1. 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

2. 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

3. 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 “

4. 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.: CD DOI: / CD pub5.

5. 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.: CD DOI: / CD pub5.

6. 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): e

7. 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

8. 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.: CD DOI: / CD pub5.

9. 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.: CD DOI / CD pub5.

10. 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.: CD DOI: / CD 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.: CD DOI / CD pub5.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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