Injectable iron in nomadic populations
injectable iron in nomadic populations Michael Golden 15.04.98
Re injectable iron in nomadic populations David Alnwick 15.04.98
Re: injectable iron in nomadic populations Penny Nestel 15.04.98
Re: injectable iron in nomadic populations Fernando E. Viteri 24.04.98
Re: injectable iron in nomadic populations Nevin Scrimshaw 01.05.98
Re: injectable iron in nomadic populations Paul Garner 01.05.98
Re: injectable iron in nomadic populations D Labadarios 03.05.98

Date: Wed, 15 Apr 1998 14:42:28 +0100

From: Michael Golden <>

Subject: Ngonut: injectable iron in nomadic populations


I wonder if anyone (and in particular Fernando Viteri and Stephen Oppenheimer) would care to comment!


>Date: 15 Apr 98 14:04:44 +0100

>From: Bruce Laurence <>

>Subject: RE>Re: iron, folic acid and malaria



>I have another iron related question pertinent to the same discussion, on possible use of IM iron administration. MERLIN is also working in Wajir, running mobile clinics, and seeing large numbers of patients with malaria and anaemia (certainly at least in part iron-deficient) amongst nomadic populations. Any regular access to these people is very difficult, and it is impossible to ensure that there will be reliable follow up to monitor and treat anaemia, so we give out iron and folate and hope that it will be of some use. Obviously poor follow up among many communities is a major issue. The group that is maybe of greatest worry is pregnant women with severe anaemia.

>What I would like to know is whether in hard to access groups of pregnant women, and maybe others as well, there is any use for IM injectable iron.

>This route of supplementation seems to have practically fallen off the menu, probably for good reasons, yet in some of the most difficult situations maybe it has a place if it can act as a sort of depot treatment.

>Also, because here the malaria situation and hopefully that of food security might improve in the near future, even a time-limited improvement might be valuable (and of course an individual pregnancy is also time limited).

>I would be interested to hear any comments and experiences relating to this... or suggestions of what to do for the best when access is so difficult.

>Bruce Laurence, MERLIN, UK



Prof. Michael H.N.Golden

Date: Wed, 15 Apr 1998 12:25:23 -0400

From: (David Alnwick)

Subject: Re: injectable iron in nomadic populations


I have forwarded this to Ray Yip, with UNICEF in Indonesia - I know Ray has some knowledge of the history of injectable iron and he might like to comment.


At a review of iron supplementation issues that UNICEF supported two years ago, at Ray;'s urging, we agreed that there was a need for a new look at injectable iron - but I do not know if this was ever done.


UNICEF did support the use of injectable iron to combat anemia in pregnancy in Sri Lanka for many years - and there is at least anecdotal evidence that this was a highly effective programme. Apparently iron injections were used fairly widely to treat/prevent anemia in young children until 10 or 15? years ago, when there was a small number of reports of cancers developing at the injection site, and this intervention was then dropped fast in many countries - Yip may have the details. I recall however that there are newer injectable iron compounds, and lower doses could be used, that might overcome some of these earlier problems.


David Alnwick

Chief, Health Section

UNICEF, New York

Date: Wed, 15 Apr 1998 13:44:30 -0400

From: Penny Nestel <>

Subject: Re: injectable iron in nomadic populations -Reply


We are currently doing a literature review and would welcome any comments based on experiences and unpublished data.

Penny Nestel

OMNI Nutrition/Research Advisor, Washington, DC, USA

Date: Fri, 24 Apr 1998 11:37:04 +0100

From: (Fernando E. Viteri)

Subject: Re:Ngonut: injectable iron in nomadic populations -Reply


I have no personal experience with parenteral iron as a public health measure. However I am willing to venture an oppinion. I believe that the use of parenteral iron needs to be reevaluated in very specific cases, particularly in pregnancy in non-malarious areas, where no other alternative for TREATMENT of severe iron deficiency anemia is present.

This limits the indications for parenteral iron to very few cases because SEVERE anemia is rarely due to dietary iron deficiency alone. Usually SEVERE anemia is complicated by malaria, hookworm , etc. and these should be treated as primary cause of anemia. Besides, in these cases other nutritional deficiencies also co-exist, particularly folate, which can become very severe if only ironis administered. PREVENTIVE parenteral iron administration seems to me difficult to justify. I think we have, in general, underestimated the capacity of community organizations in preventing and treating iron deficiency, malaria and hokworm. Empowering the community together with clear and simple indications on measures to control NUTRITIONAL ANEMIAS would be a more logical approach than massive parenteral iron. This needs to be tried first.


Fernando E. Viteri, Professor

Department of Nutritional Sciences, University of California

Berkeley, CA., 04720 - 3104

Phone: (510) 642 - 6900, FAX: (510) 642 0535

Date: Fri, 01 May 1998 10:25:27 +0100

From: "Dr. Nevin Scrimshaw" <>

Subject: Re: Ngonut: injectable iron in nomadic populations


I have just returned from extensive travel to find the subject message.

I assume that others have already responded, but the worst thing that could be done is to give parental iron to iron-deficient individuals with even latent malaria. There is good evidence from experience with Somalia refugees that this practice can exacerbate symptoms to the point of increased mortality from cerebral malaria.


Murray MJ et al. Diet and cerebral malaria: the effect of famine and refeeding. Am J Clin Nutr;31:57-61, 1978.

Murray MJ et al. The adverse effect of iron repletion on the course of certain infections. Brit. Med J 1113-1115, 1978.


The explanation is quite straight forward. Iron deficiency impairs a number of immune mechanism. However, withholding iron from invading orgaqnisms (by transferrin and lactoferrin) is an important defense mechanism because micro-organisms and parasites need iron for their replication. Parental iron provides iron for rapid agen5 replication before their is an opportunity for host defenses to recover. Iron therapy but not overwhelming host capacity to withhold iron from infectious agents.


Nevin Scrimshaw

From: Paul Garner <>

Subject: Re: Ngonut: injectable iron in nomadic populations

Date: Fri, 1 May 1998 11:06:03 +0100 (BST)


The Somali refugee studies were poorly controlled and it is very difficult to justify the conclusions reached by the authors on the basis of the evidence given.

The only way this could be answered is by a good systematic review of trials to date in this area. I have not seen such a review, but the Cochrane Infectious Diseases Group would be keen to support an individual interesting in conducting and updating such a review.


Paul Garner

Liverpool School of Tropical Medicine

From: "Prof D Labadarios, Menslike Voeding, tel 259" <DemetreatGERGA.SUN.AC.ZA> Organization: STELLENBOSCH UNIVERSITY

Date: Sun, 3 May 1998 11:46:33 +200

Subject: Re: injectable iron in nomadic populations


I have been following the current debate on iron supplementation with great interest. Dr Schrimshaw's categorical statement on the documented evidence against the practice brought forward my planned participation in the debate.

Iron supplementation is a safe practice in the correctly identified individual, at the appropriate dose, via the appropriate route, frequency and for the appropriate duration. There are, however, also many important contraindications to which insufficient attention is usually paid to. So, can we perhaps proceed to develop such a code of practice which emphsises at the field level the differences between anaemia, iron deficiency and iron deficiency anaemia together with guidelines for management.

Certainly from national studies conducted in these parts of the world (South Africa, Swaziland, Botswana) anaemia is common, indeed in some cases very common, iron deficiency less so and iron deficiency anaemia even less so. The practice, therefore, for recommending "routine iron supplements irrespective" may be ill advised and counterproductive.

As a thought, might the confusion we experience here be related to the relatively poor successes we have had with the management of this deficiency?.