Effects of multimicronutrient supplementation on helminth reinfection: a randomized, controlled trial in Kenyan schoolchildren

A Study to Improve the Vitamin A and Iodine Status of Pregnant Women through a Multiple Micronutrient Fortified Salt

Background. To study the efficacy of a multiple micronutrient fortified salt enriched with iron, iodine, vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, niacin, and folic acid in improving serum retinol and iodine status of pregnant women. Methods. It was a randomized control trial in the antenatal clinic of a hospital. 151 women in the experimental group received a multiple micronutrient fortified salt to cook all their meals, and 150 women in the control group did not receive the fortified salt. Blood was collected in the three trimesters. Urine was collected in their first and third trimesters. Serum retinol, CRP (C-reactive protein), and AGP (Alpha glycoprotein) in blood were assessed, and iodine was assessed in urine. All the women were dewormed once. Results. The inflammation adjusted mean serum retinol in three trimesters in the experimental group was 24.51, 27.29, and 25.68 µg/dL, and it was 28.97, 27.63, and 22.72 µg/dL in the control group. Over the study period of 6 months, the increase in serum retinol in the experimental group was 1.17 µg/dL whereas in the control group serum retinol decreased by 6.25 µg/dL. The experimental group increase in serum retinol is significantly more ( $p=0.0001$ ) than the changes in retinol in the control group. The prevalence of serum retinol deficiency in the three trimesters was 39.1%,25.8%, and 37.7% in the experimental group and 14%, 22.7%, and 39.3% in the control group, and the change in the experimental group was significant ( $p=0.001$ ) compared to the control group by binary logistic regression. Over the study period of 6 months there is a significant increase in urinary iodine concentration in the experimental group ( $p=0.030$ ), showing absorption of iodine from the fortified salt whereas there is a significant decline in the iodine values in the control group ( $p=0.008$ ). At the end of the study, the urinary iodine concentration of the experimental group was significantly more ( $p=0.0001$ ) than that of the control group. Conclusion. The fortified salt was able to improve serum retinol levels and urinary iodine levels in pregnant women. Trial Registration. This trial was registered retrospectively on 19/02/2022 in the ISRCTN registry with trial ID ISRCTN17782574.

Serum zinc status is a matter of concern among children and non-pregnant women in a nationwide survey of Nepal

Nationally representative population data on zinc status in Nepal is lacking at present. This study analyzed data from the recent Nepal National Micronutrient status survey 2016 to determine the prevalence of zinc deficiency and associated risk factors among children aged 6-59 months (n = 1462) and non-pregnant women aged 15-49 years (n = 1923). Venous blood was collected from the participants to measure micronutrients such as zinc, markers of anemia, RBP (vitamin A), and markers of inflammation. Stool samples were collected to assess soil-transmitted helminths and Helicobacter pylori infection. Socio-demographic, household, and other relevant factors were collected by a structured questionnaire. Serum zinc concentration was measured by Microwave Plasma Atomic Emission Spectrometry, and zinc deficiency was defined according to the International Zinc Nutrition Consultative Group's guidelines. Logistic regression was used to examine the predictors of zinc deficiency among the participants. The overall zinc deficiency in children was 22.9%, while it was higher in non-pregnant women (24.7%). The prevalence of anemia among zinc-deficient children was higher (21.3%) than the zinc non-deficit children (18.7%). The prevalence of anemia was 18% among zinc-deficient non-pregnant women compared to 22% non-deficit non-pregnant women. Predictors associated with zinc deficiency among the study children were living in rural areas (AOR = 2.25, 95% CI, [1.13, 4.49]), the occurrence of diarrhea during the two weeks preceding the survey (AOR = 1.57, 95% CI, [1.07, 2.30]), lowest household wealth quintile (AOR = 0.48, 95% CI, [0.25, 0.92]) and lower vitamin A status (AOR = 0.49, 95% CI, [0.28, 0.85]. The predictors associated with zinc deficiency among non-pregnant women were: being underweight (AOR = 1.55, 95% CI, [1.12, 2.15]), fever occurrence during two weeks preceding the survey (AOR = 1.43, 95% CI, [1.04, 1.98]), H. pylori in the stool (AOR = 1.33, 95% CI, [1.04, 1.71]), lowest household wealth quintile (AOR = 0.62, 95% CI,[0.40, 0.94]) and being at risk of folate deficiency (AOR = 0.58, 95% CI,[0.36, 0.94]). We conclude that community-level intervention programs focused on rural children and women to prevent diarrhea, improve nutrition counseling, and provide economic opportunities in rural communities may help to lower zinc deficiency and other micronutrient deficiencies in the Nepalese population. We believe that intervention programs to address zinc deficiency should not be isolated. Instead, integrated approaches are beneficial to improve overall micronutrient status, such as encouraging dietary diversity, providing livelihood opportunities to the unemployed, micronutrient supplementation to vulnerable populations, and consumption of zinc-rich animal-based foods.

Effects of nutritional supplements on the re-infection rate of soil-transmitted helminths in school-age children: A systematic review and meta-analysis

Background

The effect of nutritional supplements on the re-infection rate of species-specific soil-transmitted helminth infections in school-aged children remains complex and available evidence on the subject matter has not been synthesized.

Methods

The review included randomised controlled trials (RCTs) and cluster RCTs investigating food supplements on school-aged children between the age of 4–17 years. A search for RCTs was conducted on eight databases from inception to 12^th June 2019. Cochrane Risk of Bias tool was used to assess the risk of bias in all included studies. Meta-analysis and narrative synthesis were conducted to describe and analyze the results of the review. Outcomes were summarized using the mean difference or standardized mean difference where appropriate.

Results

The search produced 1,816 records. Six studies met the inclusion criteria (five individually RCTs and one cluster RCT). Four studies reported data on all three STH species, while one study only reported data on Ascaris lumbricoides infections and the last study reported data on only hookworm infections. Overall, the risk of bias in four individual studies was low across most domains. Nutritional supplementation failed to statistically reduce the re-infection rates of the three STH species. The effect of nutritional supplements on measures of physical wellbeing in school-aged children could not be determined.

Conclusions

The findings from this systematic review suggest that nutritional supplements for treatment of STH in children should not be encouraged unless better evidence emerges. Conclusion of earlier reviews on general populations may not necessarily apply to children since children possibly have a higher re-infection rate.

Effects of single and integrated water, sanitation, handwashing, and nutrition interventions on child soil-transmitted helminth and Giardia infections: A cluster-randomized controlled trial in rural Kenya

BACKGROUND

Helminth and protozoan infections affect more than 1 billion children globally. Improving water quality, sanitation, handwashing, and nutrition could be more sustainable control strategies for parasite infections than mass drug administration, while providing other quality of life benefits.

METHODS AND FINDINGS

We enrolled geographic clusters of pregnant women in rural western Kenya into a cluster-randomized controlled trial (ClinicalTrials.gov NCT01704105) that tested 6 interventions: water treatment, improved sanitation, handwashing with soap, combined water treatment, sanitation, and handwashing (WSH), improved nutrition, and combined WSH and nutrition (WSHN). We assessed intervention effects on parasite infections by measuring Ascaris lumbricoides, Trichuris trichiura, hookworm, and Giardia duodenalis among children born to the enrolled pregnant women (index children) and their older siblings. After 2 years of intervention exposure, we collected stool specimens from 9,077 total children aged 2 to 15 years in 622 clusters, including 2,346 children in an active control group (received household visits but no interventions), 1,117 in the water treatment arm, 1,160 in the sanitation arm, 1,141 in the handwashing arm, 1,064 in the WSH arm, 1,072 in the nutrition arm, and 1,177 in the WSHN arm. In the control group, 23% of children were infected with A. lumbricoides, 1% with T. trichiura, 2% with hookworm, and 39% with G. duodenalis. The analysis included 4,928 index children (median age in years: 2) and 4,149 older siblings (median age in years: 5); study households had an average of 5 people, <10% had electricity access, and >90% had dirt floors. Compared to the control group, Ascaris infection prevalence was lower in the water treatment arm (prevalence ratio [PR]: 0.82 [95% CI 0.67, 1.00], p = 0.056), the WSH arm (PR: 0.78 [95% CI 0.63, 0.96], p = 0.021), and the WSHN arm (PR: 0.78 [95% CI 0.64, 0.96], p = 0.017). We did not observe differences in Ascaris infection prevalence between the control group and the arms with the individual interventions sanitation (PR: 0.89 [95% CI 0.73, 1.08], p = 0.228), handwashing (PR: 0.89 [95% CI 0.73, 1.09], p = 0.277), or nutrition (PR: 86 [95% CI 0.71, 1.05], p = 0.148). Integrating nutrition with WSH did not provide additional benefit. Trichuris and hookworm were rarely detected, resulting in imprecise effect estimates. No intervention reduced Giardia. Reanalysis of stool samples by quantitative polymerase chain reaction confirmed the reductions in Ascaris infections measured by microscopy in the WSH and WSHN groups. Trial limitations included imperfect uptake of targeted intervention behaviors, limited power to detect effects on rare parasite infections, and that it was not feasible to blind participants and sample collectors to treatment status. However, lab technicians and data analysts were blinded to treatment status. The trial was funded by the Bill & Melinda Gates Foundation and the United States Agency for International Development.

CONCLUSIONS

Integration of improved water quality, sanitation, and handwashing could contribute to sustainable control strategies for Ascaris infections, particularly in similar settings with recent or ongoing deworming programs. Combining nutrition with WSH did not provide further benefits, and water treatment alone was similarly effective to integrated WSH. Our findings provide new evidence that drinking water should be given increased attention as a transmission pathway for Ascaris.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01704105.

Supplementation with micronutrients and schistosomiasis: systematic review and meta-analysis

Schistosomiasis is a parasitic disease caused by helminths of the genus Schistosoma with two presentations; one intestinal and another urinary; which depend on the specie of Schistosoma. One of the species that can produce intestinal schistosomiasis is Schistosoma mansoni, and the specie that produces urinary schistosomiasis is Schistosoma haematobium. Infection can be aggravated by a deficient nutritional status, which negatively impacts the immune system and increases susceptibility to infection. The main objective of this meta-analysis is to determine if a relationship exists between multimicronutrient supplementation and the reduction of infestation with Schistosoma mansoni and Schistosoma haematobium in children and adolescents. A search was conducted through a scientific literature database, and articles that complied with the pre-established requirements were retrieved. The Review Manager (Rev Man) 5.3 computer program was used for data processing and analysis was carried out with the objective of testing whether the addition of micronutrient supplementation to treatment with broad-spectrum antiparasitic anthelmintic medication has an impact on schistosomiasis infection. Of the 257 initial articles retrieved, eight were included both quantitatively and qualitatively in the meta-analysis. Supplementation reduces infestation with Schistosoma spp 1.33 times more than placebo. In individuals infested with Schistosoma, mansoni supplementation is 1.30 times more effective than placebo and for individuals infested with Schistosoma haematobium, supplementation is 1.62 times more effective than the placebo. The results show a clear relationship between supplementation and reduction of infestation. The supplementation with micronutrients decreases the presence of Schistosoma spp in children and adolescents.

Deworming in non-pregnant adolescent girls and adult women: a systematic review and meta-analysis

BACKGROUND

The impact of deworming on parasite load, nutritional status and other health outcomes of non-pregnant adolescent girls and adult women is uncertain.

METHODS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the WHO International Clinical Trials Registry Platform, the Cochrane Database of Systematic Reviews and Food and Technology Abstracts databases were searched until 24 September 2018. Studies were included if they were randomised controlled trials (RCTs), controlled before and after studies or interrupted time studies comparing deworming with no intervention or placebo in non-pregnant adolescent girls and women 10 to 49 years old. Outcomes of interest included parasite load, reinfection, anaemia, severe anaemia, iron deficiency, diarrhoea or all-cause morbidity. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

We included four RCTs of mass deworming involving 1086 participants, in the analyses. Mass deworming probably reduces the prevalence of roundworm infection (RR 0.29; 95% CI 0.14 to 0.62; 2 trials; 1498 participants, moderate certainty evidence), prevalence of hookworm infection (RR 0.32; 95% CI 0.18 to 0.59; 2 trials; 1498 participants, moderate certainty evidence), prevalence of whipworm infection (RR 0.77; 95% CI 0.65 to 0.91; 2 trials; 1498 participants, moderate certainty evidence) compared to the control group. Deworming may make little or no difference in prevalence of anaemia (RR 0.82; 95% CI 0.60 to 1.11, 3 studies, 683 participants, low certainty evidence) and prevalence of iron-deficiency (RR 0.89; 95% CI 0.64 to 1.23, 1 study, 186 participants, low certainty evidence) compared to control. We are uncertain whether deworming reduces the prevalence of severe anaemia compared to control as the certainty of evidence was very low. None of the included studies assessed screen and treat deworming or reported reinfection, diarrhoea or adverse events.

CONCLUSIONS

Mass deworming probably reduces the prevalence of soil-transmitted helminth infections but may have little or no effect on anaemia and iron-deficiency in adolescent girls and non-pregnant women in comparison to no intervention or placebo. We are uncertain about the effect on severe anaemia. These results are limited by sparse data and the moderate to very low quality of evidence available.

SYSTEMATIC REVIEW REGISTRATION

The protocol was registered in PROSPERO (registration number: CRD42016039557 ).  Primary source of funding: Evidence and Programme Guidance unit, Department of Nutrition for Health and Development, World Health Organization (WHO).

Evaluating the impact of integrated development: are we asking the right questions? A systematic review

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated.

Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process.

Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects.

Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Evaluating integrated development: are we asking the right questions? A systematic review

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design, the only design capable of statistically detecting synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Household and personal factors are sources of heterogenity in intestinal parasite clearance among Mexican children 6-15 months of age supplemented with vitamin A and zinc

A randomised, double-blind, placebo-controlled trial was carried out among Mexico children aged 6-15 months to determine how household characteristics modify vitamin A and zinc supplementation efficacy on Ascaris lumbricoides, Giardia intestinalis and Entamoeba histolytica/E. dispar infection durations. Children assigned to receive vitamin A every 2 months, a daily zinc supplement, a combined vitamin A-zinc supplement or a placebo were followed for 1 year. Parametric hazard models were fit to infection durations stratified by personal and household factors. Children supplemented with vitamin A and zinc combined from households lacking piped water and children in all three treatment arms from households with dirt floors had longer G. intestinalis and A. lumbricoides infection durations than their counterparts, respectively. Shorter E. histolytica/E.dispar durations were found among zinc-supplemented children of mothers who had <6 years of education and no indoor bathrooms. Heterogeneity in supplementation efficacy among children may reflect differences in exposure risk and baseline immune responses.

Efficacy and reinfection with soil-transmitted helminths 18-weeks post-treatment with albendazole-ivermectin, albendazole-mebendazole, albendazole-oxantel pamoate and mebendazole

Background

Preventive chemotherapy with albendazole or mebendazole is the current strategy to control soil-transmitted helminth (STH) infections (i.e. Ascaris lumbricoides, hookworm and Trichuris trichiura). STH reinfections, in particular A. lumbricoides and T. trichiura occur rapidly after treatment with the standard drugs. However, their low efficacy against T. trichiura, made an accurate assessment of reinfection patterns impossible.

Methods

In 2013 a randomised controlled trial was conducted on Pemba Island, Tanzania. School-aged children diagnosed positive for T. trichiura, were randomly allocated to (i) albendazole-ivermectin; (ii) albendazole-mebendazole; (iii) albendazole-oxantel pamoate; or (iv) mebendazole. Here we report the efficacy [cure rates (CR) and egg-reduction rates (ERR)], reinfection rates and new infections determined 18 weeks post-treatment.

Results

For a total of 405 children complete baseline and follow-up data were available. Similar to the efficacy determined after 3 weeks, 18 weeks after treatment albendazole-oxantel pamoate showed a significantly higher efficacy against T. trichiura (CR: 54.0 %, 95 % CI: 43.7–64.0; ERR: 98.6 %, 95 % CI: 97.8–99.2) compared to the other treatment arms. Children treated with albendazole-oxantel pamoate or albendazole-ivermectin had fewer moderate infections compared to children treated with albendazole. The reinfection rates 18 weeks post-treatment among all treatment arms were 37.2 % for T. trichiura (95 % CI: 28.3–46.8), 34.6 % for A. lumbricoides (95 % CI: 27.3–42.3) and 25.0 % for hookworms (95 % CI: 15.5–36.6).

Conclusion

The moderate reinfection rates with STHs 18 weeks post-treatment support the concept of regular anthelminthic treatment in highly endemic settings. Combination chemotherapy might achieve decreased morbidity in children since in the albendazole plus oxantel pamoate and albendazole plus ivermectin treatment arms only few moderate T. trichiura infections remained. Further trials should investigate the long term efficacy of albendazole-oxantel pamoate (i.e. 6 and 12 month post-treatment) and after several rounds of treatment in order to develop recommendations for appropriate control approaches for STH infections.

Trial registration

Current Controlled Trials ISRCTN80245406

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1406-8) contains supplementary material, which is available to authorized users.

Immigrants living in an urban milieu with sanitation in Southern Italy: persistence and transmission of intestinal parasites

In the current era of globalization, the massive movement of populations to developed countries causes a greater attention to neglected tropical diseases in places where such diseases are considered unusual. The present study was planned to assess the persistence of intestinal parasitosis in immigrants stably living in the urban central area of Naples (Southern Italy) and the spread of infection within households with a lifestyle similar to that of the country of origin. A total of 2150 stool samples were analysed with the FLOTAC dual technique, and 415 subjects (19.3 %) tested positive for pathogenic intestinal parasites. One hundred ninety-six subjects were randomly selected and monitored again after 1 year in order to evaluate the persistence of intestinal parasites in immigrants having access to proper sanitation. No pathogenic parasites were found in these 196 samples. A total of 482 cohabitants of 151 positive subjects were recruited to evaluate the interfamilial spread of the identified parasites. Only in 18 households were there subjects infected with the same parasite. Monitoring of parasites in stool samples of immigrants showed a decrease of almost all pathogenic species over the years. From the analysis of households, it is not possible to assert that there is a familial transmission. Our study provides evidence that the prevalence of parasitic infections in immigrants is likely related to the poor sanitary habits of the country of origin and that acquisition of new sanitary regulations, together with the administration of pharmacological treatment, limits the transmission in the households and in the local population of their destination.

Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis

BACKGROUND

Helminth infections and micronutrient deficiencies are highly prevalent in developing countries. Neither condition typically causes overt disease, but they do lead to indirect morbidity such as impaired physical and cognitive development.

OBJECTIVE

We aimed to systematically review current evidence on the relation of helminth infections with micronutrient status in school-age children worldwide.

DESIGN

We included both observational studies and randomized controlled trials (RCTs). We applied a random-effects meta-analysis to estimate 1) cross-sectional associations between helminths and micronutrient status, 2) effects of anthelminthic treatment on micronutrient status, and 3) effects of micronutrient supplementation on helminth infection and reinfection.

RESULTS

Meta-analyses of observational studies showed an association between helminth infections and serum retinol [standardized mean difference (SMD): -0.30; 95% CI: -0.48, -0.13] but not serum ferritin (SMD: 0.00; 95% CI: -0.7, 0.7). Conversely, meta-analyses of anthelminthic treatment RCTs showed a positive effect on ferritin (SMD: 0.16; 95% CI: 0.09, 0.22) but not retinol (SMD: 0.04; 95% CI: -0.06, 0.14). The number of studies on micronutrients other than ferritin and retinol was not sufficient for pooling. Meta-analyses of micronutrient-supplementation RCTs showed only a modest protective effect for multimicronutrient interventions on helminth infection and reinfection rates (OR: 0.77; 95% CI: 0.61, 0.97).

CONCLUSIONS

In this review, we show evidence of distinct associations between helminth infections and micronutrients in school-age children. More studies are needed on micronutrients other than iron and vitamin A and on possible helminth species-specific effects. A thorough comprehension of the interplay between helminth infections and micronutrients will help guide integrated and sustainable intervention strategies in affected children worldwide.

Influence of nutrition on infection and re-infection with soil-transmitted helminths: a systematic review

Background

The relationship between nutrition and soil-transmitted helminthiasis is complex and warrants further investigation. We conducted a systematic review examining the influence of nutrition on infection and re-infection with soil-transmitted helminths (i.e. Ascaris lumbricoides, hookworm, Trichuris trichiura and Strongyloides stercoralis) in humans. Emphasis was placed on the use of nutritional supplementation, alongside anthelminthic treatment, to prevent re-infection with soil-transmitted helminths.

Methods

We searched eight electronic databases from inception to 31 July 2013, with no restriction of language or type of publication. For studies that met our inclusion criteria, we extracted information on the soil-transmitted helminth species, nutritional supplementation and anthelminthic treatment. Outcomes were presented in forest plots and a summary of findings (SoF) table. An evidence profile (EP) was generated by rating the evidence quality of the identified studies according to the GRADE system.

Results

Fifteen studies met our inclusion criteria; eight randomised controlled trials and seven prospective cohort studies. Data on A. lumbricoides were available from all studies, whereas seven and six studies additionally contained data on T. trichiura and hookworm, respectively. None of the studies contained data on S. stercoralis. Positive effects of nutritional supplementation or the host’s natural nutritional status on (re-)infection with soil-transmitted helminths were reported in 14 studies, while negative effects were documented in six studies. In terms of quality, a high, low and very low quality rating was assigned to the evidence from four, six and five studies, respectively.

Conclusions

Our findings suggest that the current evidence-base is weak, precluding guidelines on nutrition management as a potential supplementary tool to preventive chemotherapy targeting soil-transmitted helminthiasis. Moreover, several epidemiological, immunological and methodological issues have been identified, and these should be considered when designing future studies.

Drugs for treating Schistosoma mansoni infection

BACKGROUND

Schistosoma mansoni is a parasitic infection common in the tropics and sub-tropics. Chronic and advanced disease includes abdominal pain, diarrhoea, blood in the stool, liver cirrhosis, portal hypertension, and premature death.

OBJECTIVES

To evaluate the effects of antischistosomal drugs, used alone or in combination, for treating S. mansoni infection.

SEARCH METHODS

We searched MEDLINE, EMBASE and LILACS from inception to October 2012, with no language restrictions. We also searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2012) and mRCT. The reference lists of articles were reviewed and experts were contacted for unpublished studies.

SELECTION CRITERIA

Randomized controlled trials of antischistosomal drugs, used alone or in combination, versus placebo, different antischistosomal drugs, or different doses of the same antischistosomal drug for treating S. mansoni infection.

DATA COLLECTION AND ANALYSIS

One author extracted data and assessed eligibility and risk of bias in the included studies, which were independently checked by a second author. We combined dichotomous outcomes using risk ratio (RR) and continuous data weighted mean difference (WMD); we presented both with 95% confidence intervals (CI). We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Fifty-two trials enrolling 10,269 participants were included. The evidence was of moderate or low quality due to the trial methods and small numbers of included participants.Praziquantel: Compared to placebo, praziquantel 40 mg/kg probably reduces parasitological treatment failure at one month post-treatment (RR 3.13, 95% CI 1.03 to 9.53, two trials, 414 participants, moderate quality evidence). Compared to this standard dose, lower doses may be inferior (30 mg/kg: RR 1.52, 95% CI 1.15 to 2.01, three trials, 521 participants, low quality evidence; 20 mg/kg: RR 2.23, 95% CI 1.64 to 3.02, two trials, 341 participants, low quality evidence); and higher doses, up to 60 mg/kg, do not appear to show any advantage (four trials, 783 participants, moderate quality evidence).The absolute parasitological cure rate at one month with praziquantel 40 mg/kg varied substantially across studies, ranging from 52% in Senegal in 1993 to 92% in Brazil in 2006/2007. Oxamniquine: Compared to placebo, oxamniquine 40 mg/kg probably reduces parasitological treatment failure at three months (RR 8.74, 95% CI 3.74 to 20.43, two trials, 82 participants, moderate quality evidence). Lower doses than 40 mg/kg may be inferior at one month (30 mg/kg: RR 1.78, 95% CI 1.15 to 2.75, four trials, 268 participants, low quality evidence; 20 mg/kg: RR 3.78, 95% CI 2.05 to 6.99, two trials, 190 participants, low quality evidence), and higher doses, such as 60 mg/kg, do not show a consistent benefit (four trials, 317 participants, low quality evidence).These trials are now over 20 years old and only limited information was provided on the study designs and methods. Praziquantel versus oxamniquine: Only one small study directly compared praziquantel 40 mg/kg with oxamniquine 40 mg/kg and we are uncertain which treatment is more effective in reducing parasitological failure (one trial, 33 participants, very low quality evidence). A further 10 trials compared oxamniquine at 20, 30 and 60 mg/kg with praziquantel 40 mg/kg and did not show any marked differences in failure rate or percent egg reduction.Combination treatments: We are uncertain whether combining praziquantel with artesunate reduces failures compared to praziquantel alone at one month (one trial, 75 participants, very low quality evidence).Two trials also compared combinations of praziquantel and oxamniquine in different doses, but did not find statistically significant differences in failure (two trials, 87 participants). Other outcomes and analyses: In trials reporting clinical improvement evaluating lower doses (20 mg/kg and 30 mg/kg) against the standard 40 mg/kg for both praziquantel or oxamniquine, no dose effect was demonstrable in resolving abdominal pain, diarrhoea, blood in stool, hepatomegaly, and splenomegaly (follow up at one, three, six, 12, and 24 months; three trials, 655 participants).Adverse events were not well-reported but were mostly described as minor and transient.In an additional analysis of treatment failure in the treatment arm of individual studies stratified by age, failure rates with 40 mg/kg of both praziquantel and oxamniquine were higher in children.

AUTHORS' CONCLUSIONS

Praziquantel 40 mg/kg as the standard treatment for S. mansoni infection is consistent with the evidence. Oxamniquine, a largely discarded alternative, also appears effective.Further research will help find the optimal dosing regimen of both these drugs in children.Combination therapy, ideally with drugs with unrelated mechanisms of action and targeting the different developmental stages of the schistosomes in the human host should be pursued as an area for future research.

Soil-transmitted helminth reinfection after drug treatment: a systematic review and meta-analysis

Background

Soil-transmitted helminth (STH) infections (i.e., Ascaris lumbricoides, hookworm, and Trichuris trichiura) affect more than a billion people. Preventive chemotherapy (i.e., repeated administration of anthelmintic drugs to at-risk populations), is the mainstay of control. This strategy, however, does not prevent reinfection. We performed a systematic review and meta-analysis to assess patterns and dynamics of STH reinfection after drug treatment.

Methodology

We systematically searched PubMed, ISI Web of Science, EMBASE, Cochrane Database of Systematic Reviews, China National Knowledge Infrastructure, WanFang Database, Chinese Scientific Journal Database, and Google Scholar. Information on study year, country, sample size, age of participants, diagnostic method, drug administration strategy, prevalence and intensity of infection pre- and posttreatment, cure and egg reduction rate, evaluation period posttreatment, and adherence was extracted. Pooled risk ratios from random-effects models were used to assess the risk of STH reinfection after treatment. Our protocol is available on PROSPERO, registration number: CRD42011001678.

Principal Findings

From 154 studies identified, 51 were included and 24 provided STH infection rates pre- and posttreatment, whereas 42 reported determinants of predisposition to reinfection. At 3, 6, and 12 months posttreatment, A. lumbricoides prevalence reached 26% (95% confidence interval (CI): 16–43%), 68% (95% CI: 60–76%) and 94% (95% CI: 88–100%) of pretreatment levels, respectively. For T. trichiura, respective reinfection prevalence were 36% (95% CI: 28–47%), 67% (95% CI: 42–100%), and 82% (95% CI: 62–100%), and for hookworm, 30% (95% CI: 26–34%), 55% (95% CI: 34–87%), and 57% (95% CI: 49–67%). Prevalence and intensity of reinfection were positively correlated with pretreatment infection status.

Conclusion

STH reinfections occur rapidly after treatment, particularly for A. lumbricoides and T. trichiura. Hence, there is a need for frequent anthelmintic drug administrations to maximize the benefit of preventive chemotherapy. Integrated control approaches emphasizing health education and environmental sanitation are needed to interrupt transmission of STH.

Infections with soil-transmitted helminths (the roundworm Ascaris lumbricoides, the whipworm Trichuris trichiura, and hookworm) affect over 1 billion people, particularly rural communities in the developing world. The global strategy to control soil-transmitted helminth infections is ‘preventive chemotherapy’, which means large-scale administration of anthelmintic drugs to at-risk populations. However, because reinfection occurs after treatment, ‘preventive chemotherapy’ must be repeated regularly. Our systematic review and meta-analysis found that at 3, 6, and 12 months after treatment, A. lumbricoides prevalence reached 26% (95% confidence interval (CI): 16–43%), 68% (95% CI: 60–76%) and 94% (95% CI: 88–100%) of pretreatment levels, respectively. For T. trichiura, respective reinfection prevalence at these time points were 36% (95% CI: 28–47%), 67% (95% CI: 42–100%), and 82% (95% CI: 62–100%); and for hookworm, 30% (95% CI: 26–34%), 55% (95% CI: 34–87%), and 57% (95% CI: 49–67%). Prevalence and intensity of reinfection were positively correlated with pretreatment infection status. Our results suggest a frequent anthelmintic drug administration to maximize the benefit of preventive chemotherapy. Moreover, an integrated control strategy, consisting of preventive chemotherapy combined with health education and environmental sanitation is needed to interrupt transmission of soil-transmitted helminths.

Decreased parasite load and improved cognitive outcomes caused by deworming and consumption of multi-micronutrient fortified biscuits in rural Vietnamese schoolchildren

Micronutrient deficiencies are associated with impaired growth and cognitive function. A school-based fortification program might benefit schoolchildren but a high prevalence of parasite infestation might affect effectiveness. A randomized, double-blind, placebo-controlled 2 × 2 factorial trial was conducted to assess the efficacy of multi-micronutrient fortified biscuits with or without de-worming on growth, cognitive function, and parasite load in Vietnamese schoolchildren. Schoolchildren (n = 510), 6-8 years of age were randomly allocated to receive albendazole or placebo at baseline and four months of multi-micronutrient fortified biscuits (FB) or non-fortified biscuits. Children receiving FB for four months scored higher on two cognitive tests: Raven's Colored Progressive Matrices and the Digit Span Forward test. Children receiving albendazole plus FB had the lowest parasite load after four months. In children receiving FB, mid-upper arm circumference was slightly improved (+0.082 cm) but there were no differences in other indexes of anthropometry. Combining multi-micronutrient fortified biscuits with de-worming is an effective strategy.

Antimicrobial implications of vitamin D

Evidence exists that vitamin D has a potential antimicrobial activity and its deficiency has deleterious effects on general well-being and longevity. Vitamin D may reduce the risk of infection through multiple mechanisms. Vitamin D boosts innate immunity by modulating production of anti-microbial peptides (AMPs) and cytokine response. Vitamin D and its analogues via these mechanisms are playing an increasing role in the management of atopic dermatitis, psoriasis, vitiligo, acne and rosacea. Vitamin D may reduce susceptibility to infection in patients with atopic dermatitis and the ability to regulate local immune and inflammatory responses offers exciting potential for understanding and treating chronic inflammatory dermatitides. Moreover, B and T cell activation as well as boosting the activity of monocytes and macrophages also contribute to a potent systemic anti-microbial effect. The direct invasion by pathogenic organisms may be minimized at sites such as the respiratory tract by enhancing clearance of invading organisms. A vitamin D replete state appears to benefit most infections, with the possible noteworthy exception of Leishmaniasis. Antibiotics remain an expensive option and misuse of these agents results in significant antibiotic resistance and contributes to escalating health care costs. Vitamin D constitutes an inexpensive prophylactic option and possibly therapeutic product either by itself or as a synergistic agent to traditional antimicrobial agents. This review outlines the specific antimicrobial properties of vitamin D in combating a wide range of organisms. We discuss the possible mechanisms by which vitamin D may have a therapeutic role in managing a variety of infections.

Rates and intensity of re-infection with human helminths after treatment and the influence of individual, household, and environmental factors in a Brazilian community

This study quantifies the rate and intensity of re-infection with human hookworm and Schistosoma mansoni infection 12 months following successful treatment, and investigates the influence of socio-economic, geographical and environmental factors. A longitudinal study of 642 individuals aged over 5 years was conducted in Minas Gerais State, Brazil from June 2004 to March 2006. Risk factors were assessed using interval censored regression for the rate and negative binomial regression for intensity. The crude rate and intensity of hookworm re-infection was 0·21 per year (95% confidence interval (CI) 0·15-0·29) and 70·9 epg (95% CI 47·2-106·6). For S. mansoni the rate was 0·06 per year (95% CI 0·03-0·10) and intensity 6·51 epg (95% CI 3·82-11·11). Rate and intensity of re-infection with hookworm were highest among males and positively associated with previous infection status, absence of a toilet and house structure. Rate and intensity of S. mansoni re-infection were associated with previous infection status as well as geographical, environmental and socio-economic factors. The implications of findings for the design of anti-helminth vaccine trials are discussed.

Healthcare costs of methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa infections in veterans: role of vitamin D deficiency

Methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (P. aeruginosa) infections are frequently associated with hospitalization and increased healthcare costs. Vitamin D deficiency may contribute to increased costs for patients with these infections and there is evidence that vitamin D may have an antimicrobial role. To evaluate the role of vitamin D deficiency in the costs incurred with these infections, we studied the relationship of serum 25(OH)D levels to healthcare costs in veterans in the southeastern United States. Patients with both infections were vitamin D deficient to a similar extent and so were combined for further analysis. Vitamin D deficient patients had higher costs and service utilization than those who were not vitamin D deficient. Those with vitamin D deficiency had higher inpatient costs compared to the non-deficient group, and this difference was across most categories except for the number of inpatient hospitalizations or total number of days as an inpatient. Vitamin D deficiency was not significantly related to outpatient cost or service utilization parameters. We conclude that vitamin D deficiency is intimately linked to adverse healthcare costs in veterans with MRSA and P. aeruginosa infections. Vitamin D status should be assayed in patients with these infections.

Efficacy of Fortification of School Meals with Ferrous Glycine Phosphate and Riboflavin against Anemia and Angular Stomatitis in Schoolchildren

Objective

Multiple micronutrient deficiencies exist in many developing countries. We conducted a study to test the efficacy of ferrous glycine phosphate in reducing anemia and of riboflavin in reducing angular stomatitis when these micronutrients were added to the noon meal for schoolchildren.

Methods

A pre- and post-test design was used to study children 5 to 9 years of age, with an experimental and a control group. Two schools in the same locality in Chennai were chosen for the study. The experimental school had 65 children and the control school had 71 children, all of whom consumed a noon meal at the school daily. The children in the experimental school received a powder containing ferrous glycine phosphate and riboflavin, which was added to the meal during cooking every day for 6 months. The dosage was 28 mg of elemental iron and 1 mg of riboflavin per child per day. The children attended school for 5 days each week from Monday to Friday, except for holidays; they received the fortificants on 100 days during the 6-month period. There was no intervention in the control school. Children in the experimental and control groups were matched by socioeconomic status, age, and eating habits at baseline. All the children in the experimental and control schools were dewormed at baseline and at endline after 6 months. Hemoglobin was measured by the cynamethemoglobin method at baseline and endline.

Results

Binary logistic regression showed a significant (p < .001) time x group interaction for anemia. The prevalence of anemia in the experimental school was 69.0% at baseline and 32.8% after 100 days of intervention over 6 months, a statistically significant change ( p < .001). The prevalence of anemia in the control school was 91.5% at baseline and increased to 97.2% at endline; the increase was not statistically significant. The prevalence of angular stomatitis was reduced from 21% at baseline to 0% at endline in the experimental school, whereas it was 23% at baseline and 20% at endline in the control school.

Conclusions

The added fortificants reduced the prevalence of the micronutrient deficiencies.

Interaction of zinc or vitamin A supplementation and specific parasite infections on Mexican infants' growth: a randomized clinical trial

BACKGROUND

The efficacy of micronutrient supplementation on growth may be modified by specific gastrointestinal parasite infections.

METHODS

We carried out a double-blind placebo-controlled trial to evaluate the effect of vitamin A and zinc supplementation on gastro-intestinal pathogen infections and growth among 584 infants in Mexico City. Children aged 5-15 months were assigned to receive either a vitamin A supplement every 2 months (20,000 IU of retinol for infants < or =; 1 year or 45,000 IU for infants >1 year), a daily supplement of 20 mg of zinc, a combined vitamin A-zinc supplement or a placebo, and were followed up for 1 year. Weight and length were measured once a month and morbidity histories were recorded twice a week for 12 months. Monthly stool samples were screened for Giardia duodenalis, Ascaris lumbricoides and Entamoeba spp. Growth velocity slopes, generated from the linear regression of individual child length, and height-for-age z-scores on time were analyzed as end points in regression models, adjusting for the presence of parasite infections.

RESULTS

The main effect of vitamin A supplementation was in height improvement (P<0.05), and was only found in the model evaluating infants with any parasite. There was an interaction effect of slower growth (P<0.05) found in infants infected with any parasite and supplemented with vitamin A in slower growth (P<0.05). In addition, the interaction of zinc supplementation and Giardia duodenalis or A. lumbricoides was associated with reduced growth (P<0.05).

CONCLUSION

Gastro-intestinal parasite infections may modify the effect that zinc or vitamin A supplementation has on childhood growth.

Pattern and predictors of soil-transmitted helminth reinfection among aboriginal schoolchildren in rural Peninsular Malaysia

Data on soil-transmitted helminth (STH) infections and reinfection among Orang Asli (aborigine) schoolchildren and their nutritional and socioeconomic status were analyzed to investigate the pattern and the possible predictors of STH reinfection. In this longitudinal study, 120 (60 males and 60 females) Orang Asli primary schoolchildren aged 7-12 years and living in remote areas in Pos Betau, Kuala Lipis, Pahang were screened for the presence of STH using modified cellophane thick smear and Harada Mori techniques. The overall prevalence of ascariasis, trichuriasis and hookworm infections were 65.8, 97.5 and 10.8%, respectively. After complete deworming with a 3-day course of 400mg/daily of albendazole tablets, children were re-examined at 3 and 6 months from baseline. The reinfection rate, by one or more of STH species, at 3 months after deworming was high (49.5%) while 79.6% of the children were reinfected at 6 months after deworming. Logistic regression analyses showed that females, stunted children and those living in houses without toilets had significantly higher reinfection rates than others at 3 months (P<0.05). At 6 months, maternal employment status emerged as another predictor where children of working mothers had significantly higher reinfection rates (P=0.026). In conclusion, reinfection rate of STH is high and thus necessitates frequent and periodic deworming among children. Public health personnel need to re-look at the current control measures and identify innovative and integrated ways in order to reduce STH significantly in the rural communities.

Trial using multiple micronutrient food supplement and its effect on cognition

OBJECTIVE

To test the efficacy of a multiple micronutrient food supplement (MMFS) on the nutrition status of school children and its effect on cognition.

METHODS

A MMFS was developed containing chelated ferrous sulphate and microencapsulated vitamin A, B2, B6, B12, folic acid, niacin, calcium pantothenate, vitamin C, vitamin E, lysine and calcium and the efficacy of the MMFS was assessed in 7-11 year old school children in Chennai, India by a pre-post test design. In the experimental group (N=51), the food in the school kitchen was cooked with the MMFS for the residential school children for a period of one year. The control group (N=72) consisted of day scholars who did not eat at the school. Hemoglobin, red blood cell count and hematocrit were measured at baseline and at the end of the study (after one year). A battery of 7 memory tests (The personal information test, the Mann-Suiter Visual memory screen for objects, The digit span forward test, The digit span backward test, The delayed response test, The Benton Visual Retention Test and The Cattells retentivity test), one test for attention and concentration (Letter cancellation test) and one test for intelligence (Ravens's coloured progressive matrices) were administered to all the children at baseline and endline.

RESULTS

It was seen that there was a significant (P<0.05) improvement in the experimental group in hemoglobin, hematocrit and red cell count whereas in the control group there was a statistically significant decline(P<0.05) in hemoglobin and red cell count. In 5 tests out of the 7 memory tests and in the letter cancellation test for attention, the mean change in scores in the experimental group is significantly more (P<0.05) than the control group. There was no significant improvement in the overall intelligence as seen in the Ravens progressive matrices between the experimental and control groups at endline.

CONCLUSION

The study shows that the MMFS is effective in improving the nutrition status and cognition in children.

A review and meta-analysis of the impact of intestinal worms on child growth and nutrition

More than a half of the world's population are infected with one or more species of intestinal worms of which the nematodes Ascaris lumbricoides, Trichuris trichiura and the hookworms are the most common and important in terms of child health. This paper: (1) introduces the main species of intestinal worms with particular attention to intestinal nematodes; (2) examines how such worms may affect child growth and nutrition; (3) reviews the biological and epidemiological factors that influence the effects that worms can have on the growth and nutrition of children; (4) considers the many factors that can affect the impact of treatment with anthelmintic drugs; (5) presents the results of a meta-analysis of studies of the effect of treating worm infections on child growth and nutrition; (6) discusses the results in terms of what is reasonable to expect that deworming alone can achieve; (7) describes some important characteristics of an ideal study of the effects of deworming; and (8) comments on the implications for programmes of recommendations concerning mass deworming.

Effect of vitamin A and zinc supplementation on gastrointestinal parasitic infections among Mexican children

OBJECTIVE

Gastrointestinal parasites continue to be an important cause of morbidity and stunting among children in developing countries. We evaluated the effect of vitamin A and zinc supplementation on infections by Giardia lamblia, Ascaris lumbricoides, and Entamoeba histolytica.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted among 707 children who were 6 to 15 months of age and from periurban areas of Mexico City, Mexico, between January 2000 and May 2002. Children, who were assigned to receive either vitamin A every 2 months, a daily zinc supplement, a combined vitamin A and zinc supplement, or a placebo, were followed for 1 year. The primary end points were the 12-month rates and durations of infection for the 3 parasites and rates of parasite-associated diarrheal disease as determined in stools collected once a month and after diarrheal episodes.

RESULTS

G. lamblia infections were reduced and A. lumbricoides infections increased among children in the combined vitamin A and zinc group or the zinc alone group, respectively. Durations of Giardia infections were reduced among children in all 3 treatment arms, whereas Ascaris infections were reduced in the vitamin A and zinc group. In contrast, E. histolytica infection durations were longer among zinc-supplemented children. Finally, E. histolytica- and A. lumbricoides-associated diarrheal episodes were reduced among children who received zinc alone or a combined vitamin A and zinc supplement, respectively.

CONCLUSIONS

We found that vitamin A and zinc supplementation was associated with distinct parasite-specific health outcomes. Vitamin A plus zinc reduces G. lamblia incidence, whereas zinc supplementation increases A. lumbricoides incidence but decreases E. histolytica-associated diarrhea.

A multicenter community study on the efficacy of double-fortified salt

BACKGROUND

Iron and iodine deficiencies affect more than 30% of the world's population. Typical Indian diets contain adequate amounts of iron, but the bioavailability is poor. This serious limiting factor is caused by low intake of meat products rich in heme iron and intake of phytates in staple foods in the Indian diet, which inhibits iron absorption.

OBJECTIVE

To test the stability of double-fortified salt (DFS) during storage and to assess its efficacy in improving the iron and iodine status of the communities.

METHODS

The stability of both iodized salt and DFS during storage for a 2-year period was determined. The bioefficacy of DFS was assessed in communities covering three states of the country for a period of 1 year. This was a multicenter, single-blind trial covering seven clusters. The experimental group used DFS and the control group used iodized salt. The salts were used in all meals prepared for family members, but determination of hemoglobin by the cyanmethemoglobin method was performed in only two or three members per family, and not in children under 10 years of age (n = 393 and 436 in the experimental and control groups, respectively). The family size was usually four or five, with a male: female ratio of 1:1, consisting of two parents with two or three children. Hemoglobin was measured at baseline, 6 months (midpoint), and 12 months (endpoint). Urinary iodine was measured in only one cluster at baseline and endpoint. All the participants were dewormed at baseline, 6 months, and 12 months.

RESULTS

The iron and iodine in the DFS were stable during storage for 2 years. Over a period of 1 year, there was an increase of 1.98 g/dL of hemoglobin in the experimental group and 0.77 g/dL of hemoglobin in the control group; the latter increase may have been due to deworming. The median urinary iodine changed from 200 microg/dL at baseline to 205 microg/dL at the end of the study in the experimental group and from 225 microg/dL to 220 microg/dL in the control group. There was a statistically significant (p < .05) improvement in the median urinary iodine status of subjects who were iodine deficient (urinary iodine < 100 microg/L) in both the experimental and the control groups, a result showing that DFS was as efficient as iodized salt in increasing urinary iodine from a deficient to sufficient status. There was a statistically significant increase (p < .05) in hemoglobin in all seven clusters in the experimental group compared with the control.

CONCLUSIONS

The iron and iodine in the DFS are stable in storage for 2 years. The DFS has proved beneficial in the delivery of bioavailable iron and iodine.

Impact of a multiple-micronutrient food supplement on the nutritional status of schoolchildren

BACKGROUND

. Multiple-micronutrient deficiencies exist in many developing nations. A system to deliver multiple micronutrients effectively would be of value in these countries.

OBJECTIVE

. To evaluate the delivery of multiple micronutrients through the food route. The goal was to test the stability of the supplement during cooking and storage and then to test its bioefficacy and bioavailability in residential schoolchildren 5 to 15 years of age.

METHODS

A pre- and post-test design was used to study children 5 to 15 years of age, with an experimental and a control group. The experimental group (n=211) consisted of children from two residential schools, and the control group (n=202) consisted of children from three residential schools. The experimental group received a micronutrient supplement containing vitamin A, vitamin B2, vitamin B6 vitamin B12, folic acid, niacin, calcium pantothenate, vitamin C, vitamin E, iron, lysine, and calcium daily for 9 months. There was no nutritional intervention in the control group. Children in the experimental and control groups were matched by socioeconomic status, age, and eating habits at baseline. All of the children in the experimental and control schools were dewormed at baseline, after 4 months, and at the endpoint. Biochemical measurements (hemoglobin, serum vitamin A, serum vitamin E, serum vitamin B12, and serum folic acid) were measured at baseline, after 4 months, and at the endpoint (after 9 months). The heights and weights of the children were also measured at baseline and endpoint. Serum vitamins A and E were measured in a subsample of 50% and vitamin B12 and serum folic acid measured in a subsample of 25% of the children.

RESULTS

In the experimental group, the mean gains in hemoglobin, serum vitamin A, serum vitamin E, serum vitamin B12, and serum folic acid over 9 months were 0.393 g/dL, 6.0375 microg/dL, 1037.45 microg/dL, 687.604 pg/mL, and 1.864 ng/mL, respectively. In the control group, the mean losses in hemoglobin and serum vitamin A over 9 months were 0.9556 g/dL and 10.0641 microg/dL, respectively, and the mean gains in serum vitamin E, vitamin B12, and folic acid were 903.52 microg/dL, 233.283 pg/mL, and 0.0279 ng/mL. The mean gain in all biochemical measurements was significantly higher (p < .05) in the experimental group than in the control group.

CONCLUSIONS

Vitamin A, vitamin E, vitamin B12, folic acid, and iron are bioavailable from the multiple-micronutrient food supplement used in this study. This method of micronutrient delivery has been beneficial. We believe the study intervention was beneficial because of small doses of the micronutrients added but delivered many times through meals throughout the day, over a period of 9 months.

Earth-eating and reinfection with intestinal helminths among pregnant and lactating women in western Kenya

We conducted a longitudinal study among 827 pregnant women in Nyanza Province, western Kenya, to determine the effect of earth-eating on geohelminth reinfection after treatment. The women were recruited at a gestational age of 14-24 weeks (median: 17) and followed up to 6 months postpartum. The median age was 23 (range: 14-47) years, the median parity 2 (range: 0-11). After deworming with mebendazole (500 mg, single dose) of those found infected at 32 weeks gestation, 700 women were uninfected with Ascaris lumbricoides, 670 with Trichuris trichiura and 479 with hookworm. At delivery, 11.2%, 4.6% and 3.8% of these women were reinfected with hookworm, T. trichiura and A. lumbricoides respectively. The reinfection rate for hookworm was 14.8%, for T. trichiura 6.65, and for A. lumbricoides 5.2% at 3 months postpartum, and 16.0, 5.9 and 9.4% at 6 months postpartum. There was a significant difference in hookworm intensity at delivery between geophagous and non-geophagous women (P=0.03). Women who ate termite mound earth were more often and more intensely infected with hookworm at delivery than those eating other types of earth (P=0.07 and P=0.02 respectively). There were significant differences in the prevalence of A. lumbricoides between geophagous and non-geophagous women at 3 (P=0.001) and at 6 months postpartum (P=0.001). Women who ate termite mound earth had a higher prevalence of A. lumbricoides, compared with those eating other kinds of earth, at delivery (P=0.02), 3 months postpartum (P=0.001) and at 6 months postpartum (P=0.001). The intensity of infections with T. trichiura at 6 months postpartum was significantly different between geophagous and non-geophagous women (P=0.005). Our study shows that geophagy is associated with A. lumbricoides reinfection among pregnant and lactating women and that intensities built up more rapidly among geophagous women. Geophagy might be associated with reinfection with hookworm and T. trichiura, although these results were less unequivocal. These findings call for increased emphasis, in antenatal care, on the potential risks of earth-eating, and for deworming of women after delivery.