Mid-upper-arm circumference based case-detection, admission, and discharging of under five children in a large-scale community-based management of acute malnutrition program in Nigeria

Stanley Chitekwe, Sibhatu Biadgilign, Assaye Tolla, Mark Myatt

Severe acute malnutrition (SAM) threatens the lives of millions of children worldwide particularly in low and middle-income countries (LMICs). Community-based management of acute malnutrition (CMAM) is an approach to treating large numbers of cases of severe acute malnutrition (SAM) in a community setting. There is a debate about the use of mid-upper arm circumference (MUAC) for admitting and discharging SAM children. This article describes the experience of using MUAC for screening, case-finding, referral, admission, and discharge in a large-scale CMAM program delivered through existing primary health care facilities in Nigeria. Over one hundred thousand (n = 102,245) individual CMAM beneficiary records were collected from two of the eleven states (i.e. Katsina and Jigawa) that provide CMAM programming in Nigeria. The data were double entered and checked using EpiData version 3.2 and analyzed using the R language for data-analysis graphics. The median MUAC at admission was 109 mm. Among admissions, 37.4% (38,275) had a comorbidity recorded at admission and 7.4% (7537) were recorded as having developed comorbidity during the treatment. Analysis in the better performing state program in the most recent year for which data were available found that 87.1% (n = 13,273) of admitted cases recovered and were discharged as cured, 9.2% (n = 1396) defaulted and were lost to follow-up, 2.9% (n = 443) were discharged as non-recovered, 0.7% (n = 104) were transferred to inpatient services, and 0.2% (n = 27) were known (died, to be dead or to have passed) during the treatment episode. The program met SPHERE minimum standards for treatment outcomes for therapeutic feeding programs. Factors associated with negative outcomes (default, non-recovery, transfer, and death) were distance between home and the treatment center; lower MUAC, diarrhea and cough at admission; or developing diarrhea, vomiting, fever, or cough during the treatment episode. This study confirms that MUAC can be used for both admitting and discharging criteria in CMAM programs with MUAC < 115 mm for admission and MUAC > = 115 mm or at discharge (a higher discharge threshold could be used). Long distances between home and treatment centers, lower MUAC at admission, or having diarrhea, vomiting, fever, or cough during the treatment episode were factors associated with negative outcome. Providing CMAM services closer to the community, using mobile and / or satellite clinics, counseling of mothers by health workers to encourage early treatment seeking behavior, and screening of patients at each patient visit for early detection and treatment of comorbidities are recommended.