Elevated prevalence of malnutrition and malaria among school-aged children and adolescents in war-ravaged South Sudan Rhianna Charchuk, Stan Houston, Michael T. Hawkes* Department of Pediatrics, University of Alberta, Edmonton, Canada Emerging as a sovereign state from decades of civil war, the Republic of South Sudan now faces poverty, a lack of health care infrastructure, a high burden of infectious diseases and a widespread food insecurity. School-aged children and youth, in particular, represent a high-risk demographic for malnutrition and infectious diseases. We screened 109 school-aged children and youth for nutritional status and malaria antigenaemia in Akuak Rak, South Sudan, and found a large proportion of underweight (77/109 = 73%) and prevalent malaria (44/109 = 40%). There was no significant association between malnutrition and malaria. This study represents one of the few published reports on child and youth nutritional status and malaria prevalence in South Sudan since its independence. The implementation of nutrition and malaria screening combined with evidence-based interventions in schools could help target this high burden vulnerable group. Keywords: Malaria, Malnutrition, South Sudan, Conflict and child health
Introduction
The Republic of South Sudan gained independence and was recognized as the 193rd United Nations member state on 9 July 2011. Born in crisis following decades of civil war, the country is characterized by a highly volatile political, economic and humanitarian situation.1 In this unstable, war-ravaged context, the burden of infectious diseases,2,3 food insecurity4 and child malnutrition5 are known to be elevated. Although there exist programmatic data reported from humanitarian organizations,5 published reports on child and youth nutrition and health from the region are scarce. School-aged children and adolescents in the developing world are increasingly recognized as a high-burden demographic for nutritional deprivation and infectious disease, with adverse consequences for their developmental trajectory into adulthood.6 Beyond the preschool years, during which malnutrition and infectious diseases are the principal determinants of child mortality, school-aged children and youth are also at risk of poor health, cognition and educational achievement as a result of undernutrition and infection. Schools also represent a platform for public health surveillance for the community at large, as well as a convenient and cost-effective platform to deliver health interventions, such as antimalarials, anthelmintics and micronutrients.
A mutually amplifying relationship between malaria, a leading cause of hospitalization and death in sub-Saharan Africa, and malnutrition has been documented.7,8 However, this interaction between malnutrition and malaria is complex and varies depending on the definitions and indicators used for malnutrition measurements.9–11 More specifically, the literature has supported that stunting (low height-forage), the indicator of chronic malnutrition, may increase the risk of malaria.12 Whereas wasting (low weight-forheight), the indicator of acute malnutrition, appears to be associated with a decreased risk of malaria.13 Furthermore, a well-documented interaction is that re-feeding of famine victims increases clinical manifestations of malaria, with improved host immunity and/or nutrient replenishment that promotes parasite growth.14,15 In the context of a humanitarian medical outreach in the remote community of Akuak Rak, Northern Bahrel-Ghazal State, we screened school children (aged 5–18 years) for nutritional status and malaria. At the time of the study, January 2012, indigenous populations were returning to their ancestral lands and rebuilding, following a period of massive displacement due to violent conflict during the period of internecine civil war (1986–2005). Poverty (loss of cattle, crops, seeds and farming implements) among returnees may contribute to food insecurity.5 In addition, during displacement, they may have resided in areas with lower malaria transmission and lost partial
Corresponding author. Email: [email protected]
*
© W. S. Maney & Son Ltd. 2016 DOI 10.1080/20477724.2015.1126033
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immunity. Thus, this report provides rare health data in a post-war situation in a remote sub-Saharan African context characterized by near absence of infrastructure and human resources for health, as well as extreme poverty.
Methods
This was a cross-sectional study among children and youth voluntarily undergoing screening for malaria and malnutrition in the context of a medical outreach (Connecting Lives International Mission, Christian Reaching Mission) which included health screening at a local school (Hope Mission School). Oral informed consent was obtained from each participant prior to anthropometric measurements and malaria testing. Permission to conduct medical outreach and student health screening was obtained from local authorities. The study was conducted according to the guidelines laid down in the Declaration of Helsinki. The University of Alberta Research Ethics Committee approved the study.
Patients and setting
The study was conducted at a combined boarding and day school, Hope Mission School (enrolment 160 students between the ages of 5 and 19), in Akuak Rak, Western Aweil County, Northern Bahr-el-Ghazal State (estimated State population 720,898), with a majority ethnically Dinka. The village is rural and remote, with no road access. The study took place during the dry season from 7 to 12 January 2012, 6 months after South Sudan became an independent state. Participants were included in the study if they attended the Hope Mission School and voluntarily took part in health screening; there were no exclusion criteria. A sample size calculation indicated that approximately 93 participants would need to be enrolled in order to estimate the prevalence of underweight and malaria to within ± 10%. Plasmodium falciparum is hyper-endemic in the area with peak incidence during the rainy season.3 Due to almost 50 years of protracted conflict, poverty, lack of infrastructure and disruption of social services, South Sudan is among the world’s least developed countries.1 More than half of the country lives on less than $US 1.25 per day. Food insecurity is widespread, affecting an estimated 4.7 million people (37% of the country’s population) in 2012.4 Humanitarian agencies were involved in over 30 operations in the country at the time of this study, including food assistance and provision of basic medical services. Ongoing violent conflict and fluctuating levels of international donor aid have contributed to ongoing food insecurity despite an official end to the Sudanese civil war with the Naivasha Comprehensive Peace Agreement in 2005.
Anthropometric measurements
Height and weight were measured by professional nurses licensed in the USA, well trained and experienced in the measurement of paediatric weight and height. Instruments 396
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used were a digital scale and stadiometer. Weights and heights were plotted on growth curves at the time of data collection and were reviewed by a Royal College of Physicians of Canada certified paediatrician for plausibility and for clinical assessment at the time of data collection. We compared height-for-age, weight-for-age and BMI-for-age to US Centre for Diseases Control (CDC) and Prevention norms.16 Although alternative growth charts from the World Health Organization are available, the CDC norms provide a benchmark from a well-nourished population against which to compare our cohort. Of note, at the lower centiles, the WHO and CDC curves match closely such that the choice of reference norms is unlikely to substantively affect the findings.17
Malaria diagnosis
Trained nurses performed a fingerprick rapid diagnostic test (RDT) for malaria (ParaCheck-Pf device, Orchid Biomedical Systems). This test, based on detection of histidine-rich protein 2, is able to detect P. falciparum antigen in the peripheral circulation. Recent experience in 65 schools in Kenya showed that this RDT had a sensitivity of 99% and a specificity of 85% compared to light microscopic examination of Giemsa-stained peripheral blood films.18 Children found to be RDT-positive were treated with a six dose regimen of artemisinin combination therapy (ACT) according to WHO guidelines,19 irrespective of symptoms.
Results
A total of 109 students voluntarily participated in health screening, representing 68% of the total student population of the Hope Mission School. The self-reported median age was 13 years (range 5–19) and 38/109 (35%) were female (significant underrepresentation of females in cohort, p = 0.0016). Figure 1 shows the distribution of weight, height and body mass index (BMI) for the cohort. Noteworthy is the striking proportion of underweight children and youth (BMI 37.5 °C) had a sensitivity of 30% (95%CI 18–44%)
Charchuk et al. Malnutrition and malaria in South Sudan
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Figure 1 Low weight-for-age and body mass index (BMI) in South Sudanese school-aged children and youth. Histograms illustrate the frequency distribution of weight (1a), stature (1b) and BMI (1c). The distributions of weight and BMI are both markedly left-skewed, reflecting high prevalence of underweight children and youth.
and a specificity of 93% (95%CI 84–97%) to predict malaria in this cohort. However, a higher grade fever (T > 38.0 °C) was present in only 5% of students with malaria, which was not statistically significantly different from negative controls. Weight, stature and BMI were similar in both groups.
Discussion
The point prevalence of underweight (BMI 38 °C was present in only 5% of students with malaria. Similarly, only 3.5% of infected children had documented fever in another school-based study from Kenya.22 We did not observe an association between underweight and malaria in our cross-sectional survey, similar to a recent study in Ethiopia11 but unlike other studies from Uganda.7,8 A
Charchuk et al. Malnutrition and malaria in South Sudan
prospective study examining malaria incidence in underweight school children and healthy-weight controls would help to address this discrepancy. Given the potential for exacerbation of malaria signs and symptoms upon re-feeding, caution should be exercised with nutritional interventions in this group, considering the high prevalence of malaria. School-based malaria screening, in use for over a century, is an inexpensive framework for malaria surveillance that can complement community-based surveys.18 For example, large-scale school parasite surveys documented the decline of malaria in the USA during the 1920–1940s, and continue to be used by the Ministries of Health of modern African states to monitor the impact of malaria control efforts.18 The representativeness of a school survey for the community at large depends on the catchment area and may be influenced by gender, wealth and health differentials in school enrolment.23 Unfortunately the school enrolment for South Sudan may be very low as children and youth are not able to attend school in the aftermath of war that decimated the education infrastructure. Our study involved the only mixed day and boarding school in the large geographic area around Akuak Rak. The school provided free education under foreign sponsorship, such that students from poor households may be adequately represented in our study, although we did not measure household wealth. Underrepresentation of female students in our cohort may reflect a predilection for education of males.18 Thus, high malaria prevalence in the school likely implies high transmission in the community of Akuak Rak, although the degree to which the community prevalence may be over- or underestimated is difficult to quantify. School-based screening offers a natural and convenient platform for delivery of public health interventions to a high-burden target group. Previous studies have shown positive impact of school-based intermittent preventive treatment (IPT) for malaria on health and cognitive function.24,25 On the other hand, a recent school-based cluster-randomized trial in Kenya did not demonstrate any impact of malaria intermittent screening and treatment (IST) on prevalence of anaemia, P. falciparum infection or scores of classroom attention after 1–2 years of follow-up.26 Finally, infected school children may act as a reservoir for onward transmission of malaria to others in the community, and treatment may block parasite spread.18 This may be an operationally efficient mechanism to target a high-prevalence group for malaria control.18 On the other hand, a recent trial in Burkina Faso indicated no impact of IST on community-wide malaria transmission.27 Further studies are ongoing to test whether school children can be used to detect and monitor malaria “hotpots” within a community, where localized transmission and re-infection rates are high. This could, in turn, trigger intensive hotspot-focused community interventions to interrupt malaria transmission.
Conclusions
These rare data of underweight and malaria among school children in war-ravaged South Sudan call for implementation of known inexpensive and evidence-based interventions in this high-burden vulnerable group.
References 1 Moszynski P. South Sudan: a nation born in crisis. BMJ. 2011;342:d3726. 2 Centers for Disease C, Prevention. . Notes from the field: investigation of high HIV prevalence in Western Equatoria state-South Sudan, 2012. MMWR. Morb Mortal Wkly Rep. 2013;62(22):453–454. 3 He D, Zhang Y, Liu X, Guo S, Zhao D, Zhu Y, et al. Epidemiological and clinical features of plasmodium falciparum malaria in united nations personnel in Western Bahr el Ghazal State, South Sudan. PLoS ONE. 2013;8(1):e55220. 4 Tappis H, Doocy S, Paul A, Funna S. Food security and development in South Sudan: a call to action. Public Health Nutr. 2013;16(09):1631– 1636. 5 Médecins Sans Frontières (MSF). Child malnutrition rates skyrocket in South Sudan. 2014. Available from: http://www.msf.org/article/ child-malnutrition-rates-skyrocket-south-sudan 6 Best C, Neufingerl N, van Geel L, van den Briel T, Osendarp S. The nutritional status of school-aged children: why should we care? Food Nutr Bull. 2010;31(3):400–417. 7 Lewnard JA, Berrang-Ford L, Lwasa S, Namanya DB, Patterson KA, Donnelly B, et al. Relative undernourishment and food insecurity associations with plasmodium falciparum among Batwa pygmies in Uganda: evidence from a cross-sectional survey. Am J Trop Med Hyg. 2014;91(1):39–49. 8 Arinaitwe E, Gasasira A, Verret W, Homsy J, Wanzira H, Kakuru A, et al. The association between malnutrition and the incidence of malaria among young HIV-infected and -uninfected Ugandan children: a prospective study. Malar J. 2012;11:90. 9 Carswell F, Hughes AO, Palmer RI, Higginson J, Harland PS, Meakins RH. Nutritional status, globulin titers, and parasitic infections of two populations of Tanzanian school children. Am J Clin Nutr. 1981;34(7):1292–1299. 10 Snow RW, Byass P, Shenton FC, Greenwood BM. The relationship between anthropometric measurements and measurements of iron status and susceptibility to malaria in Gambian children. Trans R Soc Trop Med Hyg. 1991;85(5):584–589. 11 Deribew A, Alemseged F, Tessema F, Sena L, Birhanu Z, Zeynudin A, et al. Malaria and under-nutrition: a community based study among under-five children at risk of malaria, south-west Ethiopia. PLoS ONE. 2010;5(5):e10775. 12 Deen JL, Walraven GE, von Seidlein L. Increased risk for malaria in chronically malnourished children under 5 years of age in rural Gambia. J Trop Pediatr. 2002;48(2):78–83. 13 Fillol F, Cournil A, Boulanger D, Cisse B, Sokhna C, Targett G, et al. Influence of wasting and stunting at the onset of the rainy season on subsequent malaria morbidity among rural preschool children in Senegal. Am J Trop Med Hyg. 2009;80(2):202–208. 14 Murray MJ, Murray AB, Murray MB, Murray CJ. Somali food shelters in the Ogaden famine and their impact on health. Lancet. 1976;307(7972):1283–1285. 15 Murray MJ, Murray NJ, Murray AB, Murray MB. Refeeding-malaria and hyperferræmia. Lancet. 1975;305(7908):653–654. 16 Center for Disease Control and Prevention (CDC). CDC growth charts. 2010. Available from: http://www.cdc.gov/growthcharts/ cdc_charts.htm 17 World Health Organization. Growth reference 5–19 years. Comparison with IOTF and CDC. 2007. Available from: http://www.who.int/ growthref/comparison_cdc2000.pdf?ua=1 18 Brooker S, Kolaczinski JH, Gitonga CW, Noor AM, Snow RW. The use of schools for malaria surveillance and programme evaluation in Africa. Malar J. 2009;8:231. 19 WHO. Guidelines for the treatment of malaria. 3rd ed. 2015. Available from: http://www.who.int/malaria/publications/atoz/9789241549127/ en/ 20 United Nations Nutrition Cluster South Sudan. Preharvest surveys. 2012. Available from: https://sites.google.com/site/ nutritionclustersouthsudan/departments/department-a/documents 21 Chali D. Anthropometric measurements of the Nilotic tribes in a refugee camp. Ethiop Med J. 1995;33(4):211–217. 22 Halliday KE, Karanja P, Turner EL, Okello G, Njagi K, Dubeck MM, et al. Plasmodium falciparum, anaemia and cognitive and educational
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performance among school children in an area of moderate malaria transmission: baseline results of a cluster randomized trial on the coast of Kenya. Trop Med Int Health: TM & IH. 2012;17(5):532–549. 23 Fentiman A, Hall A, Bundy D. Health and cultural factors associated with enrolment in basic education: a study in rural Ghana. Soc Sci Med. 2001;52(3):429–439. 24 Clarke SE, Jukes MC, Njagi JK, Khasakhala L, Cundill B, Otido J, et al. Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial. Lancet. 2008;372(9633):127–138. 25 Barger B, Maiga H, Traore OB, Tekete M, Tembine I, Dara A, et al. Intermittent preventive treatment using artemisinin-based combination
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therapy reduces malaria morbidity among school-aged children in Mali. Trop Med Int Health: TM & IH. 2009;14(7):784–791. 26 Halliday KE, Okello G, Turner EL, Njagi K, Mcharo C, Kengo J, et al. Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial. PLoS Med. 2014;11(1):e1001594. 27 Tiono AB, Ouédraogo A, Ogutu B, Diarra A, Coulibaly S, Gansané A, et al. A controlled, parallel, cluster-randomized trial of communitywide screening and treatment of asymptomatic carriers of Plasmodium falciparum in Burkina Faso. Malar J. 2013;12:79.
Introduction
The Republic of South Sudan gained independence and was recognized as the 193rd United Nations member state on 9 July 2011. Born in crisis following decades of civil war, the country is characterized by a highly volatile political, economic and humanitarian situation.1 In this unstable, war-ravaged context, the burden of infectious diseases,2,3 food insecurity4 and child malnutrition5 are known to be elevated. Although there exist programmatic data reported from humanitarian organizations,5 published reports on child and youth nutrition and health from the region are scarce. School-aged children and adolescents in the developing world are increasingly recognized as a high-burden demographic for nutritional deprivation and infectious disease, with adverse consequences for their developmental trajectory into adulthood.6 Beyond the preschool years, during which malnutrition and infectious diseases are the principal determinants of child mortality, school-aged children and youth are also at risk of poor health, cognition and educational achievement as a result of undernutrition and infection. Schools also represent a platform for public health surveillance for the community at large, as well as a convenient and cost-effective platform to deliver health interventions, such as antimalarials, anthelmintics and micronutrients.
A mutually amplifying relationship between malaria, a leading cause of hospitalization and death in sub-Saharan Africa, and malnutrition has been documented.7,8 However, this interaction between malnutrition and malaria is complex and varies depending on the definitions and indicators used for malnutrition measurements.9–11 More specifically, the literature has supported that stunting (low height-forage), the indicator of chronic malnutrition, may increase the risk of malaria.12 Whereas wasting (low weight-forheight), the indicator of acute malnutrition, appears to be associated with a decreased risk of malaria.13 Furthermore, a well-documented interaction is that re-feeding of famine victims increases clinical manifestations of malaria, with improved host immunity and/or nutrient replenishment that promotes parasite growth.14,15 In the context of a humanitarian medical outreach in the remote community of Akuak Rak, Northern Bahrel-Ghazal State, we screened school children (aged 5–18 years) for nutritional status and malaria. At the time of the study, January 2012, indigenous populations were returning to their ancestral lands and rebuilding, following a period of massive displacement due to violent conflict during the period of internecine civil war (1986–2005). Poverty (loss of cattle, crops, seeds and farming implements) among returnees may contribute to food insecurity.5 In addition, during displacement, they may have resided in areas with lower malaria transmission and lost partial
Corresponding author. Email: [email protected]
*
© W. S. Maney & Son Ltd. 2016 DOI 10.1080/20477724.2015.1126033
Pathogens and Global Health 2015 VOL. 109
NO.
8
395
Charchuk et al. Malnutrition and malaria in South Sudan
immunity. Thus, this report provides rare health data in a post-war situation in a remote sub-Saharan African context characterized by near absence of infrastructure and human resources for health, as well as extreme poverty.
Methods
This was a cross-sectional study among children and youth voluntarily undergoing screening for malaria and malnutrition in the context of a medical outreach (Connecting Lives International Mission, Christian Reaching Mission) which included health screening at a local school (Hope Mission School). Oral informed consent was obtained from each participant prior to anthropometric measurements and malaria testing. Permission to conduct medical outreach and student health screening was obtained from local authorities. The study was conducted according to the guidelines laid down in the Declaration of Helsinki. The University of Alberta Research Ethics Committee approved the study.
Patients and setting
The study was conducted at a combined boarding and day school, Hope Mission School (enrolment 160 students between the ages of 5 and 19), in Akuak Rak, Western Aweil County, Northern Bahr-el-Ghazal State (estimated State population 720,898), with a majority ethnically Dinka. The village is rural and remote, with no road access. The study took place during the dry season from 7 to 12 January 2012, 6 months after South Sudan became an independent state. Participants were included in the study if they attended the Hope Mission School and voluntarily took part in health screening; there were no exclusion criteria. A sample size calculation indicated that approximately 93 participants would need to be enrolled in order to estimate the prevalence of underweight and malaria to within ± 10%. Plasmodium falciparum is hyper-endemic in the area with peak incidence during the rainy season.3 Due to almost 50 years of protracted conflict, poverty, lack of infrastructure and disruption of social services, South Sudan is among the world’s least developed countries.1 More than half of the country lives on less than $US 1.25 per day. Food insecurity is widespread, affecting an estimated 4.7 million people (37% of the country’s population) in 2012.4 Humanitarian agencies were involved in over 30 operations in the country at the time of this study, including food assistance and provision of basic medical services. Ongoing violent conflict and fluctuating levels of international donor aid have contributed to ongoing food insecurity despite an official end to the Sudanese civil war with the Naivasha Comprehensive Peace Agreement in 2005.
Anthropometric measurements
Height and weight were measured by professional nurses licensed in the USA, well trained and experienced in the measurement of paediatric weight and height. Instruments 396
Pathogens and Global Health 2015 VOL. 109
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used were a digital scale and stadiometer. Weights and heights were plotted on growth curves at the time of data collection and were reviewed by a Royal College of Physicians of Canada certified paediatrician for plausibility and for clinical assessment at the time of data collection. We compared height-for-age, weight-for-age and BMI-for-age to US Centre for Diseases Control (CDC) and Prevention norms.16 Although alternative growth charts from the World Health Organization are available, the CDC norms provide a benchmark from a well-nourished population against which to compare our cohort. Of note, at the lower centiles, the WHO and CDC curves match closely such that the choice of reference norms is unlikely to substantively affect the findings.17
Malaria diagnosis
Trained nurses performed a fingerprick rapid diagnostic test (RDT) for malaria (ParaCheck-Pf device, Orchid Biomedical Systems). This test, based on detection of histidine-rich protein 2, is able to detect P. falciparum antigen in the peripheral circulation. Recent experience in 65 schools in Kenya showed that this RDT had a sensitivity of 99% and a specificity of 85% compared to light microscopic examination of Giemsa-stained peripheral blood films.18 Children found to be RDT-positive were treated with a six dose regimen of artemisinin combination therapy (ACT) according to WHO guidelines,19 irrespective of symptoms.
Results
A total of 109 students voluntarily participated in health screening, representing 68% of the total student population of the Hope Mission School. The self-reported median age was 13 years (range 5–19) and 38/109 (35%) were female (significant underrepresentation of females in cohort, p = 0.0016). Figure 1 shows the distribution of weight, height and body mass index (BMI) for the cohort. Noteworthy is the striking proportion of underweight children and youth (BMI 37.5 °C) had a sensitivity of 30% (95%CI 18–44%)
Charchuk et al. Malnutrition and malaria in South Sudan
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Figure 1 Low weight-for-age and body mass index (BMI) in South Sudanese school-aged children and youth. Histograms illustrate the frequency distribution of weight (1a), stature (1b) and BMI (1c). The distributions of weight and BMI are both markedly left-skewed, reflecting high prevalence of underweight children and youth.
and a specificity of 93% (95%CI 84–97%) to predict malaria in this cohort. However, a higher grade fever (T > 38.0 °C) was present in only 5% of students with malaria, which was not statistically significantly different from negative controls. Weight, stature and BMI were similar in both groups.
Discussion
The point prevalence of underweight (BMI 38 °C was present in only 5% of students with malaria. Similarly, only 3.5% of infected children had documented fever in another school-based study from Kenya.22 We did not observe an association between underweight and malaria in our cross-sectional survey, similar to a recent study in Ethiopia11 but unlike other studies from Uganda.7,8 A
Charchuk et al. Malnutrition and malaria in South Sudan
prospective study examining malaria incidence in underweight school children and healthy-weight controls would help to address this discrepancy. Given the potential for exacerbation of malaria signs and symptoms upon re-feeding, caution should be exercised with nutritional interventions in this group, considering the high prevalence of malaria. School-based malaria screening, in use for over a century, is an inexpensive framework for malaria surveillance that can complement community-based surveys.18 For example, large-scale school parasite surveys documented the decline of malaria in the USA during the 1920–1940s, and continue to be used by the Ministries of Health of modern African states to monitor the impact of malaria control efforts.18 The representativeness of a school survey for the community at large depends on the catchment area and may be influenced by gender, wealth and health differentials in school enrolment.23 Unfortunately the school enrolment for South Sudan may be very low as children and youth are not able to attend school in the aftermath of war that decimated the education infrastructure. Our study involved the only mixed day and boarding school in the large geographic area around Akuak Rak. The school provided free education under foreign sponsorship, such that students from poor households may be adequately represented in our study, although we did not measure household wealth. Underrepresentation of female students in our cohort may reflect a predilection for education of males.18 Thus, high malaria prevalence in the school likely implies high transmission in the community of Akuak Rak, although the degree to which the community prevalence may be over- or underestimated is difficult to quantify. School-based screening offers a natural and convenient platform for delivery of public health interventions to a high-burden target group. Previous studies have shown positive impact of school-based intermittent preventive treatment (IPT) for malaria on health and cognitive function.24,25 On the other hand, a recent school-based cluster-randomized trial in Kenya did not demonstrate any impact of malaria intermittent screening and treatment (IST) on prevalence of anaemia, P. falciparum infection or scores of classroom attention after 1–2 years of follow-up.26 Finally, infected school children may act as a reservoir for onward transmission of malaria to others in the community, and treatment may block parasite spread.18 This may be an operationally efficient mechanism to target a high-prevalence group for malaria control.18 On the other hand, a recent trial in Burkina Faso indicated no impact of IST on community-wide malaria transmission.27 Further studies are ongoing to test whether school children can be used to detect and monitor malaria “hotpots” within a community, where localized transmission and re-infection rates are high. This could, in turn, trigger intensive hotspot-focused community interventions to interrupt malaria transmission.
Conclusions
These rare data of underweight and malaria among school children in war-ravaged South Sudan call for implementation of known inexpensive and evidence-based interventions in this high-burden vulnerable group.
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