Over the past couple of decades, Ethiopia has made tremendous progress in reducing child morbidity and mortality. Child mortality decreased from 140.7 deaths/1000 live births in 2000 to 48.7 deaths/1000 live births in 2020 (United Nations Inter-agency Group for Child Mortality Estimation, 2021). Stunting has significantly declined, from 57.7% in 2000 to 36.8% in 2019; similarly, the prevalence of wasting decreased from 12.2% to 7.0% during the same period (Central Statistical Authority, 2001; Ethiopian Public Health Institute, 2019). These reductions in malnutrition were primarily attributed to the expansion of access to health care services through the health extension programme, increased income, and reduction in open defecation (Headey et al., 2017). While these improvements are encouraging, much remains to be done as the rates of malnutrition remain high. To sustain but also accelerate progress in preventing malnutrition, there is an urgent call for more effective interventions that match the scope, complexity, and systemic nature of the problem. This supplement entitled 'Aligning food, health, education, and WASH systems to reduce malnutrition in Ethiopia' aimed to respond to this call. Understanding the magnitude and distribution of the problem and identifying the drivers that led to observed changes is the first step toward the design of much-needed interventions. The 15 articles in this supplement provide a unique diagnosis of the problem of malnutrition in Ethiopia. The supplement highlights the trends, magnitude, and distribution of various forms of malnutrition, highlighting prevailing inequalities, and identifies several drivers. The supplement also presents promising approaches and interventions that could be considered for scale-up. Using a longitudinal study, Hirvonen et al. (2021a) evaluated the dynamics of child linear and ponderal growth faltering. This is indeed a very important contribution for a country like Ethiopia, where both stunting and wasting remain serious public health concerns. The analyses revealed that the prevalence of child wasting peaks in the first 6 months of life, whereas that of stunting starts only to increase significantly after 6 months of age. This is in line with earlier findings that linked the timing of growth faltering with the complementary feeding period (Victora et al., 2010), but also signifies the beginning of the manifestations of sustained nutritional deprivation and recurrent infections faced in the first months of the child (Benjamin-Chung et al., 2023). Worth noting is also the high (15%–20%) prevalence of stunting reported to be present at birth; a finding that suggests that poor maternal nutritional status, particularly during pregnancy, is contributing to the high burden of malnutrition. Indeed, the study by Hailu et al. (2021) showed that more than one in five women of reproductive age were anaemic in 2016, but with even higher prevalence (>50%) in some of the identified hotspots. Unlike child nutritional outcomes, the prevalence of anaemia was reported to have increased between the periods of 2000 and 2016, and these increases were primarily reflections of the widening of existing hotspot areas. Such subnational analyses and mapping help to identify priority areas, but also unmask disparities by highlighting areas that have made little or no progress. Similarly, the subnational estimates and analyses helped unravel the increasing problem of the Double Burden of Malnutrition (DBM), defined as the coexistence of undernutrition and overweight/obesity or diet-related noncommunicable diseases (NCDs), which could be at the individual, household, or population level (WHO, 2016). In cities like Addis Ababa, the prevalence of household-level DBM was quite high (22.8%), while relying on the national estimates only would have painted a very low prevalence of DBM (3.6%: 2016; Pradeilles et al., 2022). Such high prevalence of DBM in cities like Addis Ababa is not surprising and aligns with a recent multicountry study that related high DBM prevalence among the richest and in the most socially and economically globalized settings, which is the case for major cities like Addis Ababa (Seferidi et al., 2022). Several drivers of malnutrition have been identified by the studies published in this supplement. More importantly, the studies identified shared drivers that can help us take the necessary steps to address nutritional problems (e.g., stunting and wasting) through more comprehensive interventions that capture the interrelationships between the different manifestations of malnutrition, rather than focusing on those that address them in isolation. The paper by Hirvonen et al. (2021a) found that both wasting and stunting were associated with limited consumption of nutrient-dense foods like animal-source foods, maternal IYCF knowledge, and increased number of under-5 children in households. Delayed introduction to complementary feeding was reported to be widespread and associated with gaps in maternal IYCF knowledge, and increased odds of linear growth faltering (Hirvonen et al., 2021b). Progress in improving the dietary diversity of children was too little too slow (Tizazu et al., 2022), and was outpaced by increases in unhealthy feeding practices such as the consumption of ultraprocessed foods (UPFs) (Tizazu et al., 2022b). The increasing consumption of unhealthy foods was also highlighted to be widespread among adolescents in urban schools in Ethiopia, as highlighted by Iyasu et al. (2023) in a qualitative study, also published in this supplement. Worth noting, is also the finding that food safety concerns determine adolescent's food choices and diet quality, underlying the need to integrate food safety considerations into the design of nutrition programmes. Access and quality of health care are critical to prevent excess child death and improve diet quality and nutritional outcomes. The health system is indeed the primary vehicle for the delivery of nutrition-specific interventions that aim to reduce maternal and child malnutrition. In this supplement, Laillou et al. (2022) illustrate this by estimating the number of child deaths averted between 2008 and 2020 by the Community-based Management of Acute Malnutrition (CMAM) programme. The CMAM programme was reported to have averted ~34,000 child deaths per year and was reported as one of the cost-effective ways of preventing death related to child wasting. While appreciating the progress made in the treatment of wasting, the authors call for more efforts to not only treat but prevent wasting. This aligns with UNICEFs call for a systems approach to nutrition, strengthening integration between various systems (e.g. food, water, education, and social protection) (UNICEF, 2020). Using the co-coverage index, which is a count of essential reproductive, maternal, neonatal, and child health (RMNCH) interventions received, Baye et al. (2022) showed that access to health care reduces the odds of child wasting, stunting, but also increases dietary diversity. This is supported by the findings from the decomposition study by Girma et al. (2022) and the longitudinal study of Hirvonen et al. (2021a)—both in this supplement—that showed that infections were among the primary predictors of child wasting. The IYCF knowledge of health workers was also found associated with increased maternal IYCF knowledge and MDD, leading the authors to suggest that frequent and timely visits of households by health extension workers to provide messages on what, when, and how to feed the child are needed (Hirvonen et al., 2021b). On the other hand, the finding that IFA supplementation is associated with reduced odds of anaemia among women of reproductive age further suggests the need to strengthen the health system to expand coverage but also provide quality services (Hailu et al., 2021). Poor WASH conditions can expose vulnerable groups to diarrhoeal infections, compromise the safety of complementary foods, but also influence food choices away from perishable nutrient-dense foods. The study by Girma et al. (2021) in this supplement showed that improvements in WASH conditions between 2000 and 2016 led to modest reductions in the risk of diarrhoea and stunting in children less than 5 years of age. However, with less than 10% of households having access to basic sanitation facilities, much remains to be done. The timing of diarrhoea coincided with the complementary feeding period (6–23 months), a finding also reported in a multicountry study from Sub-Saharan Africa (Ogbo et al., 2017). Altogether, this suggests the need to ensure the safety of complementary foods through the implementation of baby WASH interventions (Waller et al., 2020). Socioeconomic well-being, maternal knowledge/education, diet quality, and access to quality health care were common drivers of all forms of malnutrition. Thus, accelerating progress requires alignment of policies, programmes, and interventions and leveraging synergies across food, health, WASH, and education systems as highlighted in the UNICEF global strategy 2020–2030 (UNICEF, 2020). First, inequalities in diet, access to health care, and WASH need to be addressed (Girma et al., 2021; Tizazu et al., 2022). According to the studies by Girma et al. (2021) and Tizazu et al. (2022), rural households and those from lower socioeconomic status were those that could not afford to consume nutrient-dense food groups, access essential health- and WASH services; hence, were the most affected by various forms of malnutrition. Increasing income and its distribution, but also boldly investing in women's empowerment could help improve maternal and child well-being. Indeed, in this supplement, Baye, Laillou, et al. (2021) showed that women empowerment measures (autonomy and decision-making) were more strongly associated with increased child dietary diversity (MDD) than wealth, child age, and urban residence. Second, it is critical to intensify efforts to promote the consumption of healthier foods and discourage unhealthy UPFs. However, to succeed these efforts should be accompanied by monitoring and regulations of the food environment, but also bold and innovative interventions that make nutrient-dense foods available, accessible, and affordable. The article on whole egg powder in this supplement provides an example of such innovations. Using the "cost of diet analyses", the authors reported that including egg powders into the food, basket helped reduce the minimum-cost nutritious diet by about 14%, allowing an additional ~1.2 million households to afford the optimized diet (Baye, Abera, et al., 2021). Scalable solutions like these are needed to make other missing nutrient-dense food groups more accessible and affordable. Third, increasing coverage but also quality of health and nutrition interventions is critical. Using an end-user monitoring (EUM) system, the study by Donzé et al. (2022) also in this supplement, illustrates how routine data capture can be facilitated to support timely decision-making that can improve the delivery of nutrition interventions through the health system. Also key to improving quality and effective coverage of nutrition interventions is to identify the cause of the problem. To this end, efforts to understand the aetiology of anaemia and child wasting are still limited and urgently needed to make much-needed progress on this front. Lastly, the interventions in the education system and social protection systems need to be further leveraged to fill existing programme gaps. Empowering children and youth through education, healthier school meals, along with well-designed social protection programmes that bridge various forms of inequalities can help break the vicious intergenerational cycle of malnutrition (Huicho et al., 2020; Wang et al., 2021). Schools can serve as platforms to promote healthy diets and lifestyles (Iyasu et al., 2023). Targeting adolescents can help shape dietary habits and preferences, having lifelong implications. On the other hand, well-designed nutrition-sensitive social protection programmes like cash transfers could help escape the poverty trap and help realize the aspirations of the Sustainable Development Goals of "leaving no one behind" (Renzaho et al., 2019). Altogether, this supplement provides a unique and comprehensive diagnostic of the problem of malnutrition in Ethiopia. The supplement provides a first attempt to collect evidence supporting the much-needed transition towards a better alignment of food, health, education, and WASH systems to effectively address all forms of malnutrition in Ethiopia. Stanley Chitekwe, Kaleab Baye, Ramadhani Noor and Christiane Rudert had equal roles in drafting and reviewing the manuscript. This study was supported by the Bill and Melinda Gates Foundation, Foreign, Commonwealth & Development Office, European Union Delegation for Ethiopia - DeSIRA, and UNICEF Ethiopia. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.
Development and deployment of an effective malaria vaccine would complement existing malaria control measures. A blood stage malaria vaccine candidate, Merozoite Surface Protein-3 (MSP3), produced as a long synthetic peptide, has been shown to be safe in non-immune and semi-immune adults. A phase Ib dose-escalating study was conducted to assess the vaccine's safety and immunogenicity in children aged 12 to 24 months in Korogwe, Tanzania (ClinicalTrials.gov number: NCT00469651). This was a double-blind, randomized, controlled, dose escalation phase Ib trial, in which children were given one of two different doses of the MSP3 antigen (15 μg or 30 μg) or a control vaccine (Engerix B). Children were randomly allocated either to the MSP3 candidate malaria vaccine or the control vaccine administered at a schedule of 0, 1, and 2 months. Immunization with lower and higher doses was staggered for safety reasons starting with the lower dose. The primary endpoint was safety and reactogenicity within 28 days post-vaccination. Blood samples were obtained at different time points to measure immunological responses. Results are presented up to 84 days post-vaccination. A total of 45 children were enrolled, 15 in each of the two MSP3 dose groups and 15 in the Engerix B group. There were no important differences in reactogenicity between the two MSP3 groups and Engerix B. Grade 3 adverse events were infrequent; only five were detected throughout the study, all of which were transient and resolved without sequelae. No serious adverse event reported was considered to be related to MSP3 vaccine. Both MSP3 dose regimens elicited strong cytophilic IgG responses (subclasses IgG1 and IgG3), the isotypes involved in the monocyte-dependant mechanism of Plasmodium falciparum parasite-killing. The titers reached are similar to those from African adults having reached a state of premunition. Furthermore, vaccination induced seroconversion in all vaccinees. The MSP3 malaria vaccine candidate was safe, well tolerated and immunogenic in children aged 12–24 months living in a malaria endemic community. Given the vaccine's safety and its induction of cytophilic IgG responses, its efficacy against P. falciparum infection and disease needs to be evaluated in Phase 2 studies.
In Sub-Saharan Africa (SSA), adolescents make up around one-quarter of the population who are growing up in a rapidly urbanizing environment, with its associated risks and benefits, including impacts on health, psychosocial development, nutrition, and education. However, research on adolescents' health and well-being in SSA is limited. The ARISE (African Research, Implementation Science and Education) Network's Adolescent Health and Nutrition Study is an exploratory, school-based study of 4988 urban adolescents from five countries: Burkina Faso, Ethiopia, South Africa, Sudan, and Tanzania. A multistage random sampling strategy was used to select the schools and adolescents. Adolescent boys and girls aged 10-15 years were interviewed using a standardized questionnaire by trained enumerators. The questionnaire covered multiple domains including demographic and socioeconomic characteristics, water, sanitation and hygiene practices, antimicrobial resistance, physical activity, dietary behaviours, socioemotional development, educational outcomes, media use, mental health, and menstrual hygiene (only for girls). Additionally, a desk review of health and school meal policies and programs and a qualitative investigation into health and food environments in schools were conducted with students, administrators, and food vendors. In this paper, we describe the study design and questionnaire, present profiles of young adolescents who participated in the study, and share field experiences and lessons learned for future studies. We expect that this study along with other ARISE Network projects will be a first step toward understanding young people's health risks and disease burdens, identifying opportunities for interventions and improving policies, as well as developing potential research capacities on adolescent health and well-being in the SSA region.
Vaccines may induce non-specific effects on survival and health outcomes, in addition to protection against targeted pathogens or disease. Observational evidence suggests that infant Baccillus Calmette-Guérin (BCG) vaccination may provide non-specific survival benefits, while diphtheria-tetanus-pertussis (DTP) vaccination may increase the risk of mortality. Non-specific vaccine effects have been hypothesized to modify the effect of neonatal vitamin A supplementation (NVAS) on mortality.22,955 newborns in Ghana and 31,999 newborns in Tanzania were enrolled in two parallel, randomized, double-blind, placebo-controlled trials of neonatal vitamin A supplementation from 2010 to 2014 and followed until 1-year of age. Cox proportional hazard models were used to estimate associations of BCG and DTP vaccination with infant survival.BCG vaccination was associated with a decreased risk of infant mortality after controlling for confounders in both countries (Ghana adjusted hazard ratio (aHR): 0.51, 95% CI: 0.38-0.68; Tanzania aHR: 0.08, 95% CI: 0.07-0.10). Receiving a DTP vaccination was associated with a decreased risk of death (Ghana aHR: 0.39, 95% CI: 0.26-0.59; Tanzania aHR: 0.19, 95% CI: 0.16-0.22). There was no evidence of interaction between BCG or DTP vaccination status and infant sex or NVAS.We demonstrated that BCG and DTP vaccination were associated with decreased risk of infant mortality in Ghana and Tanzania with no evidence of interaction between DTP or BCG vaccination, NVAS, and infant sex. Our study supports global recommendations on BCG and DTP vaccination and programmatic efforts to ensure all children have access to timely vaccination.Ghana (Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000582055) and Tanzania (ANZCTR: ACTRN12610000636055).
A Good Clinical Practices (GCPs) course, based on the combination of theoretical modules with a practical training in real-life conditions, was held in 2010 in Burkina Faso. It was attended by 15 trainees from nine African, Asian, and Latin American countries. There were some discrepancies between the average good results at the end of the theoretical phase and the GCP application during the first days of the practical phase, underlying the difficulties of translating theoretical knowledge into good practices. Most of the findings were not unexpected and reflected the challenges commonly faced by clinical investigators in resource-poor contexts (i.e., the high workload at peripheral health facilities, the need to conciliate routine clinical activities with clinical research, and the risk of creating a double standard among patients attending the same health facility [free care for recruited patients versus user fees for non-recruited patients with the same medical condition]). Even if limited in number and time, these observations suggest that a theoretical training alone may not be sufficient to prepare trainees for the challenges of medical research in real-life settings. Conversely, when a practical phase immediately follows a theoretical one, trainees can immediately experience what the research methodology implicates in terms of work organization and relationship with recruited and non-recruited patients. This initial experience shows the complexity of translating GCP into practice and suggests the need to rethink the current conception of GCP training.
Africa has the potential to feed the world. Agricultural production is up by 160% over the past 30 years1. Eighteen sub-Saharan African countries have reached the Millennium Development Goals‟ first target of halving the proportion of people who are hungry2. And increasingly wider efforts are being launched across the continent aimed at improving food security. There is still a long way to go as Africa remains a net importer of food3 with about 25% of the continent population still living in hunger2,4. Malnutrition in all its forms continues to ravage Africa, with huge implications for mortality, health care costs, cognitive development and the economy5,6. Today, there are more stunted children in Africa than two decades ago4, and the risk of death before reaching age of five years is 15 times higher than among children in developed regions7. Almost a third of these deaths are caused by undernutrition and this contributes up to 8% loss of Africa‟s workforce4. Half of those surviving to working-age had suffered from stunting during childhood, losing an average of 1.2 years in school education4. In 2015, Africa‟s Gross Domestic Product (GDP) losses attributed to malnutrition rose to 11%, and in some countries to 16.5%4,8, far greater than annual world GDP losses due to the global financial crisis of 2008– 2010. No single „disease‟ is a greater threat than malnutrition to the wellbeing and economic development in Africa. The number of stunted children has been declining in all parts of the world, except in subSaharan Africa, where the numbers increased by about one third9. This is primarily driven by population growth and increasing urbanization10. Emerging global health threats like the recent Ebola epidemic, as well as climate change and conflicts, also play a part9-10. On the other hand, rapid nutrition transitioning with increasing intake of processed foods and unhealthy lifestyles contribute to increasing overweight and obesity trends especially in women and children11-14. Achieving a resilient and nutrition-secure Africa is a necessary step for sustainable development. The big question is: how can Africa end all forms of malnutrition? At the end of 2015, African leaders joined the world in adopting the Sustainable Development Goals (SDGs), and committed to ending all forms of malnutrition by 203015. The SDGs represent a unique opportunity and a framework to advance commitments on nutrition. At least 12 of the 17 SDGs contain indicators related to nutrition, placing nutrition as both an input to and outcome of the SDGs8. Taken together, they represent an increased realization that investments in nutrition support macroeconomic and societal growth. Globally, every $1 invested in proven nutrition programs offers benefits worth $168; estimated returns may be higher in Africa. Focusing on nutrition can help achieve other SDGs and vice versa, especially for goals related to gender equality and health. However, the financing needed to achieve the 2030 commitments for sustainable development globally are extremely large, on the order of trillions of dollars annually16. Of particular concern is the lack of a financing mechanism, especially a mechanism to harness domestic resources in support of nutrition initiatives. New data from the Global Panel on Agriculture and Food Systems for Nutrition shows nutrition investment to achieve the World Health Assembly (WHA) Global Nutrition Target of reducing stunting by 2025 in just 15 African countries can result in $83 billion in GDP growth17. Investments in line with the new framework will drive progress toward achieving four of the six WHA nutrition targets on alleviating stunting, wasting, and anemia, and increasing exclusive breastfeeding18. Achieving these targets would require increased Noor&Fawzi Nutrition Security for Sustainable Development in Africa African Journal of Reproductive Health September 2016 (Special Edition); 20(3): 33 investment of approximately US $1.8 billion per year from donors and US $750 million per year from African governments over the next decade17. The African Development Bank, through “The African Leaders for Nutrition”, is engaging heads of state to make commitments for their countries. Political commitment is essential and a necessary catalyst towards 2025 Global Nutrition Targets in Africa. To a great extent, we know which interventions work in improving nutrition in Africa19. A number of nutrition-specific (for example, micronutrient supplementation, food fortification etc.) as well as nutrition-sensitive interventions (including those aimed at improving water, sanitation and hygiene (WASH) standards, increasing agriculture production, improving gender equality) have been documented20, perhaps the latter ones with relatively less clarity in the context of integrated interventions21. The strength of evidence on nutrition specific interventions makes their integration relatively easier20. A recent framework further identifies costs and proposes a subset of high-priority cost-effective interventions for rapid implementation17. This includes vitamin A supplementation, supportive breastfeeding policies, and food fortification. Notably, successful implementation of programs for selected high priority interventions has proven to be challenging. Vitamin A coverage in Africa, for example, has invariably turned out to be lower than reported22, while the exclusive breastfeeding rates have persistently remained below 50%23. Likewise, data from large-scale food fortification programs show challenges in terms of access, consumption and compliance issues24. To better understand how integrated packages to prevent malnutrition translate in the African context, multiple sectors need to work together25,26. These include sectors focusing on education, water and sanitation, agriculture, and health. Emerging evidence shows strong association between poor WASH standards and stunting20,27, and likewise a number of ongoing studies show links between agriculture, nutrition and health26,28,29. In many settings, however, nutrition-sensitive strategies implemented as part of development programs have largely remained vertically implemented30,31. The greatest need for impact is within the households of smallholder farmers, who represent the majority of the African population and are most affected by malnutrition32. Hence, agriculture and nutrition integration must focus on promoting production of safe and diverse nutrient rich foods, coupled with increased consumption of these foods by women and children who are at greater risk of malnutrition. Evidence on the effectiveness of integrated packages is key for their scale up. And so is the knowledge on how to implement these packages. Capacity building of front line workers at community level, including health and agriculture extension workers is needed, as is enhanced competence in evidence translation to policy and programs, and greater skills in program management and monitoring and evaluation. Stronger ties are needed between academic and research institutions in Africa on one hand, and on the other hand policy makers and public and private providers across key sectors. As the number of interventions that need to be included in integrated packages increase, implementation becomes even more challenging. Until recently the world lacked guidance on which program interventions to scale up, which were the most cost-effective and how they can be financed. This year the World Bank launched the first-ever investment framework for nutrition33 which provides the roadmap for accelerating progress against malnutrition. And countries are expected to implement evidence-based integrated interventions, packaged into minimum bundles possible, for effectiveness and impact in nutrition. The count down for the SDGs has begun, and it is critical that mechanisms are instituted to support African countries as they gather the required data on appropriate metrics for regular progress reviews at the regional as well as the country level. The monitoring of the MDGs taught us that data are an indispensable element of the development agenda16. This remains true if we are to achieve nutrition security and overall targets set for the SDGs. We believe that many countries in Africa are on the right track. Strong consensus and commitment to achieve nutrition security exists among African countries and development partners. In 2014, the first ever agriculturenutrition integrated commitment was signed by the Noor&Fawzi Nutrition Security for Sustainable Development in Africa African Journal of Reproductive Health September 2016 (Special Edition); 20(3): 34 African heads of State, the Malabo Declaration34. This year, the United Nations declared the next 10 years to be a decade focused on nutrition35. Smart investments on the highest impact, most costeffective nutrition programs that can be scaled up are the way to go. Long-term strategic investments in nutrition will require political will, and context and data-driven decisions to catalyze Africa‟s commitment to end all forms of malnutrition by 2030, and achieve the SDGs.
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