MSFSPAIN Simplified and Expanded Admission Criteria in Upper Nile, South Sudan: MSF’s experience

Structure of the session 1.Why only MUAC for admission and discharge 2.MSF Nutrition simplified and expanded protocol 3.Kodok project, outcomes and challenges 4.Conclusions/Discussion

1. Introduction Mid upper arm circumference (MUAC ) and weight-for-height z- score (WHZ) are used to diagnose SAM – Imperfect and independant indicators – Used as a proxy to assess nutritional status – Do not always identify the same children W/H <-3 SD +/- oedema MUAC<115mm +/- oedema

Low MUAC vs low WHZ MUAC and WHZ do not identify the same children WHZ is influenced by body shape and proportions: Regional effect – WHZ seems Overestimate malnutrition in long-limbed population Underestimate malnutrition in short-limbed population  This is likely to alter the link between WHZ and survival.

MUAC the best index to assess the risk of death Age Effect – MUAC grows continuously with age, and when a fixed cut-off is used for identifying SAM children, more young children are selected than with an index adjusted for height such as WHZ. – As younger children have a higher mortality, this improves the selection of a high risk group. Muscle mass relationship – Survival is linked to fat stores during starvation and muscle mass during infections  Link MUAC and survival Cahill GF Jr (2006) Fuel metabolism in starvation. Annu. Rev. Nutr. 26,1-22. Heymsfield SB, McManus C, Stevens V, et al. (1982) Muscle mass: reliable indicator of protein-energy malnutrition severity and outcome. Am. J. Clin. Nutr.35, Andre Briend – Use MUAC for severe acute malnutrition

MUAC the best index to assess the risk of death Neither MUAC nor WHZ reveal themselves to be ideal predictors of mortality. MUAC appears to show consistently better predictive power. MUAC is the best anthropometric predictor of mortality currently available. The use of both WFH and MUAC together does not appear to increase the predictive power over MUAC alone. Tamsin Walters (ENN) and Victoria Sibson (SCUK)

MSF Holland in Bentiu Retrospective analyses MUAC < 115mm would comprise 25.8% of the case load -MUAC ≤120mm would cover 53.2 % of the case load -MUAC < 125mm would include 81.1% of case load MUAC < 115: 25,8% MUAC < 120: 53,2% MUAC < 125: 81,1%

WHY ONLY MUAC FOR ADMISSION Faster and easier to use than WHZ in emergencies Better detection of younger children at high risk of death Facilitates coverage More adapted to community

WHY ONLY MUAC FOR DISCHARGE Easier to use than WHZ in CMAM Avoid to discharge children who are still malnourished (compared to 15% weight gain old criteria)

WHO RECOMMENDATIOINS WHO Nutrition Expert Advisory Group (NUGAG) guideline recommends in 2013 Per cent weight gain should no longer be used as a discharge criterion in nutrition programs Children admitted under one criterion are discharged under that same criterion

Followed up of MUAC gain in Burkina Faso program (2007 – 2011) It is possible to use MUAC as criterion for identification of cases, their follow up and discharge Goossens S, Bekele Y, Yun O, Harczi G, Ouannes M, et al. (2012) Mid-Upper Arm Circumference Based Nutrition Programming: Evidence for a New Approach in Regions with High Burden of Acute Malnutrition. PLoS ONE 7(11): e doi: /journal.pone

2.MSF Nutrition simplified and expanded protocol WeightRUTF/ day < 6 kg2 > 6 kg3 MSF has used a simplified ( MUAC -only ) protocol in acute crises like Yida, South Sudan (2012) and Timbuktu, Mali (2012), Somalia (2011) as well as in more chronic emergencies like Bihar, India (2009-present) and Burkina Faso ( )

– Many regions of Southy Sudan are in a situation of strong food insecurity, because of many factors, with direct consequences on crop > Massive Displacement > Market disruption > Lean season> Floods – Earlier identification of cases (reduce mortality) – In contexts with high morbidity it would be too risky to send home children close to the > 115 cut off criterion WHY expanding criteria  Treat RED+ORANGE as SAM

Food insecurity Upper Nile IPC outlook to August 2014 Food Insecurity FSMS Report April 2014

FOOD INSECURITY DEPLACEMENTS 03-04/2014 Food Insecurity FSMS Report April 2014

FOOD INSECURITY Risk of Floods Food Insecurity FSMS Report April 2014

3. KODOK PROJECT POPULATION KODOK LUL WAU SCHILUK

LULKODOK WAU SCHILUK Admissions Discharge Cured 45% Defaulters 54% Deaths 1% KODOK PROJECT

CHALLENGES – Reinforcement of activities at Community level (recruitment of 50 CHW) – In Wao Schilluk from 2 to 6 days/week ATFC KODOK PROJECT

4. DISCUSSION Use of MUAC as single criteria of admission and/or discharge: – Benefit/Risks – Costs – Which concrete implications for different stakeholders? MoH NGOs UN agencies Which is the best MUAC cut off for admission and discharge? – 120 vs 125? According to context