The association between nutritional status and malaria in children from a rural community in the Amazonian region: a longitudinal study.
BACKGROUND
The relationship between malaria and undernutrition is controversial and complex. Synergistic associations between malnutrition and malaria morbidity and mortality have been suggested, as well as undernutrition being protective against infection, while other studies found no association. We sought to evaluate the relationship between the number of malaria episodes and nutritional statuses in a cohort of children below 15 years of age living in a rural community in the Brazilian Amazon.


RESULTS
Following a baseline survey of clinical, malaria and nutritional assessment including anthropometry measurements and hemoglobin concentration, 202 children ranging from 1 month to 14 years of age were followed for one year through passive case detection for malaria episodes. After follow-up, all children were assessed again in order to detect changes in nutritional indicators associated with malaria infection. We also examined the risk of presenting malaria episodes during follow-up according to presence of stunting at baseline. Children who suffered malaria episodes during follow-up presented worse anthropometric parameters values during this period. The main change was a reduction of the linear growth velocity, associated with both the number of episodes and how close the last or only malaria episode and the second anthropometric assessment were. Changes were also observed for indices associated with chronic changes, such as weight-for-age and BMI-for-age, which conversely, were more frequently observed in children with the last or only episode occurring between 6 and 12 months preceding the second nutritional assessment survey. Children with inadequate height-for-age at baseline (Z-score < -2) presented lower risk of suffering malaria episodes during follow-up as assessed by both the log-rank test (p =0.057) and the multivariable Cox-proportional hazards regression (Hazard Ratio = 0.31, 95%CI [0.10; 0.99] p=0.049).


CONCLUSIONS
Malaria was associated with impaired nutritional status amongst children in an endemic area of the Western Brazilian Amazon where P. vivax predominates. Our data all supports that the association presents differential effects for each age group, suggesting distinct pathophysiology pathways. We were also able to demonstrate that undernourishment at baseline was protective to malaria during follow-up. These findings support an intriguing interaction between these conditions in the rural Amazon and the need for a more integrative approach by health systems in endemic areas.
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil.
Márcia Almeida Araújo
MA
Alexandre
Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil; Department of Pediatrics, Discipline of Nutrition and Metabolism, Federal University of São Paulo, São Paulo, Brazil.
Silvana Gomes
SG
Benzecry
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil; Laboratório de Pesquisa Clínica em Doenças Febris Agudas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
Andre Machado
AM
Siqueira
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil.
Sheila
S
Vitor-Silva
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil.
Gisely Cardoso
GC
Melo
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil.
Wuelton Marcelo
WM
Monteiro
Department of Pediatrics, Discipline of Nutrition and Metabolism, Federal University of São Paulo, São Paulo, Brazil.
Heitor Pons
HP
Leite
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil; Centro de Pesquisas Leônidas e Maria Deane, Fundação Oswaldo Cruz, Manaus, Amazonas, Brazil.
Marcus Vinícius Guimarães
MV
Lacerda
Gerência de Malaria, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, Brazil; Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Amazonas, Brazil.
Maria das Graças Costa
Md
Alecrim
D000886:Anthropometry; D001835:Body Weight; D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006130:Growth Disorders / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D008137:Longitudinal Studies; D008288:Malaria / Q000453:epidemiology*; D008297:Male; D009017:Morbidity; D009752:Nutritional Status / Q000502:physiology*; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data*