Evidence of Effectiveness of Flour Fortification on Iron Status and Anemia: A Literature Review.

Objectives: The effectiveness of wheat- and maize-flour fortification for improving iron status and anemia in real-world situations has not been documented. The objective was to review published and grey literature on the public-health impact of flour fortification. Methods: A systematic literature review was undertaken, including a search of 17 databases and an e-mail appeal for unpublished reports. Two researchers reviewed 1881 documents. Only studies on government-supported, large-scale fortification programs with anemia or iron outcomes measured prior to and > 12 months after initiation of fortification were included. Results: Twelve studies describing 25 sub-groups (n=13 for children < 15 years, n=12 for women of reproductive age (WRA)) were analyzed. Eight studies used a pre-post design, 4 included a control population, and none adjusted for possible confounding factors. From the pre- to the postfortification periods (and as difference-in-difference for those that included a control group), hemoglobin increased significantly in 4 of 11 studies with children and 5/11 studies with WRA; hemoglobin decreased significantly in 1/11 studies with children and 2/11 with WRA. Anemia prevalence decreased significantly in 4/8 studies with children and 3/10 studies with WRA; anemia prevalence increased significantly in 1/8 studies with children and 2/3 studies with WRA. The prevalence of low serum ferritin statistically decreased in 1/6 studies with children and 3/3 studies with WRA.Conclusions: Available studies confirm that large-scale fortification can positively impact iron and anemia status in children and women of reproductive age; however there is not enough evidence yet to understand under what conditions such impact is greatest.

A Paper Test Card Provides Quantitative Measurement of Iodate to Improve Quality Control of Iodized Salt in Low-resource Settings.

Objectives: Monitoring iodine content in iodized salt is necessary for program effectiveness. Iodometric titration is the most precise method but requires skills, facilities, and reagents. The WYD Iodine Checker® and Bioanalyt iCheck® are quantitative, but are expensive, require reagents and electrical power. Iodometric titration has been adapted onto a paper test card to quantitatively measure iodate in iodized salt in low-resource settings. A cell phone is used to evaluate test results. Researchers internally validated the test cards to demonstrate accuracy and conducted a field test to demonstrate applicability for quality control in factory settings. Methods: For each sample, 3 drops of a 1:5 salt-to-water dilution were placed onto the test card and mixed for 3 minutes before taking a cell phone image. Images were analyzed against a calibration curve. Two researchers internally blindly validated the test cards against titration at a university lab in Indiana, USA. The field test was performed by a quality technician in a salt factory in Mombasa, Kenya. Results: During internal validation, 78 of 100 samples ranging from 0-75 ppm iodate analyzed were within 20% of the titration result. In the field factory, 24 of 32 samples ranging from 19-55 ppm iodate analyzed by the technician were within 20% range of titration. The technician was trained within 30 minutes and carried out 24 analyses in 3 hours, compared with 15 titrations in 3 hours. Conclusions: The paper test card offers a rapid field-friendly method with sufficient accuracy to use for quality control of iodized salt.