The main objective of this study was
to investigate the nationwide spatial comorbidity between wasting and low-MUAC
with malaria. To achieve this, we implemented two geostatistical shared
component methods to model the comorbidity between (1) wasting and malaria and
(2) low-MUAC and malaria at child level. The findings showed a strong co-occurrence
of these health conditions. The relative risk was highest between low-MUAC and
malaria and relatively lower between wasting and malaria. The common risks were
greater in the South compared to the North of Somalia.


Numerous studies have investigated the
epidemiological relationship between child malnutrition with either malaria
morbidity or intensity of infection13,15,43,44. In contrast, only a few studies have
incorporated the spatial underlying component in the analysis45,46. This is the first study that has modelled
the co-distribution of wasting and low-MUAC with malaria in a geostatistical
framework to produce continuous national maps of common relative risk at high
spatial resolution. The shared component statistical framework has an advantage
in that its latent component have a direct interpretation in terms of the
prevalence of the comorbidity of the health conditions and related risk factors
which are either shared by several or specific to one of the health conditions.


In Somalia, the rates of malnutrition have
persistently remained at critical levels throughout the country47.
The rates are seen to be higher in the South compared to North of the country47.
These tenacious nutritional setbacks compromises the immune system and thus
leaving the child susceptible to subsequent infections21.  The risk of malaria is high in the South as
and therefore children in these regions are at high risk of presenting with
multiple health conditions. The development of more serious infections
simultaneously increases the risk of mortality in children48.
In addition, in developing countries in settings where resources are scarce,
children are at a higher risk of infections due to poor environmental
conditions and thus prone to concurrent infections occurring by chance and this
could lead to additive or greater risk of multiple infections49.   

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This study provide important new
information about the subnational priority areas for targeting integrated
interventions for malnutrition and malaria. Our predictive maps of the common
relative risk indicates that integrated control programmes should be prioritized
in the South of Somalia within the high endemicity areas. The hotspots in this
study correlates with areas where malaria risk has been shown in previous
studies18,19. The hotspots present opportunities
for integrating malaria interventions with the nutrition interventions
delivered through health campaigns by World Food Programme (WFP) and UNICEF
which include vitamin A distribution, deworming and nutritional screening
during bi-annual child health days with a full course of antimalarial treatment
during the peak malaria season which coincided with seasons of high
malnutrition levels50. Importantly, seasonal malaria
chemoprevention (SMC) has been shown to be 75% protective against uncomplicated
and severe malaria in children51–54 and may be effective in this setting.


The present study has some
limitations. There are important socio-demographic and environmental
confounding factors that were not measured in this study and therefore not
accounted for in the analysis. Information on access to water and sanitation,
which contributes to the prevalence of diarrhoea, was not collected in the Food
Security and Analysis Unit (FSNAU) surveys used herein. In addition, information
on market prices and purchasing power, food distribution, and household
economic status, that might influence household food security were not
available and therefore not included in the analysis.



This study has demonstrated that there
is significant spatial correlation between wasting and low-MUAC with falciparum
malaria risk in children aged 6-59 months in Somalia, indicating common
underlying determinant that causes the spatial distribution of these health
conditions be similar. The findings reinforce the need for integrating malaria and
nutrition interventions.


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