The Wasting and Risk sub-group considered these questions and agreed on the following response:

a. Simplified approaches, rather than being a single prescriptive adaptation, include a range of adaptations to protocols and programmes that aim to improve coverage/reach and/or reduce costs while maintaining quality of care.   These adaptations may include:
Protocols which combine the treatment of SAM and MAM into one combined protocol using the same therapeutic food product;
The provision of SAM treatment through community health workers (CHWs) at the village level;
Family/mother- led MUAC - Providing caregivers with MUAC tapes and advising them on how to take the MUAC and when/where to refer children, if malnourished. All adaptations typically use a MUAC-only admission and discharge protocol.

A government’s decision on whether to use these protocols will depend on a number of considerations including expected caseload and resource availability. The following points and resources highlighted below can aid these conversations:

Combined protocol
IRC have prepared a 2-page note on simplified protocols/ approaches which can be used as a guide in communicating the adaptations, advantages of using these adaptations and the evidence to date. The document explains the adaptations to the treatment protocol to combine SAM and MAM treatment.

SAM treatment through community health workers (CHWs) 
While treatment of wasting by CHWs is not part of the ‘traditional’ iCCM package, growing evidence has demonstrated that with training, CHWs are able to appropriately treat wasting in the community and that the approach can lead to early admissions and improved discharge outcomes. A review of 18 studies
found that CHWs can deliver high-quality treatment for SAM at community level. Key considerations in this approach are the need for training and close supervision of CHWs and well as the need for motivation through financial compensation and other incentives.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587873/

Family/Mother-led MUAC

Family/Mother-led mid-upper arm circumference (MUAC) screening is an approach where caregivers are trained to screen for acute malnutrition in their children by measuring MUAC and testing for oedema. Involving caregiver in nutrition screening activities recognises that they are that they well-placed to identify early signs of malnutrition and reinforces their role in protecting and promoting their child’s health. Trials of this method have found mother/family-led screening to be non-inferior to CHW screening.

Alé FGB, Phelan KPQ et al (2016). Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. Archives of Public Health.
Blackwell N et al (2015). Mothers understand and can do it: a comparison of mothers and community health workers determining mid-upper arm circumference in 102 children aged from 6 months to 5 years. Archives of Public Health. 

b. In the context where in-person training of family members on MUAC measurement is no longer recommended due to the risk of transmission of Covid-19, remote trainings could be considered. Methods considered should be based on an assessment of available communication channels. 

Pictoral guidance could be provided alongside MUAC tapes to guide their correct use and used as a tool for remote training and this will be included in upcoming guidance by UNICEF. Television or radio could be used to instruct caregivers and provide reminders of when to screen their children and where they should go if the child is found to be malnourished.

Although remote trainings are largely untested, and measurements and accuracy referrals may be suboptimal, where other screening methods are not possible, on balance this wil be helpful in identifying and referring wasted children.

d. Whether or not it is possible to meet the demand of moving to a simplified approach will be context-specific and dependent on factors such as SAM to MAM caseload ratio, whether there was pre-existing MAM treatment availability,  whether there is sufficient supply of commodities as well as the capacity of the health system and partners.

In places where MAM treatment is not currently available (i.e. no caseload projection or existing supply chain), implementers could consider prioritizing SAM treatment as a first phase. In places where SAM and MAM treatment is available and RUTF and RUSF is available, implementers could consider providing RUTF to SAM patients and RUSF to MAM patients per the simplified dosage (2 or 1 sachets).

e. Current simplified approaches vary in terms of reduced dosage; there is not one standard reduced dosage protocol. Evidence to date is limited as this is an active area of research with trials ongoing. Adequacy of dosage will depend on several considerations including the age of the child and what protocol is being used.  The decision to use a reduced dosage protocol in the context of COVD 19 adaptations will depend on wider risk benefit considerations, such as the potential to economise on RUTF where it is in shorter supply and so reach more children with treatment.  

Thank you for the answer to the question concerning the simplified approach of the management of acute malnutrition in the context of COVID 19. The particularity with the DRC, is that there are big challenges in relation to the logistics given the size of the country and the road network and railways need to be improved as well as the RUTF storage location. This approach, in fact, simplifies the management of acute malnutrition.

cordially