Prevalence of anemia and its associated factors in human immuno deficiency virus infected adult individuals in Ethiopia. A systematic review and meta-analysis

Highly active antiretroviral therapy is necessary but not sufficient. A systematic review and meta-analysis of mortality incidence rates and predictors among HIV-infected adults receiving treatment in Ethiopia, a surrogate study for resource-poor settings

BACKGROUND

Owing to the introduction of highly active antiretroviral therapy (HAART), the trajectory of mortality and morbidity associated with human immunodeficiency virus (HIV) infection has significantly decreased in developed countries. However, this remains a formidable public health challenge for people living with HIV in resource-poor settings. This study was undertaken to determine the pooled person-time incidence rate of mortality, analyze the trend, and identify predictors of survival among HIV-infected adults receiving HAART.

METHODS

Quantitative studies were searched in PubMed, Embase, Scopus, Google Scholar, African Journals Online, and Web of Science. The Joana Briggs Institute critical appraisal tool was used to assess the quality of the included articles. The data were analyzed using the random-effects Dersimonian-Laird model.

RESULTS

Data abstracted from 35 articles involving 39,988 subjects were analyzed. The pooled person-time incidence rate of mortality (all-cause) was 4.25 ([95% uncertainty interval (UI), 3.65 to 4.85]) per 100 person-years of observations. Predictors of mortality were patients aged ≥ 45 years (hazard ratio (HR), 1.70 [95% UI,1.10 to 2.63]), being female (HR, 0.82 [95% UI, 0.70 to 0.96]), history of substance use (HR, 3.10 [95% UI, 1.31 to 7.32]), HIV positive status non disclosure (HR, 3.10 [95% UI,1.31 to 7.32]), cluster of differentiation 4 + T cell - count < 200 cells/mm3 (HR, 3.23 [95% UI, [2.29 to 4.75]), anemia (HR, 2.63 [95% UI, 1.32 to 5.22]), World Health Organisation classified HIV clinical stages III and IV (HR, 3.02 [95% UI, 2.29 to 3.99]), undernutrition (HR, 2.24 [95% UI, 1.61 to 3.12]), opportunistic infections (HR, 1.89 [95% UI, 1.23 to 2.91]), tuberculosis coinfection (HR, 3.34 [95% UI, 2.33 to 4.81]),bedridden or ambulatory (HR,3.30 [95% UI, 2.29 to 4.75]), poor treatment adherence (HR, 3.37 [95% UI,1.83 to 6.22]), and antiretroviral drug toxicity (HR, 2.60 [95% UI, 1.82 to 3.71]).

CONCLUSION

Despite the early introduction of HAART in Ethiopia, since 2003, the mortality rate has remained high. Therefore, guideline-directed intervention of identified risk factors should be in place to improve overall prognosis and increase quality-adjusted life years.

Prevalence, severity and associated risk factors of anemia among human immunodeficiency virus-infected adults in Sawla General Hospital, Southern Ethiopia: A facility-based cross-sectional study

BACKGROUND

Anemia is a significant public health problem in HIV/AIDS patients worldwide. This study is aimed to determine the prevalence of anemia and its risk factors among HIV-infected adults in Sawla General Hospital, southern Ethiopia.

METHODS

A facility-based cross-sectional study involving HIV-infected adults was conducted in ART clinic of Sawla General Hospital from April 01 to May 31, 2019. A systematic random sampling technique was employed to recruit the study participants. Socio-demographic and clinical data were collected using a structured questionnaire and checklist. Hemoglobin concentration from venous blood was determined by HemoCue® 301 analyzer. Descriptive and inferential statistics, by Statistical Package for Social Science version 26.0, were applied; p-values ≤ 0.05 in the multivariable logistic regression analysis were considered statistically significant.

RESULTS

A total of 220 HIV-infected adults participated in this study. The prevalence of anemia was 38.6%, from which 90.6, 7.1, and 2.3% are mild, moderate, and severe anemia, respectively. Anemia among HIV-infected adults was significantly associated with CD4 cell count below 200 cells/mm3 (AOR: 4.32; 95% CI: 2.10-8.86), clinical stage III or above (AOR: 4.20; 95% CI: 1.06-16.62), five or more years duration of HIV infection (AOR: 2.32; 95% CI: 1.08-4.94) and BMI below 18.5 kg/m2 (AOR: 3.82; 95% CI: 1.83-8.00).

CONCLUSION

Anemia is a moderate public health problem among the study population. Longer duration of HIV infection, advanced clinical stage, lower CD4 cell count, and BMI are risk factors for anemia. Therefore, early ART enrolment for HIV-infected adults with nutritional support and rigorous monitoring of CD4 cell count are essential to lower the prevalence.

Immunohematological Outcome Among Adult HIV Patients Taking Highly Active Antiretroviral Therapy for at Least Six Months in Yabelo Hospital, Borana, Ethiopia

Background

Immunohematological abnormalities among human immunodeficiency virus-infected patients are common abnormalities associated with severe depletion of the immune system, covering a stage of acute syndrome to an advanced disease. The greatest impact was observed in the low- and middle-income countries. However, in Ethiopia, little attention has been paid, and only limited published information exists regarding immunohematological abnormalities among individuals receiving highly active antiretroviral treatment.

Objective

This study aimed to assess changes in immunological and hematological parameters in HIV-infected patients receiving HAART for at least six months at the antiretroviral therapy clinic of Yabelo Hospital, Borena, Ethiopia.

Methods

A cross-sectional study was conducted from February to July 2021 using convenient sampling to recruit 333 participants. Sociodemographic data and clinical characteristics were collected using a pretested questionnaire. Baseline data were extracted from medical records and after six month immunohematological measurements were performed on blood samples collected during the study period. Data analysis was performed using SPSS version 25. Descriptive analysis was performed, and the results are presented as numbers and percentages or means ± SD. A paired t-test was used to compare the mean values of the immunohematological parameters before and after six of taking HAART. Statistical significance was set at P < 0.05.

Results

The prevalence of anemia, leucopenia, neutropenia, lymphopenia and thrombocytopenia were 47.4%, 73.3%, 58.3%, 76.9% and 3.3% before initiation of HAART and 23.1%, 36.4%, 23.4%, 35.7% and 2.4% after initiation of HAART, respectively; Compared to baseline, there was also a significant decrease in the rate of Immunosuppression (CD4 < 350) from 62.2% at base line to 20.7% after HAART initiation.

Conclusion

Immunohematological profile of the patients improved after the initiation of HAART. The observation of large proportion of immunosuppressed individuals at baseline warrants advocating for HIV testing in the pastoralist community so that infected patients could benefit from early initiation of HAART.

The prevalence of anemia among human immunodeficiency virus-infected individuals in East Africa: A systematic review and meta-analysis

BACKGROUND

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients face several hematological abnormalities. Of these abnormalities, anemia is the most common one. Africa has a high prevalence of HIV/AIDS, especially in the East and South African region, which is heavily affected by the virus. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of anemia among patients with HIV/AIDS in East Africa.

METHODS

This systematic review and meta-analysis was conducted based on the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed, Google Scholar, Science Direct, Dove Press, Cochrane Online, and African journals online were searched systematically. The quality of the included studies was assessed by 2 independent reviewers using the Joanna Briggs Institute critical appraisal tools. Data were extracted into an Excel sheet and then exported to STATA version 11 for analysis. A random-effect model was fitted to estimate the pooled prevalence and Higgins I2 test statistics were done to test the heterogeneity of studies. Funnel plots analysis and Egger-weighted regression tests were done to detect publication bias.

RESULTS

The pooled prevalence of anemia among HIV/AIDS patients in East Africa was 25.35% (95% CI: 20.69-30.03%). A subgroup analysis by highly active antiretroviral therapy (HAART) status showed that the prevalence of anemia among HAART naive HIV/AIDS patients was 39.11% (95% CI: 29.28-48.93%) whereas the prevalence among HAART experienced was 36.72% (95% CI: 31.22-42.22%). A subgroup analysis by the study population showed that the prevalence of anemia among adult HIV/AIDS patients was 34.48% (95% CI: 29.52-39.44%) whereas the pooled prevalence among children was 36.17% (95% CI: 26.68-45.65%).

CONCLUSION

This systematic review and meta-analysis revealed that anemia is among the most common hematological abnormalities in HIV/AIDS patients in East Africa. It also underscored the importance of taking diagnostic, preventive, and therapeutic measures for the management of this abnormality.

Prevalence of anaemia and its associated factors among HIV-infected adults at the time of ART initiation at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia: a retrospective cross-sectional study

OBJECTIVE

The aim of this study was to assess the prevalence of anaemia and its associated factors at the time of antiretroviral therapy (ART) initiation among HIV-infected adults at Debre Markos Comprehensive Specialized Hospital.

METHODS

An institution-based retrospective cross-sectional study was conducted among 473 patients' charts enrolled from 2014 to 2018 at Debre Markos Comprehensive Specialized Hospital. Patients' chart numbers were selected from the computer using a simple random sampling technique. Data were entered using Epi Info V.7.2.2.6 and analysed with Stata V.14.0. Anaemia prevalence at the time of ART initiation was computed and described using frequency tables. To identify factors for anaemia, bivariate and multivariate logistic regression models were fitted. Model fitness was checked using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

From 473 patients' charts, 468 charts were included in the analysis, and a total of 164 anaemia cases were recorded. The overall prevalence of anaemia among HIV-infected adults at the time of ART initiation was 35.04% (95% CI: 30.84% to 39.49%). After multivariate analysis, an increased risk of anaemia was seen among males (adjusted OR (AOR)=2.45; 95% CI: 1.51 to 3.98); those not attending formal education (AOR=2.38; 95% CI: 1.12 to 5.05); those who had baseline CD4+ T cell count ≤200 cells/mm³ (AOR=4.67; 95% CI: 2.78 to 7.85); had body mass index (BMI) <18.5 kg/m² (AOR=2.43; 95% CI: 1.42 to 4.16) and had ambulatory/bedridden baseline functional status (AOR=2.69; 95% CI: 1.41 to 5.12).

CONCLUSION

The current study showed that a significant proportion of HIV-infected adults developed anaemia at the time of ART initiation. Hence, giving special attention to those who have not attended formal education, were males, had decreased baseline CD4+ T cell count, had lower BMI and patients with ambulatory/bedridden baseline functional status is crucial to reduce the health impact of anaemia. The result will provide insight into the development of new anaemia preventive strategies.

Prevalence and Predictors of Cytopenias in HIV-Infected Adults at Initiation of Antiretroviral Therapy in Mehal Meda Hospital, Central Ethiopia

Background

Hematologic abnormalities are common complications of patients infected with HIV associated with accelerated deterioration in CD4+ cell counts, disease progression, poor quality of life and death. Few studies have evaluated the magnitude of cytopenias at the initiation of antiretroviral therapy (ART) in sub-Saharan Africa. The aim of this study was to determine the prevalence and predictors of cytopenias among HIV-infected adults at initiation of ART in a resource-limited setting in Ethiopia.

Methods

A cross-sectional study was conducted among HIV-infected adults initiating ART at the HIV care and treatment clinic of Mehal Meda Hospital between September 2008 and June 2019. Demographic, clinical and laboratory data of patients were collected from medical records. Anemia was defined according to WHO guidelines as hemoglobin concentration <12 g/dl for non-pregnant females and <13 g/dl for males. Leucopenia was defined as total white blood cell count <4.0 × 10³ cells/μL and thrombocytopenia as platelet count <150 × 10³ cells/μL. Logistic regression analysis was used to determine factors associated with the presence of cytopenias.

Results

Out of the total 566 patients included, 36.6% (95% CI 32.7–40.6%) had anemia, 17.1% (95% CI 14.2–20.4%) had leucopenia and 14.5% (95% CI 11.8–17.6%) had thrombocytopenia. A total of 53.2% (95% CI 49.1–57.3%) of patients had at least one form of cytopenia, 14.1% (95% CI 11.4–17.2%) had bicytopenia, and only 0.5% had pancytopenia. Factors associated with the presence of any cytopenia in multivariable analysis were male sex, advanced clinical disease stage, low CD4+ cell count, low BMI, and decreased renal function.

Conclusion

A substantial burden of cytopenias was detected among HIV-infected adults enrolled for care and treatment services in our setting. Patients with HIV infection should be screened for hematological abnormalities at initiation of ART because of its potential for morbidity and mortality during ART.

Incidence and predictors of anemia among adults on HIV care at South Gondar Zone Public General Hospital Northwest Ethiopia, 2020; retrospective cohort study

BACKGROUND

Anemia is a major public health problem worldwide which accounts 24.8% of the population. Subsequently, anemia is a leading killer of people living with human immunodeficiency virus and many of these deaths occur in developing countries including Ethiopia. Cross sectional studies have done on anemia and human immunodeficiency virus. However, there is limited study on incidence of anemia and its predictors among adults on HIV care, especially no survival study has been conducted in the study area.

OBJECTIVE

To assess incidence and predictors of anemia among adults on Human immunodeficiency virus care.

METHODS

An institution-based retrospective cohort study was conducted among 434 adults on HIV care from January 1st 2015 to December 30th 2019 at Debre Tabor Referral Hospital. A computer-generated simple random sampling technique was employed to select the study participants. Ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got implied consent to review charts from the concerned bodies in the hospital. Data were entered using Epi-data version 3.1 and analyzed by using STATA version 14.0. A Kaplan Meier survival curve was utilized to estimate anemia free survival time. Bivariable and Multivariable Cox proportional hazards model were fitted to identify predictors of anemia.

RESULTS

The overall incidence density rate of anemia was 6.27 (95% CI: 0.051, 0.077) per 100 person years. Clinical stage III/IV (AHR = 1.04; 95% CI = 1.02, 1.06), Body Mass Index less than 18.5 kg/m2 (AHR = 3.11; 95% CI = 1.56, 6.22), serum creatinine greater than 1.1 IU/L(AHR = 2.07; 95% CI = 1.12, 3.81) and fair/poor level of adherence(AHR = 1.05; 95% CI = 1.03, 1.07) were statistically significant predictors of anemia while increased anti-retroviral treatment duration (AHR = 0.98; 95% CI = 0.97, 0.99) decrease the risk of anemia at 95% confidence level.

CONCLUSION

The overall incidence density rate of anemia was high. Patients with clinical stage III/IV, body mass index < 18.5 kg/m2, serum creatinine greater than 1.1 IU/L and fair/poor level of adherence were significant predictors of anemia while increased antiretroviral treatment duration had decreased the risk of anemia.

RECOMMENDATION

Even if the overall incidence rate of anemia was lower as compared to previous studies in Ethiopia, still the incidence of anemia was high. So, prevention measures should be taken beside with HIV care especially within 6-months ART initiation.

A meta-analysis on burden of postpartum depression and its predictors among lactating women in East African countries from 1998 up to 2018

Objective:

Postpartum depression is a common mental illness that affects lactating women. This not only makes daily activities difficult for them, but it also affects child’s future lives. There is little evidence of about postpartum depression and its factors in East African countries, which piqued the authors’ interest in conducting a study on this matter for future decision- and policy-making.

Methods:

The protocol for Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. To identify published articles, all major databases such as PubMed/MEDLINE, WHOLIS, Cochrane Library, Embase, PsycINFO, ScienceDirect, Web of Science, and reference lists were used. In addition, shelves, author contact, Google and Google Scholar were also used to identify unpublished studies. Joanna Briggs Institute—Meta-Analysis of Statistical Assessment and Review Instrument was used for critical appraisal of studies. STATA software version 14 was used for the analysis. The random-effect model was used to estimate postpartum depression with 95% confidence interval, while subgroup analysis and meta-regression were used to identify potential sources of heterogeneity and associated factors, respectively. Furthermore, Egger’s test and trim-and-fill analysis were used to check for publication bias.

Results:

Postpartum depression was found in 24% of lactating women in East African countries (95% confidence interval: 17.79–30.20). Postpartum depression was associated with being married (odds ratio = 2; 95% confidence interval: 1.05–3.81), domestic violence (odds ratio = 6.34; 95% confidence interval: 4:11–9.78), a lack of support (odds ratio = 6.59; 95% confidence interval: 1.98–21.89), and a lack of empowerment (odds ratio = 2.79; 95% confidence interval: 1.12–6.92).

Conclusion:

In East Africa, the prevalence of postpartum depression among lactating women is high and rising, as per global postpartum depression estimates. Therefore, the primary focus should be on women’s domestic violence prevention mechanisms. Existing national policies and development agendas must prioritize strategies for women’s support and empowerment. Future research into the relationship between marriage and postpartum depression is required.

Hematological parameters abnormalities and associated factors in HIV-positive adults before and after highly active antiretroviral treatment in Goba Referral Hospital, southeast Ethiopia: A cross-sectional study

Objectives

Hematological abnormalities of the major blood cell lines are frequently reported in patients with HIV-1 infection, in patients without antiretroviral therapy, and during the advanced stages of the disease. Chronic immune activation and inflammation results in the progressive depletion of CD4+ T-cells play a significant role in the clinical progression and pathogenesis of this infection. This study was aimed at assessing the prevalence of hematological abnormalities and their associated factors before and after the initiation of antiretroviral therapy in adults with HIV-1 infection in a referral hospital.

Methods

The study was conducted from 1 April to 30 June 2018, at Goba Referral Hospital. A total of 308 HIV-positive adults on treatment were enrolled during the study period. Socio-demographic and clinical data were collected using a structured questionnaire, with pre-highly active antiretroviral therapy data were extracted from medical records while post-treatment immuno-hematological measurements were done on blood samples collected at the time of enrollment.

Results

The prevalence of anemia, leukopenia, and thrombocytopenia before initiation of antiretroviral treatment was higher, although anemia and thrombocytopenia decreased correspondingly after initiation of treatment leukopenia increased by 4%. Mean values of immuno-hematological parameters before and after treatment initiation were significant (p < 0.05). CD4+ T-cell count <200 cells/µL was the only independent risk factor for anemia and leukopenia before highly active antiretroviral therapy, while stage IV disease, female sex, zidovudine, lamivudine, and nevirapine treatment, and intestinal parasite infection were predictors of anemia after treatment initiation.

Conclusion

The study revealed that hematological abnormalities are common in HIV infection, while the occurrence of abnormalities after highly active antiretroviral therapy initiation. Different risk factors are associated with hematological abnormalities at pre- and post-highly active antiretroviral therapy with regular monitoring of risk factors, adherence to the early initiation of highly active antiretroviral therapy, and conduct of further longitudinal studies are recommended.

Anemia and Associated Factors Among Adults with Human Immune Deficiency Virus on Antiretroviral Therapy in Public Health Facilities of Kembata Tembaro Zone, Southern Ethiopia: A Cross-Sectional Study

BACKGROUND

Anemia is an independent prognostic marker of HIV/AIDS disease progression. It causes impaired physical functioning, psychological distress, poor quality-of-life, and reduces life expectancy in HIV patients. However, there is limited information in Ethiopia. Therefore, the aim of this study was to assess the magnitude of anemia and associated factors among adult HIV patients on antiretroviral therapy in public health facilities of Kembata Tembaro Zone, southern Ethiopia.

METHODS

We conducted a facility-based cross-sectional study. A total of 401 HIV patients attending antiretroviral therapy nested in five health facilities were included in the analysis. Simple random sampling was employed using medical record number to select study units. Data were collected using pretested and structured questionnaire, anthropometric measurements were taken, and a drop of capillary blood was collected to determine hemoglobin level by HemoCue 301 analyzer. Clinical related data were collected from patient medical records by using a structured checklist. The collected data were coded and entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. Logistic regression analysis was carried out to identify factors associated with anemia and statistical tests were declared significant at a P-value<0.05.

RESULTS

The magnitude of anemia among adults HIV patients attending ART was 26.2%, 95% CI=21.7-30.4. Being female (AOR=2.06, 95% CI=1.02-4.16), body mass index <18.5 Kg/m2 (AOR=2.28, 95% CI=1.09-4.78), Zidovudine use (AOR=3.71, 95% CI=1.9-7.26), having had an opportunistic infection (AOR=5.46, 95% CI=1.67-17.7), and WHO stage III or IV (AOR=5.71, 95% C=2.68-12.14) were significantly associated with the occurrence of anemia.

CONCLUSION

Anemia was found to be a moderate public health problem among ART attendants in the current study area. Thus, early detection and intervention targeting Zidovudine users, females, patients having body mass index <18.5 Kg/m2, patients having opportunistic infections, and patients having clinical WHO stage III or IV disease is vital to reduce the magnitude of anemia and its consequences.

Prevalence of Anemia and Its Associated Factors in Antiretroviral-Treated HIV/AIDS-Positive Adults from 2013 to 2018 at Debre Berhan Referral Hospital, Ethiopia

Introduction. Anemia was defined as a hemoglobin level of less than or equal to 13.9 g/dl for male and less than or equal to 12.2 g/dl for female adults. It is one of the most common hematological abnormalities in people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and is a determining factor for disease progression and death. Among the countries in sub-Saharan Africa, Ethiopia is one of the most affected nations by HIV. Therefore, this study aimed to assess the prevalence of anemia and its associated factors among HIV-positive adults that had received antiretroviral treatment (ART) at Debre Berhan Referral Hospital.

Methods

An institution-based, descriptive, cross-sectional study was conducted involving 263 adults with HIV/AIDS that had undergone ART at Debre Berhan Referral Hospital, Ethiopia. Data were collected from patient charts using systematic sampling with a pretested data extraction tool and entered using EpiData 3.1. Variables having a p value ≤0.25 in the bivariate were fitted to a multivariable regression model with a 95% confidence interval. p value ≤0.25 in the bivariate were fitted to a multivariable regression model with a 95% confidence interval.

Results

Among the 263 HIV-positive patients, 237 (90.11%) were included in the final analysis. The overall prevalence of anemia was 26.2%. Factors that were significantly associated with anemia were past opportunistic infections, patients being in WHO clinical stage III and IV, and a BMI <18.5. Conversely, those patients who took anti-TB medication were less likely to have anemia.

Conclusion

Our study shows that the severity of anemia among HIV/AIDS patients that had undergone ART is lower than most studies conducted in Ethiopia. We also found that opportunistic infection, WHO clinical staging, anti-TB treatment, and low BMI were significantly associated with anemia. Therefore, routine screening of patient nutritional status and opportunistic infections may be useful in predicting and controlling anemia in HIV/AIDS patients.

Prevalence of goiter among children in Ethiopia and associated factors: a systematic review and meta-analysis

BACKGROUND

The distribution of goiter among children and its risk factors are not well investigated in Ethiopia. Therefore, this systematic review and meta-analysis was designed to determine the pooled prevalence of goiter and its associated factors among children in Ethiopia.

METHODS

Electronic web-based searches of PubMed, Google Scholar, EMBASE, and the World Health Organization's Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) were conducted to find primary studies. Relevant data were extracted and descriptive summaries of the studies were presented in tables. The I2 statistic was used to assess heterogeneity across studies. Funnel plot asymmetry and Egger's tests were used to check for publication bias. A random effects model was used to estimate the pooled prevalence of goiter. Odds ratios (OR) with 95% Confidence Intervals (CI) were also used to determine the association of identified variables with goiter. All statistical analyses were conducted using Stata version 14 software.

RESULTS

Our search identified 982 studies, of which, 19 articles were eligible for inclusion in the final meta-analysis. The pooled estimate of goiter among children in Ethiopia was 40.50% (95% CI: 33.6-47.40). The regional distribution of goiter ranged from 44.22 (95% CI: 17.44-71) in Southern Nations Nationalities and Peoples' Region, to 32.79% (95% CI: 19.86-45.73) in Benishangul Gumez region. The prevalence of goiter among female children (44.34%) was higher than among male (32.88%) children. Goiter prevalence was also significantly higher among children who consumed vegetables three or more times per week OR = 1.3 (95% CI: 1.02-1.66); those who had family history of goiter, OR = 2.38 (95% CI: 1.9-2.99); and those whose family stored salt near to fires, OR = 1.4 l (95% CI: 1.1-1.79).

CONCLUSION

The prevalence of goiter among children in Ethiopia was high, and endemic according to the WHO criteria. Our findings suggest the need for interventions to improve salt iodization, and for improved health education on appropriate salt storage. In addition, more research may be needed to improve our understanding of foods that increase the risk of goiter among children.