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‘Emergency threshold for SAM’ - YES or NO

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Mija Ververs

JHU and CDC

Normal user

7 Feb 2019, 14:31


Dear colleagues
Recently, UNICEF presented the new thresholds / terminology for Stunting and Wasting (GAM only). For wasting the thresholds as such did not change, only the classification terminology. However, the issue of having also a specific threshold for SAM was raised. And this was not the first time. In 2018, during a GNC meeting in NYC the same topic was on the table. Various people have expressed concerns if we establish these thresholds, and others are worried if we do not have them. Note that in the past some organizations have used 2% or 5% SAM as a threshold.
Here a few of the arguments raised by some (‘right’ or ‘wrong’).

AGAINST SAM thresholds:
- There is an inability of most surveys including SMART to demonstrate accuracy down to 2% (overlapping confidence intervals) and
- There should be another way to assess nutritional vulnerability.
- Having a SAM threshold would give actors more reason to NOT intervene if the SAM was not e.g. >2% (or whatever threshold was decided).
- Not having this threshold gives us more flexibility to look at the other factors, e.g. aggravating factors, and start programmes before any emergency threshold has been reached.

FOR SAM thresholds:
- Many people like to use thresholds as a justification to start a project (a threshold might objectively justify funding, etc.). After all, thresholds are often used for that….
-

We would like to encourage a debate amongst practitioners and hear more on their experiences and their rationale on this topic. This debate can possibly facilitate the decision for the collective whether or not to push for further establishment for such a threshold.
We very much like to hear your options and rationale on this.
Regards, Mija (and some other colleague practitioners)

André BRIEND

Frequent user

8 Feb 2019, 08:20

Dear Mija,

Defining emergencies based on MAM or SAM thresholds was proposed a long time ago. The idea was to help to decide when the number of SAM children requiring inpatient treatment was large enough to open therapeutic feeding centres (TFC). This was enshrined in the WHO 2000 document on nutrition emergency which said that TFC should be opened when the prevalence of WFH <-2 was above 10% with variations with the presence or absence of aggravating factors (1). Note that these thresholds to decide about the need for TFCs were based on moderate wasting levels, not on SAM prevalence. I guess the rationale for this is that standard nutritional surveys are not suitable to give a precise estimate of SAM prevalence for reasons explained by Brad Woodruff in another post we received this morning.

Personally, I am not in favour of having a SAM emergency threshold.

First, as discussed above, prevalence surveys are quite unreliable when estimating the number of SAM children to be treated, first again because they are not suitable to give precise SAM prevalence estimates, and second, because the number of children to be treated is related to incidence, not prevalence, and the conversion of prevalence to incidence is quite problematic as shown by quite a few recently published articles (2) (3) (4) (5) (6). There is more work going on, with much large number of surveys and which will be published soon, highlighting even more the problems of this conversion.

Second, and at a more fundamental level, I am not sure this idea of threshold, going back to the TFC days, is really relevant now that CMAM is the standard practice. Opening a TFC was something really mobilising huge resources and it was a decision which had to be taken only when one was confident TFCs would be used at full capacity. CMAM programmes can be started with low initial investment and there is no rationale to wait for an emergency threshold before treating SAM cases. All this was discussed in a very good paper published a few years ago in Field Exchange by Peter Hailey and Daniel Tewoldeberha (7). I suggest you have a look at this paper questioning the traditional use of thresholds and making the case for a new approach much more elegantly than I can do it in a short post here.

A final remark. Among obesity specialists, it is well recognised that the same BMI thresholds should not be used in different populations to define obesity due to differences in body frame and shape (8). The same debate is not really open in the malnutrition area, but I suspect the same rationale questions the use of WFH to define acute malnutrition. This would question even more the use of WFH thresholds to define nutritional emergencies.

1. World Health Organization. The management of nutrition in major emergencies [Internet]. 2000. Available from: http://www.who.int/nutrition/publications/emergencies/9241545208/en/
2. Isanaka S, Grais RF, Briend A, Checchi F. Estimates of the duration of untreated acute malnutrition in children from Niger. Am J Epidemiol. 2011;173:932–40.
3. Deconinck H, Pesonen A, Hallarou M, Gérard J-C, Briend A, Donnen P, Macq J. Challenges of Estimating the Annual Caseload of Severe Acute Malnutrition: The Case of Niger. PloS One. 2016;11:e0162534.
4. Isanaka S, Boundy EO, Grais RF, Myatt M, Briend A. Improving Estimates of Numbers of Children With Severe Acute Malnutrition Using Cohort and Survey Data. Am J Epidemiol. 2016;184:861–9.
5. Bulti A, Briend A, Dale NM, De Wagt A, Chiwile F, Chitekwe S, Isokpunwu C, Myatt M. Improving estimates of the burden of severe acute malnutrition and predictions of caseload for programs treating severe acute malnutrition: experiences from Nigeria. Arch Public Health Arch Belg Sante Publique. 2017;75:66.
6. Dale NM, Myatt M, Prudhon C, Briend A. Using cross-sectional surveys to estimate the number of severely malnourished children needing to be enrolled in specific treatment programmes. Public Health Nutr. 2017;20:1362–6.
7. Hailey P, Tewoldeberha D. Suggested New Design Framework for CMAM Programming. :4. Available at: https://www.ennonline.net//fex/39/suggested
8. Hruschka DJ, Hadley C. How much do universal anthropometric standards bias the global monitoring of obesity and undernutrition? Obes Rev Off J Int Assoc Study Obes. 2016;17:1030–9.

Mija Ververs

JHU and CDC

Normal user

8 Feb 2019, 19:42

Thanks Andre for this excellent overview. I hope there are still more people who would like to express their points of view. I encourage others to express their opinions as well.

Anonymous 24408

Normal user

9 Feb 2019, 09:28

Very interesting topic. Thank you for raising it. Can I clarify something: Do I understand correctly that there is currently no emergency threshold for SAM? I have a roving position and have been in two countries recently (DRC and CAR) where survey reports and/ or programme documents have highlighted where SAM prevalence exceeds a WHO 2% emergency threshold. Can I comment that this is not/ no longer a threshold? Does anyone have the initial reference for this threshold (or is it a myth that has become so widely used that people assume it to be correct?)
As to whether a threshold is helpful. I'm not sure it is, given the challenge in having a precise SAM prevalence from standard nutrition surveys (as mentioned).

Mija ververs

Normal user

9 Feb 2019, 12:21

Dear responder
That is correct. There is currently no formal SAM threshold issued by an UN agency. Unlike for GAM and chronic malnutrition (stunting) prevalences (used to declare levels of emergency.).

Anonymous 24408

Normal user

9 Feb 2019, 15:58

many thanks

Anonymous 31546

Normal user

12 Feb 2019, 12:02

Hi all
Does this indicate there is a gap in routine management of SAM at facility level ?
I ask this because individual health facilities will need assistance if the numbers are beyond what they can manage. And this varies from region to region.
There should be nutrition system strengthening at regional level or dependent on levels of government in place, their capacity assessed and when they have SAM cases beyond their capacity to a certain measurable level, intervention should be done. A blanket threshold for all areas is unacceptable in my view.
I have worked both in a food secure and food insecure area. Observation I made is that preparedness amongst health workers for nutritional emergencies specifically for management of SAM with or without complications is poor for staff from food secure areas. And thus, if there be a threshold, food secure areas should have a low threshold or we condemn many children to death.

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