Mothers screening for malnutrition by MUAC Ali Ouattara, Deputy Director of Operations ALIMA – the Alliance for International Medical Action MSF Scientific Day / Johannesburg June 2016

MUAC I & II: Why ALIMA began this research… -In 2011 ALIMA began studying the feasibility of training mothers to use mid-upper arm circumference (MUAC) The strategy of empowering mothers to play a more central role in screening for malnutrition responded to two recurring operational/medical issues: Late presentation (resulting in more complications) Low program coverage (often <50%)

MUAC I: Pilot Study, proof of concept September 2011 – April 2012 Arch Public Health. 2015 May 18;73(1):26. doi: 10.1186/s13690-015-0074-z. eCollection 2015. Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Blackwell N, Myatt M, Allafort-Duverger T, Balogoun A, Ibrahim A, Briend A.

MUAC I: Mothers can reliably measure MUAC Results (n = 103 mother-child pairs) Excellent agreement Errors only at boundaries No difference left/right arm measures Sensitivity and specificity of mothers’ measures: - SAM: 77%, 91% - GAM: 96%, 82% Source: Blackwell et al. Archives of Public Health 2015 73:26   doi:10.1186/s13690-015-0074-z

MUAC II: Large-scale trial May 2013 – April 2014 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 Franck G.B. Alé, Kevin P.Q. Phelan, Hassan Issa, Isabelle Defourny, Guillaume Le Duc, Geza Harczi, Kader Issaley, Sani Sayadi, Nassirou Ousmane, Issoufou Yahaya, Mark Myatt, André Briend, Thierry Allafort-Duverger, Susan Shepherd, Nikki Blackwell

MUAC II: Health Zones comparison CHWs Zone Takieta (control) 8 867 42% 4.7% 902 10.2% 28.4% Mothers Zone Dogo (intervention) 9 908 39% 4.4% 1 047 10.6% 29.4% Population < 5 y (n) % Pop. >15 km from health center SAM prevalence May/June 2013 SAM admissions Apr-Dec 2012 SAM Admissions per pop. <5 y Point coverage May/June 2013

MUAC II: Training strategy Dogo: Mothers Zone May 2013: mass training campaign Group sessions and 1-on-1 demonstrations Supplemental trainings during coverage surveys and at consultations 12,893 mothers/caretakers trained in year 1.6 /1: Ratio mothers-trained/child <5 Takieta: CHWs Zone May 2013: CHWs trained with standard curriculum (6 h theory, 2 h practical) Supplementary training when poor MUAC agreement w health center agents 36 CHWs trained and supervised in year 1 / 250: Ratio CHW/child <5

MUAC II: Key messages for mothers What is acute malnutrition? Project to identify malnutrition early, before complications arise How to perform MUAC: everyone can do it. How to ‘read’ the colors SEVERE: Go to health center within 2 days MODERATE: Refer to MAM program? NORMAL: Continue to feed your child well

MUAC II: Results (Admissions, June 2013-May 2014) Mothers 1 371 (%) 564 (41.1) 572 (41.7) 221 (16.1) 5 (0.3) 9 (0.7) CHWs 988 (%) 407 (41.2) 410 (41.5) 161 (16.3) 6 (0.6) 4 (0.4) Total admissions MUAC <115 mm, height ≥65/67 cm WHZ <-3, MUAC ≥115 mm, height ≥ 65/67 cm WHZ <-3, height <65/67 cm (no MUAC taken) Edema, MUAC <115 mm, height ≥ 65/67 cm Edema

MUAC II: Results (Distribution of MUAC at admission) Median MUAC in Mothers vs. CHWs zone was 1.6 mm greater (95% CI = 0.65; 1.87) (p = 0.007) for children admitted by MUAC 

MUAC II: Results (Hospitalization, Agreement, Coverage) Hospitalizations for all admissions: At admission During course of treatment for admissions by MUAC <115 mm: Agreement with MUAC at health center Point coverage, April 2014 Mothers 2.33% 7.22% 0.70% 7.73% 75.4% 35.14% CHWs 9.01% 11.84% 7.75% 13.32% 40.1% 32.35% Risk Ratio [95%CI] 0.26 [0.17;0.38] 0.61[0.47;0.79] 0.09 [0.03;0.25] 0.58 [0.40;0.85] 1.88 [1.69; 2.10] Difference [95%CI] 2.78% [-16.34%; 21.90%] p-value <0.0001 0.0021 0.9484

MUAC II: Results (Hospitalization, Agreement, Coverage) Hospitalizations for all admissions: At admission During course of treatment for admissions by MUAC <115 mm: Agreement with MUAC at health center Point coverage, April 2014 Mothers 2.33% 7.22% 0.70% 7.73% 75.4% 35.14% CHWs 9.01% 11.84% 7.75% 13.32% 40.1% 32.35% Risk Ratio [95%CI] 0.26 [0.17;0.38] 0.61[0.47;0.79] 0.09 [0.03;0.25] 0.58 [0.40;0.85] 1.88 [1.69; 2.10] Difference [95%CI] 2.78% [-16.34%; 21.90%] p-value <0.0001 0.0021 0.9484

MUAC II: Results (Hospitalization, Agreement, Coverage) Hospitalizations for all admissions: At admission During course of treatment for admissions by MUAC <115 mm: Agreement with MUAC at health center Point coverage, April 2014 Mothers 2.33% 7.22% 0.70% 7.73% 75.4% 35.14% CHWs 9.01% 11.84% 7.75% 13.32% 40.1% 32.35% Risk Ratio [95%CI] 0.26 [0.17;0.38] 0.61[0.47;0.79] 0.09 [0.03;0.25] 0.58 [0.40;0.85] 1.88 [1.69; 2.10] Difference [95%CI] 2.78% [-16.34%; 21.90%] p-value <0.0001 0.0021 0.9484

MUAC II: Results (Cost comparisons, in USD) Mothers 4 883 1 958 1 759 8 600 1.04 CHWs 826 1 958 611 18 585 21 980 3.00 Trainings Supervision costs and fees Materials Cash incentives Total costs Cost per child <5 years old

MUAC II: Strengths and Limitations Higher median MUAC and fewer hospitalizations in Mothers Zone Coverage similar in both zones and mothers had better agreement with MUAC by agents at health center Screening by mothers cost much less Limitations Study lasted 11 months; it takes time to see full benefits of approach Uneven MAM services; how to message when no MAM program? 65/67 cm height limit for MUAC excludes short low-MUAC kids

MUAC II: Conclusions Mothers are non-inferior to CHWs in screening by MUAC at much lower cost Making mothers the focal point of MUAC screening strategies is feasible at scale and should be included in regular CMAM programming Family MUAC screening strategies will be most efficient in MUAC-based programs integrating SAM/MAM (e.g. better coverage, Maust et al in Sierra Leone)

Acknowledgements and thanks The Ministry of Public Health in Niger UNICEF, ECHO, and OFDA The ALIMA and BEFEN teams All the mothers and children in Dogo and Takieta