Anemia Interventions in Low Iron Deficiency Settings - Low-dose Pre-natal Iron Supplementation and MNPs Technical Briefs prepared for Sierra Leone Ministry of Health and Sanitation Dr. Denish Moorthy, Team Lead, Anemia, USAID-funded SPRING project November 2018

Structure of the Briefs Purpose: Assist the Government of Sierra Leone (GoSL) in development of anemia strategy Summarizes current anemia situation in Sierra Leone Discusses pros and cons of: Low dose pre-natal iron supplementation (with folic acid) in pregnant women MNP as an anemia intervention for pre-school children Other topics covered: Efficacy and safety of pre-natal iron supplementation Brief summary of the efficacy of MNP, as well as a review of potential safety issues with regard to malaria

Iron-folic acid in Pregnancy “Daily oral iron and folic acid (IFA) supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth and reduce the risk of and associated mortality from maternal hemorrhage “

Iron-folic acid in Pregnancy - efficacy Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub5.

Iron-folic acid in Pregnancy - efficacy Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub5.

Iron-folic acid in Pregnancy - Safety Iron deficiency associated with diminished risk of malaria Sangare´ L, et al. (2014) The Association between Malaria and Iron Status or Supplementation in Pregnancy: A Systematic Review and Meta-Analysis. PLoS ONE 9(2): e87743 .

Iron-folic acid in Pregnancy - Safety Iron supplementation did not increase the risk of infection Sangare´ L, et al. (2014) The Association between Malaria and Iron Status or Supplementation in Pregnancy: A Systematic Review and Meta Analysis. PLoS ONE 9(2): e87743

Low-dose iron-folic acid in Pregnancy Range of doses provided: 9 mg – 900 mg (6 trials provided 30 mg) Iron supplementation improves maternal haematological outcomes independent of dosage Intake > 60 mg of iron or more per day - higher Hb values at or near end of term of pregnancy Intake > 60 mg more likely to report side effects (diarrhoea) as compared to intake of lower dose Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub5.

Low-dose iron-folic acid in Pregnancy Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI 10.1002/14651858.CD004736.pub5.

Low-dose iron-folic acid in Pregnancy Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI: 10.1002/14651858.CD004736.pub5. Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy.Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004736. DOI 10.1002/14651858.CD004736.pub5.

Prenatal Low-dose iron-folic acid in Pregnancy The efficacy and safety IFA in reducing anemia and iron deficiency is well established The prevalence of anemia and malaria remain high in Sierra Leone, and evidence of infection is high in children—though there are not data for pregnant women Use of bednets (50%) and IPT during pregnancy (just under 50%) suggest reasonable malaria program success; 70% of women reported receiving deworming during their last pregnancy Iron deficiency (per adjusted ferritin levels) was low (8%) Low dose prenatal iron supplementation (reduced from 60mg/d to 30 mg/d) appear justified

MNP Use with Low Prevalence of Iron Deficiency Potential benefits of MNP: Reduction in anemia in children, particularly young children with the highest anemia rates 26% reduction in anemia 52% reduction in iron deficiency Higher hemoglobin concentration Reduction in iron deficiency and iron deficiency anemia among those deficient Provision of a new platform through which other infant and young child feeding practices can be promoted

MNP Use with Low Prevalence of Iron Deficiency Potential consequences of using MNP: Small risk of adversely affecting the infectious disease pattern, particularly the potential risk of exacerbating malaria in areas where the malaria control activities are not effectively implemented. Possibility of limited impact due to the low prevalence of iron deficiency Strain on resources due to the need to establish a logistic supply chain for the program to deliver MNP  

MNP Use with Low Prevalence of Iron Deficiency The Sierra Leone National Multi-sectoral Strategy to Prevent and Control Anaemia 2017–2025 does not include MNP as a prioritized intervention Should resources for this intervention should instead be devoted to other elements of the anemia prevention and control programming? Effective intervention to reduce anemia and iron deficiency with low risk of exacerbating malaria Low prevalence of iron deficiency in Sierra Leone raise the question of whether MNP would actually have an impact on anemia prevalence

Blunted effectiveness Inflammation markers suggest high levels of inflammation in Sierra Leone, in part due to malaria Inflammation can cause anemia, can reduce iron absorption, and can affect serum ferritin (causing underestimation of iron deficiency, though most studies correct for inflammation) While MNPs would likely be beneficial to women and children with iron deficiency anemia, population-based interventions may not be efficient given the low prevalence of IDA

Evidence-based Policy Making Government of Sierra Leone is considering low-iron prenatal IFA supplement in pregnancy, in partnership with UNICEF MNPs are not included as an intervention in the “Sierra Leone National Multi-Sectoral Strategy to Prevent and Control Anemia

Thank you! For more info, please contact: denish_moorthy@jsi.com