Cécile Cazes

Background: Undernutrition and infectious diseases form a vicious cycle that endangers child survival in low-resource settings, including in Northern Nigeria. The NutriVax-Measles trial was designed to evaluate a strategy combining preventive small-quantity lipid-based nutrient supplements (SQ-LNS) distributions with community mobilization and routine immunization services for children aged 6-23 months to improve measles vaccination uptake. To inform future programs co-delivering nutrition supplementation and immunization services at scale, we aimed to assess the feasibility and acceptability of measles vaccination, SQ-LNS distribution, and the NutriVax strategy. Methods: A qualitative study was conducted at the end of the trial using in-depth interviews (n=53) and focus group discussions (n=8) with key stakeholders: caregivers, health care workers, community health workers, and community representatives. Thematic analysis was guided by multiple conceptual frameworks. Results: The majority of the participants expressed satisfaction with measles vaccines in both arms, and with SQ-LNS in the NutriVax arm, as they perceived the benefits for their children’s health. In both arms, community awareness sessions and previous experience of outbreaks were key to motivating caregivers to bring their children to healthcare centres. Although distance to health facilities was identified as one of the main barriers to accessing care, SQ-LNS was perceived as an important source of motivation to bring their child to the clinic where they subsequently received vaccination. All stakeholder groups emphasized the importance of community leaders’ support and targeted male sensitization to address the prevailing sociocultural norms. Additionally, improved service organization to reduce waiting time was considered crucial to enhance caregivers’ acceptability of the intervention. Conclusion: Both measles vaccination and SQ-LNS provision were acceptable and feasible, supporting the NutriVax strategy within primary healthcare settings in fragile health systems. Successful implementation depends on sustained community sensitization, continued engagement of fathers and community leaders, and service delivery decentralized as close as possible to beneficiaries. KEY MESSAGES: What is already known?: Co-delivering small-quantity lipid-based nutrient supplements (SQ-LNS) with routine immunization is an effective strategy to improve vaccination coverage in Northern Nigeria. Yet, evidence on how vaccination and SQ-LNS are perceived, implemented, and experienced by stakeholders at health-care and community levels remains scarce. What are the new findings?: SQ-LNS was an important source of motivation for caregivers to bring their children to health facilities, creating opportunities for vaccination. Persistent barriers to vaccination included socio-cultural misconceptions, gender norms, long waiting time and distance to health facilities. What do the new findings imply?: Sustained community engagement, including targeted male sensitization, is important to improve measles vaccination acceptability. Successful implementation of co-delivery programs also requires well-organized service delivery, with services decentralized to health facilities as close as possible to beneficiaries, particularly to reduce travel distances and waiting times.

Introduction: Control of tuberculosis (TB) in children remains a major challenge globally. There is growing recognition that children with severe acute malnutrition (SAM) are a high-risk population for TB, but the global burden of TB in this group has never been comprehensively quantified. Methods: We conducted a systematic review and meta-analysis to estimate the prevalence of TB among children with SAM. Following PRISMA guidelines, we searched PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and WHO Global Index Medicus from database inception to June 15, 2026. We included studies reporting TB among systematically sampled cohorts of children <15 years with SAM as defined by the World Health Organization. Methodological study quality was assessed with adapted versions of the Newcastle-Ottawa Scale or the Joanna Briggs Institute critical appraisal checklist. Pooled TB prevalence was calculated using a random-effects model with predefined stratification of studies by geographic region, national TB incidence, and study quality. We also conducted subgroup analyses by age, sex, HIV status, SAM type, and TB exposure. Results: We included 73 studies comprising 33,869 children with SAM across 15 countries, predominantly from sub-Saharan Africa and South Asia, and predominantly reporting on hospitalized children. The pooled TB prevalence was 13% (95% CI: 11-16%), but there was substantial heterogeneity (I²=98%). Studies conducted in Southern Africa had the highest pooled TB prevalence (36%, 95% CI: 19-56%) compared to other regions (p<0.01). Pooled TB prevalence was higher in those with history of TB household exposure compared to those without (74% vs. 17%, p=0.01). Conclusions: Approximately one in eight children hospitalized with SAM have TB, greatest among children with history of TB exposure and those in Southern Africa. These findings highlight opportunities for improved early TB diagnosis and routine, integrated TB screening within hospital-based SAM care pathways.

Justification : L'accès au traitement de la malnutrition aiguë reste faible dans le monde. Les programmes nutritionnels actuels, sous financés, prennent en charge les cas de malnutrition aiguë sévère et de malnutrition aiguë modérée, séparément, en utilisant différents traitements avec un dosage non optimal. Nous avons évalué une stratégie simplifiée basée sur un programme unique, utilisant un seul traitement pour tous les enfants pris en charge. Méthodologie: Nous avons mené un essai contrôlé randomisé ouvert, de non-infériorité, en République démocratique du Congo. Des enfants âgés de 6 à 59 mois souffrant de malnutrition aiguë présentant un périmètre brachial {PB)< 125mm ou des œdèmes nutritionnels, ont été randomisés (1:1), soit vers le protocole standard (un programme pour la malnutrition aiguë sévère utilisant des aliments thérapeutiques prêts à l'emploi [ATPE] avec une dose croissante en fonction du poids et d'autre aliments supplémentaires prêts à l'emploi [ASPE] à dose fixe pour la malnutrition aiguë modérée), soit vers le protocole OptiMA (un seul programme pour la malnutrition aiguë sévère et modérée utilisant les ATPE à une dose décroissante en fonction du PB et du poids). Le critère de jugement principal était une issue favorable à 6 mois, définie par les critères suivants : le fait d'être en vie, de ne pas souffrir de malnutrition aiguë et sans rechute pendant la période d'observation de 6 mois. La randomisation était stratifiée sur les critères de sévérité de la maladie pour le critère de jugement secondaire prioritaire. La guérison était définie par la combinaison des critères suivants: un minimum de 4 semaines de traitement, une température axillaire< 37,5°C, absence d'œdèmes nutritionnel et amélioration anthropométrique {PB ≥ à 125 mm ou un indice poids pour taille (P/T)≥ -1-5 zscore); et mesurée au cours des 6 mois de suivi parmi les enfants avec un PB<115 mm ou des œdèmes nutritionnels ou un indice P/T < -3 zscore à l'inclusion. Ces deux critères de jugement ont été analysés en intention de traiter {ITT) (tous les enfants) et en per-protocol (PP) (participants à qui l'on avait prescrit au moins 4 semaines d'ATPE, qui avaient reçu au moins 90 % de la quantité totale d'ATPE qu'ils étaient censés recevoir conformément au protocole, ou à qui l'on avait prescrit des ASPE pendant au moins 4 semaines [c'està- dire au moins 28 sachets d' ASPE], et qui avaient un intervalle maximal entre deux visites de 6 semaines au cours des 6 mois de suivi dans l'essai). Ces deux analyses de non-infériorité (marge de 10%) devaient être suivies d'une analyse de supériorité (marge 0%) si la non infériorité était conclue. Résultats : Entre le 22 juillet 2019 et le 20 janvier 2020, 997 enfants ont été randomisés ; 896 ont été inclus dans l'analyse en ITT pour l'analyse du critère de jugement principal : 282/446 (63%) enfants dans le groupe standard et 325/450 (72 %) enfants dans le groupe OptiMA ont présenté une issue favorable {différence -9-0 %, IC95 % -15-9 à -2-0). Dans le groupe standard, 315/446 {71%) enfants ont été traités avec un total de 45 637 sachets d'ATPE ou d'ASPE prescrits [12 753 USD] comparé à 450/450 {100%) enfants traités avec 37 035 [10 374 USD] sachets d'ATPE dans le groupe OptiMA. 482 enfants avec une malnutrition aigüe sévère ont été inclus dans l'analyse en ITT du critère de jugement principal secondaire: 234/240 {98%) enfants du groupe standard et 231/242 (96%) enfants du groupe OptiMA ont guéris (différence 2-0%, IC 95% -2-0% à 6-4%). La quantité d'ATPE prescrite dans le groupe standard était inférieure de 31% par rapport au groupe OptiMA. Les analyses de non-infériorité en per-protocole ont montré des résultats similaires pour les deux critères de jugements (...).

Undernutrition and infectious diseases form a vicious cycle that poses a dual threat to vulnerable children in low- and middle-income countries. Integrating small-quantity lipid-based nutrient supplements (SQ-LNS) distribution into routine immunization services in children 6–23 months may act as both a nutritional intervention and as an incentive for increased vaccine uptake. We will conduct a two-arm superiority pragmatic parallel cluster-randomized controlled trial with baseline measures in 20 wards of Nguru and Karasuwa Local Government Areas, Yobe State, Northeast Nigeria. Wards will be randomly allocated 1:1 to either the standard National Program on Immunization (NPI) arm or the NutriVax arm, which combines NPI with SQ-LNS distribution. After up to 12 months of implementation, measles immunization coverage will be assessed at two levels: population-level coverage in children aged 12–23 months (primary outcome, endline cross-sectional survey) and individual-level coverage in children aged 6–12 months (key secondary outcome, longitudinal survey). Each cross-sectional survey (baseline and endline) will include 1560 participants. The longitudinal survey will enroll 600 participants. Sampling will use a multi-stage design with probability proportional to size and systematic random household selection. All outcomes will be analyzed by intention-to-treat. Qualitative interviews will assess feasibility and acceptability. Cost-efficiency differences between arms will be estimated using an incremental cost-efficiency ratio. To our knowledge, this is the first trial to evaluate whether a preventive nutrition supplement can also serve as an incentive to increase vaccination coverage. Findings will provide evidence to guide governments and donors in settings where high rates of undernutrition and low immunization coverage persist as major public health challenges. Protocol Number NCT06387511 (clinicaltrials.gov).

Children who receive therapeutic feeding for wasting treatment but do not reach the anthropometric definitions of recovery (usually within 12–16 weeks) are categorised as ‘non-responders’ and considered as treatment failures. We conducted a pooled analysis to explore the growth trajectories of non-responders and the appropriateness of the definition of ‘non-response’. We pooled 14 studies of children aged 6–59 months receiving treatment for wasting. We included children classified by their studies as recovered or as non-responders. Observing the pooled data of non-responders’ mid-upper arm circumference (MUAC), weight, weight-for-age z-score, weight-for-height z-score and daily weight gain rate, we found that the first quartile differentiated those who did not grow at all versus those that demonstrated some growth. We therefore defined ‘low growth non-responders’ as < 25^th percentile anthropometric gain between admission and exit using the non-responders’ pooled study data, and ‘high growth non-responders’ as ≥ 25^th percentile gain. We plotted the growth trajectories of MUAC-, weight- and height-related indices of the recovered, high growth and low growth non-responder groups over time using mixed effects generalised additive models. We compared age, sex and anthropometric characteristics of the three groups and explored predictors of non-response category using a multivariate multinomial logistic regression model. For all outcomes, the high growth non-responders started with a worse anthropometric status compared to those who recovered, but then tracked along a near-parallel growth trajectory. The low growth non-responders showed limited growth throughout treatment. High growth non-responders are better viewed as ‘delayed responders’ and may need to be kept longer under treatment to recover and reduce the risks from early discharge. Low growth non-responders are the true treatment failures and should be referred for further investigations as quickly as possible. In conclusion, non-responders are not a homogenous group; ~75% of them respond well to treatment and ~25% are treatment failures.

Introduction Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) Methods and analysis This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6–59 months presenting with MUAC Ethics and dissemination Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings. Trial registration number NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.