Effectiveness of Iron Supplementation in Reducing Iron Deficiency Anemia in India.

Dear Sir,

We read with great interest the article titled, “Effectiveness and Feasibility of Weekly Iron and Folic Acid Supplementation to Adolescent Girls and Boys through Peer Educators at Community Level in the Tribal Area of Gujarat.”[1] We seek clarifications from the authors on a few methodological issues so that the readers of Indian Journal of Community Medicine are benefitted.

The authors provided weekly supplementation with iron folic acid (IFA) tablets (100 mg elemental iron and 500 µg folic acid) for a period of 3 months, that is, April, May, and June 2013 to 117 girls and 127 boys. A total of 12 doses of IFA were administered. However, in the abstract under the head of “Methods,” it is mentioned that the supplementation was given for a period of 52 weeks. The actual duration of supplementation needs to be clarified.

The authors have documented that the mean rise of hemoglobin (Hb) levels among adolescent boys was 1.5 g/dl and that among adolescent girls was 1.3 g/dl after 3 months of IFA supplementation. Earlier studies conducted by Vir et al.[2] and Bansal et al.[3] showed that the mean rise in Hb levels was by 1 g/dl after administration of IFA tablets weekly for 6 months to adolescents. An earlier systematic review conducted an assessment of the effect of administration of IFA supplementation on increase in Hb levels in children. They reported mean increase in Hb to be 0.74 g/dl.[4] Hence, the possible reasons for a mean increase in Hb in the range of 1.3-1.5 g/dl after only 3 months of weekly IFA supplementation needs to be clarified by the authors.

In the present study, Hb was estimated by HemoCue method. Comparative studies have shown that HemoCue method overestimates the hemoglobin concentrations when compared with the standard cyanmethemoglobin method.[567] The time interval between opening of the microcuvette container and their use, and humid climatic conditions may result in poor validity of estimation of Hb done by HemoCue method. The authors have not mentioned regarding the internal and external quality control measures adopted for estimation of Hb undertaken by them.

The readers would be greatly benefitted if increase in Hb from baseline among subjects with levels of 7, 8, 9, 10, and 11 g/dl of Hb may be mentioned after supplementation of 12 doses of IFA. This would help in understanding the increase in Hb at various levels of anemia. Also, which group of adolescents became nonanemic will also be explicitly depicted.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest

As rightly pointed out, the supplementation was given for a period of 52 weeks, not 12. April – June (2013 & 2014) was data collection period for baseline & endline findings; using the same Hemocue method.

Considering accuracy and ease of use in field conditions,[1] we chose Hemocue as the reference method for our study. Further, systematic review from 18 studies shows that Hemocue was generally precise and had good correlation to reference laboratory tests with sensitivity between 75–91%, specificity between 88–100% and positive predictive values ranging from 75-80% for the detection of anaemia.[2] The device was simple to operate, easily portable and rapid digital display of results was also an advantage.[2]