Malaria and malnutrition: extending integrated services into communities

1. Malaria and malnutrition: extending integrated services into communities • Malaria and malnutrition April 21st 2016 • Prudence Hamade

2. Malaria Consortium in 2016 • Vision: To improve lives in Africa and Asia through sustainable, evidence-based programmes that combat targeted diseases and promote child and maternal health • To do this Malaria Consortium will: • Design and conduct cutting edge implementation research and monitoring and evaluation • Selectively scale up and deliver sustainable, evidence-based health programmes and surveillance • Provide technical assistance and consulting services that shape and strengthen national and international health policies, strategies and systems and build local capacity • Seek to ensure our experience, practical findings and research results are effectively communicated and contribute to the coordinated improvement of access to, and quality of, healthcare

3. Areas of expertise What approaches tools and techniques? What areas? What diseases? Health system strengthening/child & maternal health Vector control Communitydelivery Integration around acute febrile illness Advocacy Malaria Publichealthcommunications Chemoprevention Researchuptake Diagnostics Data management NTDs M&E & Surveillance Case management Dengue mHealth Pneumonia Clinical quality improvement Capacitybuilding Quantitative & qualitativeresearch Diarrhoea Resistancemanagement Malnutrition Costing and economicimpactevaluation Elimination Private sector engagement

4. Combining case management of malaria and other childhood diseases and diagnosis and management of severe acute malnutrition Can low literacy community members deliver iCCM and the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) in the community where access to care is strictly limited? Experiences from South Sudan

5. South Sudan: The picture • The formal health system in Aweil is almost non functional unless supported by NGOs. • Even where infrastructure exists health staff are frequently absent and stock outs of basic essential medical supplies are common • Basic transport and roads are also difficult to negotiate especially in the rainy season which coincides with the malaria, diarrhoea and hunger season • High poverty levels and ethnic differences also contribute to limiting access

6. Data from the area to inform programming • Malaria Consortium conducted SMART surveys in 2011, 2012, 2013 and 2014 and 2015 coverage surveys in 2013 and 2015 • The surveys demonstrated high levels of severe acute malnutrition (even in post-harvest season) as well as generalised chronic levels of under nutrition • The surveys found a high prevalence of disease (fever, pneumonia and diarrhoea) • Along with poor access to healthcare, lack of access to food and WASH facilities and poor IYCF practices contributed to the high levels of malnutrition

7. Malaria Consortium has operated an iCCM programme through trained CDDs in Aweil since 2010 The programme started with home management of malaria and expanded to diagnosing and treating pneumonia and diarrhoea Training materials and tools for diagnosis and data collection were specifically developed for the low literacy and numeracy of the population

8. The iCCM package = + + Malnutrition Malaria Pneumonia Diarrhoea Diagnosis and treatment of associated diseases asunderlyingassociated causes of malnutrition

9. The model • CDDs screen children in their communities and refer children to the OTP sites They also follow up defaulters • Many patients are self referred • Children unable to eat are referred to Aweil hospital where MSF runs a stabilisationcentre • At the OTP site a modified version of community management of acute malnutrition (CMAM) is used • OTP sites operated using: • Simpler protocol, based on the low capacity of the Community Nutrition Workers • Admission based on MUAC, not weight for height as per the national IMSAM guidelines • After admission weight for height and MUAC are used as discharge criteria

10. iCCM + Nutrition programme structure

11. Major results from SMART surveys • GAM 23.1% • SAM 5.5%

12. Coverage surveys Aweil Centre 2013 • 19 OTP sites (11 in health facility, 9 in community) • Point coverage for SAM 24.3% • Point coverage for malaria treatment 60.7% • 2015 • 25 OTP sites • Point coverage for SAM 58%

13. Outcomes of OTP intervention 2015

14. Contribution of ill health to malnutrition • SMART Survey Aweil Centre 2014 • Proportion of children with fever in last 2 weeks 34.6% • Proportion of children with cough 20% • Proportion of children with diarrhoea 25% • Immunisation coverage low 55% with measles vaccination card • VitA distribution coverage 33% received in last 6 months • SMART Survey Aweil Centre 2015 • Proportion of children with fever in last 2 weeks 32.8% • Proportion of children with cough 6.5% • Proportion of children with diarrhoea 7 % • Immunisation coverage low 61.9%with measles vaccination card • Vit A distribution coverage 44.8 %received in last 6 months

15. Children treated for fever by CDDs

16. Children treated for pneumonia

17. Children treated for diarrhoea

18. Nutrition interventions at present • Malaria Consortium is delivering iCCM plus nutrition interventions in Myanmar, Mozambique, and Nigeria (Niger and Kebbistates) • The programme will continue in South Sudan but will look to increase preventive interventions • Proposal submitted for a comprehensive nutrition programme in northern Nigeria including CMAM, community mobilisation, addressing livelihoods and associated issues like WASH and strengthening government structures to take over the programme in four years • Potential avenue to explore the role of malaria in micronutrient deficiencies and acute malnutrition both of which are very high in the Sahel region. • Malaria Consortium and partners are delivering Seasonal Malaria Chemoprevention to 7.2 million children in seven African countries in 2016 (and 2017). Various nutrition interventions have been proposed to be included in this intervention

19. Platforms for improving outcomes • Malaria Consortium is a member of the iCCM and nutrition subgroup of the iCCM Task Force • Objectives for 2015-2020 • Improving implementation of essential nutrition actions/behaviour change communications, which includes improving and supporting optimal IYCF practices to prevent stunting and other forms of malnutrition • Expanding the scale and quality of evidence-based approaches to address malnutrition • Increasing programmatic focus on child, adolescent and women’s nutrition • Support the integration of nutrition into child health and nutrition sensitive sectors including agriculture, WASH and ECD programming • Support the use and application of nutrition design tools

20. Efficacy of SMC • Malaria Consortium with grant from BMGF distributed SP plus AQ to 800,000 children over the rainy season in Northern Nigeria in 2012-2014 with aprotective efficacy of 40% • With a grant from UNITAID MC ad partners delivered preventive treatment to 3.2 million children in 2015 and will cover 7.2 million children in 2016. The data for 2015 is still being analysed but the protective efficacy is certainly less that in the clinical trials. This may be due to the child not receiving all four doses , receiving incomplete doses but the contribution of the high levels of malnutrition in the Sahel cannot be underestimated • During a post intervention survey in Katsina state in Nigeria in 2013 very high levels of GAM and SAM were found as well as over 12% of children with severe anaemia

21. Possible research topics • The effect of regular net usage on malnutrition rates • The effect of early and effective treatment of malaria at community level on malnutrition rates • Would the administration of injectable artesunate (im/IV) to severely malnourished children with malaria improve outcomes • Should the dose of ACT in malnourished children be based on age or on weight and why • Could supplementation with LNS improve child's resistance to new infections especially in malaria high transmission zones • iCCM guidelines advises mothers to feed sick children: why and how can this be done • After treatment with injectable artesunate for management of severe malaria some children experience severe anaemia: what is the mechanism for this and how should it be managed (increased mortality in the period following successfully treated severe malaria)