Emergency standards for SAM/MAM when using MUAC

You can use the same thresholds regardless of which indicator you use. These thresholds are rules-of-thumb and have been around for many years (i.e. before we moved to WGS reference which tended to increase prevalence of GAM compared to the older NCHS reference). As rules-of-thumb they need to be interpreted carefully and in context. I am not sure what is meant by "MUAC ... is only mortality predictor" as I see no value in an indicator of "thinness" unrelated to, or only weakly related to, mortality. Such an indicator would lead you to declare emergencies when no emergency existed and to treat healthy older children while excluding sicker younger children (which is what WHZ tends to do). That said ... WHZ still remains a more accepted indicator for prevalence although it is now common to see both prevalence by MUAC and prevalence by WHZ reported. I think WHZ should be retired as we increasing use MUAC for admission.

 think this was meant for me.

It seems that you may be increasing the MUAC threshold in order to maintain program numbers. This does not seem very sensible to me. MUAC < 125 mm is a common cutpoint for MAM. Using this threshold, or a higher threshold, will increase sensitivity but decrease specificity. This means that you will admit a large number of false positive cases (i.e. cases that would not go on to die in the absence of treatment). A MUAC of 134 mm is quite large for younger children. Using the example of one year old girls ... the WGS reference has median MUAC - 142 mm with SD of about 11 mm. This means that in a healthy population of one year female children living in conditions ideal for growth we would expect to find about 23% of girls aged one year with MUAC < 134 mm (compared with c. 1% using MUAC < 115 mm). Many of these children will not need treatment.

I take the view that we run child survival programs and this needs us to identify children who would die without treatment but would survive with treatment. Work done by ENN's concurrent wasting and stunting group (WaSt TIG) shows that a case-definition using extreme low MUAC and/or extreme low WAZ detects all, or nearly, all such cases including all those with WHZ < -3. See this article.

ENN's WaSt TIG are currently doing the additional work suggested in this article and have found similar results using cohort data from Bangladesh, DRC, Ghana, Guinea-Bissau, India, Indonesia, Nepal, Niger, Peru, Philippines, Senegal, and Sudan.

I think the best approach would be to use a case-defintion such as:

    MUAC < 115 mm OR WAZ < -3

might do better than increase the MUAC cutpoint and better than using:

    MUAC < 115 mm OR WHZ < -3

for admission into therapeutic feeding programs. By extension, the case-definition:

    MUAC < 125 mm OR WAZ < -2

might be well suited to deciding admission into supplementary feeding programs.

using WAZ has the advantage of detecting children with concurrent wasting and stunting who we know to be at high risk of near term mortality. WAZ is well suited to clinic / hospital bases screening provided good infection control is used.

I hope this is of some use.
 

Hi Mark & Fahim,

Notwithstanding any theoretical stances on targeting of children for treatment of acute malnutrition I would like to add a note on context. A series of briefs and responses to questions were produced by the Global Technical Assistance Mechanism (GTAM) in response to the Covid-19 pandemic which considered potential programmatic adaptations in the face of widespread infections as a way of maintaining access to treatment for wasting whilst reducing the risk of crossinfection. These briefs were produced at an early phase of the pandemic and categorised the potential adaptations based on the potential restrictions of movement of the population (e.g. if partial or full lockdown measures were in place). 

Among these potential adaptations were the adoption of simplified protocols - including a shift to MUAC / oedema only admissions as a means of minimising person to person contact and covid-19 transmission through the repeated use of equipment (e.g. measuring weight and in particular height), particularly at community level. The adoption / implementation of specific protocols at national or more localised protocols would ideally be arrived at through local government and UN coordination mechanisms. 

One of the concerns raised has been how to capture the children with low weight for height (that would not be identified with MUAC / oedema only admission criteria). Some of those questions and responses are considered here:

https://docs.google.com/document/d/16TZQbBj65GT6bjmzxkhISVjzxK-EM-LTUztsO69DA-M/edit

and here:

https://www.en-net.org/forum/31.aspx

Any changes in admission / discharge criteria should be reviewed through the relevant national coordination mechanisms and the coordinated response to Covid-19. The latest Situation Analysis in Yemen can be found here:

https://reliefweb.int/report/yemen/unicef-yemen-humanitarian-situation-report-1-31-july-2020

In a hospital setting, assuming greater access to protective equipment, more rigorous implementation of infection prevention protocols and the availability of appropriate viricidal cleaning solutions, it is a reasonable question to ask whether it is acceptable to use height boards in that setting. You might try contacting UNICEF / WHO in Yemen for contextualised guidance regarding practices in a hospital setting. The adoption of WFA criteria would I think require far wider consultation and discussion.

Cheers

Paul

Paul,

Thank you for these links.