Complex interactions between malaria and malnutrition: a systematic literature review

D Das,E A Okiro,K Stepniewska,J Tarning,D J Terlouw,S Van Der Kam,K I Barnes,R Mansoor,R F Grais,P J Guerin

doi:10.1186/s12916-018-1177-5

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.

Highlights

Despite 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
A total of 32 articles identified through the search and 1 article obtained through citation tracking were included, describing cross-sectional surveys (n = 16), longitudinal studies (n = 12), interventional studies (n = 3), case-control study (n = 1) and individual patient data meta-analysis (n = 1) (Fig. 1)
Details of the 33 studies included in this review are given in Table 1, while the study characteristics are summarised in Additional file 4

Summary

Introduction

Despite 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. Malaria and malnutrition in children (refers to all forms of undernutrition) are reported independently to be major causes of morbidity and mortality in low- and middle-income countries. Being underweight (low weight for age) can result from either chronic or acute malnutrition or both. Stunting is defined by the measure of height-for-age Z-score (HAZ) and a child is considered as being underweight based on low weight-for-age Z-score (WAZ). These definitions do not take micronutrient malnutrition into account, which can occur even if the person is getting enough energy and they are not thin or short

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