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MALARIA AND NUTRITIONAL STATUS AMONG PRE-SCHOOL CHILDREN: RESULTS FROM CROSS-SECTIONAL SURVEYS IN WESTERN KENYA

Protein-energy malnutrition (PEM) affects millions of children in the developing world. The relationship between malaria and PEM is controversial. The goal of this study was to evaluate whether undernutrition is associated with increased or decreased malaria attributable morbidity. Three cross-sectional surveys were conducted using insecticide-treated bed nets (ITNs) among children aged 0–36 months living in an area with intense malaria transmission. Data were collected on nutritional status, recent history of clinical illness, socioeconomic status, current malaria infection status, and hemoglobin. In multivariate models, stunted children had more malaria parasitemia (odds ratio [OR] 1.98, P < 0.0001), high-density parasitemia (OR 1.84; P < 0.0001), clinical malaria (OR 1.77; P < 0.06), and severe malarial anemia (OR 2.65; P < 0.0001) than nonstunted children. The association was evident in children with mild-to-moderate (–3 < height-for-age Z-score [HAZ] < –2) and severe stunting (HAZ < –3). The cross-sectional nature of the study limits the interpretation of causality, but the data provide further observational support that the presence of undernutrition, in particular chronic undernutrition, places children at higher, not lower risk of malaria-related morbidity.

Received March 4, 2005. Accepted for publication June 2, 2005.

Acknowledgments: We express our gratitude to the children and caregivers who participated in the study and the many people that assisted with this project. The authors thank John Paul Clark, Neen Alrutz, and Mary Ettling for their continued interest and support. We also thank the Director of the Kenya Medical Research Institute for his permission to publish this work.

Financial support: The ITN project was funded by the United States Agency for International Development. Feiko O. Ter Kuile was supported, in part, by a grant from the Netherlands Foundation for the Advancement of Tropical Research (WOTRO) (The Hague, The Netherlands). Jennifer F. Friedman was supported by a United States Fulbright award and K23AI52125 from the National Institute of Allergy and Infectious Diseases.

^* Address correspondence to Jennifer F. Friedman, M.D., M.P.H., International Health Institute and Department of Pediatrics, Brown University, Box G-B495, Providence, RI 02912. E-mail: Jennifer_ Friedman{at}Brown.edu.

Authors’ addresses: Jennifer F. Friedman, International Health Institute and Department of Pediatrics, Brown University, Box G-B495, Providence, RI 02912, E-mail: Jennifer_Friedman{at}Brown.edu. Arthur M. Kwena, Moi University, Department of Medical Biochemistry, Faculty of Health Sciences, Eldoret, Kenya. Lisa B. Mirel, National Center for Health Statistics, Division of Health and Nutrition Examination Suveys, Centers for Disease Control and Prevention, 3311 Toledo Road, MS P08, Hyattsville, MD 20782. Simon K. Kariuki, Kenya Medical Research Institute, Center for Vector Biology and Control Research, P.O. Box 1578, Kisumu-40100, Kenya. Dianne J. Terlou and Feiko O. ter Kuile, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. Penelope A. Phillips-Howard, William A. Hawley, and Ya Ping Shi, National Center for ID, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Mail Stop F-22, 4770 Buford Highway, Atlanta, GA 30341. Bernard L. Nahlen, World Health Organization, Roll Back Malaria, Avenue Appia 20, 1211, Beneva 27, Switzerland.

Reprint requests: Jennifer F. Friedman, M.D., M.P.H., International Health Institute and Department of Pediatrics, Brown University, Box G-B495, Providence, RI 02912. E-mail: Jennifer_Friedman@ Brown.edu.

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