Home Fortification with a Small-quantity, Lipidbased Nutritional Supplement to Improve Complementary Feeding and Child Nutritional Status in Kasenga (DR Congo).

Objectives: To address the high prevalence of anemia and chronic malnutrition (71% and 43% among children <5 respectively), UNICEF and CDC supported the Ministry of Public Health to develop an integrated IYCN pilot program in October 2012, which includes the distribution of a small-quantity, lipid-based nutrition supplement (SQ-LNS), through the routine health system. The program targets 16,500 children 0-12 months and their mothers. Methods: The program involves i) monthly individual and group IYCN counseling by trained health workers and volunteers, and ii) a monthly distribution of SQ-LNS (locally known as Kulabora) to children 6-12 months through the health system, for daily consumption. Formative research was conducted to generate culturally acceptable key counseling messages and product branding. Routine health system reporting and bi-annual Lot Quality Assurance Surveys (LQAS) are used for program monitoring. Results: After 10 months of intervention, LQAS data showed 65% of mothers received the Kulabora at the last monthly health center visit, 53% received IYCN counseling at this visit, and additionally 55% received counseling by volunteers at home. Routine monitoring data reports that 3,100 women have enrolled in the program and approximately 2,000 children receive Kulabora monthly. Results from two rounds of LQAS show improvements in several IYCN indicators. LQAS data has allowed for targeted corrective action and further formative work will be used for program strengthening. Conclusions: Formative research has been important for program success, and program implementation is possible even in difficult settings. The impact assessment in October 2014 will inform a possible scaling up of the program.

Household Utilization of Iodized Bouillon Cubes Affects Iodine Intake in Senegal.

Objectives: To prevent iodine deficiency, Senegal mandated the iodization of all salt produced, imported or distributed. There has been a dramatic increase in use of bouillon, which is claimed to contain iodine in Senegal. We undertook this survey to better understand the extend of bouillon cube use in the context of salt iodization. Methods: A nationwide cross-sectional stratified cluster sample household-level survey was conducted to measure urinary iodine concentration in women 15-45 years and children 6-12 years, iodized salt and bouillon consumption, and iodine concentration in salt available in households. In all, 3,768 households were surveyed including 7,980 women and 6,309 children. Results: Only 56% of households surveyed had iodized salt. Average iodine concentration in salt was 22ppm. Average per capita daily household consumption was 4.79 g salt (5.01g urban, 4.60g rural; P<0.001) and 3.98 g bouillon cube (4.29g urban, 3.74g rural; P< 0.05). Median urinary iodine concentration in children was 104.42μg/l (141.25μg/l urban, 82.63μg/l rural) and 92.20μg/l for women (114.73μg/l urban, 72.95μg/l rural). Conclusions: This study shows that household consumption of bouillon cubes is high in Senegal; mean UI seems to be adequate in urban setting but insufficient in rural areas, suggesting a lower intake of iodine from iodized salt/bouillon cube. Adequate iodine concentration in bouillon cube could be an avenue to tackle IDD in Senegal; however, further research is warranted on current content and bioavailability of iodine in bouillon cube as well as feasibility of iodization of bouillon cube as complement to iodized salt in Senegal to guide decisions.

Formative Work to Design the Packaging of a Lipid-based Nutrient Supplement for a Home Fortification Program in the Democratic Republic of Congo (DRC) .

Objectives: To determine a culturally appropriate product name and package design that would communicate important usage instructions for a lipid-based nutrient supplement (LNS) for a target population with diverse languages and low literacy. Methods: Formative work was conducted in two locations in Katanga region, DRC: Mabaya, a rural village and Kipushi, a peri-urban area. In each site, focus group discussions with parents of children aged 0-24 months (3 with mothers, and 1 with fathers) were conducted. Additionally, two key informant interviews with mothers and health workers were conducted in each location. Two sets of 7 images, one for each LNS sachet in the strip, were tested to assess perceptions of use. Different color options and product names were tested to identify culturally appropriate packaging. Results: The majority of participants read the different images on the multi sachet strip as a story line. Participants retained the main messages that the strip should convey: Optimal child feeding and care, product use, target group and potential product benefits. All participants recognized the mother and children in the images as "Congolese". Green and brown were identified as suitable colors for the packaging and were associated with qualities such as growth, and healthy development. The names Kulazuri (eating well) and Afiabora (good health) were preferred. A combination of the first two name proposals "Kulabora" (eating better) was decided upon. Conclusions: The results from this formative assessment were used to finalize the design of the LNS product, which is currently being distributed in Kasenga health zone.

Malarial Morbidity and Postnatal HIV Infection in Breastfeeding HIV-exposed Infants.

Background: For at-risk HIV-negative individuals, whether malarial morbidity increases the likelihood of HIV infection when exposed is unknown. Hence, we investigate the malaria-associated risk of postnatal HIV infection in 1804 breastfeeding infants of HIV-positive women from Dar es Salaam, Tanzania. Methods: Six-week-old HIV-negative infants were followed until breastfeeding cessation or postnatal HIV infection. HIV-1 status was determined by a DNA PCR test. Malarial morbidity was diagnosed by physicians using a combination of clinical symptoms and laboratory tests. For analytic purposes, malaria was distinguished by diagnostic specificity as: (1) clinical; (2) probable, where laboratory testing is requested for parasitemia; and (3) blood smear-confirmed. Hazard ratios (HR) and 95% confidence intervals (CI) for the risk of HIV infection were estimated from multivariate Cox regression models. Results: Mean follow-up duration was 6.2 months (standard deviation=2.4 months), during which 91 new HIV infections developed and clinical malaria was diagnosed in 594(32.3%) children, including 283 (15.5%) probable and 80(4.4%) confirmed malaria episodes. Infants ever diagnosed with clinical and probable malaria were at 73% (95%CI:1.11 - 2.69) and 100% (95%CI:1.17-3.42) higher risk of postnatal HIV infection, respectively. This risk increased by 39% (95%CI: 1.08-1.80) and 59% (95%CI: 1.00-2.32), respectively, per episode increment in clinical and probable malarial; however, confirmed malaria was not significantly associated with HIV incidence (HR=2.09; 95%CI: 0.74 - 5.91). Conclusion: We found positive associations between child malarial infection and postnatal HIV infection among breastfeeding HIV-negative children of HIV-positive women. These findings suggest that malaria prevention in such infants may decrease the risk of HIV mother-to-child-transmission. However, specific future studies using laboratory-confirmed malaria in HIV-negative but HIV at risk populations are needed to substantiate these findings.