Utilization patterns, outcomes and costs of a simplified acute malnutrition treatment programme in Burkina Faso

Access to treatment for acute malnutrition remains a challenge, in part due to the fragmentation of treatment programmes based on case severity. This paper evaluates utilization patterns, outcomes and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. This study is a secondary analysis of a proof-of-concept trial, called Optimizing treatment for acute Malnutrition (OptiMA), conducted in Burkina Faso in 2016. A total of 4958 eligible children whose mid-upper arm circumference (MUAC) was less than 125 mm or with oedema were followed weekly and given ready-to-use therapeutic foods (RUTF). We evaluated the service utilization and outcomes among patients and estimated resource use and variable cost per patient, and examined factors driving variation in resource use. Children with lower initial MUAC level grew faster but required more time to recover than those with higher initial MUAC level. They also had higher rates of death, default and nonresponse. The simplified OptiMA approach for treating acute malnutrition achieved high rates of recovery overall (84%), especially among less severe cases, with modest quantities of RUTF. The average overall variable cost per child admitted was US$38.0 (SD: 20.5) half of which was accounted for by the cost of RUTF. Cost per recovered case was correlated with case severity, ranging from US$35.1 to US$132.8. If simplified integrated programmes using severity-based RUTF dosing can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases

Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger

IntroductionGlobally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product – ready-to-use therapeutic food, or RUTF – at reduced dosage as the child improves.MethodsThis study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization.ResultsFrom July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004).DiscussionOptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger

Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial

BACKGROUND: Global access to acute malnutrition treatment is low. Different programmes using different nutritional products manage cases of severe acute malnutrition and moderate acute malnutrition separately. We aimed to assess whether integrating severe acute malnutrition and moderate acute malnutrition treatment into one programme, using a single nutritional product and reducing the dose as the child improves, could achieve similar or higher individual efficacy, increase coverage, and minimise costs compared with the current programmes. METHODS: We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Acutely malnourished children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 125 mm or oedema were randomly assigned (1:1), using specially developed software and random blocks (size was kept confidential), to either the current standard strategy (one programme for severe acute malnutrition using ready-to-use therapeutic food [RUTF] at an increasing dose as weight increased, another for moderate acute malnutrition using a fixed dose of ready-to-use supplementary food [RUSF]) or the OptiMA strategy (a single programme for both severe acute malnutrition and moderate acute malnutrition using RUTF at a decreasing dose as MUAC and weight increased). The primary endpoint was a favourable outcome at 6 months, defined as being alive, not acutely malnourished as per the definition applied at inclusion, and with no further episodes of acute malnutrition throughout the 6-month observation period; the endpoint was analysed in the intention-to-treat (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, or were prescribed RUSF rations for a minimum of 4 weeks [ie, minimum of 28 RUSF sachets], and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority analysis (margin 10%) was to be followed by a superiority analysis (margin 0%) if non-inferiority was concluded. This trial is registered at ClinicalTrials.gov, NCT03751475, and is now closed. FINDINGS: Between July 22 and Dec 6, 2019, 912 children were randomly assigned; after 16 were excluded, 896 were analysed (446 in the standard group and 450 in the OptiMA group). In the intention-to-treat analysis, 282 (63%) of 446 children in the standard group and 325 (72%) of 450 children in the OptiMA group had a favourable outcome (difference -9.0%, 95% CI -15.9 to -2.0). In the per protocol analysis, 161 (61%) of 264 children in the standard group and 291 (74%) of 392 children in the OptiMA group had a favourable outcome (-13.2%, -21.6 to -4.9). INTERPRETATION: In this non-inferiority trial treating children with MUAC of less than 125 mm or oedema, decreasing RUTF dose according to MUAC and weight increase proved to be a superior strategy to the standard protocol in the Democratic Republic of the Congo. These results demonstrate the safety and benefits of an approach that could substantially increase access to treatment for millions of children with acute malnutrition in sub-Saharan Africa. FUNDING: Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION: For the French translation of the abstract see Supplementary Materials section

Évaluation d'une stratégie de prise en charge simplifiée de la malnutrition aiguë chez des enfants de 6 à 59 mois en Afrique Sub-saharienne dans le cadre d’un programme de recherche co-construit entre humanitaires et chercheurs

Acute malnutrition (AM) is a major public health concern, affecting 45 million children under 5 years of age. It is an underlying cause of 800,000 deaths each year. Existing treatment protocols, while effective, suffer from insufficient funding and limited coverage. Furthermore, these protocols, divided into two programmes for severe and moderate acute malnourished children, are complex to put in place and use different treatments with sub-optimal dosages. In response to these challenges, the non-governmental organisation (NGO) The Alliance for medical action (ALIMA) has developed the « Optimising treatment for acute malnutrition » (OptiMA) protocol. The OptiMA aims to treat any children presenting Mid-Upper Arm Circumference (MUAC)37.5°) and MUAC≥125 mm and no oedema for two consecutive weeks. Between 31 March and 23 December 2021, 1,732 children with MUAC 37,5°), absence d'œdèmes et PB≥125 mm pendant deux semaines consécutives. Entre le 31 mars et le 23 décembre 2021, 1 732 enfants avec PB <125 mm ou œdèmes et 1 140 enfants présentant un PB <115 mm ou des œdèmes ont été randomisés (1 :1 :1). Les résultats n’ont pas démontré la non-infériorité pour les critères de jugement mais les trajectoires de gains de poids et de PB similaires 6 mois post randomisation dans les 3 bras suggèrent que la réduction progressive de la supplémentation n'a pas eu d'impact négatif sur la croissance de l’enfant, même les plus vulnérables, alors que 40 % d'enfants supplémentaires pourraient être traités sans que le coût des ATPE n'augmente. Dans cet essai mené au Niger, bien que la non-infériorité (ITT et PP) pour les critères de jugement n'ait pas été démontrée, les gains de poids et de PB similaires 6 mois post randomisation dans les bras ComPAS et contrôle suggèrent que la réduction de la ration de supplémentation (…

Evaluation of a simplified management strategy for acute malnutrition in children aged 6-59 months in sub-Saharan Africa, as part of a research programme developed jointly by humanitarian workers and researchers.

La malnutrition aiguë (MA) est un défi mondial, touchant 45 millions d'enfants de moins de 5 ans et est une cause sous-jacente de 800 000 décès annuels. Les protocoles de prise en charge, bien que efficaces, souffrent d'un financement insuffisant et d'une couverture limitée. Ces protocoles divisés en deux programmes pour les enfants malnutris aigus sévères et modérés sont complexes et utilisent des traitements différents avec des dosages non optimaux. Pour répondre à ces défis, l’organisation non gouvernementale (ONG) « The Alliance for International medical action » (ALIMA) a développé le protocole « the Optimizing treatment for acute malnutrition » (OptiMA) visant à traiter tous les enfants présentant un Périmètre Brachial (PB) 37,5°), absence d'œdèmes et PB≥125 mm pendant deux semaines consécutives. Entre le 31 mars et le 23 décembre 2021, 1 732 enfants avec PB 37.5°) and MUAC≥125 mm and no oedema for two consecutive weeks. Between 31 March and 23 December 2021, 1,732 children with MUAC <125 mm or oedema and 1,140 children with MUAC <115 mm or oedema were randomized (1:1:1). The findings did not demonstrate non-inferiority for any of the main outcomes, but the similar weight and MUAC gains trajectories 6 months post-randomization in the 3 arms suggest that the progressive reduction in supplementation did not have a negative impact on growth, even for the most vulnerable children, whereas 40% more children could be treated without increasing the cost of RUTFs. These trials have provided scientific evidence needed to scale up simplified protocols in emergency health setting. The CORAL consortium demonstrated its strength through the implementation of individually randomized clinical trials conducted rigorously in complex areas

Évaluation d'une stratégie de prise en charge simplifiée de la malnutrition aiguë chez des enfants de 6 à 59 mois en Afrique Sub-saharienne dans le cadre d’un programme de recherche co-construit entre humanitaires et chercheurs

Acute malnutrition (AM) is a major public health concern, affecting 45 million children under 5 years of age. It is an underlying cause of 800,000 deaths each year. Existing treatment protocols, while effective, suffer from insufficient funding and limited coverage. Furthermore, these protocols, divided into two programmes for severe and moderate acute malnourished children, are complex to put in place and use different treatments with sub-optimal dosages. In response to these challenges, the non-governmental organisation (NGO) The Alliance for medical action (ALIMA) has developed the « Optimising treatment for acute malnutrition » (OptiMA) protocol. The OptiMA aims to treat any children presenting Mid-Upper Arm Circumference (MUAC)37.5°) and MUAC≥125 mm and no oedema for two consecutive weeks. Between 31 March and 23 December 2021, 1,732 children with MUAC 37,5°), absence d'œdèmes et PB≥125 mm pendant deux semaines consécutives. Entre le 31 mars et le 23 décembre 2021, 1 732 enfants avec PB <125 mm ou œdèmes et 1 140 enfants présentant un PB <115 mm ou des œdèmes ont été randomisés (1 :1 :1). Les résultats n’ont pas démontré la non-infériorité pour les critères de jugement mais les trajectoires de gains de poids et de PB similaires 6 mois post randomisation dans les 3 bras suggèrent que la réduction progressive de la supplémentation n'a pas eu d'impact négatif sur la croissance de l’enfant, même les plus vulnérables, alors que 40 % d'enfants supplémentaires pourraient être traités sans que le coût des ATPE n'augmente. Dans cet essai mené au Niger, bien que la non-infériorité (ITT et PP) pour les critères de jugement n'ait pas été démontrée, les gains de poids et de PB similaires 6 mois post randomisation dans les bras ComPAS et contrôle suggèrent que la réduction de la ration de supplémentation (…

Filariasis serosurvey, New Caledonia, South Pacific, 2013

Abstract Background Lymphatic filariasis (LF) is a major public health problem in the Pacific. As the global prevalence of infection was not known in New Caledonia (NC), a serosurvey study was conducted by determining the prevalence of circulating filarial antigens, as recommended by the World Health Organization. Findings A cross sectional study on a 2 degree stratified sample was carried out from June to November 2013. Inclusion criteria were: individuals aged 2 to 80 y/o, who had been hospitalized or sought medical care for a non-infectious cause and who had been living in NC for more than 6 months. LF antigenic detection was performed using the immunocromatographic BinaxNOW filariasis card test (ICT). Among the 1,035 individuals tested, 7 were antigenic. The overall LF antigenic prevalence was 0.62% (CI 95% [0.60-0.63]). All patients were unrelated to each other; none of them presented clinical symptoms of LF. Four of the 7 ICT positive patients reported having travelled to LF endemic areas, 2 patients had never traveled outside NC and the last one had only traveled in non-endemic areas. For the 7 ICT positive patients, the research of microfilariae in blood smears and filarial DNA by PCR was negative. Conclusion The prevalence of filarial antigenemia in NC is less than 1%, the threshold that defines the filarial endemic areas for WHO. Nevertheless, as two patients who had never travelled outside NC and one who had only travelled to non-endemic areas were antigenic, we cannot conclude that NC is totally free of LF

Br J Nutr

The Optimising 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 75 %). A single-arm proof-of-concept trial was conducted in 2017 in Yako district, Burkina Faso including children aged 6–59 months in outpatient health centres with MUAC < 125 mm or oedema. Outcomes were stratified by MUAC category at admission. Multivariate survival analysis was carried out to identify variables predictive of recovery. Among 4958 children included, 824 (16·6 %) were admitted with MUAC < 115 mm or oedema, 1070 (21·6 %) with MUAC 115–119 mm and 3064 (61·8 %) with MUAC 120–124 mm. The new dosage was correctly implemented at all visits for 75·9 % of children. Global recovery was 86·3 (95 % CI 85·4, 87·2) % and 70·5 (95 % CI 67·5, 73·5) % for children admitted with MUAC < 115 mm or oedema. Average therapeutic food consumption was 60·8 sachets per child treated. Recovery was positively associated with mothers trained to use MUAC prior to child’s admission (adjusted hazard ratio 1·09; 95 % CI 1·01, 1·19). OptiMA was successfully implemented at the scale of an entire district under ‘real-life’ conditions. Programme outcomes exceeded SPHERE standards, but further study is needed to determine if increasing therapeutic food dosages for the most severely malnourished will improve recovery

Zika virus outbreak in New Caledonia and Guillain-Barré syndrome: a case-control study

International audienceZika virus (ZIKV) infection has been associated with neurologic disorders including Guillain-Barré syndrome (GBS). In New Caledonia during the ZIKV outbreak (2014-2015), case-control and retrospective studies have been performed to assess the link between ZIKV and GBS. Among the 15 cases included, 33% had evidence of a recent ZIKV infection compared to only 3.3% in the 30 controls involved. All patients were Melanesian, had facial diplegia and similar neurophysiological pattern consistent with acute inflammatory demyelinating polyneuropathy, and recovered well. Furthermore, during the peak of ZIKV transmission, we observed a number of GBS cases higher than the calculated upper limit, emphasizing the fact that ZIKV is now a major trigger of GBS

Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial

BACKGROUND: Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response. METHODS: We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475. FINDINGS: Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis. INTERPRETATION: This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings. FUNDING: Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION: For the French translation of the abstract see Supplementary Materials section