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Background: the aim of this study is to evaluate the effectiveness and coverage of a simplified protocol that is implemented in health centers (HCs) and health posts (HPs) for children who are suffering from severe acute malnutrition (SAM) in the humanitarian context of Diffa. Methods: We conducted a non-randomized community-controlled trial. The control group received outpatient treatment for SAM, without medical complications, at HCs and HPs with the standard protocol of community management of acute malnutrition (CMAM). Meanwhile, with respect to the intervention group, the children with SAM received treatment at the HCs and HPs through a simplified protocol wherein the mid-upper arm circumference (MUAC) and the presence of edema were used as the admission criteria, and the children with SAM were administered doses of fixed ready-to-use therapeutic food (RUTF). Results: A total of 508 children, who were all under 5 years and had SAM, were admitted into the study. The cured proportion was 87.4% in the control group versus 96.6% in the intervention group (p value = 0.001). There was no difference between the groups in the length of stay, which was 35 days, but the intervention group used a lower quantity of RUTF—70 sachets versus 90 sachets, per child cured. Coverage increases were observed in both groups. Discussion: the simplified protocol used at the HCs and HPs did not result in worse recovery and resulted in fewer discharge errors compared to the standard protocol.

Treatment outcomes for acute malnutrition can be improved by integrating treatment into community case management (iCCM). However, little is known about the cost‐effectiveness of this integrated nutrition intervention. The present study investigates the cost‐effectiveness of treating moderate acute malnutrition (MAM) through community health volunteer (CHV) and integrating it with routine iCCM. A cost‐effectiveness model compared the costs and effects of CHV sites plus health facility‐based treatment (intervention) with the routine health facility‐based treatment strategy alone (control). The costing assessments combined both provider and patient costs. The cost per DALY averted was the primary metric for the comparison, on which sensitivity analysis was performed. Additionally, the integrated strategy's relative value for money was evaluated using the most recent country‐specific gross domestic product threshold metrics. The intervention dominated the health facility‐based strategy alone on all computed cost‐effectiveness outcomes. MAM treatment by CHVs plus health facilities was estimated to yield a cost per death and DALY averted of US $ 8743 and US$397, respectively, as opposed to US $ 13,846 and US$637 in the control group. The findings also showed that the intervention group spent less per child treated and recovered than the control group: US $ 214 versus US$270 and US $ 306 versus US$485, respectively. Compared with facility‐based treatment, treating MAM by CHVs and health facilities was a cost‐effective intervention. Additional gains could be achieved if more children with MAM are enrolled and treated. Key messages Treatment of MAM by CHVs and health facilities involved a lower cost compared with the health facility‐based treatment approach alone. Treatment of MAM by CHVs and health facilities was cost‐effective compared with the health facility‐based treatment approach alone. Greater health and economic gains could be realized if more children with MAM are enrolled and treated by CHVs through the integration of acute malnutrition treatment into iCCM.

A simplified, combined protocol admitting children with a mid‐upper‐arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready‐to‐use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115–<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango‐Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context. We observed the effectiveness of a simplified, combined, MUAC‐based daily ready‐to‐use therapeutic food dosage for the treatment of acute malnutrition in children under 5 in a routine setting at scale. Our results indicate satisfactory recovery and low RUTFconsumption per child treated. Key messages The simplified, combined protocol with a mid‐upper‐arm circumference (MUAC)‐based ready‐to‐use therapeutic food (RUTF) resulted in a recovery rate that reached SPHERE standards, low length of stay and low RUTF consumption per child among all children treated. Response to treatment was similar among children admitted with severe acute malnutrition (SAM) by oedema and those admitted SAM by MUAC. Contextual factors such as insecurity and stockouts in treatment products affect programme outcomes by increasing defaulting and decreasing recovery rates. The simplified, combined protocol might present an opportunity to treat more children with less product; decentralised delivery should continue to be explored.

We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). Study was conducted as part of a bigger evaluation study in South Sudan. International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.

To evaluate effectiveness of point-of-use water treatment in improving treatment of children affected by severe acute malnutrition (SAM). Programme sites were randomized to one of four intervention arms: (i) standard SAM treatment; (ii) SAM treatment plus flocculent/disinfectant water treatment; (iii) SAM treatment plus chlorine disinfectant; or (iv) SAM treatment plus ceramic water filter. Outcome measures were calculated based on participant status upon exit or after 120d of enrolment, whichever came first. Child anthropometric data were collected during weekly monitoring at programme sites. Child caregivers were interviewed at enrolment and exit. Use of water treatment products was assessed in a home visit 4-6 weeks after enrolment. Dadu District, Sindh Province, Pakistan. Children (n 901) aged 6-59 months with SAM and no medical complications. Recovery rates were 16·7-22·2 % higher among children receiving water treatment compared with the control group. The adjusted odds of recovery were approximately twice as high for those receiving water treatment compared with controls. Mean length of stay until recovery was 73 (sd 24·6) d and mean rate of weight gain was 4·7 (sd 3·0) g/kg per d. Differences in recovery rate, length of stay and rate of weight gain between intervention groups were not statistically significant. Incorporating point-of-use water treatment into outpatient treatment programmes for children with SAM increased nutritional recovery rates. No significant differences in recovery rates were observed between the different intervention groups, indicating that different water treatment approaches were equally effective in improving recovery.

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan’s standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6–59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP −10.0; TSFP −7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

Background As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. Methods A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. Results Very few (1.6%; n  = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI − 30.2, − 26.5) and 5.1 days (CI − 6.2, − 4.0); the full adapted protocol had a decrease of 3.0 (CI − 5.1, − 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18–3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45–2.19); and fully adapted protocol AOR = 2.41 (CI 1.69–3.45). Conclusions This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.

Millions of children suffer from severe acute malnutrition (SAM) in low- and middle- income countries. Much is known about the effectiveness of community treatment programmes (CMAM) but little is known about post-discharge outcomes after successful treatment. The present study aimed to evaluate post-discharge outcomes of children cured of SAM. Prospective, observational cohort study. Children with SAM who were discharged as cured were followed monthly for 6 months or until they experienced relapse to SAM. 'Cure' was defined as a child achieving a mid-upper arm circumference (MUAC) of ≥115 mm with ≥15 % weight gain after loss of oedema. Relapse was defined as a child with MUAC<115 mm and/or oedema at any monthly visit. Save the Children CMAM programme in Swabi, Pakistan, from January 2012 to December 2014. Children aged 6-59 months (n 117) discharged as cured from the CMAM programme were eligible for the study and followed for 6 months. One hundred children (92·6 %) remained free of SAM, eight (7·4 %) relapsed to SAM, nine (8·3 %) were lost to follow-up and none died. Most relapses occurred within 3 months of discharge (mean time to relapse 73·4 (sd 36·2) d). At enrolment, 90 % had moderate acute malnutrition (MAM) and 10 % were not malnourished. By the end of 6 months, 35 % persisted with MAM and the remaining were not malnourished. In rural Pakistan, fewer than 10 % of children cured of SAM relapsed. The first 3 months is the most vulnerable time.

Background Mid-upper arm circumference (MUAC) was recently endorsed and recommended for screening for acute malnutrition in the community. The objective of this study was to determine whether a colour-banded MUAC strap would allow minimally trained mothers to screen their own children for malnutrition, without locating the mid-point of the left upper arm by measurement, as currently recommended. Methods A non-randomised non-blinded evaluation of mothers’ performance when measuring MUAC after minimal training, compared with trained Community Health Workers (CHW) following current MUAC protocols. The study was conducted in 2 villages in Mirriah, Zinder region, Niger where mothers classified one of their children ( n  = 103) aged 6–59 months (the current age range for admission into community malnutrition programs) using the MUAC tape. Results Mothers’ had a sensitivity and specificity for classification of their child’s nutritional status of > 90% and > 80% respectively for global acute malnutrition (GAM, defined by a MUAC < 125 mm) and > 73% and > 98% for severe acute malnutrition (SAM, defined by a MUAC < 115 mm). The few children misclassified as not having SAM, were classified as having moderate acute malnutrition (MAM). The choice of arm did not influence the classification results; weighted Kappa of 0.88 for mothers and 0.91 for CHW represent almost perfect agreement. Errors occurred at the class boundaries and no gross errors were made. Conclusions Advanced SAM is associated with severe complications, which often require hospital admission or cause death. Mothers (with MUAC tapes costing $0.06) can screen their children frequently allowing early diagnosis and treatment thereby becoming the focal point in scaling-up community management of acute malnutrition. Trial registration The trial is registered with clinicaltrials.gov (Trial number NCT01790815 )

Background Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child’s weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM. Method This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant. Discussion We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies. Trial Registration ISRCTN 30393230 , date: 16/03/2017.