I'm not sure what you asking. I have (with co-authors) published two articles with material on indicators for screening and admission into CMAM. Both show a unified screening and admission criteria using uncorrected MUAC and oedema to be the best strategy. The original CTC research program work covers experiences with different case-finding strategies. The conclusion was that the use of a unified screening and admission criteria using uncorrected MUAC and oedema by a large network of community-based volunteers provided best coverage of both screening and admissions. I think this is summarised or referenced in the CTC manual. There are many (unpublished) CSAS, SQUEAC, and SLEAC reports of programs using different strategies and mixing W/H and MUAC with little success (i.e. low coverage). The one exception to this (to my knowledge) is a CHW delivered CMAM program that used MUAC within a growth monitoring program in Bangladesh (published). Is this the sort of material that you are interested in?

Hi Mark Thanks its knowledgeble, kindly elaborate the uncorrected MUAC a bit more? Further I am interested to know that is it possible to use different admission and discharge criteria in OTP/SFP programs. Let suppose if we admit a child in OTP program with MUAC 11cm and weight 10kg. After few visits the child gained 15% of his/her admission weight but MUAC is still lying in OTP i.e., 11.3cm. Are we going to discharge this child from OTP or we need to wait unless the MUAC of the child improves and meet the discharge criteria above 11.4cm for two consecutive visits?

Dear Junaid, allow me please to chip into the discussion in order to give you a technical point of view. 1. Most, if not all, countries have a CMAM protocol where admission and discharge criteria are set, therefore you should not "adapt" the criteria from child to child 2. Mark as already indicated several times in this forum that a gain of 15% will not favor very severely wasted children because even with a gain of 15% they will not reach a "non-SAM" weight, therefore the weight gain criteria should not be sistematically used 3. MUAC: data will be soon published on a study using MUAC for admission and discharge, meanwhile Valid is still recommending a minimum length of stay of 8 weeks; some protocols recommend that children reach >115 (or >110 in countries where the international standards have not been adopted yet) for two consecutive weeks if there is a SFP or > 125 if there is no SFP 4. The point is: MUAC measurement should always be the "golden standard" to discharge children and this considering the correlation between MUAC and mortality risk. In your example, the child might have gain weight but this didn't permit yet to reconstitute muscle which indicate that the child is not yet "cured' and may lead to a relapse All the best

Hi Lio I agree with you to use the same admission and discharge criteria in OTP/SFP and as you mentioned MUAC is the best to be used. Actually the confusion came from national guidelines which shows MUAC as an admission criteria and 15% weight gain as a discharge criteria. I hope you will share the study on using MUAC for admission and discharge so that collegues get benefit from it. Thanks & Regards

Hi Everyone Ill chip in, from a slightly different perspective. If I understood correctly, Franck, part of what you are looking for is information regarding what is most effective; active case-finding vs. spontaneous referrals, or at least see whether there is documented evidence of how these two are connected and impact on coverage. I know that NGOs often collect this data, but Im not aware of any consolidated study that has looked at how coverage, % of referred cases and % of spontaneous cases all change over time. I have a personal view on this, which we recently published in last Field Exchange (43) - if you are interested have a look at the article Quantity through Quality. Towards the end of it, we include a short section of how we feel this works in practice. In a nutshell, I am of the opinion that whilst case-finding is essential to create momentum and a critical mass of cases (and achieve high coverage in the short term), maintaining this over time can be succesfully be achieved through self-referrals. This is based on what we have seen in well-managed, public health-oriented CMAM programmes, but its admittedly heavy on anecdotal evidence and personal experiences. I am very interested in putting together a simple study looking at this question, because I feel that as CMAM is rolled out, and MoH take over, we need to find ways of optimising the investment on community mobilization so that it serves as a catalyst for mid to long-term referrals. I would be interested in knowing what triggered your question and what your own thoughts are in this regard Best Saul

Technically speaking the 15% is still "correct" since there was no revision (as far as I know) of the "WHO Child growth standards and the identification of severe acute malnutrition in infants and children. A Joint Statement by the World Health Organization and the United Children’s Fund, 2009"; so I presume the national protocol you are referring to is applying by the book this recommendations. However, further discussions pointed out the "danger" of using 15% for very wasted children. I am sure Mark can give you much more details than me. I don't know when the MUAC data will be published but they will definitely be shared

By "uncorrected MUAC" I mean a simple MUAC thresholds such as MUAC < 115 mm as opposed to using MUAC-for-age or MUAC-for-height z-scores. A common approach is to admit on MUAC < 115 mm and discharge on a proportional weight gain of 15% or greater provided that the MUAC >= 115 mm (usually for two successive visits). Your example case would not be discharged until MUAC exceeded admission criteria. I (and others) proposed this approach in an 2006 FNB article and it has proved problematic. The main problem is that it can lead to the most severe cases receiving the least treatment (and the least severe cases receiving the most treatment). Obvious in hindsight! MSF and VALID International with FANTA-III funding (as separate initiatives) have been looking at using MUAC > 125 mm (two visits) as the discharge criteria for cases admitted using MUAC. The findings (some published, some "in-press") so far are that the problem outlined above is solved and that the median duration of treatment is not increased greatly (so no great increase in program costs). A study following-up cases for three months post-discharge has recently completed data collection. INTERIM results are that there were three adverse events (i.e. death or relapse to admission criteria) in 158 patients followed up for a median of 12 weeks (we are checking and cleaning data at present). I think it is not premature to write that this results is consistent with MUAC > 125 mm (two visits) being a safe discharge criteria. Sorry not to have more details at this time.

Thanks Lio, Saul and Mark. I got it.

Dear Saul you are seeking for the information of active case findings and spontaneous referrals, according to my knowledge and experience its totally based on community mobilization, that how you have mobilized the community regarding the programme in concern project implemented area. if you have strong community mobilization, you will have more spontaneous referrals along with the active case findings.

dear Saul and al I think you understood my needs. It is for me to see if there are evidences of research that proves the efficacity of an active screening program versus a program self referred cases or cases discovered during the consultation (not malnutrition) in the health center. I already work program that does not use community health workers for screening active cases( Niger and mali). Soon I began an experiment in a program with strong community component. And as agents of community needs become important with the program expansion we investigate the idea of having a self reference programme after a brief moment of awareness of mother. Apologize, my english is very poor

To “Anonymous” : I think you are correct in stating that self-referral to CMAM (see below) would likely be highest when community sensitisation and mobilisation is well done. We need to careful about terms. The term “community mobilisation” covers active case-finding by community-based volunteers (CBVs). This is a key component (product) of community mobilisation. The term “community sensitisation” covers program awareness, awareness of malnutrition, &c. in the community. We need both community sensitisation and community mobilisation. Usually we see mobilisation as a desired outcome of sensitisation although we may have additional activities aimed at (e.g.) recruiting TBAs, THPs, and village pharmacists as CBVs. In practice, things are less clear cut. We may (e.g.) “sensitise” a religious leader who is then “mobilised” to speak about the program at religious meetings and so “sensitises” the community, some of who may go on to be “mobilised” to become CBVs or “sensitise” others by word of mouth. The main difference is that one is (sensitisation) is about knowledge, attitudes, beliefs and the other “mobilisation” is about behaviours. The term “active case finding” can cover case-finding by CBVs (as above) and screening by program outreach workers. There is also “passive case-finding” which might cover screening in other community-based programs (e.g. GMP, EPI) and screening in clinical services. The key distinction is that in active case-fining we go to the child whereas in passive case-finding the child comes to a linked service. I am not sure what is meant by “spontaneous referral”. I suppose this is self-referral (i.e. turning up) at the CMAM clinic to access CMAM services. Turning up at any other clinic and then being detected and referred to CMAM by clinic workers would not count (this would be passive case-finding). I do not think that many programs keep track of referral source so it may be difficult to report source of referral. A referral slip system can help with this. To Frank : There is a lot of evidence from (e.g.) SQUEAC assessments showing that programs that rely on passive case-finding alone do not achieve high levels of coverage. There is the additional issue of last presentation which leads to long lengths of stay and poor outcomes (less impact) which leads to poor opinions of the program which can impact upon coverage (less impact). You might also want to review the original CTC literature (usually by one or more of Collins, Sadler, and Khara) on these issues. This shows large numbers of cases as program start as (very severe) prevalent cases are picked up followed by low numbers of incidence cases with late presentation. Program numbers and early presentation (ascertained by less severe anthropometry and fewer complications) only comes with adequate sensitisation and mobilisation.

Thank you Mark for your input

Thanks you Mark