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It is estimated that a quarter of the world’s population suffers from anemia,1 and it has been established that pregnant women are one of the most affected groups, particularly in low-income countries.2 According to a study published in 2008, which summarized global data on anemia for the period 1993–2005, 55.8% of pregnant women in Africa were anemic.1 Another more recent publication, which compared anemia trends worldwide between 1995 and 2011, reported a reduction in the prevalence of anemia at the global level and showed again the heterogeneity of the problem of anemia according to the different regions of the globe.3 Between 1995 and 2011, the overall prevalence of anemia decreased from 43% to 38%. In Eastern Africa, this prevalence decreased from 46% to 36%, and in Central and Western Africa, it decreased from 61% to 56%.3 The 2007 Democratic Republic of Congo (DRC) demographic and health survey (DHS) estimated a 53% national prevalence of anemia with a 39% regional prevalence in South Kivu province among women of child-bearing age.4 Furthermore, the 2007 DRC DHS estimated the national prevalence of anemia at 60% among pregnant women, but the report lacked this data for individual provinces. According to the World Health Organization (WHO), this level of prevalence, at national level, is considered to be a severe public health problem.5 Anemia during pregnancy is known to be associated with a high risk of poor birth outcomes.6 It causes fatigue, reduces work capacity,7 and is associated with a high risk of maternal mortality6,8; which remains a real public health problem with a 2015 global estimate of 300,000 maternal deaths.9 In anemic (and undernourished) women, even minimal blood losses can have serious consequences; complications of postpartum hemorrhage are higher in the presence of preexisting anemia.10 Hemorrhage tops among the leading five clinical conditions responsible for at least 80% of maternal death.11 Geller et al.12 estimates that postpartum hemorrhage accounts for 25–33% of all maternal deaths. The etiology of anemia is multifactorial; the common causes being of nutritional origin (such as iron deficiency [ID]), infections, and genetic disorders.2,13 These causes may vary between different settings and may be synergistic at varying degrees in different settings. WHO estimates that half of all cases of anemia are related to ID.6 Despite the high burden of anemia in DRC, there are limited data on its etiology among pregnant women and especially the relative contribution of ID. In 1994, Kuvibidila et al.14 found a higher prevalence of ID in the western province of Kongo Central (formerly Bas-Congo) among pregnant women than nonpregnant women and a control group of nonpregnant Caucasian women living in the United States of America. The study used ferritin or adjusted ferritin in case of inflammation to evaluate iron store, and it was generally found that Congolese women had a lower mean plasma iron as compared with the control group regardless of their physiological status.14 In his 1996 article from the same region, Kuvibidila and colleagues15 reported a 56% ID prevalence among pregnant women without inflammation as determined by a serum ferritin (SF) < 12 μg/L and/or transferrin saturation < 16%. It should be noted that these results could not be generalized to the entire country owing to the different sociodemographic, geographic, genetic, and behavioral differences (including eating habits) between different ethnic groups and regions. The 2007 DHS used hemoglobin (Hb) alone as a proxy for ID on the assumption that ID contributes to half of all cases of anemia. This was an oversight in determining the prevalence of ID considering that causes of anemia are diverse and even synergistic in some individuals, more specifically pregnant women. There has been no documented study carried out using validated biochemical parameters for iron store evaluation among pregnant women in Kivu. This study aimed at bridging this information gap with the following objectives: 1) to determine the prevalence of anemia and that of ID and 2) to identify other factors associated with anemia among pregnant women from the rural Miti-Murhesa health zone in South Kivu province in eastern DRC.

Anemia is a worldwide public health concern especially in preschool children in developing countries and iron deficiency (ID) is generally assumed to cause at least 50% of the cases. However, data on this contribution are scarce. To close this gap, we determined in 2013 the contribution of ID in the etiology of anemia and measured others factors associated to noniron deficiency anemia (NIDA) in 900 preschool children randomly selected during a two-stage cluster nutritional survey in the Miti-Murhesa health zone, in eastern Democratic Republic of the Congo. In these children, we collected sociodemographic, clinical, and biological parameters and determined the nutritional status according to the World Health Organization 2006 standards. Anemia was defined as altitude-adjusted hemoglobin < 110 g/L and ID was defined as serum ferritin < 12 μg/L or < 30 μg/L in the absence or presence of inflammation, respectively. Median (interquartile range) age was 29.4 (12–45) months. The prevalence of anemia was 46.6% (391/838) among whom only 16.5% (62/377) had ID. Among children without signs of inflammation, only 4.4% (11/251) met the ferritin-based (unadjusted) definition of ID. Logistic regression analysis identified ID, history of fever during the last 2 weeks and mid-upper arm circumference < 125 mm as the only independent factors associated to anemia. In conclusion, anemia is a severe public health problem in the Miti-Murhesa health zone, but NIDA is mostly predominant and needs to be further studied. Control of infections and prevention of acute undernutrition (wasting) are some of appropriate interventions to reduce the burden anemia in this region.

Background Timor-Leste has a high prevalence of soil-transmitted helminth (STH) infections. High proportions of the population have been reported as being anaemic, and extremely high proportions of children as stunted or wasted. There have been no published analyses of the contributions of STH to these morbidity outcomes in Timor-Leste. Methods Using baseline cross-sectional data from 24 communities (18 communities enrolled in a cluster randomised controlled trial, and identically-collected data from six additional communities), analyses of the association between STH infections and community haemoglobin and child development indices were undertaken. Stool samples were assessed for STH using qPCR and participant haemoglobin, heights and weights were measured. Questionnaires were administered to collect demographic and socioeconomic data. Intensity of infection was categorised using correlational analysis between qPCR quantification cycle values and eggs per gram of faeces equivalents, with algorithms generated from seeding experiments. Mixed-effects logistic and multinomial regression were used to assess the association between STH infection intensity classes and anaemia, and child stunting, wasting and underweight. Results Very high stunting (60%), underweight (60%), and wasting (20%) in children, but low anaemia prevalence (15%), were found in the study communities. STH were not significantly associated with morbidity outcomes. Male children and those in the poorest socioeconomic quintile were significantly more likely to be moderately and severely stunted. Male children were significantly more likely than female children to be severely underweight. Increasing age was also a risk factor for being underweight. Few risk factors emerged for wasting in these analyses. Conclusions According to World Health Organization international reference standards, levels of child morbidity in this population constitute a public health emergency, although the international reference standards need to be critically evaluated for their applicability in Timor-Leste. Strategies to improve child development and morbidity outcomes, for example via nutrition and iron supplementation programmes, are recommended for these communities. Despite the apparent lack of an association from STH in driving anaemia, stunting, wasting and underweight, high endemicity suggests a need for STH control strategies. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12614000680662; retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s13071-017-2084-x) contains supplementary material, which is available to authorized users.

Background The epidemiology of malaria and anaemia is characterized by small-scale spatial and temporal heterogeneity, which might be influenced by human activities, such as mining and related disturbance of the environment. Private sector involvement holds promise to foster public health, including the prevention and control of malaria and anaemia. Here, results from a cross-sectional epidemiological survey, conducted in communities that might potentially be affected by the Bonikro Gold Mine (BGM) in Côte d’Ivoire, are reported. Methods In December 2012, a cross-sectional survey was carried out in seven communities situated within a 20-km radius of the BGM in central Côte d’Ivoire. Capillary blood samples were obtained from children aged six to 59 months. Samples were subjected to a rapid diagnostic test (RDT) for Plasmodium falciparum detection, whilst haemoglobin (Hb) was measured to determine anaemia. Additionally, mothers were interviewed with a malaria-related knowledge, attitudes and practices questionnaire. Results A total of 339 children and 235 mothers participated in the surveys. A positive RDT for P. falciparum was found in 69% of the children, whilst 72% of the children were anaemic (Hb

Background Intermittent iron-folic acid supplementation and regular de-worming are effective initiatives to reduce anemia, iron deficiency, iron deficiency anemia, and soil transmitted helminth infections in women of reproductive age. However, few studies have assessed the long-term effectiveness of population-based interventions delivered in resource-constrained settings. Methodology/Principal Findings The objectives were to evaluate the impact of weekly iron-folic acid supplementation and de-worming on mean hemoglobin and the prevalence of anaemia, iron deficiency, and soil transmitted helminth infection in a rural population of women in northern Vietnam and to identify predictive factors for hematological outcomes. A prospective cohort design was used to evaluate a population-based supplementation and deworming program over 54 months. The 389 participants were enrolled just prior to commencement of the intervention. After 54 months 76% (95% CI [68%, 84%]) were taking the iron-folic acid supplement and 95% (95% CI [93%, 98%]) had taken the most recently distributed deworming treatment. Mean hemoglobin rose from 122 g/L (95% CI [120, 124]) to 131 g/L (95% CI [128, 134]) and anemia prevalence fell from 38% (95% CI [31%, 45%]) to 18% (95% CI [12%, 23%]); however, results differed significantly between ethnic groups. Iron deficiency fell from 23% (95% CI [17%, 29%]) to 8% (95% CI [4%, 12%]), while the prevalence of iron deficiency anemia was reduced to 4% (95% CI [1%, 7%]). The prevalence of hookworm infection was reduced from 76% (95% CI [68%, 83%]) to 11% (95% CI [5%, 18%]). The level of moderate or heavy infestation of any soil-transmitted helminth was reduced to less than 1%. Conclusions/Significance Population-based interventions can efficiently and effectively reduce anemia and practically eliminate iron deficiency anemia and moderate to heavy soil transmitted helminth infections, maintaining them below the level of public health concern., Author Summary Nutritional deficiencies are common in women in rural and disadvantaged regions, and, in particular, iron and folate deficiencies may impact their health and that of their offspring. Weekly iron-folic acid supplementation and regular deworming help to prevent these deficiencies, yet many women in developing countries do not have access to these interventions. Using the local health system, we implemented a weekly iron-folic acid supplementation program with regular deworming for approximately 250,000 women in a rural mountainous province of Viet Nam. We present the results of a survey of women's iron and worm infection status after the program has been running for 54 months. Overall, anemia prevalence fell from 38% to 18%, iron deficiency fell from 23% to 8% and the prevalence of iron deficiency anemia was reduced to 4%. The level of moderate or heavy infestation of any soil-transmitted worm infection was reduced to less than 1%. These results show that a health system-based program can reduce and maintain the prevalence of these diseases in the community at a level where they do not constitute a public health risk.

BACKGROUND: The prevalence of anaemia and iron deficiency in women remains high worldwide. WHO recommends weekly iron-folic acid supplementation where anaemia rates in non-pregnant women of reproductive age are higher than 20%. In 2006, a demonstration project consisting of weekly iron-folic acid supplementation and regular de-worming was set up in two districts in a northern province in Vietnam where anaemia and hookworm rates were 38% and 76% respectively. In 2008 the project was expanded to all districts in the province, targeting some 250,000 women. The objectives of this study were to: 1) examine changes in haemoglobin, iron stores and soil transmitted helminth infection prevalence over three years and 2) assess women's access to and compliance with the intervention. METHODS AND FINDINGS: The study was a semi-cross-sectional, semi-longitudinal panel design with a baseline survey, three impact surveys at three-, twelve- and thirty months after commencement of the intervention, and three compliance surveys after ten weeks, eighteen and thirty six months. RESULTS: After thirty months, mean haemoglobin stabilised at 130.3 g/L, an increase of 8.2 g/L from baseline, and mean serum ferritin rose from 23.9 µg/L to 52 µg/L. Hookworm prevalence fell from 76% to 22% over the same period. After thirty six months, 81% of the target population were receiving supplements and 87% were taking 75% or more of the supplements they received. CONCLUSIONS: Weekly iron-folic acid supplementation and regular de-worming was effective in significantly and sustainably reducing the prevalence of anaemia and soil transmitted helminth infections and high compliance rates were maintained over three years.

Background The Nias district of the North Sumatra Province of Indonesia has long been known to be endemic for malaria. Following the economic crisis at the end of 1998 and the subsequent tsunami and earthquake, in December 2004 and March 2005, respectively, the malaria control programme in the area deteriorated. The present study aims to provide baseline data for the establishment of a suitable malaria control programme in the area and to analyse the frequency distribution of drug resistance alleles associated with resistance to chloroquine and sulphadoxine-pyrimethamine. Methods Malariometric and entomology surveys were performed in three subdistricts. Thin and thick blood smears were stained with Giemsa and examined under binocular light microscopy. Blood blots on filter paper were also prepared for isolation of parasite and host DNA to be used for molecular analysis of band 3 (SAO), pfcrt, pfmdr1, dhfr, and dhps. In addition, haemoglobin measurement was performed in the second and third surveys for the subjects less than 10 years old. Results Results of the three surveys revealed an average slide positivity rate of 8.13%, with a relatively higher rate in certain foci. Host genetic analysis, to identify the Band 3 deletion associated with Southeast Asian Ovalocytosis (SAO), revealed an overall frequency of 1.0% among the 1,484 samples examined. One hundred six Plasmodium falciparum isolates from three sub-districts were successfully analysed. Alleles of the dhfr and dhps genes associated with resistance to sulphadoxine-pyrimethamine, dhfr C59R and S108N, and dhps A437G and K540E, were present at frequencies of 52.2%, 82.5%, 1.18% and 1.18%, respectively. The pfmdr1 alleles N86Y and N1042D, putatively associated with mefloquine resistance, were present at 31.4% and 2%, respectively. All but one sample carried the pfcrt 76T allele associated with chloroquine resistance. Entomologic surveys identified three potential anopheline vectors in the area, Anopheles barbirostris, Anopheles kochi and Anopheles sundaicus. Conclusion The cross sectional surveys in three different sub-districts of Nias District clearly demonstrated the presence of relatively stable endemic foci of malaria in Nias District, North Sumatra Province, Indonesia. Molecular analysis of the malaria parasite isolates collected from this area strongly indicates resistance to chloroquine and a growing threat of resistance to sulphadoxine-pyrimethamine. This situation highlights the need to develop sustainable malaria control measures through regular surveillance and proper antimalarial drug deployment.

Background Soil-transmitted helminth (STH) infections are endemic in Honduras and efforts are underway to decrease their transmission. However, current evidence is lacking in regards to their prevalence, intensity and their impact on children's health. Objectives To evaluate the prevalence and intensity of STH infections and their association with nutritional status in a sample of Honduran children. Methodology A cross-sectional study was done among school-age children residing in rural communities in Honduras, in 2011. Demographic data was obtained, hemoglobin and protein concentrations were determined in blood samples and STH infections investigated in single-stool samples by Kato-Katz. Anthropometric measurements were taken to calculate height-for-age (HAZ), BMI-for-age (BAZ) and weight-for-age (WAZ) to determine stunting, thinness and underweight, respectively. Results Among 320 children studied (48% girls, aged 7–14 years, mean 9.76±1.4) an overall STH prevalence of 72.5% was found. Children >10 years of age were generally more infected than 7–10 year-olds (p = 0.015). Prevalence was 30%, 67% and 16% for Ascaris, Trichuris and hookworms, respectively. Moderate-to-heavy infections as well as polyparasitism were common among the infected children (36% and 44%, respectively). Polyparasitism was four times more likely to occur in children attending schools with absent or annual deworming schedules than in pupils attending schools deworming twice a year (p, Author Summary Soil-transmitted helminth (STH) infections are endemic in Honduras but their impact on children's health is not well studied. With the purpose of determining the prevalence and intensity of STH infections and their association with nutritional status in a sample of Honduran children, a cross-sectional study was undertaken in 2011. School-age children were enrolled, and in addition to demographic data, blood and stool samples and anthropometric measurements were obtained to determine nutritional status and STH infection. The overall STH prevalence among 320 studied children was 72.5% and almost half of the infected children harboured multiple parasites. Polyparasitism was more likely to occur in children attending schools with absent or annual deworming schedules than in pupils attending schools deworming twice a year. Prevalence by species was 30%, 67% and 16% for Ascaris, Trichuris and hookworms, respectively. Infections of moderate to heavy intensity as well as multiparasite infections were significant predictors of decreased weight-for-age scores in children ages 7–10 years after controlling for key confounders. Sustainable efforts to control STH infections in Honduras are required. Future research providing more insight on the nutritional impact of polyparasitic STH infections in childhood is necessary.

Background In heavily endemic malaria areas, it is almost inevitable that malarial infection will be associated with anaemia, although malaria may not be the prime cause of it. Anaemia is a major public health problem in Cameroon. We hypothesized that, factors other than falciparum malaria account for anaemia in the study area. Methods A longitudinal study was conducted among 351 Plasmodium falciparum positive children to determine the prevalence, risk factors and the perception of anaemia by the caregivers in a semi-rural community. The investigative methods included the use of a structured questionnaire, clinical evaluation and laboratory investigations. Results At enrolment the overall prevalence of anaemia as assessed by Hb concentration (Hb < 11 g/dl) was 80.3% (282). Following treatment the prevalence of persistent anaemia was 6% and 46.2% of the children achieved haematological recovery by day 42. Exploratory multiple linear regression analysis showed the following; parasitaemia density (P < 0.01), enlarged spleen (P < 0.05), duration of fever > 2 days (P < 0.01), high white blood cell count (P < 0.001), sex (P < 0.05), iron status indicators (ferritin and transferrin) (P < 0.001), level of education of the caregiver (P < 0.05), management of onset of malaria by caregiver (P < 0.005) and wasting (P < 0.05) to be risk factors for anaemia in children with falciparum infection. Approximately 75.5% (265) of the caregivers had some knowledge about anaemia. Conclusion The identified risk factors revealed the important contributors to the pathogenesis of anaemia in the Mount Cameroon region. Control efforts should therefore be directed towards proper health education emphasizing on proper health seeking behaviour and attitudes of the population.

Background There is limited knowledge on the malaria burden of school-aged children in Côte d’Ivoire. The aim of this study was to assess Plasmodium falciparum infection, malaria-related morbidity, use of preventive measures and treatment against malaria, and physical access to health structures among school-aged children across Côte d’Ivoire. Methods A national, cross-sectional study was designed, consisting of clinical and parasitological examinations and interviews with schoolchildren. More than 5,000 children from 93 schools in Côte d’Ivoire were interviewed to determine household socioeconomic status, self-reported morbidity and means of malaria prevention and treatment. Finger-prick blood samples were collected and Plasmodium infection and parasitaemia determined using Giemsa-stained blood films and a rapid diagnostic test (RDT). Haemoglobin levels and body temperature were measured. Children were classified into wealth quintiles using household assets and principal components analysis (PCA). The concentration index was employed to determine significant trends of health variables according to wealth quintiles. Logistic and binomial negative regression analyses were done to investigate for associations between P. falciparum prevalence and parasitaemia and any health-related variable. Results The prevalence of P. falciparum was 73.9% according to combined microscopy and RDT results with a geometric mean of parasitaemia among infected children of 499 parasites/μl of blood. Infection with P. falciparum was significantly associated with sex, socioeconomic status and study setting, while parasitaemia was associated with age. The rate of bed net use was low compared to the rate of bed net ownership. Preventive measures (bed net ownership, insecticide spray and the reported use of malaria treatment) were more frequently mentioned by children from wealthier households who were at lower risk of P. falciparum infection. Self-reported morbidity (headache) and clinical morbidity (anaemia) were more often reported by children from less wealthy households. Conclusion Seven out of ten school-aged children in Côte d’Ivoire are infected with P. falciparum and malaria-related morbidity is considerable. Furthermore, this study points out that bed net usage is quite low and there are important inequalities in preventive measures and treatment. These results can guide equity-oriented malaria control strategies in Côte d’Ivoire. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-14-7) contains supplementary material, which is available to authorized users.