Combining Treatment of Acute Malnutrition With Integrated Community Case Management: A Cluster-Randomised Controlled...

Achieving good treatment coverage and outcomes for acutely malnourished children is challenging in resource limited and remote settings. Inclusion of treatment within integrated community case management (iCCM) programmes has shown promise, but evidence is limited. We conducted a cluster randomised controlled trial in rural villages within the districts of Hargeisa, Gabiley, and Faraweyne in Somaliland. We compared treatment coverage and outcomes between 18 villages implementing iCCM, where cases of malnutrition (mid-upper arm circumference (MUAC) < 12.5 cm and/or oedema) were referred to MCH clinics, and 19 villages implementing iCCM +, where malnutrition treatment was provided by family health workers (FHW) at village level. Coverage was measured in a closed household cohort at baseline and after 6 months of intervention. Treatment outcomes were determined in an open cohort of cases that were identified by the iCCM FHW and followed up on each month. The prevalence of acute malnutrition diagnosed using MUAC was four-fold lower compared to that diagnosed using weight-for-height z-scores (WHZ) (3% vs. 13%). This larger than expected difference resulted in the study being underpowered. Treatment coverage was 27% and 23% in the control and intervention arms at baseline and increased sharply in the intervention arm with an adjusted difference of 20 percentage points. However, the improvement was not statistically significant (adjusted OR 2.55 (95% CI 0.4, 18.8) p = 0.344). Cases were more likely to start treatment in the intervention arm (difference 71.9% (95% CI 58.1, 85.7) p < 0.001), but relapse and non-response were more frequent (p = 0.041 & p = 0.004). Over diagnosis of acute malnutrition by FHW was high, with 67.4% and 77.4% of cases being misdiagnosed in the control and intervention arm, respectively. While the integration of malnutrition treatment with iCCM shows potential for improving treatment coverage in some contexts, careful consideration should be given to the level of training and supervision required. TRIAL REGISTRATION: ISRCTN31437934. Registered 3/10/2023.