Trends in severe acute malnutrition admissions, characteristics, and treatment outcomes in Malawi from 2011 through 2019

Background Community-based Management of Acute Malnutrition (CMAM) has been successfully implemented across Malawi, yet trends in admissions, characteristics, and treatment outcomes in children with severe acute malnutrition (SAM) have not been examined. The objective was therefore to investigate trends in admissions, characteristics including percentage of children with SAM with HIV and oedema, and treatment outcomes across the decade following implementation of CMAM. Methods This research involved a retrospective analysis of existing data routinely collected across Malawi by the Ministry of Health between 2011 and 2019. Results These data showed an increase in outpatient therapeutic feeding (OTP) admissions from 30323 children in 2011 to 37655 in 2019 (p=0.045). However, a significant decrease in nutritional rehabilitation unit (NRU) admissions was observed, from 11389 annual admissions in 2011 to 6271 in 2019 (p=0.006). In children identified with SAM, the percentage with oedema decreased in OTPs with an average annual rate of reduction (AARR) of 5.6% (p=0.001) and by 26.2% in NRUs in this timeframe with an AARR of 8.5% (p<0.001). There was a decrease in the percentage of children with SAM who had HIV over time in OTPs with an AARR of 16.1% (p=0.001). HIV rates also decreased in NRUs with an AARR of 7.2% (p=0.4), but this difference was not significant. Death rates decreased in OTPs with an AARR of 6.0% (p=0.01). Mortality rates did not change in NRUs over time with an AARR of 0.9% (p=0.5) with the NRU mortality rate in 2019 being 11.0%. Conclusions These trends indicate that there has been an increase in OTP admissions and a corresponding decrease in NRU admissions. There have been decreases in the percentage of children with oedematous SAM in OTPs and in NRUs and with HIV in OTPs. Children remain at high risk of mortality in NRUs. Competing interests none to declare ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Trainee support for this project was awarded from the Canadian Institutes of Health Research. The sources of support had no role in designing this study, carrying out study activities or analysis, or writing the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for this analysis was obtained from the Malawi National Health Sciences Research Committee (Protocol #20/01/2459) in Lilongwe, Malawi. The information used in the analysis was routinely collected programmatic data; no individual patient information nor identifying information were collected and therefore informed consent was not required. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data are available upon reasonable request to the authors.