Complex interactions between malaria and malnutrition: a systematic literature review

Abstract

BackgroundDespite substantial improvement in the control of malaria and decreased prevalence of malnutrition over the past two decades, both conditions remain heavy burdens that cause hundreds of thousands of deaths in children in resource-poor countries every year. Better understanding of the complex interactions between malaria and malnutrition is crucial for optimally targeting interventions where both conditions co-exist. This systematic review aimed to assess the evidence of the interplay between malaria and malnutrition.MethodsDatabase searches were conducted in PubMed, Global Health and Cochrane Libraries and articles published in English, French or Spanish between Jan 1980 and Feb 2018 were accessed and screened. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias across studies was assessed using the GRADE approach. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline were followed.ResultsOf 2945 articles screened from databases, a total of 33 articles were identified looking at the association between malnutrition and risk of malaria and/or the impact of malnutrition in antimalarial treatment efficacy. Large methodological heterogeneity of studies precluded conducting meaningful aggregated data meta-analysis. Divergent results were reported on the effect of malnutrition on malaria risk. While no consistent association between risk of malaria and acute malnutrition was found, chronic malnutrition was relatively consistently associated with severity of malaria such as high-density parasitemia and anaemia. Furthermore, there is little information on the effect of malnutrition on therapeutic responses to artemisinin combination therapies (ACTs) and their pharmacokinetic properties in malnourished children in published literature.ConclusionsThe evidence on the effect of malnutrition on malaria risk remains inconclusive. Further analyses using individual patient data could provide an important opportunity to better understand the variability observed in publications by standardising both malaria and nutritional metrics. Our findings highlight the need to improve our understanding of the pharmacodynamics and pharmacokinetics of ACTs in malnourished children. Further clarification on malaria-malnutrition interactions would also serve as a basis for designing future trials and provide an opportunity to optimise antimalarial treatment for this large, vulnerable and neglected population.Trial registrationPROSPERO CRD42017056934.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1177-5) contains supplementary material, which is available to authorized users.

A 2-month intervention study of preventive clothing against mosquito bites among malnourished and well-nourished children under 5 years of age living on the Atlantic Ocean Coast of Lagos, Southwest Nigeria

“…First, this study further stresses the association between malaria and anaemia in under-fives which various studies have documented [42][43][44][45] extensively. Secondly, this study confirms the complex and inconclusive relationship effect of malnutrition on malaria [46]. There seems to be a vicious cycle between malaria and malnutrition as malaria imposes a heavier burden on malnourished children while malnutrition worsens malaria infection.…”

Malaria and Nutritional Status Among Children With Severe Acute Malnutrition in Niger: A Prospective Cohort Study

“…While the common seasonality of malaria and malnutrition has been previously documented [ 8 ], the presence of a biological or immunological interaction between malaria and malnutrition that may encourage a high burden of both diseases remains unclear [ 9 , 10 ]. It has been suggested that malnutrition may predispose children to infection or make it more difficult to recover from infection [ 8 , 11–14 ]; however, the epidemiological evidence is mixed [ 15–25 ].…”

Malaria Parasitemia and Nutritional Status during the Low Transmission Season in the Presence of Azithromycin Distribution among Preschool Children in Niger

“…5 A systematic review of studies of the relationship between malaria and malnutrition concluded that the relationship is complex and called for analysis of additional individual patient data of malaria and malnutrition in different settings. 4 Poor nutritional status may predispose children to infection with malaria by modulating immune function, and children with malaria may be predisposed to malnutrition, particularly if they suffer from repeated infection. Conversely, some studies have shown a protective effect of malnutrition against malaria, which may be mediated by iron or other nutritional deficiencies.…”