1. MUAC ≥120mm AS A SIMPLE, SAFE AND EFFECTIVE DISCHARGE CRITERIA FOR SAM IN BIHAR, INDIA MSF SPAIN

2. Structure of the session 1.Background 2.Methods 3.Programme outcomes 4.Long-term outcomes 5.Conclusions

3. Background India has 40% of the worldwide burden of childhood SAM. WHO currently recommends admission using MUAC<115mm and/or WHZ<-3SD, and discharge when 15% body-weight has increased. Although this 15% increase has been discredited, debate is ongoing regarding using different MUAC and/or W/H cut-offs for discharge. MUAC has been shown to be an effective method for screening and admitting SAM children, and much simpler than W/H. MSF in Bihar is one of the only and longest running CMAM programmes worldwide routinely using exclusively MUAC+/-oedema for admission (<115mm) and discharge (≥120mm) This presentation describes the programmatic results and long-term outcomes of using exclusively MUAC≥120mm for discharge for children 6- 59 months of age.

4. Methods Data from all children cured (defined as MUAC≥120mm) from July 2010-September 2011 (n=2288) were retrospectively analyzed. – Children with oedema (0.3%, n=8), length of stay 140 days (2.9%,n=71) were excluded. During a targeted follow-up study, children discharged as cured from the programme were traced up to 18 months post-discharge (n=1036). These results were then matched.

5. Admission characteristics MUAC <115mm (6-59m) N (%) MUAC < 90mm MUAC < 100 mm MUAC 100-110 mm MUAC 112-114 mm Total Number of children admitted 84(2.1%) 302 (7.5%)1686 (42.0%)1947 (48.4%)4019 (%) Sex Female 61 (72.6) 226 (74.8)1150 (68.2)1277 (65.6)2714 (67.5) Male 23 (27.4) 76 (25.2)536 (31.8)670 (34.4)1305 (32.5) Age (months) 6-12 65(77.4) 183(60.6)1005(59.6)980(50.3)2233(55.6) 13-24 16(19.0) 100(33.1)574(34.0)791(40.6)1481(36.8) 25-36 3(3.6) 14(4.6)79(4.7)134(6.9)230(5.7) 37-59 0(0) 5(1.7)28(1.7)42(2.2)75(1.9) Median age 9 12 Median Height (cm) 60 62656867 MUAC, mean ± SD 83.3 ± 4.7 95.1 ± 2.7106.6 ± 3.1113.3 ± 1.0108.5 ± 6.7 WHZ, mean ± SD -4.4 ± 1.2 -4.0 ± 1.0-3.2 ± 0.8-2.8 ± 0.7-3.1 ± 0.9 Admissions with < -3 WHZ (%) 75 (89.3%) 259(85.8%)1082 (64.2%)777 (39.9%)2193 (54.6%) HAZ, mean ± SD -5.4 ± 1.8 -4.6 ± 1.5-3.8 ± 1.5-3.3 ± 1.4-3.6 ± 1.5

6. Outcomes by admission criteria (6-59m) MUAC at admission < 90mm N=31 < 100 mm N=113 100-110 mm n=837 112-114 mm n=1307 Total n=2288 Average MUAC gain, mm/day 0.47 ± 0.210.47 ± 0.260.42 ± 0.290.41 ± 0.320.42 ± 0.30 Average Height/Length gain per week (cm by LOS) 1.7±0.9 1.9±11.2±10.8±0.31.1±1

7. Outcomes stratified by height (6-59m) <65cm >65cmTOTAL N 134726383985 Outcome: n (%) Cured 636(47.2)1652(62.6)2288 (57.4) Dead 10(0.7)12 (0.5)22 (0.6) Defaulter 607(45.1)873(33.1)1480 (37.1) Refered 000 Non-responder 94(7.0)101 (3.8)195(4.9) AWG (g/kg/day) 5.2±3.35.2±3.85.2±3.7 ALS (days) 56.6±38.042±29.346.6±32.8 Nutrition Status at discharge Mean MUAC ±SD 122.9±2.0123.4±2.4123.3±2.3 WHO WHZ. mean ±SD -1.0±0.8-1.7±0.7-1.5±0.8 WHO HAZ mean ±SD -4.3±1.3-3.5±1.4-3.7±1.4  76.2% of children reached a W/H≥-2SD, 21,8% ≥-3 to <-2 and 2.0%<-3SD  Mean age at discharge:  < -3 at discharge: 20 months  ≥-3 to <-2: 18 months  > -3: 15 months

8. Follow up survey (relapses) Objective: To determine the nutritional status & mortality rates of children discharged cured from the programme over different lengths of time (3,6,9,12,18 months). Design: Retrospective cohort. 3 periods:  Mid Oct 2011: After 3 months of food insecurity  Mid Dec 2011: After 2 months of food security  Mid Feb 2012: After 4 months of food security Sample size: 1036 children followed up Results (overall follow up): Relapses: 4.0% Mortality: 0.8% 15.5%: reached MUAC ≥125mm at time of discharge Mortality and relapse rate: no significant difference between children discharged with MUAC > 120 to those having a MUAC 120-125 at discharge

9. Long Term Outcomes of Children Cured Overall Relapses (MUAC < 115mm) Percentage of children with SAM Time following discharge

10. Long Term Outcomes of Children Cured Relapses (MUAC < 115) by time of the survey Percentage of children with SAM Time following discharge Majority of children discharged as cured remain cured in the long term, however higher risk of relapse in first 3 months associated with food security season.

11. Risk factors for relapse and mortality in cured children For relapse: W/H < -3SD Not using Anganwadi services Low standard of living score Longer LOS in programme Season None associated with mortality

12. Conclusions When analysing nutrition status at discharge, MUAC≥120mm discharge demonstrated acceptable programme characteristics. Relapse rates appeared significantly higher in children discharged with WHZ<-3SD but absolute numbers were very small (2.0%, 21/1036), not reflected in mortality (0%) and represented an older admission population. When discharge is done during food insecurity period important follow up. Current MUAC > 120 mm discharge criteria results in a long LOS for children with low MUAC and for children 6 months): self recovery perception-defaulting. Need to readjust criteria for children < 65 cm.