Anemia Resource Review

The Accelerated Reduction Effort on Anaemia (AREA) Community of Practice (COP), facilitated by the United Nations System Standing Committee on Nutrition (UNSCN) and moderated by the U.S. Agency for International Development's (USAID’s) SPRING project, was launched in June 2015. The AREA COP provides a unique opportunity to connect with other professionals and stay abreast of the latest developments in anemia-related research, policy, and implementation. Since the AREA COP’s creation in May 2015, it has grown to more than 750 members from over 65 countries. The COP webinar series presents cutting-edge and timely topics to members based on their feedback and the latest happenings in the field.

On April 18, 2017, the COP hosted its sixth webinar, Reviewing Hemoglobin Thresholds for the Determination of Anaemia. Dr. Sant-Rayn Pasricha presented the ongoing work conducted alongside the World Health Organization that will inform new guidelines for how hemoglobin thresholds should be used and interpreted to detect and diagnose anemia. The slides and recording are available online. In addition to hosting webinars, the COP disseminates anemia-related vacancy and conference announcements, recent publications, and reports, many of which are then discussed among members. On average, the COP circulates six discussion topics per month, which aim to keep members abreast of the science and programming behind multi-sectoral anemia control. In the last six months, the following were some of the topics that were shared among the group:

• Members who are part of the USAID Anemia Task Force provided information on the discussions and resources shared during the last meetings
• The annual AREA CoP Community Effectiveness Survey was circulated among members to seek feedback on how to best serve the needs of the community. Almost 80 members provided feedback, which was then reported back to the community.
• The World Health Organization extended an invitation to AREA CoP members to participate in an online consultation to define the scope and outline of a WHO Policy Brief on weekly iron and folic acid supplementation (WIFS).
• An informative debate was held among members on the effectiveness and relevance of current vitamin A supplementation programs, which ultimately play a role in anemia control.
• A brief on the programmatic implications of the BRINDA project was shared with members. The brief aimed to bridge the gap between science and programming.

If you are not already a member, please join us by clicking the link below. You can also reach out on twitter: @AREAnaemia

The International Association for Adolescent Health (IAAH) 11th World Congress on Adolescent Health: Investing in Adolescent Health – the Future is Now was held from October 27 – 29, 2017 in New Delhi, India. The Congress gave over 800 participating delegates a chance to share knowledge across specializations while combining both clinical and public health perspectives. Research and experiences were presented with the goal of advancing public health in the present as well as the future. UNICEF India hosted a session on experiences from India in reducing adolescent undernutrition and anemia.

The SPRING project hosted a learning event in Washington, DC, sharing experiences from six years of multi-sectoral leadership and country implementation. At this event, SPRING presented challenges and experiences with multi-sectoral nutrition programming, key tools developed over the life of the project, country highlights, research findings, and the project’s learning and results. Some of the anemia-related topics discussed at the event included tools for assessing and addressing anemia, costing research on micronutrient powder (MNP) distribution in Uganda, and experiences from the Uganda National Anaemia Working Group.

The World Health Organization (WHO) hosted a technical consultation in Panamá City, Panamá from October 4 – 6, 2017 that examined the risks associated with excessive intake of supplements delivered through public health interventions. Participants discussed current estimates for total intake of an assortment of vitamins and minerals delivered through various means, identified current methods of mitigating risks, and proposed strategies and solutions for moving forward. The conclusions made at this meeting are intended to aid member states in the implementation of micronutrient programs.

From November 29 through December 1, 2017 in Geneva, Switzerland, the World Health Organization (WHO) will host a technical meeting regarding assessment of anemia status in individuals and populations using hemoglobin concentrations. The event is part of a larger four-year endeavor by WHO to review its guidelines for hemoglobin thresholds and definitions of anemia. The organization intends to advance the health systems of member states by drawing upon lessons learned from those states’ experiences in order to evaluate, prevent, and treat anemia more effectively.

The 21st International Congress of Nutrition (ICN) was held by the International Union of Nutritional Sciences (IUNS) from October 15 – 20, 2018 in Buenos Aires, Argentina. At the event, nutrition professionals of various sectors from all over the world gathered to exchange knowledge in an effort to improve nutrition security. The meeting focused on important facets of nutrition in a multicultural environment, and offered presentations on nutrition-related technology and scientific advancements in the field.

Researchers from the Global Alliance for Improved Nutrition (GAIN), the Research Triangle Institute, and Cornell University, conducted a study to examine the reasons for adherence to micronutrient powders (MNP). They generated factors drawn from previous studies that could influence adherence. These included: caregivers’ perceptions of positive change as a result of MNP use, their perceived child acceptance of food with MNP, and their forgetfulness. GAIN intends to incorporate these findings into their MNP programming in various countries.

This report discusses the advancements made in the treatment and elimination of neglected tropical diseases. Authors discuss control strategies and five specific public health approaches used as avenues for expanded interventions. They emphasize that integration of these activities into the larger health systems is crucial in achieving universal health coverage. The report also highlights specific successes as the push to achieve year 2020 targets accelerates. Reductions in cases of sleeping sickness, visceral leishmaniasis, and Buruli ulcer are noted.

The findings of this systematic review show that iron bio-fortification consistently improves iron status, across various population groups and contexts. HarvestPlus analyzed trials completed in Asia and Africa that showed an increase in iron status only mere months after starting to eat more iron-biofortified foods. This research has resulted in more specific studies that focus on other high-risk populations, and HarvestPlus continues to research the effects that eating biofortified beans and millet have on daily life.

GAIN Executive Director Lawrence Haddad re-emphasizes the importance of anemia interventions in the face of rising carbon dioxide (CO2) levels, as noted in a recent study. Elevated CO2 levels have a negative effect on iron concentrations of key crops. While the estimates of impacts are built on assumptions, the estimated percentages of lost dietary iron due to increased CO2 range from 1.5-5.5 percent. This calls for increased focus on mitigating CO2 emissions and, Haddad adds, requires the nutrition community to provide better ways to highlight the nutrition content of foods to consumers.

The Global Fortification Data Exchange (GFDx) was recently launched as a new analysis and visualization tool for actionable data on food fortification. This tool was intended to make existing datasets accessible and digestible to decision makers so they are well-equipped to design effective and appropriate policies and programs. The GFDx will help implementers, donors, governments, and other stakeholders better understand the current state of fortification in a given country to make informed decisions on the way forward.

When left untreated, malaria can lead to anemia, which can cause developmental delays in children. Researchers evaluated a three-pronged malaria intervention consisting of antimalarial drugs, insecticide-treated bed nets, and education on preventing the infection for children in Mali. This approach, administered in schools, saw a 95 percent drop in malaria infections and a 44 percent lower risk of anemia, compared to bed nets alone. Students who received this intervention also had an improved attention span, indicating the potential for better educational outcomes.

Scientists from the Swiss Federal Institute of Technology have discovered a new and innovative way of fortifying food and drinks with bioavailable iron. They combined protein nanofibrils with iron nanoparticles to form a substance that can be administered in powder or liquid form, and easily mixed into food, without the undesirable changes in taste, smell, or color that often come with iron supplements. Initial testing showed that the new iron compound was effective in reducing iron deficiency and anemia, was easily digested, and came without adverse side effects.

Hemoglobinopathies are genetic disorders caused by an abnormal structure or production of the hemoglobin molecule, sickle cell anemia being the most common of the disorders. Due to the growing prevalence of hemoglobinopathies, the world is seeing more advanced diagnostics and therapies, as well as an increasing number of awareness programs about these disorders. All of these factors have spurred growth in the global hemoglobinopathies market, with further growth expected in both developing and developed countries, as a result of better health care infrastructure.

While iron supplementation can be an effective intervention for anemia, it can also be harmful to those with additional infections, because pathogens feed off of the iron. Oral iron supplements release iron rapidly in the gut and can cause dangerous side effects such as diarrhea or constipation. To combat these adverse effects, researchers at University of Cambridge have developed IHAT (iron hydroxide adipate tartrate) – a slow-release iron supplement that mimics the forms of iron found in food. This new supplement, currently undergoing a clinical trial in Gambia, may offer a safer option for treating iron deficiency and anemia.

This brief, developed by SPRING, describes country-led efforts to coordinate and implement anemia prevention and control, offering lessons learned to help other countries design the best possible solutions. Based on SPRING’s experiences working with the governments of Ghana, Kyrgyz Republic, Nepal, Sierra Leone, and Uganda, the project presents six key actions: generate evidence and act on it, engage stakeholders and build commitment, establish a structure for coordination and collaboration, develop a working strategy, plan and implement at subnational levels, and train service providers.

This workshop report summarizes the experiences of experts from nine countries around iron interventions in Africa. Infections, parasitism, and poor eating habits are primarily to blame for the prevalence of iron deficiency, and yet country-comparable prevalence estimates are still needed. The benefits of iron interventions are uncontested, but may cause pathogen growth in areas where malaria and other infections are common. Efficacy and coverage of iron interventions could improve through better access, increased awareness, and a reduction in costs. Increasing bioavailable iron forms can help decrease the iron dose, which could potentially reduce the risk of infections.

Researchers detailed their process for identifying the primary causes of anemia for women in low and middle-income countries and selecting interventions to include in their Lives Saved Tool (LiST) model for anemia. Five interventions were chosen to be included in the model: iron and folic acid supplementation in pregnancy, blanket iron supplementation or fortification, multiple micronutrient supplementation in pregnancy, household ownership of an insecticide-treated bednet, and intermittent preventive treatment of malaria in pregnancy. This updated and current tool for anemia can be used by policymakers, programmers, and researchers who are interested in modeling the prevention of anemia and resulting maternal mortality.

In this study, the authors sought to determine the relationship between soil-transmitted helminth (STH) infections and risks for anemia, stunting, wasting, and underweight in children in Timor-Leste, a country with high rates of these conditions. In the Manufahi District, researchers analyzed stool samples for STH and measured hemoglobin, height, and weight. They determined that anemia prevalence was low (15%), but rates of stunting (60%), wasting (20%), and underweight (60%) were high and should be addressed using appropriate nutrition interventions. While STH did not appear to be a significant risk factor for these poor child development and morbidity outcomes, the authors conclude that its high prevalence nonetheless warrants STH control strategies.

Researchers sought to understand the end-user perspective of iron folic acid (IFA) supplementation and, more specifically, the factors that contribute to low levels of IFA consumption. Qualitative interviews, conducted in Madhya Pradesh, India, yielded five main themes associated with discontinuation of IFA use: ignorance, meaninglessness, misconceptions, difficult intake, and discontentment with the system. For an IFA program to be successful, the authors feel activities must be designed to lead to informed choice among the target groups to consume IFA.

Anemia, iron deficiency, and infections are interconnected conditions that drastically contribute to child morbidity and mortality. In this article, the authors explore current research on the association between iron supplementation and infection risk, and conclude that the universal guidelines for iron supplementation must be replaced by more tailored, area-/population-specific guidelines that are guided by methods to accurately predict the safety of giving iron.

Evidence suggests that higher iron stores may lead to a greater risk of malaria. This study, conducted in rural Zambia among children in a biofortified maize trial, assessed the link between serum ferritin (SF) concentration – a biomarker for iron – during low malaria season and the risk of malaria during the high-transmission season. Researchers found that children aged four to six years old with moderate to high iron status had a higher malaria risk, compared to those who were iron deficient. This did not include children six to eight years old. To mitigate this increased risk, it is important to integrate malaria control efforts with iron interventions.

This study assessed the impact of a local animal-sourced food (ASF) supplement on the micronutrient status of rural, Vietnamese women aged 18-30 years. Participants of this study were given either an ASF or a control snack five days per week for six months. Inflammation was monitored, including urinary tract infections (UTIs), as this can contribute to anemia and affect nutritional status. The authors concluded that ASF supplementation effectively improved the micronutrient intake and iron status of reproductive-age women in rural Vietnam; however, plasma zinc, retinol, and serum vitamin B-12 concentrations did not increase. Increased risk of UTIs among the intervention group was found and the authors concluded this needed further investigation.

Some studies have shown that while micronutrient powder (MNP) with iron has been effective in reducing anemia, it has also caused an increase in harmful effects for the gut microbiome, including enteropathogens, diarrhea, and respiratory tract infections (RTIs). This four-month long randomized controlled trial examined the risk of adverse effects and efficacy of a new MNP formula with prebiotic galacto-oligosaccharides (GOS) combined with a low dose of iron (5 mg/day) in Kenyan infants, as compared to MNP with only a low-dose iron and an MNP without iron. The addition of GOS to the low-iron-dose MNP was effective in reducing anemia while reducing intestinal damage and RTIs, when compared to low-iron-dose MNP.

This Maternal & Child Survival Program literature review, published in Public Health Nutrition, aimed to review the evidence for community-based distribution (CBD) of iron–folic acid (IFA) supplementation as a feasible approach to improve anemia rates in low- and middle-income countries. CBD programmes had moderate success with midwives and community health workers (CHW) who counseled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anemia. CBD of IFA supplementation can be a valuable platform for improving knowledge about anemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation.

Researchers conducted a systematic review to examine the health and nutrition outcomes of multiple-micronutrient (MMN) supplements with iron and folic acid (IFA) compared to IFA alone during pregnancy. They found that MMN supplements resulted in fewer babies that had low birthweight or were small-for-gestational-age; there were no significant differences between the two interventions when considering other outcomes like preterm births, stillbirth, maternal anemia in the third trimester, miscarriage, maternal mortality, perinatal or neonatal mortality, and risk of caesarean section delivery. The findings show benefits for use of MMN supplements in pregnant women.

Inflammation caused by infections and chronic conditions can modify the biomarker values used to assess micronutrient deficiencies. These recently published findings from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anaemia (BRINDA) project indicate the importance of applying adjustments for inflammation to iron and vitamin A biomarkers to correctly interpret the prevalence of these deficiencies and their association with anemia. This article discusses policy and program implications of this research, including the need for integration of infection and inflammation control efforts with iron interventions.

This study investigated the efficacy of a reusable fish-shaped iron ingot, compared to daily iron supplementation, in reducing anemia in rural Cambodia. Study participants were assigned to either an iron fish group, an iron supplement group, or a non-placebo control group, and hemoglobin measurements were taken at baseline and at 6 and 12 months. Although the iron supplementation group experienced higher serum ferritin levels by 6 months, the gains were lost by 12 months and neither intervention group experienced increased hemoglobin levels at 6 or 12 months. Therefore, the fish-shaped iron ingots are not recommended in Cambodia or in contexts with low iron deficiency and highly prevalent genetic hemoglobin disorders.

In this study, the authors investigated the impact of mandatory wheat flour fortification on micronutrient status among women aged 15–49 years and children 12–59 months of age in Yaoundé and Douala, Cameroon by conducting representative surveys two years before and one year after the large-scale fortification program. More than 90 percent of the population surveyed consumed wheat flour in the last 7 days. The researchers found an improvement in iron, zinc, folate, and vitamin B-12 status among women and children in urban Cameroon post-fortification. Additionally, anemia incidence in mothers was significantly lower after mandatory wheat flour fortification (39.1%), compared to pre-fortification (46.7%), after adjusting for inflammation and malaria; however, there was no change in either mean hemoglobin concentrations or anemia prevalence in children.