stabilization center, admitted and treated and after recovery they were sent back to concerned OTP center. Mr. Fawad case representing Relief Pakistan SFP/OTP referral to SC. Fawad is the s/o of Mr. Said Muhammad and belongs to Ali khail tribe. He is the resident of Wali Kandu Union Council Khazana. Family is financially stable and food intake was balance during pregnancy. During pregnancy the mother visited doctor regularly for checkup. Delivery took place in hospital under lady doctor observation. No complication was noted during pregnancy. He has two sisters, breastfeed and immunization status was good. His father is a labor and has joint family. Complementary feeding was started after months. He was referred SHC Khazana. During admission Mr. Fawad had no edema, MUAC was 11.5cm, weight 6.8 kg

11 and height 66cm where <-1 SD Z-score was recorded. She was suffered from loose motion, intractable vomiting, fever from two weeks and dehydration. Relief Pakistan Stabilization team provided treatment as per CMAM guidelines and protocols. Patient was regularly checked. Nutrition Assistants, LHV and Doctor have regular visits and on recovery patient was discharge and referred back to SFP/OTP center Khazana. At the time of discharge Mr. Fawad had no edema, 11.7 cm MUAC, 7.8 kg of weight and 66 cm. Z-Score recorded was >- 1SD. All possible support including logistic and financial was provided during his treatment. His dehydration was recovered, and parents thanked Relief Pakistan and UNICEF for supporting and providing treatment to their son. Ms. Iffa is same case admitted in SC through Relief Pakistan SFP/ OTP center. She belongs to UC Munda and is the daughter of Mr. Imran and Ms. Rabi. She is 17 months old. Her delivery took place under Trained Birth Assistant in hospital. At the time of birth, she had no medical complications and was normal healthy child. Mr. Imran is jobless and finically very weak to support his family, therefore balance food intake is severe issue for the mother and child. She was brought to SFP/OTP center and Nutrition Assistant on the basis of severe medical complication referred to Stabilization Center DHQ, timergara Lower Dir. At the time of admission her MUAC was 11.7 cm, Height 77 cm and weight 8 kg. She is still in SC. Medical complication diagnosis was 4 days long high fever, one week diarrhea, and 4 days vomiting. She had no appetite. Care and treatments were provided for 3 days. Doctors regularly visited and recovery has been made. Relief Pakistan team provided special care and treatment as per CMAM protocols. Mother was guided to ensure proper hygiene and follow the treatment and follow up plan strictly. Ms. Iffa is healthy and was referred back to OTP Center Munda, where continues OTP treatment is initiated. 2. Through Community ( Committees) Relief Pakistan have formed more than 250 village based health committees (groups) in 13 union council of Lower Dir. These committees were equipped with knowledge of CMAM and sessions were conducted for proper mobilization of children with SAM and Children and PLWs having nutrition deficiencies. While conducting sessions and follow up sessions some case was identified through committees members, which were later screened out in the nearest BHUs and CDs centers, where Relief Pakistan established OTP/SFP center. SAM children with Medical Complications were referred to Stabilization center for further diagnosis and treatments. After recovery in

12 stabilization center these children were sent back to OTP center and treatments were provided as per CMAM guidelines. Ms. Safna case is an example SAM case admitted through effective mobilization. Ms. Safna D/O of Mr. Wazeer Zada was admitted with relief Pakistan, Lower Dir under registration number 109.Ms. Safna is 8 month old and belongs to a poor family of tribe Myagan village Shadas. It was the most severe conflict areas, and extensive internal displacement was taken place during war. She has one sister and four brothers. Her father is disable and farming is only source of income. Since they are living in joint family system, the food intake was unbalanced. The delivery of child was taken place at home and no trained Birth Assistant was present. She was lucky to have breastfeeding from the time of birth. Complementary food started from the age of 8 months. At the time of Committees Mobilization session the case was point out and brought to committees, which was severely malnutrion. Relief Pakistan Team suggested to bring it to the nearest health facility, Hayaserai, where CMAM center has been established. The case was examined and anthropematic measurement was taken. Nutritional Assitant, BHU Hayaserai transfer the case to SC timergara. Due to financal condition, the family was not able to support logistic and medication expensis. Relief Pakistan with Support of UNICEF provided logistic and financial support and case was brought to SC- timergara for intensive treatment. At the time of admission the Ms. Safna have loose motions with vomating, high grade fever, rectal aresia and chalostomy. Admission Anthropometric Measurement Date of Admission 31 March 2011 Odema Non MUAC 7 cm Height 54 cm Weight 3 kg Z- Score -4SD Intensive medical and feeding treatment was given for three days in stabilization Center, DHQ Timergara. All support was provided during treatments and great improvement has been shown. On stabilization this case was transfer to OTP center and continous visit was advice. This case is admitted and treatment is in process in OTP/SFP center. On time of discharge the following treatment was recorded. Discharge Anthropometric Measurement Date of discharge from SC 02 April 2011 Odema Non MUAC 7.5 cm

13 Height 54 cm Weight 3.3 kg Z- Score -3SD The case has complete appetite now and continuous feeding treatment is in progress. The is a great example of Relief Pakistan team effort and mobilization. Ms. Safna family is very much happy and thankful to Relief Pakistan and UNICEF. His father comment regarding CMAM is that it has been great program and dedicated work. I am very much thankful and please to see my daughter with better health. I am sure with such support in future; she and other same cases will be identified and treated. I will do facilitate and identified other cases and will provide volunteer services 3. Other UNICEF supported Organizations There is other organizations working on CMAM e.g CERD supported by UNICEF. Some SAM case with medical complications was referred from those organization Centers and was admitted in stabilization Center. After recovery these children were referred to concerned centers and follow up plan was prepared. Mr. Tajjal s/o Rohul Amin belongs to Union Council Ouch is an example, which was referred by CERD. The case was taken care and treated in stabilization Center and was referred back to CERD center Ouch. Tajjala have 3 sisters and 6 brothers. His father is a farmer and his financial condition is very weak. They live in rented house. Tajjala delivery took place in his house in the presence of Trained Birth

14 Attendant. He was suffered from one month from fever, cough, and loose motion and dehydration. He was severely marasmic. He belongs to very poor family and the mother is epileptic. Because of infected wounds of mothers bilateral mastectomy was done. Due to lack of breastfeeding till date he was severely malnourished. On admission Tajjala was provided inpatient care and Relief Pakistan provided every support. Anthropometric measurement was taken and was admitted. During admission no edema was observed. His MUAC was 7.5 cm, weight 2.8 kg, height 52cm and Z-Score recorded was <-3 SD. Relief Pakistan provided treatment and care as per CMAM protocols and guidelines. He was admitted for 3 days. Anthropometric measurement was recorded which show great improvement. Edema was nill, MUAC was improved and became 7.8cm, weight was gained and recorded 3 kg, length was 52 cm and z-score recorded was <-3SD. Tajjala condition was good and improved at the time of discharge. Cough was cured. Temperature was normal and dehydration was treated. During admission the child mother have tears, when telling history of her child and after treatment she was happy and thankful to Relief Pakistan team. The patient was provided referral slip and follow-up plan was prepared. The mother was sensitized to take care of Tajjala and bring to CERD center for admission. Admission Process of Severe Acute Malnutrition Children with Medical Complications Relief Pakistan followed and adopted CMAM guidelines and protocols as directed by UNICEF for the admission of severe malnutrition children with medical complications in stabilization center. SAM children with medical complications referred from OPD/SFP and OTP centers or patients came through communities were admitted and treated in stabilization center with care. Relief Pakistan team emphasis on the following criteria during admission. At initial stage SAM patient is checked for presence of edema, if found then the stage is noted. For odema presence both feet are gently pressed for 3 seconds (the time to say 101,102,103) with thumb and following observation is recorded. a) If a yellow pit (depression) remains for several seconds, the child has nutritional edema. B) Pitting edema was graded as +, ++, +++. C) In case of bilateral pitting edema then second opinion is to confirm by medical specialist. MUAC is checked and noted. Weight is recorded through scale provided by UNICEF. Height is measured through height board where two staff members are used to increase accuracy and precision and remove error. Children aged 2 years are measured standing up and <2 years are measured lying down. Incase if it was difficult to assess age then children >87 cm is measured in standing and <87 cm is measured while lying down. Z-score table is always used after weight and height measurements

15 Care of SAM children in Stabilization Center after After anthropometry of SAM children with medical complications, Relief Pakistan Team including child specialist and Nutrition Assistant diagnosis patients for the following medical complications. If any of following are present the patients is admitted and inpatient care is started for rehabilitation. Likewise most of the children admitted were suffered from hypoglycemia, hypothermia, dehydration. Intractable vomiting, silent hunger of micronutrient deficiencies, unconsciousness, anemia, dermtosis ( Skin infections) and low reparatory track infections ( LRTI). Treatments and preventions are provided against hypoglycemia, hypothermia, infection and dehydration whereas electrolyte imbalance and micronutrients was corrected. After patients history confirmation and diagnosis caused of malnutrition cautious feeding e.g F-75 was initiated for three consecutive days. F-100 was provided to SAM children for catch up growth for 7 days along with routine and medicine. After child recovery care taker and patients was sensitize and emotion support was provided, which help both child and mother. The care taker was prepared for follow-up and referral slip was provided for concerned nearest OTP center for further treatments. Report and Recording keeping The records of SC patients are maintained through register provided by UNICEF, where all the details of medicines and nutrition food are entered. The patients are under strict observation and for minimum 4 days in SC and clinical records are taken twice a day. Daily reporting is done center wise whereas weekly report is carried out to Relief Pakistan on Weekly basis. Procedure adopted after recovery from stabilization center After child recovery from medical complications in stabilization Center, Relief Pakistan team adopted the following procedure as per CMAM protocols. Mother concealing was carried, where parents or care takers are sensitize on health and hygiene practices, IYCF and referral to respective nearest CMAM OTP/SFP centers. The Feeding practices ( F-100) required for SC patients is advised to continue for 7 consecutive days along with other OTP protocols Relief Pakistan team kept regular coordination with concerned nutrition assistant at BHUs or CDs level to take care of the OTP or SFP patient.

16 Annexture-1 Details updated Stabilization Center Records (Jan-June 2011) District UC Village Name Registration Admission date Exit date Status LOWER DIR Mian Banda Yaseen Jan Jan 11 Cured LOWER DIR Timergara Wajid Jan Jan 11 Cured LOWER DIR Shamshi Khan Centre Ilham Jan Jan 11 Cured LOWER DIR Timergara Aleena Jan Jan 11 Cured LOWER DIR Afghan Refugees Camp Husna Jan Jan 11 Cured LOWER DIR Upper Dir Manahil Jan Jan 11 Cured LOWER DIR Upper Dir Habeeba Jan Jan 11 Cured LOWER DIR Shamshi Khan Centre Saima Jan Jan 11 Cured LOWER DIR Timergara Haseeba Jan Jan 11 Cured LOWER DIR Maidan Hamad Jan Jan 11 Cured LOWER DIR Timergara Zaryab Feb Feb 11 Cured LOWER DIR Timergara Fawad Feb Feb 11 Cured LOWER DIR Timergara Sawera Feb Feb 11 Cured LOWER DIR Munda Centre Shaisma Feb Feb 11 Cured LOWER DIR Timergara Inam ullah Feb Feb 11 Cured LOWER DIR Asigai Centre Jahid Feb Feb 11 Cured LOWER DIR Afghan Refugees Camp Madeha Feb Feb 11 Cured LOWER DIR Paito Dara Centre Hurmat Feb Mar 11 Cured LOWER DIR Afghan Refugees Camp Naveed Feb Feb 11 Cured LOWER DIR Afghan Refugees Camp Najma Feb Mar 11 Cured LOWER DIR Afghan Refugees Camp Irshad Feb Mar 11 Cured LOWER DIR Rabat Centre Husna Mar Mar 11 Cured LOWER DIR Maidan Laiba Mar Mar 11 Cured LOWER DIR Upper Dir Maria Mar Mar 11 Cured LOWER DIR Malakand Payeen Centre Abeeda Mar Mar 11 Cured LOWER DIR Munda Centre Waleed Mar Mar 11 Cured LOWER DIR Afghan Refugees Camp Madeena Mar Mar 11 Cured LOWER DIR Maidan Safna Mar Apr 11 Cured LOWER DIR Upper Dir Khalida Apr 11 4/14/2011 Cured LOWER DIR Munda Centre Yousaf Apr 11 5/3/2011 Cured LOWER DIR Balambat Muskan May 11 5/7/2011 Cured LOWER DIR Malakand Payeen Centre Muskan May 11 5/7/2011 Cured LOWER DIR Timergara Fawad May 11 5/10/2011 Cured LOWER DIR Shamshi Khan Centre Ubeed May 11 5/14/2011 Cured LOWER DIR Munda Centre Kashif May 11 5/26/2011 Cured LOWER DIR Timergara Aisha May 11 5/29/2011 Cured LOWER DIR Timergara Seema May 11 6/5/2011 Cured LOWER DIR Timergara Tajalla May 11 6/5/2011 Cured

17 LOWER DIR Maidan Sania Jun 11 6/9/2011 Cured LOWER DIR Afghan Refugees Camp Humeera Jun 11 6/15/2011 Cured LOWER DIR Munda Centre Ifa Jun 11 6/19/2011 Cured

18 Annexture-2 Table.2. Admission and Cured Records Month ADMITTED CURED JAN FEB MARCH 7 7 APRIL 2 2 MAY 8 8 JUNE 4 4 GRAND 42 42

19 Snapshots Annexture-3