Presentation on MUAC response in CTC / CMAM programs

Here is a presentations from the 2008 Washington CMAM conference regarding the use of MUAC as a monitoring and discharge criteria in CTC (CMAM) programs. UPDATE 25/11/2011 : I have also attached the protocol to the study referred to below. This proposal was developed for FANTA-2 after the 2008 Washington CMAM conference.

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MUAC.Response.CMAM2008.pdf753.86 KB
protocolMUACstudy.pdf180.89 KB

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MUAC as discharge criterion

I would like to find more evidence on the evolution of MUAC during nutritional rehabilitation and this in relation to different parameters (age, sex, stunting)? Are you aware of published studies or field reports who used MUAC single cut off as an independent discharge criterion? What is the cut-off that was used?

An answer of sorts ...

MSF are currently analysing data from their CRENAS programs. They have noted some problems with the 15% weight gain discharge criteria (i.e. the most severely wasted get the least treatment) so they are investigating the use of MUAC in a program using MUAC for admission and discharge. The discharge criteria was MUAC >= 125 mm. I will leave it to them to summarise the findings.

I am currently working on a study ongoing in Malawi looking at MUAC as a discharge criteria. We are using MUAC >= 125 as the discharge criteria and active follow-up each month for three months after discharge. We are just over half-way through recruitment now. The preliminary results indicate that that this is a safe threshold. We have seen no deaths and only a few relapses to MAM (i.e. 115 mm <= MUAC < 125 mm) with spontaneous recovery during the three month active follow-up. We hope to be able to use the study data to design (for further testing) simple MUAC-based monitoring tools.

In the last two years, I have seen several programs using MUAC for admission and discharge. They have used a variety of thresholds. Some have used the 125 mm threshold on the basis that mortality in cohort studies show mortality at or about baseline levels at MUAC >= 125 mm (this is the basis for the 125 mm threshold for MAM). Others have used 110 mm or 115 mm (i.e. above the admitting threshold) for two weeks and clinically well. There do not appear to be many relapses in these programs but this is based on passive detection (i.e. do they come back to the program). Some of these programs discharge to SFP. I would, at this time, be wary of using these lower thresholds when discharging to the community unless I had a functioning cadre of community-based volunteers to follow-up discharged cases. A program in Bangladesh used this approach and found 2.5% relapse to below admission criteria with follow-up periods of up to 11 months.

You may also want to post your question on EN-NET. See this post about EN-NET.

MUAC as discharge criterion

Thank you for your reply. Are you also collecting data on % of weight gain and / or WH z-score in your study in Malawi where children are discharged on the basis of MUAC >= 125 mm ?

Scope of dataset and proposed analyses

I have uploaded the protocol for this study so you can see the scope of the dataset and the proposed analyses. I hope that you find this useful. The link is located just below the main "story" (above).

MUAC as discharge criterion

Dear Mark,

Thank you for sending me your study protocol. Very interesting.

I am keen to know where I can find the data from the Save the Children-US program in Ethiopia, comparing MUAC and Weight gain response and also Length of Stay in the Programme.

Is there any particular reason for the choice of your cut-off at 125 mm?

Best regards,
Naïma

MUAC response dataset and the 125 mm threshold

Are you asking for access to the clinical dataset? I have this here but I do not feel that I can give this to you without first obtaining permission from SC-US. Let me know if this is what you want and we can start the process.

The 125 mm threshold was selected because data from the historical cohort studies indicated that at MUAC > 125 the mortality risk is at or just below the acceptable baseline threshold of 1 / 10,000 / day. A child discharged as cured with a MUAC of 125 or a little higher will be clinically well, be nutritionally rehabilitated (i.e. neither a SAM nor a MAM case), be demonstrably gaining weight and muscle-mass, be vitamin-A supplemented, and probably have a fuller vaccination card and definitely be a little older than before the episode of SAM. Discharge will also probably be after the peak of the "hunger season" has passed. Such a child will we at low risk of relapse and low risk of mortality. This threshold appeared to be achievable given the CMAM datasets available for analysis. Most of this is summarised in this presentation which I gave to the 2008 Washington CMAM conference and led directly to the ongoing study in Malawi. It is important to stress that 125 mm was selected for the study because it is likely to be safe. Lower thresholds might also be safe but we did not want to minimise the risk to the study population.

Now that admission is at MUAC < 115 mm it seems very unlikely that a discharge threshold less than 125 mm will be used although I have seen (e.g.) discharge at 115 mm in some programs but these have been discharge to SFP where nutritional support is given and MUAC and weight monitored. It seems likely that the 125 mm threshold will be suitable for discharge with SFP or "bridging ration".