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Recovering case

This question was posted the Coverage assessment forum area and has 11 replies. You can also reply via email – be sure to leave the subject unchanged.

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Freddy H.

Normal user

18 Sep 2012, 10:34

Hello Everyone,
Could someone help me understand why in the circumstance described below we consider the child in the "recovering case group" while conducting a SQUEAC survey?

- SAM case as defined for the SQUEAC survey: MUAC < 115mm and/or Presence of bilateral pitting edema
- Admission criteria in OTP: Presence of bilateral pitting edema, WHZ < -3 or MUAC < 115mm

Situation: while searching for SAM case in a village, we found a child who enrolled in the OTP programme the week before with WHZ criteria. Here are his anthropometrics on admission: WHZ<-3, MUAC=118mm and NO edema.

Question: why do we classify this child in the "recovering case group" while we actually know that he was not a SAM case (as defined for SQUEAC survey) upon admission in the OTP?

Thank you.

Mark Myatt

Frequent user

18 Sep 2012, 11:24

It is confusing. It is not common practice to use W/H in SQUEAC surveys because the measurements are resource intensive and most programs do not admit many cases using W/H in most CMAM programs.

You could ...

(1) Not include this case in the period coverage calculation presented in the body of the report. In this case you should note that this case was found and then present the period coverage estimate as calculated including this case. It should not make a great deal of difference to an estimate.

(2) as (1) above but the other way round (i.e. include the case in the main estimate but note the effect of excluding it).

(3) Censor the case. You may want to mention that the case was found but leave it that.

I would use approach (3) because it is simpler and because we do not use W/H for the current cases.

I'd be interest to hear what other SQUEACers would do in this situation.

Lionella Fieschi

CMAM Advisor

Technical expert

18 Sep 2012, 14:21

Dear Freddy,

Your example is a common situation found during a SQUEAC investigation, but let’s start step by step:
- You have the OTP admission criteria which are general the one you mentionned (Oedema, MUAC and WH). As Mark indicated, in CMAM programme a very small proportion of children are admitted based on WH, these cases are what we call “indirect admissions” because they are usually identified during medical consultation and not during active case finding activities at the community level
- When doing a SQUEAC investigation, the criteria used (what we call the case definition) do not include WH and this for two reasons: as Mark indicated, WH measurements are resource intensive and, most of all, weight and height are not “community friendly measurements” and thus not suitable for a community based programme.
- During SQUAEC, two types of children are considered: SAM children at the moment of the survey (based on Oedema or MUAC) and children in the OTP programme (they can still be SAM or recovering)
- “Children in OTP programme” have to “prove” that they are in the programme by showing a RUTF sachet
- This means that as long a child can prove to be in the programme he is considered as being part of the SQUEAC targeted children;
- This means that we don’t need to know the reason (the criteria) used for admission because we assume that at a certain moment the child was a SAM case based on Oedema, MUAC or WH;
- Children admitted based on WH may indicate good practices at HF level: staff routinely take ALL measurements, and therefore this good practice will still be accounted during SQUEAC investigation
- Therefore, yes………… in your example, the child will be considered as a “child in the programme” and it will be accounted in the “period coverage” equation.
- But my question is: how did you manage to know that the child was admitted based on WH? Why did you look for this information while doing active case finding?

Mark Myatt

Frequent user

18 Sep 2012, 14:56

OK. How to classify this child? We have:

1. The child is in the program.

2. The child is still a case based on the admitting criteria.

This child is, therefore, a current case in the program and will be counted in the point coverage and period coverage calculations.

Is this right?

What interests me is:

1. How often does this sort of question arise?

2. When it does, does it make much of a difference to the coverage estimate?

I doubt it will make much of a difference in the point or period coverage estimate. If this is for a stage III SQUEAC survey can you do the calculations and give us the estimates and 95% CIs with the case included and the case excluded?

I can see that it might make a difference in a coverage classification done in a SQUEAC small-area survey (i.e. make the survey return a different classification) or a SLEAC survey. This is most likely to happen when coverage is "borderline" between the coverage classes. When this happens I would be tempted to base the decision on the direction of error and always favour the population. For example, if the difference were between a SLEAC survey returning a moderate coverage or a high coverage classification I would make the moderate coverage classification. I did something similar in a SQUEAC survey when I found a severely malnourished (MUAC = 104 mm and dropping) maternal orphan (not exclusively breast-fed, mother died in childbirth, father's second wife acting as a wet-nurse breast-feeding the case as well as her own older girl) that was three days short of six calendar months of age (i.e. 180 days old) who was not in the program but known to program staff. I included this as an uncovered case. Did I do wrong?

Lionella Fieschi

CMAM Advisor

Technical expert

18 Sep 2012, 15:35

Some answers (based on my opinion and experience):
- as said, unless the mother has the ration card where the anthropometric measurements are indicated, we don't know the admission criteria used and thus we “assume” that the child was a SAM case at certain moment (based on the protocol admission criteria which may or may not include WH)
Saying this, what I would do:
- If data in the ration card indicate that the child was a Case or maybe he is still a case based on WH, I would still not use it for the point calculation because it doesn’t correspond to the SQUEAC case definition which is Oedema and MUAC only
- But if we present the SQUEAC data using the period coverage equation, I will account this child
- We can “argue” about this choice but, according to me, it is more coherent following the SQUEAC case definition
- However, I definitely agree with you that the number of these children should be very small and thus they will impact very little on the final coverage figure

Concerning your example (child 180 days), again I would not account this child in the coverage estimate because it doesn’t correspond to the “case definition” of 6-59 months but I will definitely pointed out as an example of possible poor active case finding since this child will definitely look skinny and his condition was already present for a while (I believe 104 mm is very low even for <6 months); the child should have been referred to the HC for WH measurements and most probably referred to inpatient (or put on OTP if the age is very close to 6 months and the child has appetite).

Interesting question and yes……………. would be interesting having the opinion of other SQUEACers

Freddy H.

Normal user

18 Sep 2012, 18:28

I thank both Lio and Mark for their reply, comments and clarifications. I actually got this question while training field workers for squeac data collection. I answered them in a way that they were absolutely right but the methodology allows us to assume that at a certain moment this child was SAM. And I am happy that Lio mentioned it somewhere in his argumentation. Trainers were not so convinced of my answer. That ‘s why I am looking for more arguments about this issue.
Lio, U have already answered your question. Well, I know that this child was admitted, based on WH because I wanted to make sure that he is actually in the program. I asked his mother to provide me with his weekly follow-up paper. The admission criterion was mentioned on it. If the follow-up paper was not available I would ask for PPN sachet or some other things to make sure he is actually in the program. So, missing weekly follow-up paper would make me assume that a period of time he was SAM case who is now recovering. Therefore, I join your point of view.

As the methodology is flexible, I think depending on who is reporting, we can either count the child as recovering case or not, but mention is to be made somewhere in the report. I failed to count how many cases I have got in my survey but will pay attention to it next time. To stick to SQUEAC case definition this child in Mark’s example will not be counted in coverage estimation but will definitely be referred to an OTP
Once again thank you very very much .

Mark Myatt

Frequent user

18 Sep 2012, 18:32

Ethiopia has been using the old cut off of 110 mm (11cm) for admission of children with SAM and the discharge was based on target gain as most of the facilities (health posts) don't do height/length measurement.

Now we are revising our guideline for management of acute malnutrition as per latest global recommendation (WHO 2013). It is stated that the discharge of children admitted with MUAC should be once they reach 125 mm (12.5 cm) and this would take long time and means children would stay in the program for more than 8 weeks which is the country uses now. Is there any specific recommendation or experience on this. What would be the implication? Is there a better and successful way....? What if a TSFP program is in the area? Can the kids be referred there?

Jose Luis Alvarez Moran

ACF Senior Technical Advisor

Normal user

19 Sep 2012, 16:10

I was discussing this issue with Freddy last week and I encouraged him to post it here since it will be nice to have more opinions. My point of view has already been shared and matches Lio's. As said "we can argue about this choice but, according to me, it is more coherent following the SQUEAC case definition". So if I want to be "rigid" with the methodology and case definition this child should be counted when calculating period coverage.

This also lead to another debate pointed out by Gwyneth, in this case using MUAC as case definition for SQUEAC while W/H is also used as an admission was in the interests of simplicity and making field work more easy but also because W/H admission criteria was not predominant.

SQUEAC can be very flexible and it has to be adapted to every program as you said

Ernest Guevarra

Valid International

Technical expert

20 Sep 2012, 07:25

I am curious to hear from other's experiences regarding adaptations of SQUEAC particularly in stage 3 (likelihood surveys) and also during the small area survey for hypothesis testing. You mention the flexibility of SQUEAC and that it should be adapted to the situation. Has anyone adapted the likelihood surveys or small area surveys such that you also looked for SAM cases by WHZ? If so, did you do active adaptive case finding as well? Did you do any sensitivity analysis to see if active adaptive case finding finds all or nearly all cases of SAM by WHZ as well?

I am asking because I think if someone is going to be flexible with the likelihood surveys and include finding cases of SAM by WHZ, the standard case finding approach of active and adaptive case finding might not be sensitive for SAM by WHZ hence the survey is not exhaustive and provides a biased result?

Mark Myatt

Frequent user

20 Sep 2012, 09:37

Dear en-net users,

We are alerting you to a strategic review that is being conducted by the Department of Maternal, Newborn, Child and Adolescent Health of the World Health Organization, to seek your urgent inputs. Marko Kerac, LSHTM is coordinating the inputs for the nutrition component. The deadline is Wednesday April 27 5pm EST.

The strategic review will take stock of child health programming in the past two decades, with specific attention to integrated management of childhood illness as a key global strategy promoted by WHO and UNICEF to address major childhood conditions. The aim is to learn from the past and inform the future in terms of guidelines, protocols, delivery approaches and program management in order to increase access, use and coverage of effective case management of sick children.

The objectives of the review cover a comprehensive assessment of clinical guidelines, including Integrated Management of Childhood Illness (IMCI), Integrated Community Case Management (iCCM), and the Pocketbook of Hospital Care for Children.

The strategic review involves a scoping to assess the rapid, high-level assessment of diagnostic and treatment guidelines used at hospitals, in frontline health facilities, and by community health workers. It is looking to understand:

1. If there are any new diagnostic devices, management algorithms, or treatments that are ready for integration into a revised set of clinical guidelines and for implementation at scale, for any of the five major childhood conditions:
a. newborn illnesses
b. pneumonia
c. diarrhea
d. malaria
e. severe malnutrition

2. Information on promising innovations that are not yet ready for implementation, although the priority is to identify innovations that can be readily implemented and have supporting evidence.

There is a short survey to complete at the following link: The deadline is Wednesday April 27 5pm EST.

Please note that when you access the survey, you will also be able to provide recommendations or comments for other disease areas where you have experience. There may be follow up for clarifications/further information based on your responses. Contributors to this review will be duly acknowledged.

This is a great opportunity to jointly impact the conclusions of the WHO strategic review that will have important implications for how global child health programming will evolve in the next decade. Please share with your colleagues.

For any clarifications or to share further information beyond the survey, please contact: Marko Kerac, marko.kerac[AT]

Lionella Fieschi

CMAM Advisor

Technical expert

21 Sep 2012, 05:24

Dear All,

I think we are missing the point here. I would like to remind that the main objective of SQUEAC is not to give a coverage figure but to provide barriers/booster for coverage therefore even if we miss out “few” children, this doesn’t have an impact on the barriers/booster you will find. I easily foresee programme managers trying now to include WH during SQUEAC investigation in order to “gain” 1 or 2% extra coverage figure; how bad!!! Introducing WH, meaning carrying scale and height board during the ACF, will be as bad as for the CHW using WH when doing ACF; this will lead 1) to less time taken in discussing with community stakeholders about barriers/boosters and 2) will switch the core objective of SQUEAC which is indeed barriers/boosters. I say “few” children because this is what it will be in the reality: in a good CMAM programme, most children will be referred using MUAC/oedema; children with low WH will be identified during medical consultations or, rarely, during outreach activities done by health clinic staff. The systematic measurement of WH is not yet a practice systematically included in health clinics activities so very few children are identified during these activities.

I see that we are going back to the old discussions: using WH or not using WH? This is the question (Shakespeare said). I believe that all methods of coverage, and particularly SQUEAC, has already highlighted that coverage is in a large majority of programme low and often very low and this particularly related to the community component which is not very well developed/supported/etc.

So yes, WH has a good sensitivity in finding SAM children, should we start using it now? My answer is definitely no! Sorry if I sound a little sensitive myself but I am well placed (because I have done several coverage surveys) to tell that coverage is generally low and this not because we missed out the WH counting but because the community component is still weak. I see again discussions about/against WH but I see very little discussions/initiatives to really address the community component. Yes, I definitely think we are missing the point. All the best.

Mark Myatt

Frequent user

21 Sep 2012, 19:21

Yes! We should not go back to the bad old days of using W/H. That would bring us rejected referrals and all the misery of low coverage and low impact. It was never my intention to give the impression that using W/H is anything but a bad idea. It is a very bad idea.

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