MUAC ≥120mm AS A SIMPLE, SAFE ANDEFFECTIVE DISCHARGE CRITERIA FOR SAM

IN BIHAR, INDIA

MSF SPAIN

Structure of the session

1. Background

2. Methods

3. Programme outcomes

4. Long-term outcomes

5. Conclusions

Background • India has 40% of the worldwide burden of childhood SAM.

• WHO currently recommends admission using MUAC<115mm and/or WHZ<-3SD, and discharge when 15% body-weight has increased. Although this 15% increase has been discredited, debate is ongoing regarding using different MUAC and/or W/H cut-offs for discharge.

• MUAC has been shown to be an effective method for screening and admitting SAM children, and much simpler than W/H.

• MSF in Bihar is one of the only and longest running CMAM programmes worldwide routinely using exclusively MUAC+/-oedema for admission (<115mm) and discharge (≥120mm)

• This presentation describes the programmatic results and long-term outcomes of using exclusively MUAC≥120mm for discharge for children 6-59 months of age.

Methods• Data from all children cured (defined as MUAC≥120mm) from

July 2010-September 2011 (n=2288) were retrospectively analyzed. – Children with oedema (0.3%, n=8), length of stay<14 days (3.8%,n=95)

and >140 days (2.9%,n=71) were excluded.

• During a targeted follow-up study, children discharged as cured from the programme were traced up to 18 months post-discharge (n=1036) .

• These results were then matched.

Admission characteristics MUAC <115mm (6-59m)

N (%)MUAC

< 90mmMUAC

< 100 mmMUAC

100-110 mmMUAC

112-114 mmTotal

Number of children admitted 84(2.1%) 302 (7.5%) 1686 (42.0%) 1947 (48.4%) 4019 (%)

Sex

Female 61 (72.6) 226 (74.8) 1150 (68.2) 1277 (65.6) 2714 (67.5)

Male 23 (27.4) 76 (25.2) 536 (31.8) 670 (34.4) 1305 (32.5)

Age (months)

6-12 65(77.4) 183(60.6) 1005(59.6) 980(50.3) 2233(55.6)

13-24 16(19.0) 100(33.1) 574(34.0) 791(40.6) 1481(36.8)

25-36 3(3.6) 14(4.6) 79(4.7) 134(6.9) 230(5.7)

37-59 0(0) 5(1.7) 28(1.7) 42(2.2) 75(1.9)

Median age 9 12 12 12 12

Median Height (cm) 60 62 65 68 67

MUAC, mean ± SD 83.3 ± 4.7 95.1 ± 2.7 106.6 ± 3.1 113.3 ± 1.0 108.5 ± 6.7

WHZ, mean ± SD -4.4 ± 1.2 -4.0 ± 1.0 -3.2 ± 0.8 -2.8 ± 0.7 -3.1 ± 0.9

Admissions with < -3 WHZ (%) 75 (89.3%) 259(85.8%) 1082 (64.2%) 777 (39.9%) 2193 (54.6%)

HAZ, mean ± SD -5.4 ± 1.8 -4.6 ± 1.5 -3.8 ± 1.5 -3.3 ± 1.4 -3.6 ± 1.5

Outcomes by admission criteria (6-59m)

MUAC at admission< 90mm

N=31< 100 mm

N=113100-110 mm

n=837112-114 mm

n=1307Total

n=2288

Average MUAC gain, mm/day 0.47 ± 0.21 0.47 ± 0.26 0.42 ± 0.29 0.41 ± 0.32 0.42 ± 0.30

Average Height/Length gain per week (cm by LOS)

1.7±0.9 1.9±1 1.2±1 0.8±0.3 1.1±1

Outcomes stratified by height (6-59m)<65cm >65cm TOTAL

N 1347 2638 3985Outcome: n (%)

Cured 636(47.2) 1652(62.6) 2288 (57.4)Dead 10(0.7) 12 (0.5) 22 (0.6)Defaulter 607(45.1) 873(33.1) 1480 (37.1)Refered 0 0 0Non-responder 94(7.0) 101 (3.8) 195(4.9)AWG (g/kg/day) 5.2±3.3 5.2±3.8 5.2±3.7ALS (days) 56.6±38.0 42±29.3 46.6±32.8

Nutrition Status at discharge

Mean MUAC ±SD 122.9±2.0 123.4±2.4 123.3±2.3WHO WHZ. mean ±SD -1.0±0.8 -1.7±0.7 -1.5±0.8WHO HAZ mean ±SD -4.3±1.3 -3.5±1.4 -3.7±1.4

76.2% of children reached a W/H≥-2SD, 21,8% ≥-3 to <-2 and 2.0%<-3SD Mean age at discharge:

< -3 at discharge: 20 months ≥-3 to <-2: 18 months > -3: 15 months

Follow up survey (relapses)Objective: To determine the nutritional status & mortality rates of children discharged cured from the programme over different lengths of time (3,6,9,12,18 months) .

Design: Retrospective cohort. 3 periods: Mid Oct 2011: After 3 months of food insecurity Mid Dec 2011: After 2 months of food security Mid Feb 2012: After 4 months of food security

Sample size: 1036 children followed up

Results (overall follow up): •Relapses: 4.0%•Mortality: 0.8% •15.5%: reached MUAC ≥125mm at time of discharge•Mortality and relapse rate: no significant difference between children discharged with MUAC > 120 to those having a MUAC 120-125 at discharge

Long Term Outcomes of Children CuredOverall Relapses (MUAC < 115mm)

Perc

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Time following discharge

Long Term Outcomes of Children CuredRelapses (MUAC < 115) by time of the survey

Perc

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Time following discharge

Majority of children discharged as cured remain cured in the long term, however higher risk of relapse in first 3 months associated with food security season.

Risk factors for relapse and mortality in cured children

For relapse: •W/H < -3SD•Not using Anganwadi services•Low standard of living score•Longer LOS in programme•Season

None associated with mortality

Conclusions

• When analysing nutrition status at discharge, MUAC≥120mm discharge demonstrated acceptable programme characteristics.

• Relapse rates appeared significantly higher in children discharged with WHZ<-3SD but absolute numbers were very small (2.0%, 21/1036), not reflected in mortality (0%) and represented an older admission population.

• When discharge is done during food insecurity period important follow up.

• Current MUAC > 120 mm discharge criteria results in a long LOS for children with low MUAC and for children < 65 cm (> 6 months): self recovery perception-defaulting. Need to readjust criteria for children < 65 cm.