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MSF SPAIN

MSF SPAIN. Simplified and Expanded Admission Criteria in Upper Nile, South Sudan: MSF’s experience. Structure of the session. Why only M U A C for admission and discharge MSF Nutrition simplified and expanded protocol Kodok project , outcomes and challenges

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MSF SPAIN

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

  2. Structure of the session • WhyonlyMUACforadmission and discharge • MSF Nutritionsimplified and expandedprotocol • Kodok project, outcomes and challenges • Conclusions/Discussion

  3. 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

  4. 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.

  5. MUACthe best index to assess the risk of death • Age Effect • MUACgrows 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 MUACand 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, 1192-1199. Andre Briend – Use MUAC for severe acute malnutrition

  6. MUACthe 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)

  7. MSF Holland in BentiuRetrospective analyses 2012 MUAC < 115: 25,8% MUAC < 120: 53,2% MUAC < 125: 81,1% • MUAC < 115mm would comprise 25.8% of the case load • MUAC ≤120mm would cover 53.2 % of the case load • MUAC< 125mm would include81.1% of case load

  8. WHY ONLY MUACFOR ADMISSION • Faster and easier to use than WHZ in emergencies • Betterdetection of youngerchildren at highrisk of death • Facilitatescoverage • More adapted to community

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

  10. 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

  11. Followed up ofMUACgain in Burkina Faso program (2007 – 2011) It is possible to use MUACas 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): e49320. doi:10.1371/journal.pone.0049320

  12. 2.MSF Nutrition simplified and expanded protocol 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 (2007-2011)

  13. WHY expanding criteria Treat RED+ORANGE as SAM • Manyregions of Southy Sudan are in a situation of strongfoodinsecurity, because of manyfactors,withdirectconsequencesoncrop > MassiveDisplacement > Marketdisruption > Lean season > Floods • Earlier identification of cases (reduce mortality) • In contextswithhighmorbidityitwould be toorisky to send home childrenclose to the > 115 cut off criterion

  14. Food insecurity UpperNile332.500481.60097.900 IPC outlook to August 2014 FoodInsecurity FSMS ReportApril 2014

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

  16. FOOD INSECURITY Risk of Floods Food Insecurity FSMS Report April 2014

  17. 3. KODOK PROJECT POPULATION • KODOK 20.000 - 30.000 • LUL 10.000 - 15.000 • WAU SCHILUK 40.000 - 50.000

  18. KODOK PROJECT LUL KODOK Admissions 2.206 Discharge 1.333 Cured 45% Defaulters 54% Deaths 1% WAU SCHILUK

  19. KODOK PROJECT • CHALLENGES • Reinforcement of activities at Communitylevel(recruitment of 50 CHW) • In WaoSchilluk • from 2 to 6 days/week ATFC

  20. 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

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