CORE Group Global Health Practitioner Conference Fall 2017

1. Families screening for malnutrition
by MUAC and edema
Kevin P.Q. Phelan, Nutrition Referent
ALIMA – the Alliance for International Medical Action
September 2017
The Alliance for International Medical Action

2. -In 2011 ALIMA began studying the feasibility of training
mothers to use mid-upper arm circumference (MUAC)
-We were responding to two recurring operational/
medical issues:
1. Late presentation (resulting in more complications)
2. Low program coverage (often <50%)
Family MUAC : Why ALIMA began this research…
The Alliance for International Medical Action

3. 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.
The Alliance for International Medical Action

4. Source: Blackwell et al. Archives of Public Health 2015 73:26 doi:10.1186/s13690-015-0074-z
Results
(n = 103 mother-child pairs)
Excellent agreement
Errors only at boundaries
No difference in:
- left vs right arm
measures
- Estimating vs
measuring mid point
MUAC I: Mothers can reliably measure MUAC
The Alliance for International Medical Action

5. MUAC II: Large-scale trial
May 2013 – April 2014
Arch Public Health. 2016 September (74:38). doi: 10.1186/s13690-016-0149-5. 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. Alé F, Phelan KP, Issa H, Defourny I, Le
Duc G, Harczi G, Issaley K, Sayadi S, Ousmane N, Yahaya I, Myatt M, Briend A, Allafort-Duverger T,
Shepherd S, Blackwell N
The Alliance for International Medical Action

6. MUAC II: Results (Distribution of MUAC at admission)
N Mothers = 12,893
N CHWs = 36
Median MUAC by health agent in
Mothers vs. CHWs zone was 1.6
mm greater (95% CI = 0.65;
1.87) (p = 0.007) for children
admitted by MUAC
The Alliance for International Medical Action

7. Mothers
Zone
2.33%
7.22%
0.70%
7.73%
75.4%
8 600
1.04
CHWs
Zone
9.01%
11.84%
7.75%
13.32%
40.1%
21 980
3.00
MUAC II: Results (Hospitalization, Agreement, Costs)
Hospitalizations for all admissions:
At admission
During course of treatment
for admissions by MUAC <115 mm:
At admission
During course of treatment
Agreement with MUAC at health center
Overall costs (in USD)
Cost per child <5 yo
p-value
<0.001
<0.001
<0.001
0.002
<0.001
---
---
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]
---
---
The Alliance for International Medical Action

8. MUAC II: Conclusions
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, earlier treatment initiation like
Maust et al in Sierra Leone)
The Alliance for International Medical Action

9. Integrating SAM/MAM : Key messages
SEVERE: Go to health center within 2 days
MODERATE: ?????????
NORMAL: Continue to feed your child well
The Alliance for International Medical Action
What do we say to mothers when
there is no MAM programming?

10. Family MUAC : Beginning the Journey to Scale
2015 – today
The Alliance for International Medical Action

11. The Alliance for International Medical Action
Family MUAC : Internal changes to policy and practice
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
500000
2015 2016 2017
Number trained in Family MUAC by ALIMA and its
partners, 2015-2017
Niger
Niger
Burkina Faso
Chad
Mali
Nigeria
Cameroon

12. The Alliance for International Medical Action
Family MUAC : Country focus, Niger
 Mid-term impact of Family MUAC in Mirriah, Niger:
- 60.0% coverage in Mirriah, July 2016
- 71% of all admissions are referred by mothers
- Median MUAC from 110 mm (2014) to 113 mm (2016)
- Hospitalizations reduced by ~ 35%
 Scale-up in Maradi with MoH, UNICEF, WFP : 800,000 in 18 months

13. The Alliance for International Medical Action
Family MUAC : Country focus, Burkina Faso
 Cost analysis, 2016 and first semester 2017:
- Mass campaign (51,012 trained): 0.98 USD/caretaker
- Routine in health center (19,855 trained): 0.23 USD/caretaker
 Three part strategy of ongoing « MUAC Only » study :
- 1. Family MUAC screening (58.3% coverage, February 2017)
- 2. MUAC only <125 mm admissions and edema
- 3. Gradual reduction of RUTF based on MUAC status

14. The Alliance for International Medical Action
Family MUAC : External advocacy for scaling-up
 Released training guidelines and FAQ to facilitate journey to scale
http://alima-ngo.org/empowering-mothers-prevent-malnutrition/
Very well received by policymakers, funders and practitioners (e.g. Part of
Niger’s new protocol, Mali’s national plan)
Remaining gaps:
- Strategies in Emergencies - Edema

15. Thanks for listening!
Special thanks to 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
The Alliance for International Medical Action
PS: Guidelines available at: http://alima-ngo.org/empowering-mothers-prevent-malnutrition/