The Effect of Intermittent Antenatal Iron Supplementation on Infant Outcomes in Rural Vietnam: A Cluster Randomized Trial.

Objectives: Intermittent antenatal iron supplementation is an attractive alternative to daily dosing during pregnancy, however the impact of this strategy on infant outcomes remains unclear. We compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Vietnam. Methods: This cluster randomised trial was conducted in Ha Nam province, Vietnam. 1,258 pregnant women in 104 communes were assigned to daily iron-folic acid (IFA), twice weekly IFA, or twice weekly multiple micronutrient (MMN) supplementation. Primary outcome was birth weight. Results: There was no difference in birth weights of infants of women receiving twice weekly IFA compared to daily IFA (mean difference [MD] 28 g; 95% CI -22 to 78), or twice weekly MMN compared to daily IFA (MD -36.8 g; 95% CI -82 to 8.2). At 32 wk gestation, maternal ferritin was lower in women receiving twice weekly compared to daily IFA (geometric mean ratio (GMR) 0.73; 95% CI 0.67 to 0.80), and in women receiving twice weekly MMN compared to daily IFA (GMR 0.62; 95% CI 0.57 to 0.68), with no difference in hemoglobin levels. Infants of mothers who received twice weekly IFA had higher cognitive scores at 6 mo of age compared to those who received daily IFA (MD 1.89; 95% CI 0.23 to 3.56). Conclusions: Twice-weekly antenatal IFA supplementation achieved similar mean birthweight, and improved cognitive scores in infants at 6 months of age, compared to daily IFA supplementation, and should be considered for use in settings with low anemia prevalence.

Is Weekly Iron Folic Acid Supplementation and Deworming in Vietnamese Women of Reproductive Age Sustainable? The Yen Bai Cohort 6 Years on.

Objectives: Weekly iron-folic acid supplementation (WIFS) and regular deworming for women of reproductive age (WRA) is an effective way of preventing anaemia and iron deficiency in a population but long-term sustainability is challenging. The objectives of this study were to: 1) Determeine the effectiveness of a free WIFS and biannual deworming program for WRA that has been implemented in rural Vietnam for six years. 2) Assess compliance and identify challenges and barriers to ongoing sustainability. Methods: In July 2012, we conducted a follow-up survey in this rural mountainous province to evaluate haematological parameters (haemoglobin and ferritin), soil transmitted helminth burden and compliance in a cohort of women first recruited in 2005, and who have had access to an externally funded WIFS/deworming program since May 2006. Results: Of the original cohort of 389, 256 (65.8%) women attended the survey. Mean haemoglobin had increased to from 122 g/L [95% C.I. 120, 124] to 135g/L [95% C.I. 133g/L, 138g/L] and anaemia prevalence reduced from 37.8% [95% C.I. 31.0%, 44.7%] to 14.3% [95% C.I. 9.5%, 19.1%]. The prevalence of hookworm infection was lower at 10.2% [95% C.I. 5.4%, 15.0%]. Seventy two per cent of survey participants continued to take the weekly supplements regularly. Without further support the WIFS program will cease in 2014. Conclusions: Anaemia rates continued to fall duringr the six year period, and soil transmitted helminth infections have been eliminated as a public health risk. Complianace was well maintained but sustainability is a major challenge. The issues surrounding long term sustainability of WIFS for WRA will be discussed.

Efficacy and Safety of Daily Iron Supplementation in Children: Lessons from Three Systematic Reviews and Meta-analyses of Randomized Controlled Trials.

Objectives: 47% of pre-school children and 25% of school-aged children are anaemic. Daily iron supplementation remains a key anaemia control intervention, but benefits and safety in children are debated. We systematically reviewed evidence for daily iron supplementation in 4–23m, 2-5y and 5-12y children. Methods: Separate searches and systematic-reviews/meta-analyses were performed for each age-group. Electronic databases and other sources were searched for randomized controlled trials comparing daily iron supplementation with control. Random-effects meta-analysis was used. Risk-of-bias was estimated using the Cochrane tool. Results: For children 4-23m, 2-5y and 5-12y respectively we identified 9533, 9169 and 16501 citations, from which 35, 15 and 32 eligible studies were identified, of which 9, 0 and 4 were at low overall risk-of-bias. Iron improved haemoglobin and ferritin and, in 4-23 m and 5-12y, reduced anaemia and iron deficiency. In 5-12y, iron improved global cognitive scores (SMD 0.50 [0.11, 0.90], p = 0.01) and in anaemic children, IQ (MD 4.55 [0.16, 8.94], p = 0.04). In 2-5y, limited data suggested a small improvement from iron in cognitive performance. No benefit was evident in 4-23 m (Bayley’s mental development index: MD 1·65 [–0·63, 3·94]) overall but was seen in iron deficient children (MD 5.90 [1.91, 10.00], p=0.005). Iron did not benefit growth in 4-23 m or 2-5y, but did improve growth in 5-12y. Vomiting and fever were increased in 4-23m receiving iron. Conclusions: Although supplementation iron improves cognition in older children or children with ID, evidence of non-haematologic benefit in pre-school children is inadequate. Further research is needed to enable guideline development.

Prevalence of polymorphisms in DHFR, DHPS, PFMDR1 and PFCRT genes of Plasmodium falciparum isolates in Quang Tri Province, Vietnam.

In 2002 an antimalarial drug resistance survey was carried out in a seasonally endemic area of Vietnam. Sulfadoxine/pyrimethamine (S/P) was the standard treatment recommended for uncomplicated Plasmodium falciparum malaria in that area at the time. Early or late treatment failure as defined by WHO was observed in 14.9% (7/47) of patients. Molecular analysis of treatment failure isolates identified that 5/6 carried two or more dhfr and dhps polymorphisms associated with S/P resistance. Chloroquine resistance-associated polymorphisms occurred in 38.5% (15/39) of the isolates. These results support the move to artemisinin-based combination therapy for malaria in Vietnam.

KAP surveys and malaria control in Vietnam: findings and cautions about community research.

The malaria disease burden is increasing in many countries despite the existence of effective preventative strategies and antimalarial drugs. An understanding of community perspectives and practices is one of the essential components of a successful malaria control program. This paper reports on a KAP (Knowledge, Attitudes and Practices) survey among the Raglai ethnic minority population in Ninh Thuan Province, Vietnam, which in 2003 had one of the country's highest confirmed rates of malaria. We found high levels of correct knowledge about malaria's transmission and symptoms, and self-reports of adequate bed net usage and appropriate health-seeking behavior. While the survey generated useful findings, an initial, qualitative investigation (eg, observation and focus group discussions) to explore the large numbers of potential influences on behavior and exposure risk would have provided a more robust underpinning for the design of survey questions. This would have strengthened its validity and generated additional information. The adoption of rigorous, multi-disciplinary research methods offers the best chance of contributing to the development of successful malaria control programs and effective policies.