Do we have "SAM Cure Rate" in health facilities running CMAM program

Hi Tammam,
Take a look at this paper; Maust et al. report on integrated programming in Sierra Leone:

https://publichealth.wustl.edu/wp-content/uploads/2014/08/NnekaPubJN.pdf

In this paper there are two different protocols; 'standard' management and 'integrated' management.

Standard management transfers the child from OTP to SFP and uses a MUAC >11.5cm / WFH > -3z as criteria for 'discharge cured'. The child is then discharged 'cured' from SFP with a MUAC of >12.5cm or WFH >-2z. The operational key here is that these are 2 different treatment programmes in different locations. I think there are some potential problems with reporting in this scenario.

Firstly, to my knowledge the use of MUAC >11.5cm / WFH >-3z as stand alone criteria have not been shown to be safe discharge criteria. MUAC >12.5cm is associated with low relapse and short term mortality rate and MUAC >12.5cm / WFH>-2z are recognised by WHO as acceptable discharge criteria for SAM. I would therefore be very cautious to call the child 'cured' unless the discharge cured criterion when MUAC was > 11.5cm (unless this was combined with some other criteria such as a minimum stay + absence of oedema + clinical wellness etc). Ultimately the discharge criterion is about physiological recovery, not a number.

Secondly, the intention in the programmes, although they are separate, is to continue treatment in SFP after OTP and as such the child is not truly discharged from treatment until cure is obtained in SFP. The child may be lost in transfer or may be 'double counted' as a case of SAM AND a case of MAM although this is one episode of acute malnutrition.

In the integrated protocol the child receives graduated treatment depending on whether they are SAM or MAM and recovery for MAM + SAM are reported together and compared against sphere standards. The operational key here is that the same health facility conducts the treatment.

There are also potential problems with reporting in this scenario if you wish to report against sphere standards. The joint reporting of recovery rate would likely not be problematic, however the acceptable mortality rate for 'OTP' and 'SFP' are different and may be problematic if you have a mortality rate greater than 3% in OTP.

For reporting you could consider combined reporting or you might also consider separate reporting for OTP and SFP.

Separate reporting would report the negative outcomes of the OTP and SFP separately. The criterion of 'transferred to SFP' would be considered a SUCCESSFUL outcome for OTP. This is not the same as cure and should not be reported as such. It would be acceptable to have a zero 'cure rate' since this is not your measure of success for this component in this particular programme. Your narrative report can clarify the reporting scenario and you can report a combined recovery rate for OTP and SFP if you wish.

Another option might be to consider this programme a graduated programme. The child with SAM might have the nutritional intervention changed when the MUAC >11.5cm (e.g. from high dose RUTF to reduced RUTF / RUSF) but continue to be considered recovering in OTP and continue monitoring on the OTP card. You would then report the child as cured when discharged from OTP at MUAC >12.5cm / WFH .-2z. OTP and SFP would be reported separately as the child does not transfer between different 'programmes'.

I am aware that there are national guidelines that do consider >11.5cm / >-3z to be 'cure'. In this case you would report according to the national guidelines.

One final point, just to add to the complexity, is that if you also have inpatient care in this programme, consider how you are reporting for transfers from inpatient to OTP to SFP and then subsequent cure. Again in this scenario, a 'transfer to OTP' can be considered a successful outcome but is not the same as cure - the child is merely moving between different components of the same treatment schedule.

I hope this helps,
Paul

Hi All,
Some interesting points raised and these issues are deserving of more discussion (and dare i say consensus) at international level. Reporting is always tricky and I definitely don't have definitive answers. Apologies for the following stream of consciousness in response to some of the issues raised.

We measure malnutrition by proxy using anthropometry and combine it with clinical signs to determine it's clinical severity (e.g. appetite / complications).What then is 'cure'? Physiologically it is that the child has returned to a normal or near normal physiological state. The environmental conditions into which the child is discharged will undoubtedly have an effect but ideally the child should not relapse or be at a greater risk of death than other children in the population. If we are discharging a child as 'cured' with a MUAC >11.5cm then where is the evidence that this is safe? Children with MAM do not have normal physiological function; children recovering from SAM do not have a normal physiological function as has been demonstrated by some of Mike Golden's excellent work describing the physiological status of children with acute malnutrition.

I would argue that a child is SAM when identified by anthropometric criteria and when their condition improves they are a "recovering SAM" not SFP-MAM. This change, calling a SAM child MAM, is being done on the basis of numbers alone and ignores the child's history of profound physiological compromise. When we do coverage evaluations we use the term "recovering case' [of SAM], we do not discount them because they are 'MAM' by anthropometry.

If we discharge to a SFP programme in a different location or as a separate programmatic entity then there must be safeguards to ensure that this child is not lost in transfer since (in my opinion) the child is not 'cured' no matter that we might report it as such.

Reporting depends very much on having clarity in terms of the nature and design of the programme and the purposes of reporting (e.g. to donors or to national databases). There are as many ideas on how to report as there are experts and no doubt there will be debate about any system, I do however thing we need to think about what we are actually reporting on. A child cannot be 'cured' twice from one episode of acute malnutrition. Reporting needs to consider the CMAM programme as a whole (and see recovery as a continuum) and not see each component as a different programme, unless they are specifically designed as such (e.g. supportive care to prevent relapse in SFP due to food insecurity after cure in OTP).

If we want to have graduated programmes where a child with SAM is treated as 'MAM' when they are >11.5cm / >-3Z then we need also to have a step change in the way we report. Although the concept of reporting recovery for 'OTP' and 'SFP' combined is controversial it more closely resembles the reality of the intended continuum of care. Reporting negative outcomes separately (for OTP and SFP) also has validity since the factors for default, death and non-response may be different for each phase of the graduated treatment. This is clearly seen when we have 'early' or 'late' defaulters in OTP for different reasons, for example.

In Tammam's case I understand the challenge of supplies. There have been successful studies reported that have used low dose RUTF (e.g. 1 packet per day) as the child recovers. When the child is SAM they receive the usual weight based dose and when they are recovering (i.e. MUAC > 11.5cm) the dose is reduced. This approach would reduce consumption by 1/2 or 2/3rds for recovering case. I have not personally evaluated such a programme but there are peer reviewed studies of such approaches. I imagine this might affect the length of stay to some degree but since cure is the primary outcome that we seek, this is probably acceptable.

One of the reasons that 15% weight gain is now not recommended is that the most malnourished children receive the least treatment. The more malnourished a child is the longer they should stay in treatment until cure. National guidelines may indicate 15% weight gain is cure and report it as such but this does not change the evidence that it cannot be considered to be safe for all children. Using MUAC >12.5cm has the opposite effect and children receive the treatment they need depending on the severity of their case on admission. A child admitted with a MUAC of <10.5cm might stay twice as long as a child with a MUAC > 11cm on admission. Early case finding leads to shorter lengths of stay and reduced cost of treatment. Investment in sensitisation and early referral can be cost effective.

Ultimately the evidence base will grow and it may be that early discharge approaches are (peer reviewed) and proven to be safe but until that day we should be cautious and ensure our reporting is not (consciously or unconsciously) designed to make our programmes look good but potentially compromising the proper care of the child.

Regards,
Paul

I would like to pick up on a couple of points raised in this thread. I see some of the guidance being given as absolute rules and yet most protocols are contextually dependent. What applies in one country does not apply in others.

1. Please consider carefully before discharging a child as non-cured if the child remains both < 11.5cm MUAC and < -3z scores. The child is still SAM. Check on what care the hospital provided. Are you sure that the hospital applied appropriate nutrition protocols or did they just treat any medical issue? Did the hospital check for any other underlying causes? (Please see also my last point on the Rohingya language)

2. Many protocols are context dependent. There is no maximum stay in OTP. A child admitted with a very low MUAC (< 10cm) can take around 15 weeks to achieve a MUAC of 12.5cm. Maximum stays for 'non-cured' (e.g. 4 months) are an artificial cut off designed for programmatic purposes. This cut off varies from country to country and between NGOs; some use 3 months and some use 4 months. In an integrated programme (e.g. as part of primary health care services) there should be no such thing as 'non-cured'. If they do not respond to treatment they should be transferred to hospital or referred to another service for ongoing support.

3. Relapse is defined differently in different contexts. In some countries (and the linked document) 2 months is chosen. In some it is 4 months while in others a relapse is a relapse whenever it occurs. Treat the child not the number! If the child appears sick and you feel treatment is appropriate then treat them.

4. By discharging a child that is SAM and refusing to treat again you are potentially making an end of life decision and I do not think such information should be given lightly in a forum such as this. Only a medical doctor can make that decision based on the condition of the individual child so refer the child to an appropriate facility.

5. It is an interesting point that this is a Rohingya refugee population. Rohingya is an extremely difficult language spoken by few people and there is no written form. I wonder whether the guidance that has been given (e.g. for medications / RUTF etc) has been understood properly by some of the carers of beneficiaries. There are languages that are close but it shouldn't be assumed that verbal (and especially written) guidance is understood. There are agencies that assist with these language issues and have guidance summarising issues faced by the Rohingya when communicating with humanitarians in Bangladesh (see below). For example, it is assumed that agency staff are understood. Students from Chittagong University are often used as translators because there is a 70% similarity between the Chittagonian dialect and Rohingya however when these assumptions were tested it was found that 70% of Rohingya were unable to communicate appropriately with agency staff and were unable to understand how to give ORS. Please be rigorous and ensure that the carers are truly able to understand the care being delivered by OTP staff - do not make assumptions. Please see:

Translators Without Borders: https://translatorswithoutborders.org

Rohingya communication issues: https://www.arcgis.com/apps/Cascade/index.html?appid=683a58b07dba4db189297061b4f8cd40