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A study of the rural population of the village of Belumbang, Province of Bali, Indonesia, has been conducted to assess the relationship between intensity of hookworm infection (hookworm egg count) and iron stores, hemoglobin level or hematocrit. There was a significant negative correlation between serum ferritin level and hookworm egg count. However no correlation was found between hookworm egg count and hemoglobin level or hematocrit. In a separate analysis the above correlation could be shown in male hosts but not in female hosts. It is concluded that hookworm infection, even in light infection, can interfere with iron stores, but in female hosts this effect might be masked by other factors.

A prospective study of 41 patients (24 male and 17 female) aged over 40 years with iron deficiency anemia and hookworm infection was performed by endoscopy and barium enema to determine the incidence of GI lesions. Alcohol ingestion, smoking, abdominal pain, anorexia, loss in weight, bowel habit change, analgesic consumption and stool occult blood test were analyzed for their positive predictive value of GI lesions. The mean age of the patients was 62.8 years (SD = 10.1). The mean hemoglobin was 5.99 gm.% (SD = 1.9). Twenty patients (48.8%) had GI lesions. The lesions included 10 erosive gastritis, 1 erosive duodenitis, 5 gastric ulcers, 2 duodenal ulcers, 1 carcinoma of stomach and 1 carcinoma of colon. Gastric ulcer, duodenal ulcer and carcinoma were regarded as significant lesions. Abdominal pain was found in 16 of the 20 patients with GI lesions and 8 of the 21 without GI lesion (Chi square with Yate's correction, x2 = 5.78 p = 0.02). Four of the 17 patients without pain had GI lesions but only one of these 4 (5.8%) had gastric ulcer. Abdominal pain had an 80% sensitivity and 62% specificity for the positive prediction of GI lesions based on the above findings. GI investigation is recommended for all patients with abdominal pain. In those without pain, treatment of hookworm and iron therapy with follow-up may be justified.

Dose-response curves for the effect of continuous infusion of histamine on gastric acid secretion were obtained in 10 patients with iron deficiency anemia due to hookworm infection. Each patient was studied with 4 doses (40, 60, 80 and 100 mug/kg/h) of histamine acid phosphate administered for 3 h, on separate days, in random fashion. The acid output increased with the dose of histamine, the maximal acid output was reached in all patients at the dose of 100 mug/kg/h. The dose of histamine when calculated according to body weight correlated well with the maximal acid output; the absolute dose of histamine had no correlation with the maximal acid response. The dose-response curve of stimulated acid output in anemia patients was much flatter than in control patients.

A new parenteral iron preparation, iron-poly (sorbitol-gluconic acid) complex, (Ferastral) has been evaluated in the treatment of iron-deficient, non-pregnant Gambian adults. A total of twenty patients of both sexes were included in the study. The cause of anaemia in the majority of cases was hookworm infection but also other diagnostic categories were present. Sixteen patients completed their treatment without difficulty. All patients showed a good initial haematological response. Over the first three weeks the mean daily increments followed a linear trend. There was a significant inverse correlation between initial haemoglobin concentration and the increment in concentration after three weeks treatment. Side-effects were noted in four patients; in two patients it was ascribed to treatment, in two there was concurrent infection. Parenteral iron therapy is considered to have definite advantages over oral iron in the tropics because of certainty of administration, replenishment of iron stores, and effectiveness when small bowel disease or dietary factors reduce absorption.

The treatment of iron-deficiency anaemia in pregnancy with a new intramuscular iron preparation, iron-poly (sorbitol-gluconic acid) complex (Ferastral), has been assessed and compared with oral iron therapy. Sixty-one of the eighty-four patients studied, many of whom had mild to moderate degree of anaemia were treated with Ferastral. The results were satisfactory, the mean increase of haematocrit at the sixth post treatment week was 28.7% for the whole series. Complete correction of anaemia was achieved in most patients between the 4th and 6th week of treatment. The mean haematocrit of the group treated with oral iron was initially significantly higher than for the group treated with Ferastral. At the first follow-up, two weeks after beginning treatment, the mean values for both groups were similar; at four weeks, those receiving Ferastral had a significantly higher mean PCV than those on oral iron, and remained so through the period of observation. No side-effects were detected using 10 ml of Ferastral intramuscularly on alternate days. The mean hospitalization time of patients with severe to moderate anaemia was reduced when given parenteral therapy, and the frequency of blood transfusion in these patients was also decreased.

Full blood counts and some serum biochemistry were carried out on 349 male and 22 female apparently healthy Papua New Guinea subjects, most of whom were highlanders. In males, RBC, Hb, PCV, MCH, MCHC, serum albumin, ferritin, iron, per cent transferrin saturation and folate means were significantly lower than the Australian normal means; WBC and MCV means were similar to Australian values; and eosinophil and reticulocyte counts and serum transferrin and vitamin B12 means were higher than Australian means. In females, WBC, RBC, Hb, PCV, MCV, MHC, MCHC and serum ferritin means were lower than Australian means; eosinophil counts, serum iron, per cent transferrin saturation, and folate means were similar to Australian means; and serum transferrin and B12 means were higher than the Australian means. Hepatomegaly and mild splenomegaly were common. beta-Thalassemia was present in three subjects two of whom were from Simbu Province.

Severe anaemia often assumes emergency dimensions in West Africa. Previous studies in Nigeria and Ghana incriminate malaria as the main single cause of anaemia in early infancy. This prospective study was conducted to verify this for the Enugu region. The series included 50 anaemic patients aged between 4 months and 10 years admitted to the children's ward. Our results rank poor nutrition much more then malaria among the causes in children under 2 years of age. Hookworm infestation may be a more common cause in children over 2 years.

In a coastal population in whom anaemia was common, two randomised controlled trials were undertaken to investigate the effectiveness of treating iron deficiency anaemia at a dispensary and at primary schools. For anaemic adult villagers treated at a dispensary, one dose of tetrachlorethylene for hookworm infection and a once per week visit to collect medicines were found to be satisfactory. A small but significant increase in haemoglobin level was produced by four weeks oral iron therapy, but this was only maintained after seven months by the group that had initially also received tetrachlorethylene. In children (5-14 years) no significant rise in haemoglobin level was obtained by using oral iron and/or TCE, either at the dispensary or at the primary schools. This suggests that malaria was a more potent cause of anaemia in these children.

Treatment of severe iron deficiency with iron-poly(sorbitol-gluconic acid) complex (Ferastral) intramuscular 10 ml (iron 500 mg) on alternate days has been shown highly effective and well tolerated. In order to see whether the time of treatment could be shortened, 20 Nigerians with severe iron deficiency (mostly from hookworm infection) were treated with daily intramuscular Ferastral 10 ml until their calculated total requirement of iron was met. The total iron deficit was 877-2763 mg (mean 1875 mg). Supportive treatment included antimalarials, folic acid and anthelmintics. No patient complained of undue pain at injection sites or of any other undesirable side-effects. There was no evidence of hepatic or renal toxicity in any patient, including eight who were followed at intervals up to eight weeks from the start of treatment. The initial haemoglobin (Hb) level was 2.2-7.8 g/dl (mean 4.6 g/dl). Daily regeneration of Hb in the first 14 days was 0.12-0.49 g/dl (mean 0.30 g/dl), and haematological indices were generally normal by eight weeks. Recovery was slow or incomplete in six patients, all of whom had complications other than iron deficiency. Serum iron was measured in five patients, rose to around 8000 micrograms/dl on about day 4, and fell to physiological levels by day 14. The serum unsaturated iron binding capacity fell to nil in five out of six patients on around day 3, and reappeared between days 7 and 10. Five patients who had persistent blood loss from continued hookworm infestation received a further single dose of Ferastral (iron 1000 mg) 10 ml into each buttock after four weeks, and one patient after two weeks. This large dose was also acceptable to patients if given slowly; it was followed by an accelerated Hb regeneration, but no toxicity. Daily intramuscular Ferastral 10 ml until the calculated iron requirements are met (usually in less than five days) is recommended for the treatment of severe iron deficiency. Patients with continued blood loss or Hb less than 10 g/dl after four weeks without other cause of anaemia, may receive a boost of one intramuscular injection of Ferastral 20 ml (10 ml into each buttock).

Different populations in the tropics show wide variation in their iron status, even when living in the same area. These differences range from the most profound iron-deficiency anaemia to nutritional haemosiderosis. The extremes of dietary iron content so far reported are 5 mg per day in Mauritius to 180 mg per day in Ethiopia. Contamination with inorganic iron is an important source in some communities. Generally, the iron in food is in excess of requirement, but lumenal factors are all important in deciding how much is available for absorption. The iron of some diets is readily absorbed, but in other only a small percentage is utilizable. Hookworm infection is the commonest cause of severe iron-deficiency in many parts of the world. Its prevalence and its density depends on social habits, and may vary considerably even within tribes. The development of iron-deficiency anaemia depends on the hookworm load being sufficient to cause iron loss in excess of available intake. Anaemia impairs work capacity, reproductive ability of women and the development of children, and has wide social and economic repercussions. An intramuscular preparation by which 500 mg of iron may be administered in one injection has most useful application in areas where medical care is minimal.