Use of tuberculin skin test for assessment of immune recovery among previously malnourished children in Ethiopia.

OBJECTIVE: To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls). RESULTS: At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved

Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience High Rates of Deterioration and No Improvement: Results from a Prospective Cohort Study in Rural Ethiopia

Background: Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. In parts of Ethiopia not considered chronically food insecure there are no supplementary feeding programmes (SFPs) for treating MAM. The short-term outcomes of children who have MAM in such areas are not currently described, and there remains an urgent need for evidence-based policy recommendations. Methods: We defined MAM as mid-upper arm circumference (MUAC) of ≥11.0cm and <12.5cm with no bilateral pitting oedema to include Ethiopian government and World Health Organisation cut-offs. We prospectively surveyed 884 children aged 6–59 months living with MAM in a rural area of Ethiopia not eligible for a supplementary feeding programme. Weekly home visits were made for seven months (28 weeks), covering the end of peak malnutrition through to the post-harvest period (the most food secure window), collecting anthropometric, socio-demographic and food security data. Results: By the end of the study follow up, 32.5% (287/884) remained with MAM, 9.3% (82/884) experienced at least one episode of SAM (MUAC <11cm and/or bilateral pitting oedema), and 0.9% (8/884) died. Only 54.2% of the children recovered with no episode of SAM by the end of the study. Of those who developed SAM half still had MAM at the end of the follow up period. The median (interquartile range) time to recovery was 9 (4–15) weeks. Children with the lowest MUAC at enrolment had a significantly higher risk of remaining with MAM and a lower chance of recovering. Conclusions: Children with MAM during the post-harvest season in an area not eligible for SFP experience an extremely high incidence of SAM and a low recovery rate. Not having a targeted nutrition-specific intervention to address MAM in this context places children with MAM at excessive risk of adverse outcomes. Further preventive and curative approaches should urgently be considered

Subject flow diagram.

<p>Subject flow diagram.</p

Baseline household and child characteristics.

<p>Baseline household and child characteristics.</p

Predictors of occurrence of severe acute malnutrition based on parameters at enrolment: bivariate and Cox proportional hazards analyses^†.

<p>Predictors of occurrence of severe acute malnutrition based on parameters at enrolment: bivariate and Cox proportional hazards analyses<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0153530#t004fn001" target="_blank">^†</a>.</p

Survival curve for developing Severe Acute Malnutrition as per Ethiopian operational criteria (MUAC <11cm or bilateral pitting oedema), stratified by MUAC category at enrolment.

<p>Survival curve for developing Severe Acute Malnutrition as per Ethiopian operational criteria (MUAC <11cm or bilateral pitting oedema), stratified by MUAC category at enrolment.</p

Final Outcomes of the MAM cohort after 28 weeks of follow up.

<p>Final Outcomes of the MAM cohort after 28 weeks of follow up.</p

Agricultural calendar of Jimma zone and study implementation period.

<p>Agricultural calendar of Jimma zone and study implementation period.</p

Distribution of outcomes based on the WHO (2009) MUAC based operational definitions.

<p>Distribution of outcomes based on the WHO (2009) MUAC based operational definitions.</p

Incidence of Severe Acute Malnutrition as per Ethiopian operational definition and protocols (MUAC <11cm or bilateral pitting oedema).

<p>Incidence of Severe Acute Malnutrition as per Ethiopian operational definition and protocols (MUAC <11cm or bilateral pitting oedema).</p