Intended for healthcare professionals


Reducing anaemia in low income countries: control of infection is essential

BMJ 2018; 362 doi: (Published 01 August 2018) Cite this as: BMJ 2018;362:k3165
  1. Sant-Rayn Pasricha, laboratory head1 2 3 4,
  2. Andrew E Armitage, senior postdoctoral scientist1,
  3. Andrew M Prentice, professor5,
  4. Hal Drakesmith, associate professor1 6
  1. 1MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
  2. 2Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
  3. 3Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
  4. 4Diagnostic and Clinical Haematology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  5. 5MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, Gambia
  6. 6Haematology Theme, Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
  1. Correspondence to: S-R Pasricha Pasricha.s{at}

In settings with high infection burdens, iron interventions for anaemia may be neither safe nor effective. Strategies to tackle the global burden of anaemia must take this into account, argue Sant-Rayn Pasricha and colleagues

Anaemia affects 273 million children and 529 million women globally,1 accounting for 8.8% of all years lived with disability.2 The prevalence of anaemia in children under 5 years is highest in sub-Saharan Africa (62.3%) and South East Asia (53.8%),1 where rates of concomitant infection are also high. Between 1993 and 2011, the estimated prevalence of anaemia worldwide fell only from 33% to 29% in non-pregnant women and from 47% to 43% in preschool children.3 The 2016 Global Nutrition Report found that progress towards the World Health Organization target of a 50% reduction in anaemia in women by 2025 is 100 years behind schedule.4

Iron is an essential micronutrient required for many biological processes, including oxygen transport, mitochondrial function, and numerous enzymatic pathways. Iron deficiency can therefore compromise diverse physiological functions and ultimately lead to anaemia. Public health strategies to control anaemia emphasise iron replenishment: fortification of food with iron, universal distribution of iron supplements, and home fortification of complementary foods with iron containing multiple micronutrient powders.567 Failures in resolving the burden of anaemia have been attributed to programmatic limitations: problems with financing, supplying, distributing, or adherence to interventions.48 However, as discussed in this article, new understanding of iron-infection interactions, evidence from clinical trials, and anaemia epidemiology cast doubt on the safety and prominence of universal iron interventions as the mainstay of public health anaemia control, especially among young children in areas of high infectious burden. Although this has resulted in modifications to WHO iron intervention guidelines, a further change of approach to anaemia control is needed. …

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