1. Malaria and Nutrition: Impact of Integrating the Delivery of Seasonal Malaria
Chemoprevention (SMC) with Nutrition Supplementation in Northern Nigeria
BACKGROUND Objectives METHODS
DisCussion & Conclusions
RESULTS
Abigail Ward1
, Andrea Guillot1
, Lyudmila Gorokhovich1
, Justin C. Graves1
, Kathleen Maloney1
, Omowunmi F. Omoniwa1
, Leslie Emegbuonye1
, Charles Opondo2
, Marko Kerac2
,
Alan Dangour2
, Sharon K. Greene3
, Elizabeth Omoluabi4
, Antoinette Bhattacharya1
, Karen Milch Hariharan1
, Owens Wiwa1
, Justin M. Cohen1
, Arnaud Le Menach1
The Nigerian Context
• Malaria: Kano is one of 9 Nigerian states
recommended for annual delivery of seasonal
malaria chemoprevention to children under five.1
Malaria accounts for up to 25% of under-five mortality
in Kano State.2
• Malnutrition: The 2013 DHS Survey estimated that
chronic malnutrition affected nearly half of under-fives
in Kano (stunted) and 38% of children were acutely
malnourished (wasted).3
• Malnutrition doubles the risk of dying from malaria.4
Distribution of SMC/LNS
• Monthly door-to-door distribution from August-
November 2014 in 7 wards in Madobi LGA, Kano
• 4 wards received SP-AQ only
• 3 wards received SP-AQ+LNS (lipid-based
nutritional supplement Plumpy ‘Doz)
• SP-AQ distributed to children ages 3-59 months
• LNS distributed to children ages 6-24 months
Evaluation
• Cross-sectional household
surveys conducted in August 2014,
November 2014, and May 2015.
• Data collected included demographics, coverage
and adherence, and length, weight, and mid-upper
arm circumference for children 6-24 months in
August 2014.
• Measured the impact of adding LNS on nutrition
outcomes using multivariable logistic regression
models.
The study had three major evaluation objectives.
Compared with delivery of SMC alone to children ages
6-24 months:
Objective 1
To evaluate changes in coverage and adherence within
target communities due to integrating the delivery of
LNS during SMC campaigns.
OBJECTIVE 2
To evaluate changes in malnutrition outcomes
(stunting, wasting, underweight) due to integrating
the delivery of LNS during SMC campaigns.
Prevalence of Malnutrition Indicators
This study was funded by CIFF. The authors are grateful to the Kano State Ministry of Health, for their guidance and active collaboration, NutriSet for LNS donation, as well as Akena Research, Evaluation and Consulting for their technical expertise.
Resources
1. WHO Global Malaria Programme (2012). WHO Policy Recommendation: Seasonal Malaria Chemoprevention (SMC) for
Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa.
2. Nigeria FMOH Newborn Health Report (2011).
3. Nigeria 2013 Demographic and Health Survey. www.measuredhs.com.
4. Black RE, Allen LH, et al. (2008). Maternal and child undernutrition: global and regional exposures and health consequences.
Lancet, 371(9608:243-60.
1
Clinton Health Access Initiative, Boston, MA, USA
2
London School of Hygiene & Tropical Medicine, London, UK
3
Independent Consultant, New York, NY
4
Akena Research, Evaluation and Consulting, Kano, Nigeria

award@clintonhealthaccess.org
SMC campaigns present an opportunity to
integrate delivery of malnutrition interventions.
Study Area
Figure 1. Coverage of SP-AQ did not change when integrated
with LNS delivery. Adherence to SP-AQ did not differ between
intervention groups (p=0.38).
SP-AQ LNS SP-AQ+LNS
88.3 88
82.6 80.4
SMC+LNS Arm SMC Only Arm
Percent Intervention Coverage and Adherence
STUNTING UNDERWEIGHT WASTING LOW MUAC
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
78.9 76.4
53.5
74.9
74.7
50.6
55.1
61.5
26.7
51.5
58.4
29.5
15.1
21
12
13.8
25.5
15.2
2.7
0.2
0.8
4.4
0.1 0.2
FIGURE 2. Malnutrition outcomes did not change significantly change immediately
following distribution of SP-AQ and LNS. Between November 2014 and May 2015,
stunting and underweight declined significantly in both arms (p<0.001).
Baseline
Endline
Midline
SMC+LNS SMC Only
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Children6-24monthsatbaseline
Child-monthsofcoverage
M A D O B I L G A
SMC ONLY
SMC+LNS
Regression Results: Nutrition Outcomes
K A N O
Malaria Outcomes
Presented Wednesday
10:15 AM
Scientific Session 128
n=840
n=803
n=954
n=860
n=650
n=861
Children who received 4 rounds of SMC and LNS (SMC+LNS area):
• had similar nutrition outcomes (stunting, underweight, wasting,
MUAC) to children who received 4 rounds of SMC (SMC Only
area).
• had similar z-scores (length-for-age, weight-for-age, length-for-
weight) to children who received 4 rounds of SMC (SMC Only
area).
• had higher mid-upper arm circumference (MUAC) z-scores
than children who received 4 rounds of SMC (SMC Only area)
(p=0.002, comparing August 2014 and May 2015).
*Models are adjusted for household wealth.
57
83.4
SMC Adherence
*children who took
the 3-day course of
SP-AQ in the fourth
treatment round as
reported by parent or
head of household
LNS Adherence
*based on
consumption in
the past 24 hours
reported by parent or
head of household
• Bundling LNS in SMC campgains did not positively or negatively affect coverage or adherence.
• LNS was not shown to improve malnutrition outcomes in this study. Reductions following LNS
distribution may be due to seasonality or measurement improvement during the study.
Limitations
• This study was limited by a cross-sectional design, length measurement underestimation, and
recall bias among parents and heads of household.
STEPS FORWARD
• Although programmatic costs of integration are not high, LNS product cost is considerably more
expensive than SP-AQ. Other, less resource-intensive commodities should be explored.
• Alternative nutritional interventions to reduce rates and prevent stunting, underweight, and SAM
should be explored urgently, and, if feasible, integrated into relevant delivery platforms such as
malaria prevention programs.