Adopting the WHO Growth Standards for Diagnosis and Classification of Acute Malnutrition in Emergencies: An Assessment of Resource Implications

Andrew Seal
UCL Centre for International Health and Development Institute of Child Health, London

Abbreviations
CTC GAM IQR MAM NCHS SAM SFP TFP WH WHO WHZ WHM Community Therapeutic Care Global Acute Malnutrition Inter-quartile range Moderate Acute Malnutrition National Center for Health Statistics Severe Acute Malnutrition Supplementary Feeding Programme Therapeutic Feeding Programme weight-for-height World Health Organisation weight-for-height z-scores weight-for-height percentage of the median

Acknowledgments
I gratefully acknowledge the contribution of Mark Myatt and SC(UK) who kindly provided the database of nutritional surveys that was analysed for part of this report. I would also like to thank all the reviewers who provided valuable feedback and comments on earlier drafts. This work was funded by a grant from the IASC Nutrition Cluster, via RNIS, Geneva.

Contents
Part 1 - Modelling the Resource Implications of Using Different Diagnostic and Classification Criteria for Acute Malnutrition...................................................................................................4 Overview..............................................................................................................................4 Section 1..............................................................................................................................4 Assumptions....................................................................................................................5 Classification of Scenarios ..............................................................................................5 Classification of Responses.............................................................................................7 Implications for Number of Potential Programme Beneficiaries .......................................8 Section 2............................................................................................................................12 Modelling weight gains required for nutritional cure.......................................................12 Modelling days of treatment required for nutritional cure ...............................................13 Section 3............................................................................................................................14 Modelling costs of treatment..........................................................................................14 Conclusions and recommendations ...................................................................................17 Part 2 - A Review of Software Available for the Calculation of Acute Malnutrition Using the NCHS Reference and WHO Standards .................................................................................19 Overview............................................................................................................................19 Objective technical and user service comparisons ........................................................19 Subjective assessments of usability ..............................................................................21 Conclusions and recommendations ...................................................................................21

Tables
Table 1 - Classification of Survey Results for Global Acute Malnutrition (n=560) .....................7 Table 2 - Survey Sites with Indicated Selective Feeding Interventions for Children1 ................7 Table 3 - Number of Potential Child Beneficiaries for Selective Feeding1 ..............................11 Table 4 - Estimation of the change in costs for treatment of SAM (US$)* ..............................15 Table 5 - Estimation of the change in costs for treatment of MAM (US$)*..............................16 Table 6 - Comparison of Selected Software Characteristics ..................................................23

Figures
Figure 1: Comparison of Prevalence Estimates for Global Acute malnutrition..........................6 Figure 2: Comparison of Survey Estimates of Moderate Acute Malnutrition (n=560) ...............9 Figure 3: Comparison of Prevalence Estimates for Severe Acute Malnutrition (n=560) .........10 Figure 4: Weight Gain Required for Nutritional Cure of SAM (Boys)1 .....................................12 Figure 5: Days of Recovery Required for Nutritional Cure of SAM.........................................13 Figure 6: Days of Treatment Required for SAM at Different Rates of Weight Gain (Boys)1,2 ..14 Figure 7: Sensitivity of the SAM treatment programme cost model to different levels of ........17

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Part 1 - Modelling the Resource Implications of Using Different Diagnostic and Classification Criteria for Acute Malnutrition Overview
The diagnosis of childhood malnutrition is usually performed using anthropometric criteria. In emergencies, the weight-for-height index (WH), in conjunction with oedema, is commonly used for characterising moderate and severe acute malnutrition. The WH index may be expressed using a standard deviation score (z-score), as a percentile, or as a percentage of the median value. The use of the WH z-score (WHZ) has several statistical advantages and has been recommended for reporting survey results for some years. However, due to its ease of calculation and conceptual simplicity, the WH percentage of the median (WHM) is currently widely used for admission and discharge criteria in selective feeding programmes. WHM based diagnostic criteria have also been shown to be better predictors of response to treatment than WHZ based criteria when calculated using the NCHS Reference. 1 Calculation of WH requires comparison against a growth norm, and since 1978 the NCHS/WHO/CDC Growth Reference (NCHS Reference) has been widely used in international nutrition. However, new Child Growth Standards were released by WHO in April 2006 for use with children between 0 and 59 months.2 These have significant differences compared to the NCHS Reference but little was known about the implications of using this new norm on the numbers of patients that would eligible for treatment and the resources required for their care. To assess the resource implications of adopting different diagnostic criteria for acute malnutrition two things need to be considered. Firstly, the numbers diagnosed as requiring treatment and secondly, the cost of providing that treatment. In the first section of this report, data from Myatt and Duffield3 is re-analysed to assess the number of scenarios that would be classified as requiring selective feeding interventions and the number of individuals requiring treatment. A comparison is made between WHM calculated with the NCHS Reference (WHM-NCHS), and the diagnostic criteria proposed by WHO, which uses WHZ based on the WHO 2006 Child Growth Standards (WHZ-WHO). In the second section I examine the duration of treatment involved and if this is affected by the use of the different diagnostic criteria. In the third section the costs of treatment are considered based on the available data for centre based and community based programmes, and drawing on our estimates for changes in the number of potential programme beneficiaries and the average duration of treatment.

Section 1
This report follows on from work conducted by Myatt and Duffield for the Nutrition Cluster, which involved the analysis of a dataset comprising the results from 560 nutrition surveys. The surveys were carried out in 31 different countries between September 1992 and October 2006 and include data on 459,036 children. To construct this data base individual datasets were collated by SC(UK), whose nutrition adviser contacted her counterparts at the main agencies working in the field of international nutrition. The aims of the work were outlined and permission to use the agencies data was requested. Datasets of nutritional anthropometry surveys including age, sex, weight, height,
1

Prudhon, C., Briend, A., Laurier, D., Golden, M. H. N., & Mary, J. Y. (1996) Comparison of weight- and height-based indices for assessing the risk of death in severely malnourished children. American Journal of Epidemiology 144: 116-123. 2 http://www.who.int/childgrowth/en/ 3 Weight-for-height and MUAC for estimating the prevalence of acute undernutrition? A review of survey data collected between September 1992 and October 2006 (2008) Myatt M and Duffield A

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MUAC and oedema were requested. Agencies were also asked to describe where and when the survey took place. Data was received from ACF-F, ACF-US, Concern, FSAU, Goal, MSF-B, MSF-CH, MSF-H, MSF-S SC UK and SC US. The data was obtained in a variety of file formats and then imported into R4, which was used for subsequent analysis. Additional analysis for this report was done using SPSS v14.5 Myatts report considers the differences in estimates of malnutrition prevalence derived using WHZ and WHM and defined using either the NCHS Reference or WHO Standard. They also compare these with the use of MUAC. Of relevance to this report, they consider the implications for programme size by comparing the estimated numbers of potential beneficiaries calculated using WHM-NCHS with the estimated numbers of potential beneficiaries calculated using WHM-WHO and WHZ-WHO. This comparison was done separately for moderate acute malnutrition (MAM) and SAM. In this report we extend the analysis of the difference in need estimated using WHM-NCHS and WHZ-WHO based diagnosis, and go on to look at how these differences may be reflected in changes in resource requirements.

Assumptions
Calculation of the number of individuals requiring treatment for acute malnutrition is based on prevalence data from anthropometric surveys of the beneficiary population and estimates of total population size. It should be noted that this estimated need will usually be different than the numbers actually treated, as this will also depend on beneficiary access to the programme and on the programme coverage actually achieved (4). For the analysis conducted here we assume that the degree of programme access and coverage is not affected by the use of the different anthropometric criteria. The use of different criteria to define an acutely malnourished child will inevitably lead to the selection of a group that has differing clinical as well as anthropometric characteristics. For example, as well as differences in weight, the prevalence of clinical features such as diarrhoea, ARI and anaemia has been shown to vary according to whether patients were admitted using MUAC or weight-for-height (5). Unfortunately, data are not currently available on how the average characteristics of patients will vary if they are admitted and discharged using weight-for-height Z-scores based on the WHO Standards (WHZ-WHO) or percentage of the median cut-offs based on the NCHS Reference (WHM-NCHS). Therefore, due to lack of data on these issues, the analysis reported below assumes that the differences in the characteristics of patients are negligible. With that in mind, it is also assumed that the cost per day of treatment will remain constant whichever diagnostic criteria are used. Therefore, any differences in cost will be attributable to the duration of treatment, which are enumerated in this analysis as treatment days, and the number of patients that are treated.

Classification of Scenarios
The classification of emergency situations and their nutritional seriousness depends, largely, upon the reported prevalence of GAM in a survey area. While this is by no means the sole criterion by which a decision to launch a humanitarian response is made, it nonetheless forms an important piece of the information jigsaw. Taken together with other contextual information, the prevalence of GAM helps drive the decision making process of donors and operational agencies. Therefore, the estimation of GAM, and the resulting classification of scenarios, has important operational significance.
4 5

http://www.r-project.org/index.html http://www.spss.com/

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The histograms shown in figure 1 compare the distributions of GAM prevalence estimates when using WHZ-WHO and WHZ-NCHS.
Figure 1: Comparison of Prevalence Estimates for Global Acute malnutrition (n=560 surveys)

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In Table 1 the 560 survey results from the study by Myatt et al. are classified according to the WHO prevalence categories that are currently used, where < 5% wasting is considered acceptable, 5-9% as poor, 10-14% as serious, and 15% or more as critical (6). The surveys are classified according to 2 different case definitions of GAM: (1) WHZ-NCHS <-2 or bipedal oedema; and (2) WHZ-WHO <-2 or bipedal oedema.
Table 1 - Classification of Survey Results for Global Acute Malnutrition (n=560) Case Definition <-2 WHZ -NCHS or oedema <-2 WHZ -WHO or oedema Difference in the number of surveys within each category Acceptable 0<5% 95 (17.0 %) 88 (15.7 %) - 7.4 % WHO Prevalence Categories Poor Serious 59% 10 14 % 183 100 (32.7 %) (17.9 %) 175 99 (31.3 %) (17.7 %) -4.4 % - 1.0 % Critical 15 % 182 (32.5 %) 198 (35.4 %) + 8.8 % Totals 560 (100 %) 560 (100 %)

It can be seen that the overall pattern of classification between categories is similar when using WHZ-NCHS and WHZ-WHO. When WHZ-WHO is used there is a slight reduction in the proportion of survey results categorised as acceptable, poor or serious, with an increase in the classification of situations as critical. This increase in the proportion of surveys in the critical category is not unexpected, given the increase in the prevalence of GAM found with WHZ-WHO, compared to WHZ-NCHS.

Classification of Responses
In table 2 we consider what type of response might be considered based on the prevalence categories shown in table 1, and using a decision chart published by WHO in 2000 (6)6. In the decision chart the presence of aggravating factors is essential for deciding what type of selective feeding interventions to run. These factors include, for example, a general food ration below the mean energy requirement or an epidemic of measles or whooping cough. Unfortunately, in the survey database used for this analysis information on aggravating factors was not available. Therefore, to ensure a fair comparison of the diagnostic criteria under consideration, the decision responses were assigned assuming that no aggravating factors were present in any of the survey sites.
Table 2 - Survey Sites with Indicated Selective Feeding Interventions for Children System Used for Case Definitions WHZ -NCHS <-2 or oedema WHZ -WHO <-2 or oedema Difference in the number of surveys within each category
1
1

No response 278 263 -5.4 %

Interventions Targeted SFP Blanket SFP 100 99 - 1.0 % 182 198 + 8.8 %

TFP 282 297 + 5.3 %

Based on the WHO decision chart criteria it is assumed that targeted SFP and TFP would be implemented in sites where GAM was 10 %, and blanket SFP implemented where GAM 15 %.

The results from table 2 show that adoption of WHZ-WHO for the analysis of nutrition surveys, combined with the use of the current WHO decision chart criteria, is likely to lead to a 6% drop in the number of GAM survey results that indicate no selective feeding intervention
An initial version of the decision chart was first published in MSF Nutrition Guidelines in 1995 with different cut-offs (7). It was then adapted and published in the UNHCR Handbook for Emergencies, 2nd Edition, (un-dated), and this version was reproduced in WHO s Managing Nutrition in Major Emergencies in 2000.
6

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is required. There may also be a 9% increase in results indicating the need for blanket SFPs and a 5% increase in results indicating the need for a TFP.

Implications for Number of Potential Programme Beneficiaries

The potential beneficiary numbers for selective feeding programmes are usually calculated separately by program type. Targeted SFP interventions generally admit cases of moderately acute malnutrition (MAM), and TFPs admit cases of SAM. To arrive at an estimate of beneficiary numbers we first look at differences in estimates of MAM and SAM prevalence by the WHM NCHS references and WHZ WHO standards, and then extrapolate this to reach an estimate for the number of children. Moderate Acute Malnutrition Figure 2 shows the distribution of the survey estimates of MAM prevalence according to two different case definitions. Note that in this analysis the case definitions that are compared are those used and proposed for admission and discharge of patients to programmes, not for the classification of situations as presented in the section above. If the current practice case definition for MAM (<80 to 70% WHM-NCHS) is compared to the case definition proposed by WHO (<-2 to -3 WHZ-WHO), it can be seen that the distribution of survey prevalence estimates moves by a small amount, the median MAM prevalence increasing slightly from 6.85 % (IQR 7.7) to 7.78 % (IQR 8.4). Comparing the medians using Wilcoxons non-parametric Signed Rank Test for paired samples shows a statistically significant increase (p<0.001). Severe Acute Malnutrition Figure 3 shows the distribution of SAM prevalence estimates according to different case definitions. Throughout this analysis SAM includes cases of oedema as well cases of severe wasting. The prevalence of SAM is sometimes used independently of GAM and other variables for deciding whether to initiate feeding interventions. Therefore, we first compare the two case definitions likely to be used in survey reports. If the prevalence of SAM measured using WHZ-NCHS (panel A) is compared to the prevalence measured using WHZ-WHO (panel B), it can be seen that the distribution shifts to the right when WHZ-WHO is used. This shift reflects, overall, a less stringent case definition, the median SAM prevalence increasing from 1.34 % (IQR 2.0) to 2.71 % (IQR 3.3).7 However, the comparison of interest in considering the number of potential programme beneficiaries is the change that would result from a move from the case definition currently used in most therapeutic programmes, <70% WHM-NCHS, to that proposed by WHO, <-3 WHZ-WHO. This difference can be seen in Figure 3 by comparing panels (C) and (B). In this case the median prevalence increases from 0.68 % (IQR 1.2) to 2.71 % (IQR 3.30), a 4-fold increase. Comparing the medians using Wilcoxons non-parametric Signed Rank Test for paired samples confirmed the statistical significance of the difference (p<0.001). It is also important to note that although the median increase was 4 fold, the increase in SAM prevalence ranged from 1 up to 30 times the prevalence measured using WHM-NCHS. The increase in the prevalence of SAM, measured using the proposed case definition of <-3 WHZ-WHO, raises questions about the resource requirements needed to meet the additional patient numbers that would be eligible for admission to TFPs.

Over a small range in heights the <-3 z-score cut-off is more stringent, i.e. will diagnose less children, when using the WHO Standards. However, overall the effect of using the WHO cut-off is to produce a less stringent case definition, i.e. it will identify a higher proportion of children as being malnourished.

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Figure 2: Comparison of Survey Estimates of Moderate Acute Malnutrition (n=560 surveys)

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Figure 3: Comparison of Prevalence Estimates for Severe Acute Malnutrition (n=560 surveys)

(A) <-3 WHZ-NCHS or oedema

(B) <-3 WHZ-WHO or oedema

(C) < 70% WHM-NCHS or oedema

120
200

120

100

100

80

80

150

Number of Surveys

40

Number of surveys
60

40
50

20

20

Number of surveys

60

100

0
15.0 20.0

0.0

5.0

10.0

0.0

5.0

10.0

15.0

20.0

0.0

5.0

10.0

15.0

20.0

Prevalence of SAM (%)

Prevalence of SAM (%)

Prevalence of SAM (%)

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To calculate the number of potential programme beneficiaries involved we will, to allow comparability with Myatt et al., assume a notional service delivery unit size of 100,000 people with 20% of these aged between 6 and 59 months. In other words, we will assume that the sampling frame for each survey was 20,000 potential beneficiaries, that is children between 6 and 59 months. While the real situation may well have been somewhat different, this approach meets the requirement of allowing an internally consistent comparison between the different diagnostic criteria that we are considering. Table 3 presents an analysis of the number of sites where interventions would be indicated and the number of expected potential beneficiaries in each type of programme.
Table 3 - Number of Potential Child Beneficiaries for Selective Feeding System Used for Case Definition WHM-NCHS WHZ-WHO Increase (N) Increase (%)
1

Sites where one or more 2 interventions are indicated

(GAM 10%)

Potential Beneficiaries3 Targeted SFP Blanket SFP

(GAM 10 and <15%) (GAM 15%)

TFP
(GAM 10%)

282 / 560 297 / 560 15 5.3

146,308 177,344 31,036 21.2

3,572,664 3,700,186 127,522 3.6

89,864 325,660 235,796 362.4

Based on an analysis of the 560 survey results in the database and assuming a population size of 100,000 with 20,000 children (6 59 months) at each survey site. 2 Based on the WHO decision chart criteria, it is assumed that targeted SFP and TFP would be implemented in sites where GAM was 10 %, and blanket SFP implemented where GAM 15 %. For calculation of numbers for programmes using WHM-NCHS based admission criteria we have followed current practice and calculated GAM using WHZ-NCHS, but MAM and SAM using WHM-NCHS. For calculation of beneficiary numbers using WHZ-WHO we have assumed that GAM, MAM and SAM would be calculated using WHZ-WHO. 3 Number of potential beneficiaries for targeted SFP = Prevalence of MAM/100 x 20,000 in sites where GAM 10 % and < 15 %. Number of potential beneficiaries for blanket SFP = 20,000 - (Prevalence of SAM/100 x 20,000) in sites where GAM 15 %. Number of potential beneficiaries for TFP = Prevalence of SAM/100 x 20,000 in sites where GAM 10 %.

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Section 2
Modelling weight gains required for nutritional cure
In section 1 it was seen that a change in diagnostic criteria would result in changes in the number of patients that are eligible for admission to selective feeding programmes. To assess the resource implications of this change in patient numbers it is also necessary to look at any associated change in the duration of treatment. In this section a model is presented based on changes in weight gain required for nutritional cure. To determine the weight gain required it is assumed that the lowest weight during treatment is given by 70% WHM or -3 WHZ, and that patients are discharged at 85% or -1 WHZ respectively. These discharge criteria were selected as they are commonly used or likely to be so in the future, however, it is important to note that they are not universally adopted by all programmes. The analysis presented in this section is shown for lengths or heights between 49.0 and 110.0 cm and therefore includes young infants. To enable comparisons it is necessary to assume that programme technical performance is not affected by the diagnostic criteria adopted. This is a necessary assumption both for clarity of analysis and also because there is no comparative data available, so far, on the performance of TFPs using the WHO recommended admission and discharge criteria. However, it should be borne in mind that factors like overcrowding or the presence of more complex clinical cases can affect outcomes as much as the nutritional profile of admitted patients. Mean weight gain during selective feeding is calculated as grams per kg per day. A routinely used formula for calculating rates of weight gain is given below (8):

Mean weight gain =

weight on exit (g ) weight on admission (g ) weight on admission (kg ) duration of treatment (days)

Figure 4 shows a comparison of the weight gain required for patients admitted at 70% WHMNCHS or -3 WHZ-WHO, who are then discharged at 85% WHM-NCHS or -1 WHZ-WHO respectively. It can be seen that, in general, a larger absolute weight gain is required under the current WHM-NCHS based system compared to the proposed WHZ-WHO criteria.
Figure 4: Weight Gain Required for Nutritional Cure of SAM (Boys)
1

Admission criteria -3 Z-score WHO or 70% of the median NCHS; Discharge criteria -1 Z-score WHO or 85% of the NCHS median.

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Modelling days of treatment required for nutritional cure

The days of treatment required depend on the initial weight at admission and on the rate of weight gain. To estimate any difference in the number of treatment days required for nutritional cure of SAM, a weight gain rate of 8g/kg/day was used for initial comparisons. This is the minimum standard indicator adopted by the Sphere Project (8)8. Children between 65.0 and 110 cm are included in this analysis so that the results are consistent with the survey dataset analysed above. When considering the use of the percentage of the median diagnostic criteria, the length of treatment required for nutritional cure is independent of the length or height of the patient. For example, if a patient is admitted at 70% weight-for-height and gains weight at 10 g/kg/day then they will take 21 days to recover. This is mathematically true no mater what length or height they may be at admission. At a weight gain of 8 g/kg/d the number of treatment days required will be 27. However, when diagnostic criteria are based on a z-score then the days of treatment required will depend on the relative difference between the -3 and -1 z-score weights. This may differ according to the length/height of the child. The relationship between the recovery weight gain required at different lengths or heights and the diagnostic criteria used is shown in figure 5.
Figure 5: Days of Recovery Required for Nutritional Cure of SAM with a Weight Gain of 8g/kg/day (Boys)
1

Admission criteria -3 WHZ-WHO or 70% WHM-NCHS; Discharge criteria -1 WHZ-WHO or 85% WHMNCHS

It can be seen that, other things remaining equal, the treatment days required for cases admitted using WHZ-WHO will be less than those admitted using WHM-NCHS. At a weight gain of 8g/kg/day, 27 days of treatment would be required for programmes using WHM-NCHS while only 21 days of treatment would be required if using WHZ-WHO. With whichever diagnostic are used, if the rate of weight gain is slower then the number of treatment days will obviously increase. However, the relationship is not linear. In figure 6 it can be seen that there is a curvilinear relationship between the rate of weight gain and the average number of days of treatment required for children between 65 and 110 cm. Below a
8

Although 8g/kg/d is the current Sphere standard, it only applies to inpatient treatment and so is not applicable as a standard to home care based programmes. In the 2005 WHO/joint meeting on community based management, it was agreed that 5g/kg/day would be an appropriate criteria for the effectiveness of treatment in community-based management programmes (SCN/NPP 21/FNB p 104).

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rate of about 7 g/kg/day there is a steep increase in the duration of treatment required. The difference in the number of treatment days required also increases with decreasing weight gain, from 4.1 days at a rate of 10g/kg/day, up to 14.2 days at a weight gain of only 3g/kg/day. The difference in the duration of treatment required reflects the fact that the weight gain required for cure is consistently lower when using WHO-WHZ based diagnosis compared to WHM-NCHS.
Figure 6: Days of Treatment Required for SAM at Different Rates of Weight Gain (Boys)
1,2

80

WHM-NCHS
70

WHZ-WHO

60

Days of treatment

50

40

30

20

10

0 3 4 5 6 7 8 9 10

Rate of weight gain (g/kg/d)

Average duration of treatment for boys of length or height 65.0 - 110.0 cm.

Section 3
Modelling costs of treatment
The costs of running a selective feeding programme can be considered as comprising programme capital or fixed costs (e.g. vehicles, buildings, core staff) plus costs that vary by patient numbers (e.g. feeds, drugs). For the purposes of this report, the variable costs per patient will be expressed as an average cost per day of treatment. Total costs can therefore be expressed as:
Total costs = (capital costs per programme x no. of programmes) + (cost per treatment day x average duration of treatment x no. of patients)

From analysis of the 560 surveys considered for this report, we have seen that the results from 282 surveys indicated the need for selective feeding interventions when using WHZNCHS based diagnostic criteria, and that results from 297 surveys indicated the need for selective feeding programmes when using WHZ-WHO diagnostic criteria (table 3). Potential beneficiary numbers were calculated based on a sampling frame of 20,000 children and using the measured estimate of MAM and SAM prevalence. These numbers are also shown in table 3. However, it should be noted that while the overall number of potential beneficiaries for TFP increased much more than for SFP, the increase in absolute numbers for SFP was still substantial (158,000 vs. 236,000). The increase in potential beneficiary numbers for Blanket SFPs was the most important contributor to the increase in total SFP numbers.

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A major constraint in attempting a calculation of changes in treatment costs is the paucity of published data on the costs of running selective feeding programmes. One comprehensive compilation of costing estimates for community-based approaches to the treatment of SAM was made by Ashworth in 2006 (9). Even so, differences in the design of the programmes and the way cost data was collected and reported prevents a clear comparison between studies and limits the validity of any global estimates. There is a clear need for further research in this area. Another source of costing estimates comes from grey literature and conference presentations on the cost of implementing CTC programmes. Box 1 Sources of cost data on CTC programmes
1. Frexia (2003) provided estimates from ECHO for the cost per child per month (1) : SFC dry feeding, all costs included 9.00 TFC, all costs included 115 to 150 (3.80 4.96 /day) midpoint 132.5 / month; 4.38/day Combined SFC (20) & TFC (1) 20 25 2. 3. Caldwell and Hallam (2004) quote costs per Outpatient Treatment Programme (OTP) patient of 43 115 (2) Collins (2005) provided estimates of US$ 101 197 per OTP patient treated in emergency CTC, and US$ 308 326 per OTP patient treated in CTC programmes in developmental contexts (3).

For the purposes of this report the estimates provided by Frexia (10) (Box 1) are the most useful for two reasons. Firstly, they include costs for all SAM patients, not just those treated in outpatient programmes; and secondly, the costs are expressed per unit of time. Using the midpoint estimate of 4.38/day and the current conversion rate of 1.36 US$, gives a working estimate of US$ 5.96 per patient per day of SAM treatment. For capital (fixed) costs a figure of US$ 50,000 was selected as a reasonable estimate. These estimates are included in the calculation presented below in Table 4.
Table 4 - Estimation of the change in costs for treatment of SAM (US$)*
WHM-NCHS WHZ-WHO

Programme capital cost

50,000

50,000

Cost per treatment day

5.96

5.96

Number of programmes

282

297

Number of patients

89,864

325,660

Duration of treatment (days)

26.8

21.3

Rate of weight gain

Total costs Difference Difference per site Difference (%)

$28,427,860

$56,113,502 $27,685,642 $49,439 97%

*Data on programme and patient numbers are taken from the analysis of 560 surveys described in section 1

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To assess the impact on costs of treating MAM the estimate of 9.00/patient/month was used (US$ 0.30/patient/day) with the assumption that treatment would proceed for a fixed duration 9 of 90 days. The results of this assessment are shown in table 5.

Table 5 - Estimation of the change in costs for treatment of MAM (US$)*

WHM-NCHS WHZ-WHO

Programme capital cost

50,000

50,000

Cost per treatment day

0.40

0.40

Number of programmes

282

297

Number of patients

3,718,972

3,877,530

Duration of treatment (days) Total costs Total cost difference Difference per site Difference (%)

90 $149,532,051

90 $156,056,183 $6,524,132 $11,650 4%

*Data on programme and patient numbers are taken from the analysis of 560 surveys described in section 1

While the nature of the data underlying the assumptions in the model reduce confidence in the absolute amounts, what is important is the magnitude of the difference in total programme costs incurred when using the different diagnostic criteria. It can be seen that the funding required for implementing therapeutic feeding nearly doubles when moving from WHM-NCHS to WHZ-WHO. This, at first glance, appears a somewhat lower increase than might be expected given that about 4 times as many patients are expected to be eligible for admission under the new criteria. However, it should be noted that average duration of treatment decreases when using WHZ-WHO due to the lower weight gains required. In addition, the increase in capital (fixed) costs is relatively small as only an additional 15 programmes are initiated when using the proposed diagnostic criteria. The sensitivity of the SAM treatment cost model was evaluated by varying the rate of weight gain, which determines the treatment duration, and varying the level of programme capital costs. An increase in the variable costs per patient will tend to increase the difference in total costs resulting from the use of the two diagnostic criteria, while if capital costs increase proportionately then there will be less difference in total costs. For example, if the duration of treatment increases due to lower weight gain, the difference in total costs would be expected to increase. The results of the sensitivity analysis are plotted in figure 7. The curves show programme costs at different levels of capital costs and rates of weight gain. It can be seen that as capital costs increase the difference in total costs falls. Also, at each level of capital cost the total cost difference increases with decreasing rates of weight gain. The range of difference encompassed by these curves is an increase in costs from between 160 to 260 %.

Recent research has suggested that the median duration of SFP treatment is 68 days.

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Figure 7: Sensitivity of the SAM treatment programme cost model to different levels of capital cost and rates of weight gain
280

$100,000 Capital Cost

260 240

$50,000 $25,000

% increase in costs

220 200 180 160 140 120 100 3 4 5 6 7 8 9 10

Weight gain (g/kg/day)

As noted above, for the MAM treatment cost model it is assumed that duration of treatment is fixed. Varying the capital costs produced only a minor change in total costs and costs per programme (data not shown). The 4 % increase in costs for MAM treatment can be estimated as equivalent to about US$ 12,000 per site. This contrasts with the nearly US$ 50,000 increase per site required for treatment of SAM. To assess the overall impact it is necessary to combine the models for SAM and MAM treatment costs. The approx. US$ 60,000 increase per site equates to an overall 19% increase in the total programme costs for the combined treatment of SAM and MAM if programmes move to the proposed WHZ-WHO based diagnostic criteria.

Conclusions and recommendations

1. If emergency nutrition programme move from the use of WHM-NCHS to using WHZWHO diagnostic criteria there will a requirement for substantial additional funding to enable the additional TFP patient load to be managed effectively. 2. However, it should be noted that programme costs do not increase in direct proportion to the number of patients. Although the median estimate indicates four times as many patients would be eligible for treatment when using diagnostic criteria based on the WHO 2006 Growth Standards, the total programme costs associated with this increase would only double. This is partly accounted for by the reduction in treatment duration associated with the use of WHZ-WHO diagnostic criteria. 3. To facilitate a smooth transition a number of related steps would be required. One of these would be to engage donors with a clear explanation of the functioning of the new diagnostic criteria and a justification for the additional funding that would be required for this aspect of their humanitarian funding. 4. Programme managers and proposal writers would need to understand the additional resource requirements needed for running TFPs, whether these are centre or community based approaches.

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5. Consideration needs to be given by a technical review committee to the use of the GAM-based WHO decision criteria for selective feeding implementation (6). Are the criteria appropriate for use with the proposed WHZ-WHO diagnostic criteria?

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Part 2 - A Review of Software Available for the Calculation of Acute Malnutrition Using the NCHS Reference and WHO Standards Overview
Calculation of anthropometric status may be achieved using a number of different indicators and methods. This review will look at the software available for use in the calculation of weight-for-height z-scores and percentage of the median from the NCHS Reference, and the calculation of z-scores from the WHO Growth Standards. In emergency nutrition work it is desirable to have software that requires a minimum of preservice training, is easy and quick to use, and which produces results in a standardised format. This will facilitate efficient report preparation and aid appropriate decision-making by the users of the information. Software was therefore assessed on the basis of ease of use and compatibility of the results generated with the standard reporting formats used in emergency nutrition surveys and assessments. A formal international standard exists for the evaluation of software in the form of ISO/IEC 9126.10 This standard has 4 parts that were published between 2001 and 2004 and are concerned with describing a quality model, external metrics, internal metrics, and quality in use metrics. Within this quality model the usability characteristic is defined as a set of attributes that bear on the effort needed for use, and on the individual assessment of such use, by a stated or implied set of users and has three sub-characteristics: learnability; understandability; and operability. While this review in no way pretends to be a formal ISO evaluation, some of the ISO principles and assessment criteria have been used in evaluating key characteristics of the software.

Objective technical and user service comparisons

Parameters that could be objectively assessed are displayed in the first part of table 6. All the software considered is easily available to those with a reasonable internet connection and is free to use and distribute. With the exception of EpiInfo v6.04 and the WHO macros, installation of all the software is quick and easy, and can be completed within 30 minutes. The operating systems required for most is MS Windows, although WHO Anthro 2005 can also operate on MS PocketPC or MS Windows Mobile systems11. With the exception of the WHO macros, which are designed for use with commercial statistical packages, there is no software currently available for use with Macintosh computers. Technical support, help documentation and the facility for bug reporting show some variation between products. Epi Info for windows is the only package that currently provides the desirable level of full user support. One important technical requirement, in the context of this review, is that anthropometric results can be calculated using either the NCHS 1978 Reference or the WHO 2006 Standard.
International Standards Organisation http://www.iso.org/iso/en/CatalogueDetailPage.CatalogueDetail?CSNUMBER=39752&ICS1=35&ICS2=80&ICS3 11 A new version of WHO Anthro has been released since the compilation of this report.
10

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However, this limits the options to only two of the software packages considered, WHO Anthro 2005 and ENA. Some other packages include the CDC 2000 reference but this is of very limited use in the context of emergency nutrition assessments. It should be noted that the ENA upgrade that permits use of the WHO 2006 standards has only just been released. We might anticipate that other packages may also offer use of the WHO standards in forthcoming upgrades. Data file import and export functions are available in all packages except Nutrisurvey and are not regarded as a constraint to the use of any of these software, assuming that users also have Excel available. For the purposes of compatibility, both ENA and WHO Anthro 2005 allow direct import of Epi Info version 5 and 6 .rec data files, aswell as more generic .dbf files. For Epi Info 5/6 users, this feature would allow the continued use of Epi Info for questionnaire design, data entry and cleaning, whilst permitting analysis and summary statistics to be produced in the newer packages. Data double entry and validation functions vary between packages with only Epi Info having the full range of programmable functions. However, the plausibility reports available in Nutrisurvey and ENA are valuable tools for data checking and cleaning. These include consideration of skewness and kurtosis and digit preferences. Complex sample analysis that involves weighting and stratification is only possible in Epi Info or by using the WHO macros in conjunction with a commercially available statistics package. Another analysis issue that has been of longstanding concern is the exclusion of oedema cases from the standard summary output of the EpiNut programme within Epi Info v6.04. This omission has the effect of reducing the estimated prevalence of GAM and SAM in situations where oedematous malnutrition is found. Users have worked around this issue by analysing results manually using C-Sample, but, inevitably, mistakes have occurred (11). The production of a summary statistics output is extremely useful in ensuring rapid analysis and report preparation. However, only one package, ENA, provides this in a standard format that can be immediately included in a nutrition survey report. Users of this function will also require MS-Word or Excel to be installed on their computers. It is important to mention here that there are serious concerns over the reporting format used by WHO Anthro 2005 (12). Unfortunately, WHO Anthro 2005 does not report the prevalence of oedematous malnutrition in a way that that is easy to interpret, and in situations where there is a high prevalence of oedema the reported prevalence of wasting may be misleading. This is because the software adds together children with nutritional oedema or wasting and, instead of labelling then as acutely malnourished, labels them misleadingly as wasted (<-2 SD Weight for length/height) and/or severely wasted (<-3 SD Weight for length/height). The results output does include a footnote stating that cases with oedema are included in the <-2 and <-3 z-score categories and gives the number of cases with oedema. However, to ensure correct and easy reporting the data needs to be presented both in its disaggregated form, with separate prevalence figures given and associated confidence intervals, and as aggregated totals, correctly labelled as global acute and severe acute malnutrition. Finally, the calculation of confidence intervals is performed by all packages except Nutrisurvey and, in addition, Epi Info and ENA also provide a measure of the design effect when analysing cluster surveys. When using a sample database for testing, it was noted that the 95% CI for GAM, generated using Epi Info 6.04 (C-sample), WHO Anthro 2005, and ENA, were different. For a database with 850 children and a GAM prevalence of 10.6% the 95% CI reported by the three software packages were 7.8 - 13.5; 8.5% - 12.7%; and 6.9 - 14.3 respectively. The design effect reported by C-Sample and ENA was 1.96. It appears that the WHO Anthro 95% CI is calculated without allowing for the design effect of cluster sampling. This seems likely as the interval reported is very similar to that calculated using other methods for a simple random sample.12 This represents an important technical error that requires urgent correction.
12

Analysis was conducted using Epitable in Epi Info 6.04.

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The reason for the difference between the intervals reported by Epi Info 6.04 (C-Sample) and ENA is not immediately obvious. A number of different formulas exist for the calculation of confidence intervals and clarification of the methods used in both programmes would be of obvious benefit to the users.

Subjective assessments of usability

The results from a subjective assessment of usability are shown in the second part of table 6. The gradings are presented in terms of the amount of training and knowledge that would be required by a user to effectively utilise the software. Green, orange and red colour coding is used to aid interpretation, and represents low, medium, and high requirements respectively. The assessment was performed by the author on the basis of his experience of conducting surveys and training workshops. However, as such, the assessment of usability remains a subjective personal judgement. The package that emerges with the best usability profile is ENA, with Epi Info 6.04 and the WHO macros possessing the least user-friendly characteristics. The different elements of usability that were assessed are described in table 6.

Conclusions and recommendations

There are important constraints with using most of the available software for calculation of the prevalence of acute malnutrition from survey data. The choice of software is, for many workers, a personal issue and will depend on their previous experience and training, preference for user interface, technical knowledge, intended usage (e.g. will they want to conduct complex survey designs with stratification or are they only interested in standardised 30 cluster designs) and the policy of the organisation for which they are working. Any recommendations should therefore be viewed with this in mind. However, after a comparison of the various characteristics, summarised in table 6, two recommendations on software use are possible: 1. For standardised nutrition cluster or simple random sample surveys ENA stands out as being the most user friendly and providing the highest level of functionality. It can analyse results using the WHO standards or NCHS references. Due to the fact that the latest upgrade was only released in June 2007, operational experience with this software is limited. Contingent on successful field experience, this software is recommended for routine use in emergency nutrition surveys. 2. For surveys with more complex designs including strata or requiring sample weighting ENA does not include the required functionality. In this case, and if only NCHS reference based analysis is required, analysis with one of the Epi Info packages is recommended. If results also need to be analysed with the WHO standards then use of one of the WHO macros and a commercial statistics package will be required. While the nomenclature of the different references/standards will only be a minor issue for most users, there is potential for some confusion in this area. This is reflected by the different naming convention currently in use. Historically, the World Health Organization recommended in 1978 that the normalised form of the National Center for Health Statistics/Centers for Disease Control growth reference curves be used as an international growth reference (13). In April 2006, the WHO Child Growth Standards, having been developed over a number of years, were released for public use. It is therefore recommended that in software programmes: 3. The WHO Standards are referred to in full as the WHO 2006 Child Growth Standards.

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4. The NCHS Reference is referred to in full as the NCHS 1978 International Child Growth Reference. 5. It is recommended that the methods used for the calculation of the 95% confidence intervals for prevalence estimates is fully documented for ENA and WHO Anthro. This would allow users to understand why there may be differences in the intervals calculated by the different software and to interpret the significance of their results more fully.

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Table 6 - Comparison of Selected Software Characteristics

Criteria

Epi Info

Epi Info (for Windows) NutriSurvey WHO Anthro 2005

Version 1, 2000 None NutriSurvey for SMART, 2004 None

Emergency Nutrition Assessment (ENA)

WHO Macros for Statistical Software

None

Previous versions

Version 1, 1986 Version 5, 1990 Version 6, 1992

Current version and release dates

Version 3.4.1 rd July 3 2007 NutriSurvey, 2005 ENA th June 9 2007

Version 6.04d 2001

PC beta version th Feb 17 2006 Mobile devices version 1.00, 2006

SPSS 27th Sept 2006 (including versions for DHS and MICS survey results) SAS S-Plus STATA NCHS Reference 1978 WHO Standards 2006 English WHO Standards 2006 English

Incorporated anthropometric references/standards

NCHS Reference 1978 CDC 2000 English. Spanish, Italian and Russian translations available English English Freeware/Internet download CDC, Atlanta Dr Juergen Erhardt Freeware/Internet download NCHS Reference 1978 CDC 2000 NCHS Reference 1978 WHO Standards 2006

NCHS Reference 1978

Languages

English

Pricing/Availability

Freeware/Internet download

Freeware/Internet download Dr Juergen Erhardt

Freeware/Internet download WHO, Geneva

Freeware/Internet download WHO, Geneva

Authors/Publishers
http://www.cdc.gov/epii nfo/downloads.htm http://www.nutrisurvey. de/

CDC, Atlanta

Download site

http://www.cdc.gov/ep iinfo/Epi6/ei6.htm

http://www.nutrisurvey.de /ena/ena.html

http://www.who.int/child growth/software/en/

http://www.who.int/childgr owth/software/en/

Operating Systems requirements

PC-DOS or MS-DOS (will run on MS Windows 98/2000/XP) No Macintosh version MS Windows 98/NT 4.0/2000/XP No Macintosh version Yes Yes

MS Windows 98/NT 4.0/2000/XP No Macintosh version

MS Windows 98/NT 4.0/2000/XP No Macintosh version

MS Windows for PCs or MS PocketPC or MS Windows Mobile No Macintosh version No Yes Yes

MS Windows or Macintosh

Manuals available (electronic or hard copy)

Yes

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Criteria

Epi Info

Epi Info (for Windows) NutriSurvey WHO Anthro 2005

Yes No Yes Yes

Emergency Nutrition Assessment (ENA)

WHO Macros for Statistical Software

Yes

Manuals available (electronic or hard copy)

Yes Free support from CDC Epi Info helpdesk http://www.cdc.gov/epo/ dphsi/contact.htm Yes Not available Not available Not shown Yes (standard formats) No Yes (EpiInfo 5/6 or dbase files) Yes (Excel .xls file) Not shown Not shown Not shown Yes (EpiInfo 5/6 or dbase files) Yes (Excel .xls file)

Technical support

Free support from CDC Epi Info helpdesk http://www.cdc.gov/ep o/dphsi/contact.htm

Not available

Calculation algorithms/formulae

Not shown

Available in syntax files N/A

Data file import

Yes (standard formats) Yes (to SPSS)

Yes (standard formats)

Data file export

Yes (standard formats)

N/A

Data double entry and validation functions

Plausibility checks Sample weighting and stratification can be performed Not included Not in standard reporting format Included Not in standard reporting format Not included

Double entry and data entry programming and validation Double entry and data entry programming and validation

Built in data entry checks, double entry and data plausibility reports Not included

Built in data entry checks

N/A

Complex sample analysis (weighting and stratification)

Sample weighting and stratification can be performed

Not included

N/A

Summary statistics output

Not in standard reporting format

Provided in standard reporting format Included

Not in standard reporting format Included

Not in standard reporting format Not included

Calculation of confidence intervals

Bug reporting facility. Regular upgrades.

Included

Maintainability (Upgrades and bug reporting/fixes)

No longer upgraded.

Bug reporting facility. Last upgrade in 2005.

Bug reporting facility. Regular upgrades.

Bug reporting facility. New release so no assessment of upgrades possible.

Bug reporting facility. New release so no assessment of upgrades possible.

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Criteria

Epi Info

Epi Info (for Windows) NutriSurvey WHO Anthro 2005

MS Windows MS Windows MS Windows MS Windows

Emergency Nutrition Assessment (ENA)

WHO Macros for Statistical Software

MS Windows or Macintosh

User interface

DOS command line/windows emulation

Usability assessment13
Low level of user knowledge/training required Moderate level of user Moderate level of user Low level of user knowledge/training required Low level of user knowledge/training required Low level of user knowledge/training required

Moderate level of

- Installation

High level of user knowledge/training required

- Learnability

- Operability
Moderate level of user Moderate level of user

user knowledge/training required High level of user knowledge/training required High level of user knowledge/training required knowledge/training required Moderate level of user knowledge/training required High level of user knowledge/training required knowledge/training required knowledge/training required knowledge/training required Low level of user knowledge/training required
Low level of user knowledge/training required Low level of user knowledge/training required

Low level of user knowledge/training required Low level of user knowledge/training required

High level of user knowledge/training required High level of user knowledge/training required High level of user knowledge/training required High level of user knowledge/training required

- Understandability

High level of user knowledge/training required

Subjective measures of usability were scored solely on the personal experience and views of the author as a trainer and user of the software products. The scores are colour coded to aid interpretation. N/A - not applicable

13

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References
(1) Costs and trends in treating severe acute malnutrition, CTC Workshop, October 2003. 03 Mar 20; Dublin: ECHO, 2003.

(2) Caldwell R, Hallam A. Community-based therapeutic care (CTC). Khara T, Collins S, editors. 2. 2004. Oxford, Emergency Nutrition Network. Special Supplement Series. (3) Cost of emergency CTC: Early data from NGO implemented emergency CTC programs. 05 Nov 1; 2005. (4) Penchansky R, Thomas JW. The Concept of Access - Definition and Relationship to Consumer Satisfaction. Medical Care 1981; 19(2):127-140. (5) Berkley J, Mwangi I, Griffiths K, Ahmed I, Mithwani S, English M et al. Assessment of severe malnutrition among hospitalized children in rural Kenya - Comparison of weight for height and mid upper arm circumference. Jama-Journal of the American Medical Association 2005; 294(5):591-597. (6) World Health Organization. The Management of Nutrition in Major Emergencies. Geneva: World Health Organization, 2000. (7) MSF. Nutrition Guidelines. Paris: Medecins Sans Frontieres, 1995. (8) Sphere Project. The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response. The Sphere Project, 2004. (9) Ashworth A. Efficacy and effectiveness of community-based treatment of severe malnutrition. Food and Nutrition Bulletin 2006; 27(3):S24-S48. (10) Costs and trends in treating severe acute malnutrition, CTC Workshop, October 2003. 03 Mar 20; Dublin: ECHO, 2003.

(11) Prudhon C, Spiegel PB. A review of methodology and analysis of nutrition and mortality surveys conducted in humanitarian emergencies from October 1993 to April 2004. Emerg Themes Epidemiol 2007; 4:10. (12) Seal A, Kerac M. Operational implications of using 2006 World Health Organization growth standards in nutrition programmes: secondary data analysis. British Medical Journal 2007; 334(7596):733-735. (13) Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL. Development of normalized curves for the international growth reference: historical and technical considerations. Am J Clin Nutr 1987; 46(5):736-748.

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