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Archive for "Nutrition"

Nutrition &Seasonal Malaria Chemoprevention Bill Brieger | 23 Nov 2019

Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition

Moumouni Bonkoungou, Ousmane Badolo, Youssouf Sawadogo, Stanislas Nebie, Thierry Ouedraogo, Yacouba Savadogo, William Brieger, Gladys Tetteh, and Blami Dao (affiliation PMI Improving Malaria Care Project; Jhpiego Baltimore; Johns Hopkins University; Ministry of Health, National Malaria Control Program) presented a poster entitled Using Seasonal Malaria Chemoprevention (SMC) to Screen for Acute Malnutrition at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria and malnutrition remain major public health burdens in Burkina Faso for children under five years of age. In 2017 the case fatality rate of malaria was 1.5 percent among children under five years of age and malaria was responsible for 35.9 percent of deaths in primary health facilities. Malnutrition was responsible for 4.6 percent of deaths in primary health facilities and 3.3 percent of deaths in hospitals in 2017.

What is IMC project? The US President’s Malaria Initiative (PMI) funded the Improving malaria Care (IMC) since 2013 to support National Malaria Control Program (NMCP). The goal is to improve quality of malaria prevention, diagnosis and treatment through 05 strategies.

Malnutrition was detected at the level of health facilities. The nutrition program did not have resources for active screening for malnutrition Since 2018, it has been decided on the couple with the SMC to recruit more children.

What is the strategy? In 2018, Burkina Faso Seasonal Malaria Chemoprevention (SMC) campaign integrated malnutrition screening in 12 health districts supported by IMC. During the SMC campaign, community health workers administer sulfadoxine-pyrimethamine + amodiaquine (SP+AQ).

They also screened for malnutrition using the Shakir sling to measure mid-upper arm circumference to detect for acute malnutrition. Children who are not severely malnourished receive the standard malaria preventative treatment by SP+AQ. Children diagnosed with severe malnutrition do not receive SP+AQ and are referred to health facilities for appropriate case management.

Moderate and severe malnutrition was documented in October 2019. In November, after the last round (October), 427 children with severe acute malnutrition have been reported by health facilities. 81.3 percent of severe acute malnutrition detected during SMC.

Challenges of SMC and malnutrition screening were documented as follows:

  • Inaccessibility of some areas
  • Reference of severe cases for management
  • Adequate home management of moderate cases
  • Proper care of referred children in health facilities
  • Follow-up of referrals
  • Search for those not followed-up

In Conclusion in the context of a limited resource country, SMC is a good strategy for the reduction of malaria cases as well as a great opportunity for the detection and management of malnutrition in children under five years of age. It is recommended to Couple the screening of malnutrition with other activities (immunization, distribution of bednets …). Raising parents’ awareness of the importance of managing cases is necessary as is Encouraging active case finding and community referral.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

Agriculture &Costs &Economics &Food Security &Nutrition Bill Brieger | 24 May 2018

Malaria Affects Agriculture and Food Security

The connections between malaria and food security are recognized in various international health and development frameworks. Below is a look at one side of the equation, how malaria in the household affects food security and agricultural production.

Lewnard and colleagues reported that severe food insecurity was associated with increased risk for positive malaria tests among the Batwa pygmies in Uganda. Also malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security in central Tanzania. The authors concluded that achieving targets like the MDGs, “requires the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions,” i.e. an integrated development approach.

A study in Niger hypothesized that Unconditional Cash Transfers (UCT) would have a positive impact on food security. Two different UTC regimens were tested along with a supplemental food package, but ironically the study found no difference in endline food security between arms. The group felt that the results were possibly driven by increased fever/malaria in children, and thus nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs.

Tusting and co-researchers recognize that agricultural development interventions reduce poverty. They also documented that relative agricultural success was associated with higher socio-economic position, which in turn, was associated with lower human biting rate of malaria-infected mosquitoes. They conclude that “Further interdisplinary research is needed to understand fully the complex pathways between poverty and malaria and to develop strategies for sustainable malaria control.” One possible pathway would be malaria prevention interventions. A study in Ghana reported that, “Children who slept under a bednet were also more likely than those who did not to live in a food secure household.”

Malaria interventions can also affect agricultural productivity. In a Zambian experiment, access to subsidized bed nets was randomly assigned at the community level, and 516 farmers were followed over a one-year farming period. The researchers found “large positive effects of preventative health investment on productivity: among farmers provided with access to free nets, harvest value increased by US$ 76, corresponding to about 14.7% of the average output value.”

Malaria and other endemic diseases affect agricultural productivity, income, and thus quality of housing

Studying the effects of malaria on employees of an oil palm plantation in Papua New Guinea, Pluess and team found that, “on average, an employee sick with malaria was absent for 1.8 days, resulting in a total of 9,313 workdays lost.” This is an indirect influence on a family’s food security.

farming communities often have access only to small medicine shops in the markets

Seeking malaria care can have untoward effects when fees are attached to health services. Johnson and co-researchers report that, “The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances.”

Malaria can deprive the household of funds needed for food. It can also reduce the ability of the family to work and produce or buy food. Such economic, social and nutritional impacts need to be taken into account in developing intersectoral malaria policies.

Nutrition Bill Brieger | 23 Dec 2011

Malnutrition’s multiple pathways, including malaria

The Sahel of West and Central Africa with its successive droughts is an area of nearly constant food insecurity and malnutrition.  Development partners, in trying to find more accurate ways to predict malnutrition and food insecurity have come to realize that the relationship between crop production on one hand and malnutrition on the other is complicated.

IRIN quotes USAID as saying “… the links between cereal production and malnutrition have been exaggerated, the complexities of regional market conditions inadequately conveyed, and the need for long-term structural solutions under-emphasized.” Furthermore, “While harvest outputs and malnutrition rates are linked, they are not inextricable.”  Ironically, food aid may not solve food problems.

dscn9123sm.jpgIRIN commented on the structural factors of the chronic malnutrition problem by saying that, “This is because much of the malnutrition in the region is caused by other factors: poor water quality, low-quality health care, poor sanitation and poor feeding practices.”

According to IRIN the magnitude of the problem is huge. “A third of the population of Chad is chronically undernourished, regardless of the rains or size of the harvest. More than 50 percent of the population in Niger suffers from food insecurity, with 22 percent extremely food insecure, according to the World Bank in 2009.”

IRIN suggests that the solution to the problem requires addressing “the multi-dimensional aspects of malnutrition, including livelihoods, food production, social protection, health, water and disaster risk reduction; and on responses that focus on strengthening the incomes of poor households.”

Although malaria prevalence is low and seasonal in the Sahel, it is one of the health risks that contribute to chronic malnutrition in the Sahel. Bechir and colleagues researching the problem in Chad found …

“Thirty-four percent (CI 27-40) of nonpregnant women, 53% (CI 34-72) of pregnant women, and 27% (CI 23-32) of children were anemic. In subjects infected with Plasmodium, all women and 54% (CI 22-85) of children were anemic. Malnutrition was significantly associated with anemia in mothers and with selected intestinal parasites, anemia and age in their children.”

As an intervention, Tine et al. found in Senegal that “Combining IPTc and HMM can provide significant additional benefit in preventing clinical episodes of malaria as well as anaemia among children in Senegal.”

We must not forget the interrelatedness of health and development issues and their interventions. More inter-sectoral thinking and planning is needed.

Agriculture &Nutrition &Urban Bill Brieger | 02 Jan 2009

urban hunger –> urban agriculture –> urban malaria

The growing problem of urban hunger and urban food insecurity was featured in the Wall Street Journal today. In Monrovia, Liberia, “The cost of a cup of rice has risen to nearly 50 cents from 20 cents, a huge leap for many families who live on less than $1 per day.” The result: “Escalating hunger in African cities is forcing aid agencies accustomed to tackling food shortages in rural areas to scramble for strategies to address the more complex hunger problems in sprawling slums.”

One of these strategies, according to IDRC is urban agriculture:

Urban agriculture (UA) is wrongly considered an oxymoron. Despite its critical role in producing food for city dwellers around the world, urban food production has largely been ignored by scholars and agricultural planners; government officials and policymakers at best dismiss the activity as peripheral and at worst burn crops and evict farmers, claiming that urban farms are not only unsightly but also promote pollution and illness. Contradicting this image, recent studies document the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women heads of households.

Urban farming requires water. The International Water Management Institute reports that, “Manual water fetching with watering cans is most common.” They often get water from “polluted streams or they do farming along storm water drains and gutters.” This sometimes leads to “wastewater irrigation.”

Of course malaria vectors need water. In urban Accra, Ghana, Klinkenberg and collaegues found that Anopheles and Culex “outdoor biting rates were respectively three and four times higher in areas around agricultural sites (UA) than in areas far from agriculture.”

The solution to the problem of urban malaria is not to stop urban agriculture, but to intensify integrated vector management interventions.  We certainly don’t want to protect people from malaria and then have then suffer from food insecurity.

Nutrition &Treatment Bill Brieger | 30 Sep 2008

When people can’t afford food – what of malaria treatment?

crs-food-crisis-urban-poor.jpgCatholic Relief Services describes the life of Rasmané, a day laborer in Burkina Faso, who works at “a plastic chair factory, where he makes about $37 a month. This won’t go far for Rasmané, his four kids, his mother and wife. That’s why they eat baobab leaves and cheap millet (see photo by Lane Hartill/CRS). A sack of rice that would last a few weeks costs about $55.”  According to CRS, “Some 75 percent of people living in or near Burkina’s major cities don’t have enough food to eat.”

Staple food prices have more than doubled. “Rasmané says he has never seen food prices jump like this. A portion of corn last year was 50 cents. Now, it’s $1.15. A portion of millet was 55 cents. Now it’s $1.25. For someone who doesn’t know from one day to the next if he will work, these price swings sting.” CRS notes the contrast: “Residents of Burkina Faso spend about 76 percent of their monthly income on food. Americans, on the other hand, spend only about 10 percent of their income on food a year, according to the USDA.”

The question arises, what if one of those 4 children get malaria?  Kouéta and colleagues found in Burkina that poor nutritional status was one of the key factors associated with increased risk of death in children with malaria.

Burkina had a short-lived Global Fund Malaria Grant in Round 2 and recently started on its Round 7 grant in June 2008. The first objective of the new grant is to “ensure proper treatment of simple malaria cases diagnosed in health facilities.” Public, private and community health workers are to be trained in proper case management. The GFATM expressed concern in the first progress report that there be proper coordination between principle and sub-recipients for full implementation. The need to closely monitor ACT estimations and actual consumption was stressed.

A reading of the Round 7 proposal implies that ACTs may be subject to the overall national strategy of cost recovery.  One wonders if people like Rasmané can really pay for proper malaria treatment for their children?

Mortality &Nutrition Bill Brieger | 23 Apr 2008

World food crisis and malaria

The Washington Post reports today that “More than 100 million people are being driven deeper into poverty by a “silent tsunami” of sharply rising food prices, which have sparked riots around the world and threaten UN-backed feeding programs for 20 million children,” according to the director of the World Food Program (WFP). The article reports that the WFP is running out of funds and may cut back on school feeding programs.

The WFP Director explained that because of rapidly rising food prices, “Those living on less than $1 a day were giving up meat and vegetables, and those living on less than 50 cents were facing increasingly desperate hunger.” WFP food rations are depicted in the WFP ‘red cup’ photo seen below.

wfp154505sm.jpgWhat are the implications for malaria?

In Mozambique, Bassat et al. (2008) found that. “For children aged eight months to four years, the risk factors [for dying from with malaria] were malnutrition, hypoglycaemia, chest indrawing, inability to sit and a history of vomiting.” In Tanzania Sunguya et al. (Tanzania Health Research Bulletin, 2006) found that, “coinfections [such as malaria] complicate the management of severe malnutrition and are associated with higher death rate.”

A review by Schaible and Kaufmann (2007) linked malnutrition with impaired immunity. They state that, “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.”

Whether the current food crises results from the international economic meltdown, global warming or diversion of food crops to make biofuels, the potential impact on mortality from malaria is serious. There has never been a greater need to link nutrition, agriculture policy and food aid with malaria programming. Vertical funding will not solve the problem.

Nutrition Bill Brieger | 07 Feb 2008

A to Z of reducing malaria morbidity

Nutrition Journal has just published a study that shows micronutrient supplements – Vitamin A and Zinc – can produce a ‘major reduction’ in malaria morbidity in Burkina Faso. Previous work has been pointing to a positive role for Vitamin A on malaria, and zinc has shown positive effects on other health problems such as diarrhoeal diseases. The authors hypothesized a positive effect of the two micronutrients, and were not disappointed. There was a 30% reduction in malaria cases and a 22% reduction in fever episodes in the supplemented group compared to the placebo group.

The study covered a 6-month period, and the regimen consisted of Vitamin A once and zinc supplementation daily, 6 days a week for the 6 months. The authors acknowledge that comparison arms with zinc only and Vitamin A only would have been instructive in determining whether the results were additive or synergistic. We assume others will take up this challenge, but assuming that we want now to add this A-Z regimen to the toolkit of malaria prevention, what are the implications for a safe and feasible delivery mechanism?

Concerning safety, the BBC quoted Dr Ron Behrens, an expert in tropical diseases at the London School of Hygiene and Tropical Medicine. He addressed the issue of seasonality of micronutrient deficiencies as well as the need for caution to avoid excess dosing of these supplements. “Neither of these micro-nutrients is totally safe. They should be used like pharmaceuticals, and not seen as cure alls,” he said.

Vitamin A has already been incorporated into immunization campaigns. The authors think that, “Ultimately, the more affordable and sustainable solution would be the incorporation of vitamin A and zinc in food fortification for children.” Campaigns may not offer a long term or sustainable delivery mechanism, and food supplementation in resource poor settings, especially more remote rural areas is not likely feasible in the foreseeable future.

the-tdr-program-has-shown-that-vitamin-a.jpgEnabling the community to take charge of delivery of malaria interventions has been advocated here. This works for Vitamin A supplementation as seen in the graph to the left and continues to be the preferred approach to ensure people participate in their own health care. Hopefully the Global Fund and other donors will be willing to pay for this addition to the malaria prevention toolkit.

Finally, Bhutta et al. in the Lancet this month offer another ‘ultimate’ or long term solution by recommending that nutritional “interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women’s empowerment.”

IPTi &Nutrition Bill Brieger | 08 Dec 2007

Better Nutritional Status through Malaria Prevention

Researchers in Senegal studied the effect of intermittent preventive treatment (IPT) of malaria for children during the malaria transmission season in that country and found that, “The prevention of malaria would improve child nutritional status in areas with seasonal transmission.” In particular mean weight gain was significantly better for those receiving IPT.

These researchers also note that similar positive results have been observed in other malaria prevention research efforts in the Gambia and Tanzania. The Tanzania work included ITNs in addition to IPT.

A basic child health monitoring tool, the Road to Health Chart, comes to mind. The guidance with the charts was usually to suspect illness, such as diarrhoeal diseases and TB should a child’s weight remain static or decrease between clinic visits. It is encouraging to know that we can also improve overall child nutritional status through malaria prevention. More work is needed to document these effects of preventive interventions in areas with year-round malaria transmission. Such results also add to the economic benefits arguments for malaria control as children with better nutritional status will hopefully grow into more productive adults.

Nutrition Bill Brieger | 14 Jul 2007

Hunger and Malaria

On Thursday a demonstration protesting hunger in Nigeria was broken up because of littering, a trivial excuse for trying to block attention to a crucial development and health issue.  Action Aid, organizers of the Abuja march said, “Despite the country’s massive oil wealth, one in three of Nigeria’s 140 million people goes to bed hungry.” Hunger and the related issue of malnutrition is especially important to control infectious diseases like malaria.
sscn1268.JPGThere has been controversy about the exact relationship between malnutrition and malaria, but greater death rates from all causes is associated with malnutrition. A recent PLoS review summarized the issue as follows: “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.” The review clarified that Chronic PEM was associated with malaria.

The association between malaria and the nutritional problem of anemia is not in doubt, and not long ago we shared findings about diet and Artemisinin-Lumenfantrine (AL), the most commonly recommended ACT. Studies found the need for adequate fat consumption to enhance AL absorption, a major challenge for hungry children who have poor diets with low energy intake.

Regardless of associations, the two issues, ending hunger and ending malaria, come together in the Millennium Development Goals. Both should receive the undivided attention of child health advocates and government policy makers