title: Malaria is associated with poor school performance in an endemic area of the Brazilian Amazon.
abstract: BACKGROUND
  Approximately 40% of the world's population is at risk for malaria. In highly endemic tropical areas, malaria is a major cause of morbidity and mortality during infancy. There is a complex interrelationship between malaria, malnutrition and intestinal helminths, and this may impair cognitive development in children. The aim of this study was to determine the relationship between malaria and school performance in children living in an endemic area where Plasmodium vivax is the species responsible for most of the cases.
  
  
  METHODS
  The study was conducted in the Municipality of Careiro, Amazonas, Brazil, with five to 14 year-old children, studying the first eight grades of public school, during the year 2008. After an initial active case detection, during nine months of follow-up, passive malaria cases detection was instituted, through a thick blood smear performed in every child with fever. School performance was evaluated by the final notes in Mathematics and Portuguese Language. Performance was considered poor when either of the final notes in these disciplines was below the 50th percentile for the respective class and grade.
  
  
  RESULTS
  The total number of students followed-up in the cohort was 198. Malarial attacks were reported in 70 (35.4%) of these students, with no cases of severe disease. Plasmodium vivax was detected in 69.2% of the attacks, Plasmodium falciparum in 25.5% and both species in 5.3%. In the multivariate analysis, adjusting for age, mother's education, time living in the study area and school absenteeism, presenting with at least one episode of malaria independently predicted a poor performance at school [OR = 1.91 (1.04-3.54); p = 0.039].
  
  
  CONCLUSIONS
  Non-severe malaria compromises the school performance of children even during a nine-month follow-up, potentially contributing to the maintenance of underdevelopment in countries endemic for malaria. This is the first evidence of such impact in Latin America, where P. vivax is responsible for the majority of the cases.
authors.affiliation: Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, 69065-001 Manaus, Brazil. vitorsheila@hotmail.com
authors.forename: Sheila
authors.initials: S
authors.lastname: Vitor-Silva
authors.forename: Roberto C
authors.initials: RC
authors.lastname: Reyes-Lecca
authors.forename: Tamam R A
authors.initials: TR
authors.lastname: Pinheiro
authors.forename: Marcus V G
authors.initials: MV
authors.lastname: Lacerda
mesh_terms: D000293:Adolescent; D000818:Animals; D001769:Blood / Q000469:parasitology; D001938:Brazil; D002648:Child; D002675:Child, Preschool; D003072:Cognition Disorders / Q000209:etiology*; D004521:Educational Measurement; D005260:Female; D006801:Humans; D016778:Malaria, Falciparum / Q000150:complications*; D016780:Malaria, Vivax / Q000150:complications*; D008297:Male; D010963:Plasmodium falciparum / Q000302:isolation & purification; D010966:Plasmodium vivax / Q000302:isolation & purification; D012574:Schools