Acute malnutrition recovery rates improve with COVID-19 adapted nutrition treatment protocols in South Sudan: a mixed methods study – BMC Nutrition – BioMed Central
The national analysis of CMAM program data included sites operated by 58 partners, including both national and international NGOs. A total of 1852 unique CMAM sites provided data for at least 1 month during the review period, including 120 operating only OTPs, 75 operating only TSFPs, and 1657 operating both. Of all sites, 257 (14%) reported data for all 30 months under review. The number of CMAM sites reporting ranged from 1082 to 1197 in the pre-COVID period and 1164–1223 during COVID with the median number of CMAM sites increasing from 1167 pre-COVID to 1189 during COVID. The monthly median number of CMAM sites reporting data increased in seven of the ten states, with only Upper Nile (− 24), Northern Bahr el Gazal (− 11), and Lakes (− 9) states reporting decreases (Additional file 1).
Admissions
South Sudan experiences seasonal trends in nutrition program admissions, characterized by an increase in monthly admissions between the beginning of the year (January) and spring (April to June), and a decrease through the second half of the year. Prior to the onset of the pandemic, seasonal declines in SAM and MAM admissions were observed from May to December 2019, which were followed by enrollment increases in the first quarter of 2020. Following the onset of COVID-19, trends for both SAM and MAM admissions were similar, though there was less month-to-month variation in SAM admissions compared to the previous year.
Aggregated by period, the total number of SAM admissions declined by 8.2% during COVID-19 (from 282,289 pre-COVID to 259,067 during COVID) despite the increase in the number of reporting sites. The total number of MAM admissions increased slightly by 1.1% (from 639,752 pre-COVID to 646,877 during COVID) (Fig. 1). Total admissions for SAM and MAM decreased during COVID in eight and six states, respectively. Western Equatoria and Jonglei were the only states with increases in total admission for both SAM and MAM (Fig. 2). In eight of ten states, the directional change of SAM and MAM admissions was the same; the exceptions were Warrap and Unity, which saw decreases in SAM admissions and increases in MAM admissions. Northern Bahr el Ghazal, Lakes, and Upper Nile had the largest declines in admissions and were also the only states to have fewer CMAM sites reporting during COVID.
Trends in Monthly SAM and MAM Admissions Over Time
Change in Total SAM and MAM Admissions by State (percent change pre-COVID [January 2019-March 2020] to COVID [April 2020-June 2021] periods)
Given relatively large fluctuations in the absolute number of admissions in select sites, median monthly admissions were also reviewed. Nationally, median monthly admissions decreased by 21.8% for SAM and 6.7% for MAM between periods (Table 1). At the state level, changes in median monthly SAM admissions ranged from − 38.3% (Upper Nile) to 25.4% (Western Equatoria); for these states, changes in median monthly MAM admissions were similar, ranging from − 34.9% (Upper Nile) to 24.9% (Jonglei).
The ratio of children admitted for treatment of MAM to those admitted for SAM treatment pre-COVID was 2.3 compared to 2.5 during COVID, with state-level ranges of 2.0–3.1 pre-COVID and 2.0–4.0 during COVID. The largest shift in MAM:SAM admissions ratio was in Warrap, which was the only state with opposing admissions trends: a 22.8% decrease in SAM admissions in parallel with an 11.8% increase in MAM admissions.
Recovery rates and other treatment outcomes
Monthly recovery rates of children with SAM from March 2020 onwards exceeded those of the corresponding month in the pre-COVID period. Monthly recovery rates for MAM increased slightly from March 2020 through late 2020 and remained consistently above recovery rates for the corresponding month of 2019 through November (Fig. 3). Monthly SAM recovery rates from January 2019 to February 2020 ranged from 89 to 94% compared to 93–96% from March 2020 forward, and median monthly recovery rates improved from 92.0% pre-COVID to 95.7% during the COVID period. For MAM, monthly recovery rates ranged from 91 to 93% from January 2019 to February 2020 and increased to 92–95% from March 2020 forward, with the median monthly recovery rate increasing from 91.5% pre-COVID to 94.3% during COVID.
Trends in Monthly SAM and MAM Recovery Rates Over Time
All states saw improvements in median monthly recovery rates for both SAM and MAM during COVID (Table 2). The greatest improvements in median monthly SAM recovery rates were seen in Upper Nile (7.9%) and Central Equatoria (5.6%), which had the lowest pre-COVID recovery rates. The highest median monthly SAM recovery rates during COVID were in Western Bahr el Ghazal (98.2%) and Western Equatoria (97.9%). Median monthly MAM recovery rates increased the most between periods and at similar levels (4.0–4.6%) in Western Bahr el Ghazal, Eastern Equatoria, Upper Nile, and Northern Bahr el Ghazal. During COVID, the highest recovery rate was in Western Bahr el Ghazal (98.0%), and the lowest was in Northern Bahr el Gazal (88.6%). Unity State had the smallest increase in median monthly SAM and MAM recovery rates, though this was attributed to having the highest pre-COVID recovery rates (97.0% for SAM and 95.9% for MAM). With the exception of Aweil Centre County in Northern Bahr el Gazal, all counties had SAM and MAM recovery rates above the 85% treshold set out in the Sphere Standards [13]. With pre-COVID recovery rates of 72.6% for SAM and 61.8% for MAM, Aweil Centre was an outlier. Recovery rates for SAM and MAM increased by 0.5 and 7.4%, respectively, from the pre-COVID to COVID period in Aweil Centre, however, gains were insufficient to meet performance standards.
While recovery rates increased for both SAM and MAM, the total number of children recovered decreased by 8.3% for SAM with varied direction of change across states, and by 1.8% for MAM (Table 3). This change is primarily due to declines in CMAM program admissions. The greatest reduction in the number of SAM children recovered was in Northern Bahr el Ghazal, where there was a similar proportional decrease in median monthly SAM admissions (a common occurrence). The greatest increase in the number of MAM children recovered was in Warrap (17.3%), and the greatest decrease was in Central Equatoria (14.9%).
In addition to the proportion of children recovered (recovery rate), CMAM programs report the proportion of children that exit as non-recovered, defaulters, and deceased. The recovery, default, and non-recovered rates improved for both OTP and TSFP at the national level, with mortality rates remaining constant at 0.05–0.15%. The default rate declined from the pre-COVID to COVID period by 2.4% (4.8% pre-COVID vs. 2.4% during COVID) for SAM and 1.7% for MAM (4.3% pre-COVID vs. 2.6% during COVID). The non-recovered rate declined by 0.9% (2.6% pre-COVID vs. 1.7% during COVID) for SAM and 1.1% for MAM (4.1% pre-COVID vs. 3.0% during COVID) (Fig. 4). While median monthly mortality rates were stable for both SAM and MAM, the total number of SAM deaths fell by 35.2% (324 deaths pre-COVID vs. 210 during COVID), and the total number of MAM deaths decreased by 42.1% (324 deaths pre-COVID vs. 210 during COVID). The largest proportional increases in SAM deaths occurred in Western Bahr el Ghazal (300%) and Unity (100%), whereas the largest increases in the number of MAM deaths were in Western Bahr El Ghazal (717%) and Central Equatoria (137%).
Change in Exit Outcomes for SAM and MAM During COVID-19
