Mark Myatt

A Review of Methods to Detect Cases of Severely Malnourished Children in the Community for Their Admission into Community-Based Therapeutic Care Programs

Background The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. This has led community therapeutic care programs to adopt a two-stage screening and admission procedure in which mid-upper-arm circumference (MUAC) is used for referral and weight-for-height is used for admission. Such a procedure results in many individuals being referred for care on the basis of MUAC but subsequently being refused treatment because they do not meet the weight-for-height admission criterion. This “problem of rejected referrals” has proved to be a major barrier to program uptake. Objective To systematically review methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Methods Clinical and anthropometric methods for case detection of severely malnourished children in the community were reviewed with regard to their ability to reflect both mortality risk and nutritional status. Results MUAC, with the addition of the presence of bipedal edema, was found to be the indicator best suited to screening and case detection of malnutrition in the community. The case definition “MUAC < 110 mm OR the presence of bipedal edema,” with MUAC measured by a color-banded strap, is suitable for screening and case detection of malnutrition in the community for children aged between 6 and 59 months. Monitoring and discharge criteria were also reviewed. Conclusions There is no compelling evidence to support a move away from using weight in combination with clinical criteria for monitoring and discharge.

Key Issues in the Success of Community-Based Management of Severe Malnutrition

Background Acute malnutrition is an underlying factor in almost 50% of the 10 to 11 million children under 5 years of age who die each year of preventable causes. Inpatient treatment for severe acute malnutrition is associated with high opportunity and economic costs for affected families and health service providers. Community-based therapeutic care attempts to address these problems and to maximize population-level impact through improving coverage, access, and cost-effectiveness of treatment. The community-based therapeutic care model Community-based therapeutic care programs provide effective care to the majority of acutely malnourished people as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. People with severe acute malnutrition without medical complications are treated in an outpatient therapeutic program with ready-to-use therapeutic food and routine medication. Those suffering from severe acute malnutrition with medical complications are treated in an inpatient stabilization center according to standard World Health Organization protocols until they are well enough to be transferred to the outpatient therapeutic program. Impact of community-based therapeutic care programs Twenty-one (21) community-based therapeutic care programs were implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005. These programs, which treated 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients. Initial data indicate that these programs are affordable, with the cost-effectiveness of emergency community-based therapeutic programs varying from US

Rapid assessment of Schistosoma mansoni: the validity, applicability and cost-effectiveness of the Lot Quality Assurance Sampling method in Uganda

12 to US

Routine monitoring of visual outcome of cataract surgery. Part 2: Results from eight study centres.

132 per year of life gained.

Longitudinal study of trachomatous trichiasis in the Gambia

Rapid and accurate identification of communities at highest risk of morbidity from schistosomiasis is key for sustainable control. Although school questionnaires can effectively and inexpensively identify communities with a high prevalence of Schistosoma haematobium, parasitological screening remains the preferred option for S. mansoni. To help reduce screening costs, we investigated the validity of Lot Quality Assurance Sampling (LQAS) in classifying schools according to categories of S. mansoni prevalence in Uganda, and explored its applicability and cost‐effectiveness. First, we evaluated several sampling plans using computer simulation and then field tested one sampling plan in 34 schools in Uganda. Finally, cost‐effectiveness of different screening and control strategies (including mass treatment without prior screening) was determined, and sensitivity analysis undertaken to assess the effect of infection levels and treatment costs. In identifying schools with prevalences ≥50%, computer simulations showed that LQAS had high levels of sensitivity and specificity (>90%) at sample sizes <20. The method also provides an ability to classify communities into three prevalence categories. Field testing showed that LQAS where 15 children were sampled had excellent diagnostic performance (sensitivity: 100%, specificity: 96.4%, positive predictive value: 85.7% and negative predictive value: 92.3%). Screening using LQAS was more cost‐effective than mass treating all schools (US

Natural history of trachomatous scarring in the Gambia: Results of a 12-year longitudinal follow-up☆

218 vs. US

Field trial of applicability of lot quality assurance sampling survey method for rapid assessment of prevalence of active trachoma

482/high prevalence school treated). Threshold analysis indicated that parasitological screening and mass treatment would become equivalent for settings where prevalence ≥50% in 75% of schools and for treatment costs of US

Relationship between body composition and blood pressure in Bahraini adolescents.

0.19 per schoolchild. We conclude that, in Uganda, LQAS provides a rapid, valid and cost‐effective method for guiding decision makers in allocating finite resources for the control of schistosomiasis.

The effect of body shape on weight-for-height and mid-upper arm circumference based case definitions of acute malnutrition in Ethiopian children.

Aim: To determine whether monitoring of cataract outcome can be implemented as a routine activity in different hospital settings in Africa and Asia, and to assess the impact of routine monitoring. Methods: Eight eye centres in Asia and Africa were involved in the study between 1 June and 31 December 2000. Seven centres used a specifically designed cataract surgery record form with computerised data entry and analysis (CCSRF), and one centre used a manual recording form (MCSRF). Data were used to evaluate quality of data entry, follow up after surgery, and to assess trends in the proportion of complications and visual outcome after surgery. Findings: The reporting systems were accepted and used by all centres, and data were recorded for 5198 cataract operations. Overall, 54% of eyes were followed for 8 weeks or more and 41% for 6 months. Follow up rates varied between centres from nil to almost 100%. Visual acuity tended to improve over time. The outcome could be improved at all follow up periods by providing best spectacle correction. At 8 weeks or more follow up, surgical complications or inadequate spectacle correction accounted for 72% of the causes of poor outcome. Three centres showed a significant reduction in complication rates over the course of the 6 month study. Data entry was identified as a problem and the CCSRF software has been modified to include consistency checks to reduce data entry errors. Conclusion: A simple system to monitor cataract outcome has been successfully field tested. The results suggest that monitoring can sensitise surgeons to quality control, which can lead to a decrease in complication rates and improved visual outcomes.

Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children.

Aim: Investigation of the natural history of trachomatous trichiasis in the Gambia and of the outcome of self epilation and surgery for the condition. Methods: A 1 year longitudinal study of 190 subjects with trichiasis was performed. Major trichiasis cases (five lashes or more) were referred for surgery and minor trichiasis cases were advised to epilate. Outcome measures included progression of trichiasis and corneal scarring; attendance for and results of surgery. Results: 34 of 148 (23%, 95% CI 16 to 31) subjects with major trichiasis attended for surgery over the year. Progression from minor to major trichiasis occurred in 18 of 55 subjects (33%, 95% CI 21 to 47). Progression of corneal scarring occurred in 60 of 167 patients (36%, 95% CI 29 to 44). Clinically active trachoma and conjunctival bacterial isolation predicted progression of corneal opacity. Surgery was successful in 39 of 54 (72%) eyes. Conclusions: Despite the overall decline in trachoma in the Gambia, patients with both minor and major trichiasis remain at risk of developing corneal opacity. Active trachomatous inflammation and additional infection with bacteria may accelerate this process. Antibiotic treatment for trichiasis patients (in addition to surgery) should be investigated. Surgery for minor trichiasis may be indicated. Regular audit of surgical results is necessary with retraining where needed.