SMART survey, treatment needs and performance of a CMAM programme

Classification: WHZ GAM of 15.8%, above the 15% threshold (critical situation, "very high" in the 2018 WHO-UNICEF classification). The interval (13.1 to 18.9%) includes values below 15%: prevalence is at least "high" and probably critical; it should be treated as an emergency, all the more so as the survey took place at the end of the rainy season, the usual peak period.

WHZ and MUAC: MUAC identifies far fewer children (SAM 2.1% versus 3.2%), which is common in the Sahel; the two criteria select partly different children (combined SAM 4.0%). Admission on MUAC alone excludes a large share of cases.

Mortality: 0.62 and 1.40 per 10,000 per day, below the commonly used emergency thresholds (1 and 2), but to be monitored: mortality often follows malnutrition with a delay.

Aggravating factors: measles coverage of 58% (risk of an outbreak, hence a catch-up campaign), stunting at 41% (chronic vulnerability), lean season approaching. Recommendation: scale up CMAM, mass screening, treatment of MAM, vaccination, and analysis of causes (infant and young child feeding, water, health).

Children aged 6 to 59 months: 410,000 × 19% = 77,900.

Annual caseload (combined SAM): 77,900 × 4.0% × 2.6 = 8,101.6, i.e. 8,102 children. Expected admissions at 50% coverage: 4,050.8, i.e. 4,051.

RUTF: 4,051 × 1.1 = 4,456.1, i.e. 4,457 cartons.

With MUAC alone: 77,900 × 2.1% × 2.6 = 4,253.3, i.e. 4,253 children. Gap: 8,102 − 4,253 = 3,849 children (47.5% of the caseload) with SAM by WHZ only and not eligible. Recommendation: also admit on WHZ in the centres (trained staff, height boards and scales), while keeping MUAC for community screening, or document this choice with the ministry and the working group.

Total exits: 612 + 41 + 198 + 49 = 900. Cure 612 / 900 = 68.0% (Sphere standard > 75%): insufficient. Deaths 41 / 900 = 4.6% (standard < 10%): compliant, but high for outpatient care, to be analysed (late referrals to stabilisation?). Defaulters 198 / 900 = 22.0% (standard < 15%): insufficient. Non-response: 5.4%.

Length of stay of 62 days: long, consistent with the RUTF stock-out (slower weight gain).

Actions: (1) secure supply: stock alert threshold per centre, early ordering, loans between partners; (2) reduce defaulting: outreach sites or mobile teams for villages more than 10 km away, follow-up of absences by community volunteers; (3) audit of deaths and non-responders: referral time, appetite test, screening for complications; (4) coverage survey (SQUEAC type) to identify other barriers.

(1) Uncomplicated SAM (MUAC < 115 mm): outpatient treatment (OTP), RUTF, systematic treatment according to the protocol.

(2) Uncomplicated SAM by WHZ (< -3 Z) despite a MAM-range MUAC: outpatient. This child would be refused in the current programme, which admits on MUAC only.

(3) SAM due to bilateral oedema, even with a normal MUAC. Oedema ++ without complications and appetite preserved: outpatient according to the 2013 WHO recommendations, with close follow-up; inpatient care if oedema +++ or complications.

(4) SAM with complications (appetite test failed, high fever): immediate referral to stabilisation (SC), transport arranged.

(5) MAM (MUAC between 115 and 124 mm, WHZ between -3 and -2 Z): supplementary feeding programme (TSFP), with MUAC follow-up.

The stock covers 380 / 320 = 1.19 months, i.e. about 5.1 weeks. Requirement over 10 weeks: 320 × 10 / 4.33 = 739 cartons. Shortfall: about 360 cartons, i.e. 5 weeks.

I oppose a general halving of the ration: it lengthens treatment, increases failures and deaths and is not a validated protocol. Actions: (1) immediate alert to the nutrition working group and the pipeline supplier, request for early delivery; (2) loan or transfer of stock between partners and districts; (3) priority to admitted children and complicated cases discharged from stabilisation; (4) a simplified or reduced-dose protocol may only be applied if validated by the ministry of health; (5) weekly stock monitoring per centre.