Abstract
INTRODUCTION
The Optimizing Treatment for Acute Malnutrition (OptiMA) strategy trains mothers to use mid-upper arm circumference (MUAC) bracelets for screening, and targets treatment to children with MUAC<125mm or oedema, with one product, ready-to-use therapeutic food (RUTF), at a gradually tapering dose, based on child weight and MUAC status. We aimed to determine incidence of relapse and associated factors among children who recovered under the OptiMA protocol.
METHODS
We conducted a prospective cohort study among all children who recovered from malnutrition under OptiMA at randomly selected health centers between April and November 2017. A one-stage clustered and stratified sampling design randomly selected 12 of the 54 health centers where the OptiMA strategy was implemented. Recovered children were then seen at home by community health workers every two weeks for three months. Relapse was defined as a child who initially recovered after OptiMA management but subsequently had a MUAC<125mm at any home visit. Overall incidence of relapse, and by MUAC category at admission and discharge, was calculated with 95% confidence intervals (CI). Multivariable survival analysis was run using a shared frailty model, using a random effect on health facilities to identify associated factors.
ETHICS
This study was approved by the Ethics Committee for Health Research, Burkina Faso.
Results
Of 758 eligible children, 118 (15.6%) were lost to follow-up. 640 (84.5%) children were analysed, with a global incidence of relapse (MUAC<125mm at three months post-recovery) of 6.9% (95%CI 5.1-8.8), including 0.5% (95%CI 0.1-1.0) who relapsed with MUAC<115mm. Median time to relapse was 42 days (interquartile range 28.0-59.5). Most children (84.4%) relapsed with a MUAC of 120-124mm. Relapse was positively associated with low MUAC at discharge, adjusted hazard ratio (aHR) 2.75 (95%CI 1.11-6.83) for MUAC 126-128mm, and aHR 5.54 (95%CI 1.98-15.52) for MUAC=125mm, as compared to children with MUAC>=129mm. Relapse was also associated with having been hospitalised at any point during treatment, aHR 1.98 (95%CI 0.93-4.23).
CONCLUSIONS
Incidence of relapse following recovery under OptiMA was relatively low in this context, but the lack of a standard relapse definition does not allow comparison with other settings. The decrease in incidence of relapse among children with MUAC>=129mm at exit is in line with previous studies showing that MUAC>130mm at discharge reduced risk of mortality one year post-recovery. This finding challenges definition of the threshold for discharge under OptiMA, and standard protocols, of 125mm. Re-training caretakers at discharge to screen their children for relapse by MUAC at home could also be more effective at detecting early relapse, and less costly, than home visits by CHWs. One limitation to this study is the high percentage of children lost to follow up could impact on validity of the results. Further work is needed to define the most effective MUAC discharge threshold.
CONFLICTS OF INTEREST
KP serves on the Social Purposes Advisory Commission of Nutriset, a producer of lipid-based nutrient supplement products. Other authors declare no conflicts of interest.
