Research Center Health Policy and Systems - International Health, School of Public Health, Université Libre de Bruxelles, Bruxelles, Belgium.
Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland.
Nutr J. 2018 Sep 15;17(1):81. doi: 10.1186/s12937-018-0382-6.
Severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO standards, or a mid-upper-arm circumference (MUAC) of < 115 mm or there is nutritional oedema. Although there has been a move to eliminate WHZ as a diagnostic criterion we have shown that children with a low WHZ have at least as high a mortality risk as those with a low MUAC. Here we take the estimated case fatality rates and published case-loads to estimate the proportion of total SAM related deaths occurring in children that would be excluded from treatment with a MUAC-only policy.
The effect of varying case-load and mortality rates on the proportion of all deaths that would occur in admitted children was examined. We used the same calculations to estimate the proportion of all SAM-related deaths that would be excluded with a MUAC-only policy in 48 countries with very different relative case loads for SAM by only MUAC, only WHZ and children with both deficits. The case fatality rates (CFR) are taken from simulations, empirical data and the literature.
The relative number of cases of SAM by MUAC alone, WHZ alone and those with both criteria have a dominant effect on the proportion of all SAM-related deaths that would occur in children excluded from treatment by a MUAC-only program. Many countries, particularly in the Sahel, West Africa and South East Asia would fail to identify the majority of SAM-related deaths if a MUAC only program were to be implemented. Globally, the estimated minimum number of deaths that would occur among children excluded from treatment in our analyses is 300,000 annually.
The number, proportion or attributable fraction of children excluded from treatment with any change of current policy are the correct indicators to guide policy change. CRFs alone should not be used to guide policy in choosing whether or not to drop WHZ as a diagnostic for SAM. All the criteria for diagnosis of malnutrition need to be retained. It is critical that methods are found to identify those children with a low WHZ, but not a low MUAC, in the community so that they will not remain undetected.
当体重与身高的 Z 评分（WHZ）为 <-3Z 低于世界卫生组织标准，或中上臂围（MUAC）< 115 毫米，或存在营养性水肿时，诊断为严重急性营养不良（SAM）。尽管已经采取措施消除 WHZ 作为诊断标准，但我们已经表明，WHZ 较低的儿童的死亡率风险至少与 MUAC 较低的儿童一样高。在这里，我们根据估计的病死率和已发表的病例数，估计仅采用 MUAC 作为诊断标准时，SAM 相关死亡总数中会排除多少儿童。
我们检查了病例数和死亡率的变化对纳入儿童所有死亡比例的影响。我们使用相同的计算方法，根据仅 MUAC、仅 WHZ 和两种指标均有缺陷的儿童的相对病例数，估计在 48 个 SAM 病例相对负荷差异很大的国家，仅 MUAC 政策将排除多少与 SAM 相关的死亡。病死率（CFR）取自模拟、实证数据和文献。
仅 MUAC、仅 WHZ 和同时具有两种指标的 SAM 病例数对排除在 MUAC 单一方案治疗之外的儿童中所有 SAM 相关死亡的比例有很大影响。如果实施 MUAC 单一方案，许多国家，特别是萨赫勒地区、西非和东南亚的国家，将无法识别大多数 SAM 相关死亡。全球范围内，在我们的分析中，由于治疗而被排除在外的儿童每年发生的死亡人数估计至少为 30 万。
任何现行政策变化都会排除治疗的儿童数量、比例或归因分数是指导政策变化的正确指标。仅病死率不应作为指导政策是否放弃 WHZ 作为 SAM 诊断标准的依据。所有营养不良诊断标准都需要保留。找到一种方法，在社区中识别那些 WHZ 低但 MUAC 不低的儿童，至关重要，这样他们就不会被遗漏。
