Why does nutrition deserve close attention in our fight against malaria?

Studies have shown that infections and nutrition are closely related due to their significant effects on metabolism and immunity. Poor socioeconomic conditions and the limited capacity of health systems can increase infection rates and these may result in poor nutrition outcomes.

As the COVID-19 pandemic continues to strain health systems and drain economies, millions more children under five years old will be vulnerable to undernutrition and infections, including malaria.

While the COVID-19 pandemic is putting enormous pressure on Indonesia’s health system, 12 regencies and cities received certification of malaria elimination in April of this year from the Health Ministry, increasing the total number of regions having eliminated malaria to 318 nationwide.

East Nusa Tenggara (NTT) has become the first of Indonesia’s eastern provinces to see malaria eliminated in parts of its regencies and/or cities. The provincial capital of Kupang and the regencies of Manggarai and East Manggarai had succeeded in eliminating malaria transmission for three years by the end of 2020.

They were certified malaria free based on three main indicators: An annual incidence of malaria of fewer than one per 1,000 people, a positivity rate of less than 5 percent and zero indigenous cases of malaria.

These impressive achievements have certainly boosted optimism about malaria elimination by 2030.

But we must be vigilant about the prevailing threats of malaria across regions in years to come. Official data show a stubbornly high number of deaths caused by malaria in vulnerable populations, such as children under five years and pregnant women, in several areas.

Essential nutrient deficiencies – health problems regarded as normal in malaria-endemic areas in eastern Indonesia, such as NTT, Maluku, Papua and West Papua – can increase the risk of developing malaria as a result of low immunity.

Remote rural areas in these four eastern provinces have seen a higher prevalence of childhood stunting compared with the national average, data show. These provinces also have a higher concentration of malaria cases and account for 86 percent of all cases nationwide, according to the Health Ministry.

During the 2021 World Nutrition Day webinar on May 28, the Asia Pacific Leaders Malaria Alliance (APLMA), RBM Partnership to End Malaria and UNICEF highlighted the strong connection between nutrition and infectious diseases, such as malaria. UNICEF predicts that the COVID-19 pandemic, which has disrupted people’s access to food sources, will put millions more children under five years old at risk of malnutrition and hence infectious diseases like malaria.

During the webinar, experts explored the interaction between nutrition, and in particular malnutrition and deficiencies, with infectious diseases to support better nutrition outcomes and to strengthen efforts toward malaria elimination in the Asia-Pacific region. A lack of essential nutrients, such as iron, can reduce the ability of the human body to respond to infections and this must be tackled through integrated approaches.

Malaria and malnutrition coexist in a vicious cycle because malnutrition and key deficiencies can increase the risks of developing severe malaria and lead to increased illness and deaths from infectious diseases, APLMA-Asia Pacific Malaria Elimination Network (APMEN) senior director Amita Chebbi said in an interview on July 16.

Evidence shows that malnutrition increases susceptibility to malaria, and undernutrition in children is an important risk factor for progression to severe malaria. Hence, investing in interventions to reduce stunting and anemia in children has benefits far beyond improving the nutrition status of children.

The government may have achieved some progress toward reducing the burden of malnutrition. But it is too early to feel satisfied because in the midst of the global health crisis, malnutrition remains a long-standing threat for many of us.

According to the 2018 Basic Health Survey (Riskesdas), 30.8 percent of children under five are stunted, making Indonesia the country with the fourth-highest stunting prevalence worldwide. Meanwhile, 48.9 percent of pregnant mothers suffer anemia. In children under five years the rate hits 38.5 percent, while in adolescents aged 15 to 24 years the number stands at 32 percent.

Globally, about 50-60 percent of anemia cases occur because of iron deficiency, commonly referred to as “iron deficiency anemia”.

The deficiency weakens the immune system in children, which eventually increases their risk of infection, including malaria.

The government’s recently declared commitment to reduce the prevalence of stunting in children to 14 percent by 2024 may serve as a good start to achieve the 2030 malaria-elimination goal. Indonesia, however, needs to build an integrated approach for effective management of malaria and nutrition so these two health problems can be addressed all at once.

Jointly published by the World Health Organization and UNICEF in 2012, integrated community case management (iCCM) – an equity-focused strategy to improve access to essential treatment services for children – remains the center of any integrated approach to address malaria and malnutrition in Indonesia. The iCCM – a cost-effective and evidence-based strategy – helps bridge healthcare disparities in hard-to-reach communities. This approach helps to train and support community health workers to provide diagnostics and treatment for multiple illnesses for sick children.

Chebbi highlighted the need to ensure the enabling infrastructure – in the form of integrated surveillance systems – are in place to facilitate reporting, analysis and use of data for decision making and interventions.

COVID-related disruptions in malaria-control services have been reported everywhere, including in Indonesia. Health workers, for instance, are afraid they will contract COVID-19 if they continue their field work. Therefore guidelines and protocols need to be in place to ensure they can continue malaria testing and treatment.

We must not lose the progress we have made in curbing malaria, malnutrition, anemia and stunting. 

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Staff writer at The Jakarta Post