|Year : 2017 | Volume
| Issue : 2 | Page : 113-116
Prevalence of malaria parasitaemia among febrile Nigerian children with severe malnutrition in Northwestern Nigeria
Idris A Umma1, Wammanda D Robinson2, Faruk A Jamilu2, Garba D Gwarzo3
1 Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria
2 Department of Paediatrics, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||5-Oct-2017|
Idris A Umma
Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State
Source of Support: None, Conflict of Interest: None
Background: Malnutrition and malaria are common in sub-Saharan Africa, and understanding the relationship between protein-energy malnutrition (PEM) and malaria is of great public health importance. Findings from studies evaluating associations between various forms of malnutrition and malaria have been contradictory. This study aimed to determine the prevalence of malaria parasitemia among malnourished children and its various determinants studied. Materials and Methods: This was a cross-sectional study. Ninety febrile children with severe PEM aged 6–59 months (44 males and 46 females) based on modified Wellcome classification were enrolled as subjects and; 90 febrile well-nourished children age and sex matched children as controls. Both subjects and controls were enrolled consecutively in the emergency pediatrics unit of Aminu Kano Teaching Hospital from May to October 2013. The diagnosis of malaria parasitemia was based on the identification of asexual parasites on microscopy after Giemsa staining. Results: The prevalence of malaria parasitemia was 72.2% in the subjects, this was significantly higher than 37.8% in the controls (OR = 4.28, CI = 2.29–8.02). Parasite density was 2122 μL (400–1821). Age, sex, and type of PEM had no significant effect on the prevalence of malaria parasitemia and parasite density (P > 0.05). Plasmodium falciparum (P. falciparum) was seen in all the positive slides. Conclusion and Recommendation: Malnourished children experience more malaria than well-nourished children. Based on the findings of this study malnourished children should have access to the use of insecticide treated nets (ITN) and commence on malaria chemoprophylaxis.
Keywords: Children, malaria, malnutrition, Nigeria, prevalence
|How to cite this article:|
Umma IA, Robinson WD, Jamilu FA, Gwarzo GD. Prevalence of malaria parasitaemia among febrile Nigerian children with severe malnutrition in Northwestern Nigeria. Niger J Basic Clin Sci 2017;14:113-6
|How to cite this URL:|
Umma IA, Robinson WD, Jamilu FA, Gwarzo GD. Prevalence of malaria parasitaemia among febrile Nigerian children with severe malnutrition in Northwestern Nigeria. Niger J Basic Clin Sci [serial online] 2017 [cited 2021 Jan 18];14:113-6. Available from: https://www.njbcs.net/text.asp?2017/14/2/113/216048
| Introduction|| |
Globally protein-energy malnutrition (PEM) is the most important risk factor for morbidity and mortality among under-five (U-5), with hundreds of millions of these children affected., It is highly prevalent in many areas where morbidity and mortality from malaria are unacceptably high. Children in sub-Saharan Africa are the group most affected by poor nutrition and malaria., The African region accounts for 85% of malaria cases.
PEM and malaria are common in sub-Saharan Africa; therefore understanding the relationship between PEM and malaria is of great public health importance. Although several studies have evaluated the association between malnutrition and malaria, but their findings have been conflicting.,,,, For instance Fillol and coworkers  from Senegal and Snow et al. from Papua New Guinea have shown that malnourished children have reduced immunological response to malaria infection and lower risk of malaria. In contrast, an increased risk of malaria among malnourished children has been documented among malnourished children in North Central Nigeria, Ethiopia, and The Gambia. The differences in their findings may be explained by the varied study designs, definitions of malnutrition and malaria morbidity, patient populations, and local malaria epidemiology.
This study aimed at determining whether the prevalence of malaria is higher or lower among febrile children with severe PEM compared to febrile well-nourished children.
| Materials and Methods|| |
The study was conducted at Aminu Kano Teaching Hospital (AKTH) between May to October 2013 (both months inclusive). AKTH is a 520-bed tertiary facility located in Kano state. It also provides primary and secondary healthcare services.
Kano has a population of more than 9 million. Kano state falls within latitude 12°021 North and longitude 08° 301 east of the equator. There are two major seasons, the rainy season is usually from the months of May to October and the dry season is within the months of November to April. Malaria transmission occurs throughout the year with peaks during the rainy season.
The Department of Paediatrics comprises of the Paediatrics Outpatient Department (POPD), Pediatric Specialty Clinic, Emergency Pediatric Unit (EPU), Special Care Baby Unit (SCBU), and the Paediatric Medical Ward (PMW). EPU manned by a team of doctors comprising of two consultants, three senior registrars, registrars and house officers with an average of 50 admissions per week.
This was a hospital-based descriptive cross-sectional study. The minimum sample size of 90 was calculated using the standard formula using the documented prevalence of 5.4% of severe PEM in U-5 children in AKTH. Using non-probability sampling method, 90 febrile severely malnourished, and 90 febrile well-nourished children were consecutively recruited for this study.
Children on malarial prophylaxis or those who had antimalarial drugs in the preceding one week of presentation were excluded.
A proforma was used to obtain a detailed clinical history including relevant demographic data of the children (age, sex, and socio-economic status), and maternal age. Physical examination of the enrolled children was carried out with emphasis on overt features of PEM and the presence of fever (axillary temperature greater than or equal to 37.5°C using a digital thermometer) and pedal edema.
Children were weighed completely undressed and without shoes using Seca ® 376 digital weighing scale to the nearest 10 grams. The scale was standardized with known standard weights every morning. The enrolled children were classified according to modified Wellcome classification into Marasmus: Weight for age (WFA) less than 60% without edema, Marasmic-Kwashiorkor: WFA less than 60% with edema, Underweight -kwashiorkor; WFA 60–80% with edema. Kwashiorkor: WFA 80–100% with edema and well-nourished WFA 80–100% without edema.
Thick and thin blood films were stained with 2% Giemsa for 30 minutes and read by two WHO-certified microscopists. The films were made according to the standard malaria microscopy described by WHO. Asexual parasitemia is considered positive or negative. Thick blood film was considered negative if no parasite was seen after reviewing 100 HPF. Thin blood smears were used to determine parasites species.
Clinical and laboratory were entered into statistical package for social sciences version 16.0 (SPSS Inc., Chicago, IL). Data analysis was done using the same software. The test of association between categorical variables was done using Chi-square or Fisher's exact test where applicable. For the variables with the significant association, the odds ratio and 95% confidence limits were estimated. Comparison between continuous variables and outcome variable was made using the Student's t-test. For all statistical analysis, a P value of < 0.05 was considered significant.
| Results|| |
General characteristics of the study population
A total of 90 children with severe PEM and fever presenting to EPU of AKTH; and 90 well-nourished age and sex-matched children with fever, who served as controls were enrolled in the study. The median age of the study population (subjects and control) was 20 months (interquartile range = 11–24 months). The majority (75/83.3%) of the children enrolled were between the ages of 6 months and 24 months. There were 44 (48.9%) males and 46 (51.1%) females with a male to female ratio (M:F) of 1:1.01. As shown in [Table 1]. Seventy-four (82.2%) of the subjects with severe PEM were in the lower socioeconomic class (SEC) whereas 52 (57.8%) of the controls were in the upper SEC. The difference in the SEC between the study and control group was statistically significant (χ2 = 72, P = <0.001).
Prevalence of malaria parasitemia
Sixty-five (72.2%) of the subjects and 34 (37.8%) of the control group had malaria parasitemia. The difference was statistically significant (OR = 4.28, CI = 2.29-8.02). Mean malaria parasite density was 22112 ± 10300 in the subjects, which was significantly (P = <0.001) higher compared to that of the control group (9667 ± 1041) as shown in [Table 2]. P. falciparum was the only species identified in the subjects and controls.
Fifty-two (69.3%) of the 75 subjects aged 6–24 months old had malaria parasitemia. However, the difference was not significant statistically. Twenty-three of the 28 subjects (82.1%) in the 6–12 months age range had malaria parasitemia. Twenty-nine (61.7%) of the 47 subjects in 13–24 months age range had positive malaria parasites in their blood. Seven (78%), of the 9 subjects in the 25–36 months age range were parasitemic, while all the 6 (100%) subjects in the 37–48 and 49–59 months age ranges were also parasitemic.
43 (47.8%) of the malaria parasitemia occurred in children with marasmus. However, the difference in the prevalence across the classes of severe PEM was not significant (P = 0.59) as shown in [Table 3].
|Table 3: Frequency of malaria parasitemia among the subjects according to age group, gender and type of severe PEM|
Click here to view
| Discussion|| |
This study compared prevalence of malaria parasitemia among febrile children with severe malnutrition (subjects) and febrile well-nourished counterparts (controls). The prevalence of malaria parasitemia of 72.2% among febrile severely malnourished children which is significantly higher than 37.8% in well-nourished children. This implies that severely malnourished children studied have increased odds of malaria parasitemia when compared to well-nourished children. This may be due to defective humoral and cell-mediated immunity coupled with the reduction in the number of effective neutrophils and macrophages and significant reduction in the cytokine production in children with severe PEM.,,,,
It is also worthy to mention that most of the malnourished children are from low SEC which might have further increased their risk of malaria in that malaria thrives well in impoverished localities. Malaria infection particularly caused by P. falciparum has been geographically restricted and remains entrenched in poor areas of the world, particularly in sub-Saharan Africa.
Our finding of higher risk of malaria among malnourished children is consistent with the findings from North Central Nigeria, Cameroon , and Ethiopia. These studies also reported increased risk of malaria among various forms of malnutrition.
In contrast to the findings from this present study, Filol and co-workers  from Senegal reported a very low risk of malaria parasitemia among malnourished (wasted) children. These studies defined malaria as the presence parasitemia only and malnourished children were few among the population studied so may be difficult to generalize. The present study defined malaria as the presence of fever and included equal number of malnourished and well-nourished children.
P. falciparum was responsible for all the malaria cases, a finding similar to that previously reported in Nigeria among preschool children in Sokoto, and Jos  which found P. falciparum as the only species causing malaria among U-5 children.
The preponderance of malaria parasitemia among children of 6–24 months age group as compared to the 25–59 months found in this study was consistent with the general observation that children in that age group (6–24 months) are more vulnerable to the disease in areas of high transmission. Naturally, acquired immunity builds up in older children following repeated exposure to the parasite and is manifested by lower parasite densities and fewer clinical malaria episodes than younger children.
The higher mean parasite density found among the malnourished children as compared to well-nourished children in the present study may suggest that children with severe PEM are unable to resist malaria infection optimally due to depressed immunity. It may also signify that children with severe PEM might likely experience severe forms of malaria as they are associated with higher degree of parasitemia. This is similar to reports from Ilorin by Saka et al. and Sumbele et al. from Cameroon which showed that children with severe PEM had higher parasite density compared to those that were well nourished and those with mild to moderate forms of malnutrition.
It is also observed that the prevalence of malaria parasitemia varied by the type of severe PEM in the present study, with highest among children with marasmus. This was similar to the findings of Saka et al. from Ilorin, North Central Nigeria. The high prevalence of malaria parasitemia amongst children with marasmus may be accounted by the presence of aflatoxin in children with kwashiorkor which is said to be toxic to malaria parasites.
| Conclusions and Recommendation|| |
Prevalence of malaria parasitemia was high among children with SAM. The prevalence is not significantly affected by age, sex, and type of SAM. Based on our findings, we recommend that children with malnutrition should be encouraged to use ITN and other measures to prevent malaria. All malnourished children presenting with fever should be screened for malaria and effective treatment of cases.
Limitation of the study
Malaria parasite microscopy was done only once; it ought to have been done serially in those with slide negative.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hendrickse RT. Protein Energy Malnutrition. In: Hendrikse RC, Barr BDG, Mathews TS, editors. Pediatrics in the Tropics. London: Blackwell Scientific Publications; 1991. p. 119-31.
UNICEF state of the world's children: Official publication of the United Nations. 2005:85-8.
Müller O, Garenne M, Kouyaté B, Becher H. The association between protein-energy malnutrition, malaria morbidity and all-cause mortality in West African children. Trop Med Int Health 2003;8:507-11.
Breman JG. The ears of the Hippopotamus: Manifestations, determinants, and estimates of the malaria burden. Am J Trop Med Hyg 2001;64:1-11.
PeterJK. Malaria. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson text book of Paediatrics. 17th
ed. Elsevier; 2008. p. 1139-43.
Murray MJ, Murray AB, Murray MB, Murray CJ. Somali food shelters in the Ogden famine and their impact on health. Lancet 1976;1:1283-5.
Fillol F, Cournil A, Boulanger D, Cisse B, Sokhna C, Targett G, et al
. Influence of wasting and stunting at the onset of the rainy season on subsequent malaria morbidity among rural preschool children in Senegal. Am J Trop Med Hyg 2009;80:202-8.
Snow RW, Byass P, Shenton FC, Greenwood BM. The relationship between anthropometric measurements and measurements of iron status and susceptibility to malaria in Gambian children. Trans R Soc Trop Med Hyg 1991;85:584-9.
Saka AO, Saka MJ, Adeboye MN, Mokuolu OA, Abu-Saeed MB, Abu-Saeed K. Malaria Parasitaemia in Children With Protein Energy Malnutrition In North Central Nigeria: A Case Control Study. IORSJPBS 2012;1:49-55.
Shikur B, Deressa W, Lindtiron B. Association between malaria and malnutrition among children aged under five years in adani tulu district- south central Ethiopia: A case control study. BMC Public Health 2016;16:174.
Deen JL, Walraven GE, von Seidlein L. Increased risk for malaria in chronically malnourished children under 5 years of age in rural Gambia. J Trop Pediatr 2002;48:78-83.
Federal Government of Nigeria. Official gazatte (FGP 71/52007/2500 OL 24): Legal notice on publication of the details of break down of the national and the state provisional totals 2006 census.
Molyneaux L, Gramiccia GG. Research on the Epidemiology and Control of Malaria in the Sudan Savannah of West Africa. Geneva: WHO; 1980. Parasitology. p. 311.
Adeleke SI, Asani MO, Belonwu RO, Gwarzo GD. Children with protein energy malnutrition: Management and out-come in a tertiary hospital in Nigeria. Sahel Med J 2007;10:84-8. [Full text]
Medzhitov R, Janeway CA Jr. An ancient system of host defense. Curr Opin Immunol 1998;10:12-5.
Steihm ER. Humoral immunity in malnutrition. Fed Proc 1980;39:3053-67.
Savino W, Dardenne M, Velloso La, Dayse Silva-Barbosa S. The thymus is a common target in malnutrition and infection. Br J Nutr 2007;98:S11-6.
Bachou H, Tylleskär T, Downing R. Severe malnutrition with or without HIV-1 infection in hospitalized children in Kampala, Uganda: Differences in clinical features, haematological findings and CD4+
cell counts. Nutr J 2006;5:27.
Yusuf T. The pattern of CD4+
T-lymphocyte counts in children aged6 months to 5 years with protein-energy malnutrition at UDUTH, Sokoto, Nigeria Dissertation. National Postgraduate Medical College of Nigeria; 2011.
Sharma SK, Pati SS, Tyagi PK, Das BS, Adak T, Misra SK, et al
. Epidemiology of malaria transmission and development of natural immunity in a malaria-endemic village, San Dulakudar, in Orissa state, India. Am J Trop Med Hyg 2004;71:457-65.
Nkuo-Akenji TK, Sumbele I, Mankah EN, Njunda AL, Samje M, Kamga L. The burden of malaria and malnutrition among children less than 14 years of age in a rural village of Cameroon. AJFAND 2008;8:252-64.
Agghedo FI, Resqua AS, Rabiu AU, Jiya MN, Erhabor O. Antioxidant vitamin levels among preschool children with uncomplicated Plasmodium falciparum malaria in Sokoto, Nigeria. J Multidiscip Healthc 2013;6:259-63.
Ikeh EI, Teclaire NN. Prevalence of malaria parasitaemia and associated factors in febrile under-5 children seen in Primary Health Care Centre in Jos, North Central Nigeria. Niger Postgrad Med J 2008;15:65-9.
Custodio E, Descalzo Ma, Villamor E, Molina L, Lwanga M, Bernis C, et al
. Nutritional and socio-economic factors associated with Plasmodium falciparum infection in children from Equatorial Guinea: Results from a nationally representative survey. Malar J 2009;8:225.
Golden MHN. Consequence of protein deficiency in man and its relationship to the feature of kwashiorkor. In: Blaxter K, Waterlow JC, editors. Nutrition and adaptation in Man. London: John Libby; 1985. p. 169-87.
[Table 1], [Table 2], [Table 3]