COVID-19 adaptations to outpatient nutrition programmes in East Africa
This is a summary of the following paper: Shragai T, Talley L, Summers A et al (2022) Outcomes after Acute Malnutrition Program Adaptations to COVID-19, Uganda, Ethiopia, and Somalia. Emerging Infectious Diseases, 28, 13. https://doi.org/10.3201/eid2813.212266
After the onset of the COVID-19 pandemic, guidance for Community-Based Management of Acute Malnutrition (CMAM) was released to support the continuity of services while mitigating the risk of COVID-19 transmission. In response, countries adopted a variety of programme adaptations, including family mid-upper arm circumference (MUAC),1 longer intervals between clinic visits and MUAC-only programming. However, while experiences and lessons learnt have been documented in Field Exchange issue 64 (Wrabel et al, 2021), there remains a lack of data on the impact of implementing these adaptations at scale and as a part of routine programming.
The study reviewed here used routine CMAM programme data from Ethiopia (81 facilities), Somalia (12 facilities) and Uganda (five facilities) to evaluate changes in enrolment and treatment outcomes at facility level that corresponded with the implementation of COVID-19 programme adaptations (Table 1). In addition, eight facilities in Somalia provided child-level data for weight and MUAC at admission and discharge, and average length of stay (ALOS). The analysis adjusted for expected increases in enrolment due to seasonal periods of increased food insecurity and for expected decreases due to national COVID-19 mitigation measures, such as travel restrictions.
Table 1: Programme adaptations in Ethiopia, Somalia and Uganda
Country | Programme type | Dates data available; date adaptations began | Programme adaptations |
Uganda | Targeted supplementary feeding programme | Jan 2019-Dec 2020; Apr 2020 | Family MUAC; suspension of community screening; reduced frequency of follow-up visits from weekly to every two weeks; modified admission and discharge criteria from a MUAC threshold of 12.5 cm to 12.9 cm |
Ethiopia | Outpatient therapeutic feeding programme | Jul 2019-Dec 2020; May 2020 | Family MUAC; suspension of community screening; reduced frequency of follow-up visits from weekly to every two weeks |
Somalia | Outpatient therapeutic feeding programme | Facility-level data: Nov 2019-Dec 2020; Mar 2020
Child-level data: Jan 2017-Nov 2020; Mar 2020 | Family MUAC; suspension of community screening; reduced frequency of follow-up visits from weekly to every two weeks |
The study found no statistically significant changes in total admissions, ALOS, total children screened for admission or recovery rates at facility level before and after adaptations. Although several facilities closed temporarily because of stock outages, these closures were short-term - upon reopening, admissions and the total number screened returned to pre-closure levels. MUAC and weight at discharge did not change meaningfully within the Somalia facilities that provided child-level data. However, the ALOS did significantly increase immediately after adaptations, but then decreased to pre-adaptation levels. The authors highlight four limitations to the study: its limited statistical power; challenges in isolating the effects of CMAM programme adaptations from other simultaneous COVID-19 mitigation efforts; the limited number of countries studied; and, finally, the fact that models do not capture the important qualitative experience of putting programme adaptations into practice.
Nevertheless, overall, the results provide initial evidence that adaptations to CMAM programmes did not significantly affect programme efficacy when adopted in the context of the COVID-19 pandemic. However, there is a need for further prospective studies with greater power to evaluate how the COVID-19 programme adaptations affected performance outcomes.
References
Wrabel M, King S & Stobaugh H (2021) Adaptations to community-based acute malnutrition treatment during the COVID-19 pandemic. Field Exchange 64. https://www.ennonline.net/fex/64/covid19cmamadaptations
1 Family MUAC: Caregivers are trained to monitor their children's MUAC at home and to refer them to a community health worker or health facility when they detect signs of wasting.