Infection in Nigeria[6–9] and Senegal[7], leading some to suggest

Infection and nutrition are intimately
related from the coincidental shared pathways of poverty to effects on
metabolism and immunity1. Distinguishing the contributions of
infectious diseases and nutrition as causes of death is complex. In most
reporting systems and global disease burden estimations, infectious diseases
represent an immediate, direct cause of death, while mortality attributed to
malnutrition may only be recognized as a cause of death when it is severe
enough to cause clinical manifestations2. However, Pelletier et al. suggested
that malnutrition, by virtue of its synergistic relationship with infectious
disease, caused 56% of child mortality, a much larger fraction than classification
of “nutritional deficiencies”2. Similarly, community-based studies
of malaria reveal that this infection contributes to under-five mortality more
than would be attributed to malaria-specific deaths alone2. Importantly, both malaria and
undernutrition are highly prevalent in sub-Saharan Africa and often share
common spatial distributions3–5.  


The precise clinical relationships
between undernutrition and malaria have been the subject of competing
hypotheses. Nutritional interventions appeared to exacerbate the clinical
outcomes of malaria infection in Nigeria6–9 and Senegal7, leading some to suggest that
nutrient deficiency, notably iron10, may protect against malaria. While
other studies found no significant association11,12 and more recent cross-sectional
studies offer no support to the hypothesis that under-nutrition protection
against malaria infection and disease progression13,14. In fact, increased risks of poor
outcomes of malaria are described in several studies13 indicate that malnutrition and
malaria form a vicious circle that has a large impact on morbidity and
mortality among the most vulnerable in the population, likely operating through
broad effects on the functional capacity of the immune system4,15. In Somalia, there are high levels of
acute malnutrition in the South Central zone, estimated to be at least 35%;
followed by Puntland zone and lowest levels are in Somaliland zone16. A similar pattern is observed in the
distribution of malaria in Somalia17. Plasmodium falciparum parasite rate
(PfPR) is estimated to range from 0–9% in the north of Somalia and from 0–52%
in south of Somalia, with high PfPR locations occurring in the densely
populated regions between the Juba and Shabelle rivers. Majority of the area in
the northern part of Somalia have been reported to have a PfPR of <5% with a small number of locations in Puntland and on the south-western border between Somaliland and Ethiopia having PfPR of >5–9%. In the south, PfPR is lower
along the two rivers, compared to the area in between18,19.

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are several pathways that may explain the comorbidity. On one hand, children in
developing countries are at a higher risk of both malnutrition and infections
due to environmental conditions, and thus more prone to concurrent conditions
occurring by chance20.  Both are subject to seasonal variation driven
by weather and food supply. On the other hand, malnutrition compromises the
immunity, leaving the child susceptible to infection21;
and malaria may result in anorexia, weight-loss or, when pregnant women are infected,
low birth weight.


The overlapping epidemiology may be
explored by joint mapping of the two health conditions to quantify the
correlation structures between their relative risks by modelling common and
disease-specific observed effects and spatial patterns simultaneously22. In this study, we aimed to undertake
the first nationwide investigation of ecological co-morbidity of wasting and
low mid upper arm circumference (MUAC) with falciparum
malaria in Somalia to determine the spatial patterns of these health conditions.
A shared component model was used to fit common and indicator-specific
unobserved and unmeasured spatial risks 23,24.



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