From Malaria to Malnutrition

in Orissa

Connecting the
Dots

TMST
 The Research Questions

1. Is Malaria a Significant Causative Factor

of Childhood Malnutrition in Orissa?
 

2. Can Malaria Prevention / Treatment /

Control Strategies Actually Reduce
Malnutrition ?
What is the existing evidence
available on these issues,
both globally and locally ?

Reviewing the Evidence in

5 Steps
 Question 1 : (Epidemiological)

• How much Childhood Malaria is there in Orissa ?

• How much Childhood Malnutrition is there in

Orissa ?

Is there a correlation between the distribution

pattern of Childhood Malaria and Childhood
Malnutrition in Orissa – in terms of Region or
Age-Group or Community or Season ?
 We just had two
presentations

Mapping Malaria in Orissa

&

Mapping Malnutrition in Orissa

We continue from there…

 Evidence on Point Prevalence of Malaria
Parasitemia
in Children Under 5 Years
Surveys done by Civil Society Organisations in
Orissa
YEAR ORGANISN DISTRICT No. of No. of No. of Percentag
Villages Children Children e Positive
Surveyed (< 5 Positive for
yrs) Malaria
Tested
2001 Prem Plan Gajapati 1000 15,676 5613 35.8 %
& 16
Partner
NGOs
2004 Mitra Rayagada 5 169 99 59 %

2010 DAPTA Kalahandi 7 202 130 64 %

2010 FARR Kalahandi 6 162 61 38 %

 Question 2 : (Biological
Plausibility)

Can Malaria Cause

Malnutrition ?

What are the possible biological

pathways through which Acute /
Chronic / Recurrent Malaria can
cause Malnutrition ?
Malaria : Nutritional Implications
McGregor IA
Review of Infectious Diseases.
1982 Jul- Aug ; 4 (4) : 798-804

“Three areas are identified in which malaria

may adversely affect host nutrition:
low birth weight,
the development of protein energy
malnutrition,
and the pathogenesis of anemia”
Question 3 : (Literature
Review)

Does Malaria Cause

Malnutrition ?
 Associations Between Placental and Cord Blood
Malaria Infection and Fetal Malnutrition in an
Area of Malaria Holoendemicity
O. Joseph Adebami*, J. Aderinsola Owa, G. Ademola Oyedeji, O.
Akibu Oyelami, AND G. Olutoyin Omoniyi-Esan
Am. J. Trop. Med. Hyg., 77(2), 2007, pp. 209-213

“ The means of birth weight, ponderal index,

and placenta weight were significantly lower
among the babies of mothers with malaria-
infected placentae than those without (P <
0.05 in all cases).”

“ Placental malaria is a major factor in the

etiology of Fetal Malnutrition in Nigeria”
Epidemiology of Malaria in Pregnancy
Malaria Research Centre, Govt of india
 
A study in collaboration with Government Medical
College, Jabalpur, (Singh et al 1999).
 
“ The average weight of 155 neonates from infected
mothers was 350 g less than that of 175 neonates
from non-infected mothers.

This difference in birth weight was statistically

significant for both P.falciparum (p<0.0001; df =
278) and P. vivax (p<0.0001; df = 223) infection. “
Malaria and nutritional status in children
living on the coast of Kenya
Alice M Nyakeriga, Marita Troye-Blomberg, Alex K
Chemtai, Kevin Marsh and Thomas N Williams
 
American Journal of Clinical Nutrition, Vol. 80,
No. 6, 1604-1610, Dec 2004

The Incidence Rate Ratios for malaria in children aged 0–2 y,

who were subsequently characterized as underweight, was 1.65
(1.10, 2.20; P = 0.01), and a significant overall relation between
malaria and stunting was found on regression analysis after
adjustment for the interaction with age (IRR: 1.91; 1.01, 3.58; P
= 0.04).

Although children living on the coast of Kenya continue to

experience clinical episodes of uncomplicated malaria
throughout the first decade of life, the effect of malaria on
nutritional status appears to be greatest during the first
2 y of life.
 Question 4 : (Interventional)

Can Prevention / Treatment / Control

of Malaria Improve Nutritional Status
?

Strategies being used include :

Prevention with ITMN
Chemoprophylaxis
IPTi (Intermittent Presumptive Treatment of Infants)
Screening & Treatment
 Excerpts from Cochrane Review, prepared and
maintained by The Cochrane Collaboration, and
published in The Cochrane Library 2009, Issue 2

[Intervention Review]
Insecticide-treated bed nets and curtains for preventing
malaria
Christian Lengeler
“ Three trials carried out with ITNs have demonstrated a
positive impact on anthropological measurements in children
sleeping under treated nets.”
In The Gambia (D’Alessandro)
In Kenya (Nevill)
In Kenya (Phillips-Howard)

In all 3 Studies, the children using nets had significantly

higher z-scores for weight-for-age.
 Excerpt from a Cochrane review, prepared and
maintained by The Cochrane Collaboration
and published in The Cochrane Library 2009, Issue
1

[Intervention Review]
Chemoprophylaxis and intermittent treatment for
preventing malaria in children
Martin M Meremikwu, Sarah Donegan, Ekpereonne Esu

Conclusion :
Both Chemoprophylaxis and Intermittent Presumptive
Treatment reduced malaria episodes and severe
anemia in pre-school children.
Impact on nutritional status was not measured in these
studies.
 Malnutrition
Analysis of 74 NAR Children Aged 1-3
Years
by Adequacy of Weight Gain and Stage
CATEGOR of Protocol
STAGE OF INTERVENTION
Y
PRE INTRA POST
NEGATIVE
29 (39.2%) 04 (05.4%) 11 (14.9%)
ZERO
14 (18.9%) 01 (01.4%) 08 (10.8%)
INADEQUATE
(<200 31 (41.9%) 24 (32.4%) 17 (23.0%)
gm/mth)

ADEQUATE
(>200 45 (60.8%) 38 (51.4%)
 Mitra, Bissamcuttack : Treating
Malnutrition
Analysis of 74 NAR Children Aged 1-3 Years
Mean Monthly Weight Gain by Stage of
Protocol
Mean weight gain per month for pre-intervention phase
- 29 gms

Mean weight gain per month for intra-intervention phase

+ 325 gms

Mean weight gain per month for post-intervention phase

+ 182 gms
Question 5 : (Programmatic)

What should Orissa do

based on the rationale and
evidence ?
 That is why we are all
here….
15th May 2010

To put our hearts and our heads

together
Our experience and our expertise
Our passion and our critical reasoning

For the children of Orissa

We request your inputs and advice