Iron deficiency, cell-mediated immunity and resistance against infections: Present knowledge and controversies

Landscape analysis of interactions between nutrition and vaccine responses in children

The world's poorest children are likely to be malnourished when receiving their childhood vaccines. It is uncertain whether this affects vaccine efficacy and whether the coadministration of nutrient supplements with vaccines has beneficial or detrimental effects. More recently, a detrimental interaction between vitamin A (VA) supplementation (VAS) and the killed diphtheria-tetanus-pertussis vaccine given in early childhood has been suggested. This report provides a critical review of the published interactions between nutritional status and/or supplementation and vaccine responses in children. Due to an absence of evidence for most nutrients, this analysis focused on protein-energy, vitamins A and D, and iron and zinc. All vaccines were considered. Both observational studies and clinical trials that led to peer-reviewed publications in English or French were included. These criteria led to a pool of 58 studies for protein-energy malnutrition, 43 for VA, 4 for vitamin D, 10 for iron, and 22 for zinc. Our analysis indicates that malnutrition has surprisingly little or no effect on vaccine responses. Evidence for definitive adjunctive effects of micronutrient supplementation at the time of vaccination is also weak. Overall, the paucity, poor quality, and heterogeneity of data make it difficult to draw firm conclusions. The use of simple endpoints that may not correlate strongly with disease protection adds uncertainty. A detailed examination of the immunological mechanisms involved in potential interactions, employing modern methodologies, is therefore required. This would also help us understand the proposed, but still unproven, negative interactions between VAS and vaccine safety, a resolution of which is urgently required.

The immune response in iron-deficient young children: effect of iron supplementation on cell-mediated immunity

The effects of iron deficiency on immunity remain controversial. This study was designed to assess the impact of iron supplementation on the immune status, in 81 children aged 6 months-3 years, at high risk for iron deficiency, using a longitudinal double blind randomised and placebo-controlled study. Lymphocytes of iron-deficient children produced less interleukin-2 in vitro. Iron supplementation for 2 months increased mean corpuscular volume, serum ferritin and serum transferrin, but had no effect on the parameters of T-cell mediated immunity. The lower interleukin-2 levels in iron-deficient suggest that cell-mediated immunity may be impaired in iron deficiency.

Iron and immunity

Review of animal and human studies concerning the impact of iron deficiency on immune function in vivo indicates that in many instances there is no firm consensus of opinion as to the relationship between iron status and immunity. One major problem with almost all human studies is that other micro- and macronutrient deficiencies are inadequately controlled for and thus it is often unclear as to whether reported abnormalities of immune function can be attributed specifically to iron deficiency. Even when abnormalities of immune function have been detected it is often uncertain as to the biological and clinical relevance that these may have for the host. Within these restraints the available studies suggest that iron deficiency may at least contribute to impaired T lymphocyte function as judged by DTH responses in skin and impaired mitogen-induced proliferation. As in protein energy malnutrition, humoral immunity is largely spared in humans, the balance of evidence suggesting that immunoglobulin production and function is normal, as are serum concentrations of complement. The only other abnormality of non-specific immunity which has been reported consistently to be abnormal is that of reduced bactericidal activity of polymorphonuclear leucocytes. The clinical relevance of these abnormalities remains to be established. There is, however, no evidence to suggest that individuals with iron deficiency suffer the devastating infective complications of the well defined immunodeficiency syndromes either congenital or acquired. It seems likely therefore that despite the fundamental importance of iron in maintaining the integrity of immune function, humans can tolerate the extremes of deficiency and excess and survive in a relatively healthy state.

Iron status, immune capacity and resistance to infections

1. The importance of iron on immune functions is reviewed. 2. The consequences of iron deficiency upon resistance to infection in men (adults and children) and animals are controversial. 3. Cellular immunity is often altered in iron-deficient humans and in murine species. 4. Humoral immune responses seem far less affected in iron-deficient humans than is cellular immunity, but is impaired in iron-deficient animals. Results on complement are scarce and controversial. 5. There is almost no perturbation of phagocytosis but bactericidal activity is decreased in most studies on iron-deficient subjects. 6. Natural Killer activity is decreased in iron-deficient mice. Iron deficiency also affects lymphokine production in mice and rats.