When a child fulfill the discharge criteria in OTP the child is declared/recorded as cured from SAM. So, you count him/her as cured in OTP record/performance. So, there is no such thing called ‘zero SAM cure rate’.

If there is available SFP service all children who are cured from SAM should be referred to SFP. Then OTP has the obligation to follow them up if they are being admitted to SFP. Once he/she is being treated in SFP and fulfilled the discharge criteria of SFP should be recorded as cured from MAM which add to SFP performance record. Hope this clarifies your question.

Hi Tammam,
Take a look at this paper; Maust et al. report on integrated programming in Sierra Leone:

https://publichealth.wustl.edu/wp-content/uploads/2014/08/NnekaPubJN.pdf

In this paper there are two different protocols; 'standard' management and 'integrated' management.

Standard management transfers the child from OTP to SFP and uses a MUAC >11.5cm / WFH > -3z as criteria for 'discharge cured'. The child is then discharged 'cured' from SFP with a MUAC of >12.5cm or WFH >-2z. The operational key here is that these are 2 different treatment programmes in different locations. I think there are some potential problems with reporting in this scenario.

Firstly, to my knowledge the use of MUAC >11.5cm / WFH >-3z as stand alone criteria have not been shown to be safe discharge criteria. MUAC >12.5cm is associated with low relapse and short term mortality rate and MUAC >12.5cm / WFH>-2z are recognised by WHO as acceptable discharge criteria for SAM. I would therefore be very cautious to call the child 'cured' unless the discharge cured criterion when MUAC was > 11.5cm (unless this was combined with some other criteria such as a minimum stay + absence of oedema + clinical wellness etc). Ultimately the discharge criterion is about physiological recovery, not a number.

Secondly, the intention in the programmes, although they are separate, is to continue treatment in SFP after OTP and as such the child is not truly discharged from treatment until cure is obtained in SFP. The child may be lost in transfer or may be 'double counted' as a case of SAM AND a case of MAM although this is one episode of acute malnutrition.

In the integrated protocol the child receives graduated treatment depending on whether they are SAM or MAM and recovery for MAM + SAM are reported together and compared against sphere standards. The operational key here is that the same health facility conducts the treatment.

There are also potential problems with reporting in this scenario if you wish to report against sphere standards. The joint reporting of recovery rate would likely not be problematic, however the acceptable mortality rate for 'OTP' and 'SFP' are different and may be problematic if you have a mortality rate greater than 3% in OTP.

For reporting you could consider combined reporting or you might also consider separate reporting for OTP and SFP.

Separate reporting would report the negative outcomes of the OTP and SFP separately. The criterion of 'transferred to SFP' would be considered a SUCCESSFUL outcome for OTP. This is not the same as cure and should not be reported as such. It would be acceptable to have a zero 'cure rate' since this is not your measure of success for this component in this particular programme. Your narrative report can clarify the reporting scenario and you can report a combined recovery rate for OTP and SFP if you wish.

Another option might be to consider this programme a graduated programme. The child with SAM might have the nutritional intervention changed when the MUAC >11.5cm (e.g. from high dose RUTF to reduced RUTF / RUSF) but continue to be considered recovering in OTP and continue monitoring on the OTP card. You would then report the child as cured when discharged from OTP at MUAC >12.5cm / WFH .-2z. OTP and SFP would be reported separately as the child does not transfer between different 'programmes'.

I am aware that there are national guidelines that do consider >11.5cm / >-3z to be 'cure'. In this case you would report according to the national guidelines.

One final point, just to add to the complexity, is that if you also have inpatient care in this programme, consider how you are reporting for transfers from inpatient to OTP to SFP and then subsequent cure. Again in this scenario, a 'transfer to OTP' can be considered a successful outcome but is not the same as cure - the child is merely moving between different components of the same treatment schedule.

I hope this helps,
Paul

Thanks Paul for the fruity explanation and detailed clarification. I agree with you that we should follow the national guideline. I prefer not to transfer the SAM child to SFP-MAM for the reasons you mentioned (transferred child may be lost, decrease the relapse and mortality rate, and physiologic stable child in discharge ). I would like to add frequent MAM supplies stock out so transferred SAM cases may not be given their required RUSF quantity so early relapse is common.

Dear Tammam,

Have you checked the latest MoH guidelines in Yemen? The version I have is 2014', not sure if a newer version has been published. The discharge criteria according to these guidelines say:

-15 percent weight gain maintained for two consecutive visits (of admission weight or
weight free of oedema).
-Oedema free for two consecutive visits
- Child clinically well and alert
(Children are referred to receive supplementary feeding if available). Are you using these criteria in your programme?

The guidelines can be downloaded from here:

https://www.humanitarianresponse.info/system/files/documents/files/final_yemen_cmam_guidelines_-_feb_2014.pdf

If you have a newer version, please do share it.

Lovely Amin mentioned what is standard in nutrition programmes' performance indicators/sphere standards which is the case in many countries (including Yemen-unless the new guidelines is applied).

I am not getting your last point about keeping the SAM in OTP and not transferring them to SFP. Why would you do that? And how are you going to address the length of stay and the cure rate in your programmes? That would complicate the performance indicators both programmes I believe.

Thanks Paul for your valuable comments and observations, some of which require an in-depth field research. The RCT study from Sierra Leone is interesting, but I am wondering how did the researchers conclude the results while the variables are different: MUAC vs WHZ as admission/discharge, RUTF vs RUTF+Fortied food? I see there are many factors between the two groups that are not comparable which affecting the validity of the study.

Kind regards,

Sameh

Thank you very much Sameh Alawlaqi,
I meant" I prefer not transfer SAM children to SFP-MAM" to keep them in the OTP program until discharged cured( MUAC=12.5cm and SD is >-2 ) as per the WHO acceptable discharge criteria. We are afraid if there is RUSF supplies stock out or interrupted then OTP-Follow up cases cannot be traced in the SFP-MAM and may be defaulted.

Thanks paul,

Your comments were really helpful to understand some dynamics of CMAM. In your post you have mentioned that some national guidelines that do consider >11.5cm / >-3z to be 'cure'. In this case you would report according to the national guidelines.

Could you either share their names or if possible their country guidelines?

Regards,

Narendra

Hi All,
Some interesting points raised and these issues are deserving of more discussion (and dare i say consensus) at international level. Reporting is always tricky and I definitely don't have definitive answers. Apologies for the following stream of consciousness in response to some of the issues raised.

We measure malnutrition by proxy using anthropometry and combine it with clinical signs to determine it's clinical severity (e.g. appetite / complications).What then is 'cure'? Physiologically it is that the child has returned to a normal or near normal physiological state. The environmental conditions into which the child is discharged will undoubtedly have an effect but ideally the child should not relapse or be at a greater risk of death than other children in the population. If we are discharging a child as 'cured' with a MUAC >11.5cm then where is the evidence that this is safe? Children with MAM do not have normal physiological function; children recovering from SAM do not have a normal physiological function as has been demonstrated by some of Mike Golden's excellent work describing the physiological status of children with acute malnutrition.

I would argue that a child is SAM when identified by anthropometric criteria and when their condition improves they are a "recovering SAM" not SFP-MAM. This change, calling a SAM child MAM, is being done on the basis of numbers alone and ignores the child's history of profound physiological compromise. When we do coverage evaluations we use the term "recovering case' [of SAM], we do not discount them because they are 'MAM' by anthropometry.

If we discharge to a SFP programme in a different location or as a separate programmatic entity then there must be safeguards to ensure that this child is not lost in transfer since (in my opinion) the child is not 'cured' no matter that we might report it as such.

Reporting depends very much on having clarity in terms of the nature and design of the programme and the purposes of reporting (e.g. to donors or to national databases). There are as many ideas on how to report as there are experts and no doubt there will be debate about any system, I do however thing we need to think about what we are actually reporting on. A child cannot be 'cured' twice from one episode of acute malnutrition. Reporting needs to consider the CMAM programme as a whole (and see recovery as a continuum) and not see each component as a different programme, unless they are specifically designed as such (e.g. supportive care to prevent relapse in SFP due to food insecurity after cure in OTP).

If we want to have graduated programmes where a child with SAM is treated as 'MAM' when they are >11.5cm / >-3Z then we need also to have a step change in the way we report. Although the concept of reporting recovery for 'OTP' and 'SFP' combined is controversial it more closely resembles the reality of the intended continuum of care. Reporting negative outcomes separately (for OTP and SFP) also has validity since the factors for default, death and non-response may be different for each phase of the graduated treatment. This is clearly seen when we have 'early' or 'late' defaulters in OTP for different reasons, for example.

In Tammam's case I understand the challenge of supplies. There have been successful studies reported that have used low dose RUTF (e.g. 1 packet per day) as the child recovers. When the child is SAM they receive the usual weight based dose and when they are recovering (i.e. MUAC > 11.5cm) the dose is reduced. This approach would reduce consumption by 1/2 or 2/3rds for recovering case. I have not personally evaluated such a programme but there are peer reviewed studies of such approaches. I imagine this might affect the length of stay to some degree but since cure is the primary outcome that we seek, this is probably acceptable.

One of the reasons that 15% weight gain is now not recommended is that the most malnourished children receive the least treatment. The more malnourished a child is the longer they should stay in treatment until cure. National guidelines may indicate 15% weight gain is cure and report it as such but this does not change the evidence that it cannot be considered to be safe for all children. Using MUAC >12.5cm has the opposite effect and children receive the treatment they need depending on the severity of their case on admission. A child admitted with a MUAC of <10.5cm might stay twice as long as a child with a MUAC > 11cm on admission. Early case finding leads to shorter lengths of stay and reduced cost of treatment. Investment in sensitisation and early referral can be cost effective.

Ultimately the evidence base will grow and it may be that early discharge approaches are (peer reviewed) and proven to be safe but until that day we should be cautious and ensure our reporting is not (consciously or unconsciously) designed to make our programmes look good but potentially compromising the proper care of the child.

Regards,
Paul

We have found some SAM children who had been at OTP for 12 weeks and did not achieve MUAC equal to or great than 11.5 cm and -3 Z score (we have both the criteria for discharge for displaced Rohingya Refugee population from Myanmar). We then referred them to available hospital/clinic/health centers and after receiving treatment from health centers (still not achieving the discharge criteria) while children get back they are still SAM.
In this case we are admitting them again at OTP however we are not sure in which category we'll admit them? Our field staffs are admitting them under the category of 'relapse case' however they are not relapse as they never recovered from SAM.
May I get any suggestion from you?

Hi Asfia,
My understanding is your staff working with SAM children are experienced in CMAM protocol and only some children were not discharged as "Cure" despite their length of stay in the OTP for 3 months(12 weeds) which is the maximum length of stay in OTP. You can check the admission/follow up cares of those children from the zero visit up to week 12. I have two possible scenarios:
1. May be those children are "non response" to standard treatment for any reason (social, Psychological, or medical). You referred the cases to health centers and this means they have medical causes, right?
2. May be those children are stunted already, in particular, if they are above 2 years of age. And If yes then they will be irreversible to the treatment as in your case.
I hope this will help
Best

Please consider this reply as I have added your point" readmitted as relapse"

Hi Asfia,
My understanding is your staff working with SAM children are experienced in CMAM protocol and only some children were not discharged as "Cure" despite their length of stay in the OTP for 3 months(12 weeds) which is the maximum length of stay in OTP. You can check the admission/follow up cards of those children from the zero visit up to week 12. I have two possible scenarios:
1. May be those children are "non response" to standard treatment for any reason (social, Psychological, or medical). You referred the cases to health centers and this means they have medical causes, right?
2. May be those children are stunted already, in particular, if they are above 2 years of age. And If yes then they will be irreversible to the treatment as in your case.

- Basically if the child dischareged as "non respondent" or "non recovered" after exclusion of the (social, psychological, medical)causes or the child is stunted there is no hope for re admission as those children will reach the maximum length of stay without improvement and will be discharged again as"non respondent" and may be will affect the cure rate and SAM supplies
I hope this will help
Best

Dear Asfia Apa,

For sure, these children should not be admitted again as "Relapse" as the definition of relapse you have already mentioned (Re-admission of Cured children within 2 months). Another thing is that, this referral to health center for the children who are not performing well in the OTP center (i.e. very slow weight gain or no weight gain or losing weight for consecutive weeks) - should ideally be happened even before following the "Failure to respond to OTP treatment" protocol. So the staff should not be waiting for 12 weeks or stipulated Max LoS to send them to hospital and discharge them as "non-cured". Usually those children with poor OTP performance show signs of poor weight gain from the beginning (usually but not necessarily) and should be taken appropriate measures at an early stage to minimize non-recovery - like sending them to a hospital as a last resort (considering OTP has limited medical and diagnosis capacity and you don't have a SC) to further investigate the medical complications and treat any possible underlying causes. This we report as "medical referral" which is also a kind of non-response. But in your particular situation, the child has been already discharged as "non-cured" after treating for a stipulated maximum length of 12 weeks and sent to a hospital. So these children should be reported as "Re-admission" upon admission again within 2 months in the OTP - if you find/get the children again in SAM condition after returning from the hospital. Here is a link of Reference Doc with much detail, please see page number 12 in particular.

Thanks,
Bijoy

Dear Asfia,

Thanks for bring this important questions , some people lack clarity on these issues
1. Are we going to discharge them as "Cured" so in this case we will have a percentage of SAM cure rate

Answer- These children are not going to be discharged as cured as they need still medical and psycho social care taking in to consideration the bottom line contributing
delay the recovery time.

However, it is advisable to focus on the individual case monitoring like the weight gain ,MUAC increase and Oedema Progress on each visit, In addition we have to the children are taking the full dosage of the RUTF and routine medicines, Appetite test every visit and other danger signs , these all will give you direction to take action before the maximum length of stay and focus on the OTP key messages during follow up.

Finally if if still the child/case does not recover refer to the nearby health facility for further investigation and follow and record as non-respondent.

2. Are we going to discharge them as "transferred to SFP-MAM" so in this case we will have zero SAM cure rate

Answer- Readmitting as relapse will not be possible , no improvement is expected even if you readmit . As mentioned above if you follow the instructions you will not reach to the level of "Zero SAM cure" unless there is program quality issue.

Those discharges will be calculated as Non-respondent rate which is Total number of non-respondents/ Total number of discharges x 100

Many thanks Tammam Ali, Bijoyda and anonymous for your valuable comments and direction. I can now communicate with my field team with confidence and ask them not to feel obliged by readmitting 'non response child' to OTP again.
Great help :)!

Hi Asfia,
Even as the children get readmitted to OTP, the monitoring of the RUTF administration yo the children might be a key issue. It will be useful to ensure the following:
1. That the RuTF is not shared with another child in the family as this will affect the dosage taken. In some programs, siblings who are likely to share RUTF with the malnourished child are linked as beneficiaries to a food distribution program to 'distract' them from sharing. It is usually argued that if they are feeding from the same pot with the malnourished child, they might also be vulnerable and at risk if malnutrition.
2. That the child does not have an underlying illness such as TB, HIV, recurrent fevers, acute respiratory infections or helminthic infestation.
3. That the digestive system is ok, no diarrhoea or steatorrhea. And that they do not have a metabolic disorder.
4. That the children actually take the RUTF at all (various reasons have been cited in the past for non-compliance), and that the dose calculations are correct.
Lastly, use Muac as the admission and discharge criteria, it is more sensitive (ever heard of genetically 'long-legged' population who take long for a z score measurement to record any change?)
All the best.

I would like to pick up on a couple of points raised in this thread. I see some of the guidance being given as absolute rules and yet most protocols are contextually dependent. What applies in one country does not apply in others.

1. Please consider carefully before discharging a child as non-cured if the child remains both < 11.5cm MUAC and < -3z scores. The child is still SAM. Check on what care the hospital provided. Are you sure that the hospital applied appropriate nutrition protocols or did they just treat any medical issue? Did the hospital check for any other underlying causes? (Please see also my last point on the Rohingya language)

2. Many protocols are context dependent. There is no maximum stay in OTP. A child admitted with a very low MUAC (< 10cm) can take around 15 weeks to achieve a MUAC of 12.5cm. Maximum stays for 'non-cured' (e.g. 4 months) are an artificial cut off designed for programmatic purposes. This cut off varies from country to country and between NGOs; some use 3 months and some use 4 months. In an integrated programme (e.g. as part of primary health care services) there should be no such thing as 'non-cured'. If they do not respond to treatment they should be transferred to hospital or referred to another service for ongoing support.

3. Relapse is defined differently in different contexts. In some countries (and the linked document) 2 months is chosen. In some it is 4 months while in others a relapse is a relapse whenever it occurs. Treat the child not the number! If the child appears sick and you feel treatment is appropriate then treat them.

4. By discharging a child that is SAM and refusing to treat again you are potentially making an end of life decision and I do not think such information should be given lightly in a forum such as this. Only a medical doctor can make that decision based on the condition of the individual child so refer the child to an appropriate facility.

5. It is an interesting point that this is a Rohingya refugee population. Rohingya is an extremely difficult language spoken by few people and there is no written form. I wonder whether the guidance that has been given (e.g. for medications / RUTF etc) has been understood properly by some of the carers of beneficiaries. There are languages that are close but it shouldn't be assumed that verbal (and especially written) guidance is understood. There are agencies that assist with these language issues and have guidance summarising issues faced by the Rohingya when communicating with humanitarians in Bangladesh (see below). For example, it is assumed that agency staff are understood. Students from Chittagong University are often used as translators because there is a 70% similarity between the Chittagonian dialect and Rohingya however when these assumptions were tested it was found that 70% of Rohingya were unable to communicate appropriately with agency staff and were unable to understand how to give ORS. Please be rigorous and ensure that the carers are truly able to understand the care being delivered by OTP staff - do not make assumptions. Please see:

Translators Without Borders: https://translatorswithoutborders.org

Rohingya communication issues: https://www.arcgis.com/apps/Cascade/index.html?appid=683a58b07dba4db189297061b4f8cd40