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GAM Among OTP cured

This question was posted the Management of wasting/acute malnutrition forum area and has 6 replies.

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Anonymous 5324

Nutrition Officer

Normal user

11 Mar 2020, 11:35

Dear All,

We are in a process to analyse our OTP program peformance to identify the reasons of relapse among those who were reported as cured discharged from the program as reported by our staff, then to improve the program performance.

The table below shows percentage of patients still acutely malnourished (after examination of their anthropometric data) among patients that were already reported as cured, in our four OTPs districts and we are applying the WHO recommendation for admission and exit criteria.

Districts Number of cured patients Percentage of cured patients Number  of GAM* among cured

Percentage

of  GAM* among cured
A 317 69% 64 14%
B 949 78% 231** 19%**
C 1074 88% 478** 39%**
D 1709 89% 784 41%

* GAM according to the criteria recognized by the relevant UN agencies: WH<-2Z-scores (WHO standards) OR MUAC<125mm

** According to the height measurement on admission only, meaning the figures are potentially under-estimated

I hope I provide you all the required information to get your analysis/recommendation for the below three questions:

-          How could you explain for us the occurrence of MAM or even SAM patients among the cured ones as reported by our health agents?

-          What are the consequences over real cure rate for these programs?

-          What would you suggest to tackle the problem?

With best regards,

Paul

Technical expert

3 Apr 2020, 13:49

Hi Anonymous,

I am unable to read the table properly since the columns appear to have no headings and I dont understand how you arrived at the calculations of the percentages. Is it possible to resubmit your question with the complete column headings?

1. You mention children as having been cured and then relapsed, however you say that when 'examining their anthropometric data' there are several that are still acutely malnourished. If this is a new measurement of a child previously discharged cured then the reasons for relapse will be dependent on prevailing conditions of disease, food insecurity or other underlying factor (see the UNICEF conceptual framework for malnutrition). Identifying the causes may be possible from examining the history on admission (e.g. diarrhoea, cough, fever, inadequate complementary feeding practices etc.). If, however, this is a re-examination of the data from the OTP card then it would appear to be a failure to adhere to the appropriate discharge criteria and incorrect reporting. 

2. I may be able to better answer the second question regarding 'real cure rate'  if you send a complete table. Many programmes use height data from admission only as a way of minimising measurement errors, so if this is the method recommended by your national guidelines then you probably needn't worry about this being the reason for 'relapse'. If you think there may be a problem with height measurements then check the measurement procedures used by OTP staff. 

3. With the information available:

a) Check that your OTP staff understand and apply the correct discharge protocols

b) Check the staff perform measurements correctly

c) Check staff are completing the reporting forms correctly

d) Examine the child's history on the OTP card as reported by the carer for possible reasons for their admission. Crosscheck with other relapses for each district for common underlying causes

e) Map where the relapses are coming from and visit the relevant communities / village leaders to discuss any potential issues / underlying causes & solutions

I hope this helps,

Paul

Anonymous 5324

Nutrition Officer

Normal user

3 Apr 2020, 14:29

Hi Paul,

Thank you a lot for your detailed explannation. The table colomn heading could be visible if you select the columns heading cells. If not visible, see the below please: 

- The 1st column's heading is the name of district,

- The 2nd column - number of cured patient,

- The 3rd - percentage of cured patient

- The 4th - Number of GAM* among cured,

- The 5th - percentage of GAM* among cured

Thanks again for your swift responses and I will reply latter once I get your full clarification using the column heading. 

Mark Myatt

Consultant Epidemiologist

Frequent user

3 Apr 2020, 17:18

I am not sure what you are asking and what follow-up period is being used.

I am not sure that you are measuring relapse with this data. I assume that OTP is treating SAM cases (MUAC < 115 mm or WHZ < -3 or oedema). This SAM case-definition should be used as the case-definition for relapse to SAM.

It is possible that yor program is discharging prematurely or discharging on one nutritional index only (e.. if admitted with MUAC < 115 mm discharge is on MUAC > 125 mm regardless of WHZ).

Paul

Technical expert

6 Apr 2020, 09:30

Hi Anonymous. 

I agree with Mark, these are extremely high percentages for them to be relapsed cases. To put this into context, we monitored children closely for 3 months after recovery and found 1.9% relapse.

It sounds more likely that:

(i) the criteria for discharge are not being implemented correctly or

(ii) measurements are not being done correctly and / or

(iii) reporting is inaccurate

or some combination of the above. It is odd that the problem is widespread across the districts. This would suggest the problem is more systematic and that you may need to check the training materials and speak with programme supervisors about what support is given to staff. 

Paul

Anonymous 35933

Normal user

6 Apr 2020, 16:15

Dear Anonymous,

 You better conduct/ commission a coverage survey with SQUEAC methodology to investigate the reasons why and to identify other unforeseen barriers of your OTP program. This will also help to redesign your CMAM program and curb associated bottlenecks based on evidence. 

Best,

Anonymous 5324

Nutrition Officer

Normal user

9 Apr 2020, 10:33

Dear All colleagues, 

Sorry for my late responses and thanks a lot for all your detailed and comprehensive feedback and guidance,

With best regards,

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