Project

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Aetiology, prevention and control of anaemia in sub-Saharan Africa

English title Aetiology, prevention and control of anaemia in sub-Saharan Africa
Applicant Wegmüller Rita
Number 123900
Funding scheme Resource not found: 'bd31932a-e257-46d9-9dba-079f6f2c77c6'
Research institution Labor für Humanernährung Institut für Lebensmittel, Ernährung und Gesundheit, ETH Zürich
Institution of higher education ETH Zurich - ETHZ
Main discipline Methods of Epidemiology and Preventive Medicine
Start/End 01.07.2009 - 30.06.2013
Approved amount 606'047.00
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All Disciplines (2)

Discipline
Methods of Epidemiology and Preventive Medicine
Other disciplines of Engineering Sciences

Keywords (15)

Haemoglobin; Inflammation; Helminth; Infectious Disease; Hookworm; Côte d'Ivoire; anaemia; iron deficiency; haemoglobin; inflammation; malaria; helminth; infectious disease; Côte d'Ivoire; Africa

Lay Summary (English)

Lead
The goal of this project was to further our understanding of the aetiology of anaemia and to investigate how anaemia can be reduced among children in a typical rural setting of sub-Saharan Africa by using a combination of food-based and parasite-control interventions. Our results show that malaria plays a key role as it is clearly associated with anaemia in young children and we have demonstrated reduced iron absorption in adolescents during a malaria infection.
Lay summary

Aetiology, prevention and control of anaemia in sub-Saharan Africa

Background:Anaemia is defined as a reduction in the mass of red blood cells and the haemoglobin (Hb) content of blood. In clinical terms, anaemia is considered as an Hb concentration that is insufficient to meet the oxygen needs of the tissues. The consequences of this shortage include reduced work capacity, poor pregnancy outcomes including maternal death, increased mortality and sickness from infectious diseases and poorer educational achievements. The World Health Organization currently estimates that 2 billion people are affected by anaemia worldwide. In Africa, the estimated prevalence of anaemia is 46%, and half of the children and women of childbearing age suffer from iron deficiency. The major causes of anaemia are low iron in the consumed food, low iron uptake by the body from the food, malaria, and worm infections. With a low iron intake and uptake the body doesn't have enough iron to produce haemoglobin which leads to anaemia. Malaria and intestinal worm infections cause inflammation in the human body which leads to an iron restriction in the body and thereby causes anaemia. Strategies for prevention and control of anaemia include increasing dietary iron intake through food fortification or supplementation, and it has been suggested that the efficacy of these interventions is enhanced when combined with parasite control.

Objective:The overall goal of this project was to further our understanding of the sources and causes of anaemia and to investigate how anaemia can be reduced among children in sub-Saharan Africa by using a combination of food-based and parasite-control interventions.

Methodology:Our studies were carried out in Taabo district, central Côte d'Ivoire, and were readily embedded in a Health and Demographic Surveillance System (HDSS) site covering ~40,000 people. The HDSS enabled to select the participants randomly from three groups at high risk, namely infants, school-aged children and women of childbearing age. In order to assess the causes of anaemia, and to investigate the contribution of malaria, helminth infection and iron deficiency to the development of anaemia blood, urine and stool samples were collected and analyzed in different studies.

Outcomes: We found high prevalence of anaemia, malaria, inflammation, and deficiencies of iron, vitamin B2 and vitamin A but low prevalence of intestinal worms. In young children, iron deficiency and malaria as well as general infections were the main causes of anaemia. Our results further showed that anaemia was less of a problem in children co-infected with worms and malaria than in children with a single malaria infection. Non-pregnant women seemed to be protected from worms if they had malaria whereas in children malaria infection lead to an increased infection with worms.

We found that the uptake of dietary iron from the gut is clearly reduced during a malaria infection, whereas worm infections did not have a negative impact. Thus, iron interventions should always be combined with a malaria control programme.

Statistical analyses of our large intervention study are still pending.


Direct link to Lay Summary Last update: 23.08.2013

Responsible applicant and co-applicants

Employees

Project partner

Publications

Publication
In Ivorian school-age children, infection with hookworm does not reduce dietary iron absorption or systemic iron utilization, whereas afebrile Plasmodium falciparum infection reduces iron absorption b
Glinz Dominik, Hurrell Richard F, Righetti Aurelie A, Zeder Christophe, Adiossan LG, Tjalsma H, Utzinger Jürg, Zimmermann Michael B, N'Goran Elsier K, Wegmüller Rita (2015), In Ivorian school-age children, infection with hookworm does not reduce dietary iron absorption or systemic iron utilization, whereas afebrile Plasmodium falciparum infection reduces iron absorption b, in American Journal of Clinical Nutrition, 101(3), 462.
The effect of iron-fortified complementary food and intermittent preventive treatment of malaria on anaemia in 12- to 36-month-old children: a cluster-randomised controlled trial
Glinz Dominik, Hurrell Richard F, Ouattara M, Zimmermann Michael B, Brittenham Garry M, Adiossan LG, Righetti Aurelie A, Seifert B, Diakité VG, Utzinger Jürg, N'Gora Elster K, Wegmüller Rita (2015), The effect of iron-fortified complementary food and intermittent preventive treatment of malaria on anaemia in 12- to 36-month-old children: a cluster-randomised controlled trial, in Malaria Journal, 17(14), 347.
The effect of timing of iron supplementation on iron absorption and haemoglobin in post-malaria anaemia: a longitudinal stable isotope study in Malawian toddlers
Glinz Dominik, Kamiyango Moses, Phiri Kamija S, Munthali Francis, Zeder Christophe, Zimmermann Michael B, Hurrell Richard F, Wegmüller Rita (2014), The effect of timing of iron supplementation on iron absorption and haemoglobin in post-malaria anaemia: a longitudinal stable isotope study in Malawian toddlers, in Malaria Journal, 10(13), 397.
Dynamics of anemia in relation to parasitic infections, micronutrient status, and increasing age in south-central Côte d’Ivoire
Righetti Aurelie, Adiossan Lukas, Ouattara Mamadou, Glinz Dominik, Hurrell Richard, N'Goran Eliezer, Wegmüller Rita, Utzinger Jürg (2013), Dynamics of anemia in relation to parasitic infections, micronutrient status, and increasing age in south-central Côte d’Ivoire, in J Infect Dis, 207, 1604-1615.
Effects of hygiene and defecation behavior on helminths and intestinal protozoa infections in Taabo, Côte d’Ivoire
Schmidlin Thomas, Hürlimann Eveline, Silue Kigbafori, Yapi Richard, Houngbedji Clarisse, Kouadio Bernadette, Acka-Douabele Cinthia, Kouassi Dongo, Ouattara Mamadou, Zouzou Fabien, Bonfoh Bassirou, N'Goran Eliezer, Utzinger Jürg, Raso Giovanna (2013), Effects of hygiene and defecation behavior on helminths and intestinal protozoa infections in Taabo, Côte d’Ivoire, in PLoS One, 8, e65722.
Effects of inflammation and Plasmodium falciparum infection on soluble transferrin receptor and plasma ferritin concentrations in different age groups: a prospective longitudinal study in Côte d’Ivoir
Righetti Aurelie, Wegmüller Rita, Glinz Dominik, Ouattara Mamamdou, Adiossan Lukas, N'Goran Eliezer, Utzinger Jürg, Hurrell Richard (2013), Effects of inflammation and Plasmodium falciparum infection on soluble transferrin receptor and plasma ferritin concentrations in different age groups: a prospective longitudinal study in Côte d’Ivoir, in Am J Clin Nutr, 97, 1364-1374.
In response
Righetti Aurelie, Utzinger Jürg, Koua Gisele, Niamke Sebastien, Adiossan Lukas, Glinz Dominik, Hurrell Richard, Wegmüller Rita, N'Goran Eliezer (2013), In response, in Am J Trop Med Hyg, 89, 399-400.
Local concepts of anemia-related illnesses and public health implications in the Taabo health demographic surveillance system, Côte d’Ivoire
Kouadio M'Bra, Righetti Aurelie, Abe Noel, Wegmüller Rita, Weiss Mitchell, N'Goran Eliezer, Utzinger Jürg (2013), Local concepts of anemia-related illnesses and public health implications in the Taabo health demographic surveillance system, Côte d’Ivoire, in BMC Hematology, 13, 5.
Patients routinely report more symptoms to experienced field enumerators than physicians in rural Côte d’Ivoire
Fürst Thomas, Silue Kigbafori, Ouattara Mamadou, Adiossan Lukas, N'Goran Dje, Yao Azragnou, Kone Siaka, N'Goran Eliezer, Utzinger Jürg, Boboch Isaac (2013), Patients routinely report more symptoms to experienced field enumerators than physicians in rural Côte d’Ivoire, in Am J Trop Med Hyg, x.
Scope and limits of an anamnestic questionnaire in a control-induced low-endemicity helminthiasis setting in south-central Côte d’Ivoire
Fürst Thomas, Ouattara Mamadou, Silue Kigbafori, N'Goran Dje, Adiossan Lukas, Bogoch Isaac, N'Guessan Yao, Kone Siaka, Utzinger Jürg, N'Goran Eliezer (2013), Scope and limits of an anamnestic questionnaire in a control-induced low-endemicity helminthiasis setting in south-central Côte d’Ivoire, in PLoS One, 8, e64380.
Etiology of anemia among infants, school-aged children, and young non-pregnant women in different settings of south-central Côte d’Ivoire
Righetti Aurélie, Koua Gisèle, Adiossan Lukas, Glinz Dominik, Hurrell Richard, N'Goran Eliezer, Niamke Sebastien, Wegmüller Rita, Utzinger Jürg (2012), Etiology of anemia among infants, school-aged children, and young non-pregnant women in different settings of south-central Côte d’Ivoire, in Am J Trop Med Hyg, 87, 425-434.
Interactions and potential implications of Plasmodium falciparum-hookworm coinfection in different age groups in south-central Côte d’Ivoire
Righetti Aurelie, Glinz Dominik, Adiossan Lukas, Koua Gisele, Niamke Sebastien, Hurrell Richard, Wegmüller Rita, N'Goran Eliezer, Utzinger Jürg (2012), Interactions and potential implications of Plasmodium falciparum-hookworm coinfection in different age groups in south-central Côte d’Ivoire, in PLoS Negl Trop Dis, 6, e1889.
Mapping malaria risk among children in Cote d'Ivoire using Bayesian geo-statistical models.
Raso Giovanna, Schur Nadine, Utzinger Jürg, Koudou Benjamin G, Tchicaya Emile S, Rohner Fabian, N'goran Eliézer K, Silué Kigbafori D, Matthys Barbara, Assi Serge, Tanner Marcel, Vounatsou Penelope (2012), Mapping malaria risk among children in Cote d'Ivoire using Bayesian geo-statistical models., in Malaria journal, 11(1), 160-160.
Accuracy of Urine Circulating Cathodic Antigen (CCA) Test for Schistosoma mansoni Diagnosis in Different Settings of Cote d'Ivoire
Coulibaly JT, Knopp S, N'Guessan NA, Silue KD, Furst T, Lohourignon LK, Brou JK, N'Gbesso YK, Vounatsou P, N'Goran EK, Utzinger J (2011), Accuracy of Urine Circulating Cathodic Antigen (CCA) Test for Schistosoma mansoni Diagnosis in Different Settings of Cote d'Ivoire, in PLOS NEGLECTED TROPICAL DISEASES, 5(11), e1384-e1384.
Effect of Schistosomiasis and Soil-Transmitted Helminth Infections on Physical Fitness of School Children in Cote d'Ivoire
Muller I, Coulibaly JT, Furst T, Knopp S, Hattendorf J, Krauth SJ, Stete K, Righetti AA, Glinz D, Yao AK, Puhse U, N'Goran EK, Utzinger J (2011), Effect of Schistosomiasis and Soil-Transmitted Helminth Infections on Physical Fitness of School Children in Cote d'Ivoire, in PLOS NEGLECTED TROPICAL DISEASES, 5(7), e1239-e1239.
Malaria knowledge and long-lasting insecticidal net use in rural communities of central Cote d'Ivoire
Ouattara AF, Raso G, Edi CVA, Utzinger J, Tanner M, Dagnogo M, Koudou BG (2011), Malaria knowledge and long-lasting insecticidal net use in rural communities of central Cote d'Ivoire, in MALARIA JOURNAL, 10, 288-288.
Questionnaire-based approach to assess schoolchildren's physical fitness and its potential role in exploring the putative impact of helminth and Plasmodium spp. infections in Côte d'Ivoire.
Fürst Thomas, Müller Ivan, Coulibaly Jean T, Yao Adrien K, Utzinger Jürg, N'Goran Eliézer K (2011), Questionnaire-based approach to assess schoolchildren's physical fitness and its potential role in exploring the putative impact of helminth and Plasmodium spp. infections in Côte d'Ivoire., in Parasites & vectors, 4, 116-116.
Research in a war zone
Bonfoh B, Raso G, Kone I, Dao D, Girardin O, Cisse G, Zinsstag J, Utzinger J, Tanner M (2011), Research in a war zone, in NATURE, 474(7353), 569-571.
Statistical methodological issues in mapping historical schistosomiasis survey data
Chammartin F, Hürlimann Eveline, Raso Giovanna, N'Goran Eliezer, Utzinger Jürg, Vounatsou Penelope, Statistical methodological issues in mapping historical schistosomiasis survey data, in Acta Trop.

Collaboration

Group / person Country
Types of collaboration
Swiss TPH Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
- Exchange of personnel
Universite Felix Houphouet-Boigny Ivory Coast (Africa)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
- Exchange of personnel
Global Alliance for Improved Nutrition Switzerland (Europe)
- Industry/business/other use-inspired collaboration
Centre Suisse de Recherches Scientifiques Ivory Coast (Africa)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
- Exchange of personnel

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
III World Congress of Public Health Nutrition Talk given at a conference The effect of timing of iron supplementation on iron absorption and haemoglobin in post-malaria anaemia: a longitudinal stable isotope study in Malawian toddlers 09.11.2014 Las Palmas de Gran Canaria, Spain Wegmüller Rita; Glinz Dominik;
III World Congress of Public Health Nutrition Talk given at a conference The effect of iron-fortified complementary food and intermittent preventive treatment of malaria on anaemia in young children: a 2x2 randomized controlled intervention trial 09.11.2014 Las Palmas de Gran Canaria, Spain Wegmüller Rita; Glinz Dominik;
Micronutrient Forum Conference Poster Dietary iron absorption and utilization in Ivorian children infected with hookworm, Schistosoma haematobium or afebrile malaria 02.06.2014 Addis Ababa, Ethiopia Glinz Dominik; Wegmüller Rita;
Seminar presentations Medical Research Council, The Gambia Individual talk Preventing Anaemia in Sub-Saharan Africa – The Challenge of Iron Fortification 28.06.2013 Fajara, Gambia Wegmüller Rita;
Nutrition Congress Africa Talk given at a conference Influence of malaria and hookworm infection on iron absorption in adolescents in Côte d’Ivoire 01.10.2012 Bloemfontein, South Africa Glinz Dominik;
Yearly conference of the Swiss Society of Tropical Medicine and Parasitology Talk given at a conference Aetiology of anaemia among infants, school-aged children and young non-pregnant women in Cote d'Ivoire 17.11.2011 Basel, Switzerland, Switzerland Righetti Aurélie Assunta;


Abstract

BackgroundAnaemia is a major global health problem. Its aetiology is multifactorial, yet in West Africa low dietary iron intake and parasitic diseases (i.e. malaria and hookworm) have been identified as the main causes. Anaemia can cause fatigue, impaired cognitive development, and increased morbidity and mortality from infectious diseases. Strategies for prevention and control include increasing dietary iron intake through food fortification or supplementation. It has been suggested that the efficacy of these interventions is enhanced when combined with parasite control (i.e. chemotherapy targeting helminth infections and intermittent preventive treatment (IPT) of malaria). Our own work in Côte d’Ivoire, however, showed no effect of iron fortification and IPT of malaria on haemoglobin (Hb) and anaemia. Administration of anthelminthic drugs showed a significant, yet only modest improvement of Hb levels in school children. The lack of efficacy of the IPT intervention might be explained by resistance to the antimalarial drug used, i.e. sulfadoxine-pyrimethamine (SP), whereas the inefficacy of iron fortification might be due to the use of a poorly absorbed elemental iron powder. Indeed, in Africa, inflammation and infection can blunt the efficacy of iron absorption and utilization of such iron fortificants. However, other factors may also affect Hb levels, including haemoglobinopathies, micronutrient deficiencies, infections and inflammatory disorders.ObjectivesThe goal of this project is to further our understanding of the aetiology of anaemia and to investigate how anaemia can be reduced among children in sub-Saharan Africa by using a combination of food-based and parasite-control interventions. There are three specific objectives: (i) to monitor anaemia, helminth infections, malaria parasitaemia, micronutrient deficiencies and haemoglobinopathies in a cohort of individuals within a demographic surveillance system (DSS); (ii) to investigate the impact of IPT of malaria, anthelminthic treatment and iron fortification in an intervention study in school children; and (iii) to assess changes in iron metabolism in relation to malaria and helminth infections.MethodologyOur studies were carried out in Taabo district, central Côte d’Ivoire embedded in a HDSS site covering ~40,000 people. In order to elucidate the aetiology of anaemia, blood, urine and stool samples were collected during repeated cross-sectional surveys from three sentinel groups (infants, school-aged children, women of childbearing age). Samples were analyzed for anaemia, iron deficiency (ID), helminths and malaria using quality-controlled methods. Micronutrient deficiencies known to affect Hb, haemoglobinopathies and chronic inflammation were measured. A 9-month intervention study in young children was designed to investigate the contribution of malaria and ID to anaemia. The children were provided IPT with SP+amodiaquine (3 times at 3-month intervals) and a NaFeEDTA fortified instant porridge (6 times per week). Anaemia, ID, and malaria prevalence was assessed at baseline and after 6 and 9 months of intervention. To investigate the effect of a helminth infection and malaria on iron metabolism, stable isotopes of iron were given (orally and intravenously). Iron absorption and utilization (incorporation into red blood cells) of subjects while infected with helminths or asymptomatic malaria was compared to after treatment (no infection). OutcomesWe found high prevalence of anaemia, malaria, inflammation, and deficiencies of iron, riboflavin and vitamin A but low prevalence of intestinal worms. In young children, iron deficiency and malaria as well as general infections were the main causes of anaemia. Our results further showed that anaemia was less of a problem in children co-infected with hookworms and malaria than in children with a single malaria infection. Non-pregnant women seemed to be protected from hookworms if they had malaria whereas in children malaria infection lead to an increased infection with hookworms.We found that iron absorption is clearly reduced during a malaria infection, whereas hookworm and Schistosoma infections did not have a negative impact. Iron incorportation into red blood cells was not affected by any of the infections. Thus, iron interventions should always be combined with a malaria control programme.Statistical analyses of our large intervention study looking at the effect of IPT and iron fortified porridge are pending.
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