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Non-responder rate

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Anonymous 1349

Nutrition PM

Normal user

18 Apr 2013, 14:56

Is there any acceptable level of Non responder rate and ideal way to manage in CMAM Program?

Mark Myatt

Consultant Epideomiologist

Frequent user

20 Apr 2013, 10:27

Non-response can be seen as a species of program failure along with death and default.

A good program will minimise failures.

SPHERE presents minimum standards for the percentage of patients that are discharged cured (i.e. the opposite of failure). Examination of program data that I have to hand show that cure-rates of 90% or higher are achievable in well-run CMAM programs (i.e. the sum deaths, non-response, default, transfers can be kept below 10%). Review of CTC literature give an expectation of non-recovery in OTP as about 5% in early admissions (who can be very severe) and dropping over time.

Managing the problem always requires diagnosis of the problem. We can list main reasons for non-response:

Late treatment seeking : More severe cases are more likely to be complicated cases who will fail to respond to treatment. This is a coverage issue.

Compliance (clinic) : Non-response can be due to failure to provide sufficient RUTF or continuous RUTF, failure to provide a potent antimicrobial (recent evidence shows that this is an extremely important component of the CMAM protocol), antihelminthics, &c. Clinic non-compliance can be extended to failure to clinically screen to identify and treat / refer cases of relevant underlying diseases which need more than the basic CMAM protocol (e.g. HIV, TB). Failure to properly monitor weight or MUAC gains (which should be very rapid in the early weeks of treatment) leading to failure to detect and treat (e.g. with second line antimicrobials, counselling, referral, &c.) non-responders early in the treatment episode. I'm sure you can think of other issues.

Compliance (home) : Issues here are sales of RUTF, intra-household sharing of RUTF, patchy attendance leading to treatment interruptions, &c.

Most, if not all, of these are under program control. We know this because all of these issues have been addressed in CMAM programs. If you have a non-response problem then you need to reform your program. The first step would be to diagnose your problems. Some of the SQUEAC tools will help your there. Why SQUEAC? Typically non-response is or will become a coverage issue because programs that do not cure and do not cure rapidly tend to be low coverage programs. A cycle of non-response leading to poor opinions undermining early treatment seeking leading to non-response leading to ... (it keeps going round and round and the problem gets worse and worse) can develop.

I hope this is of some help.

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