Johns Hopkins University
Plasma hepcidin concentrations and factors associated with hemoglobin levels in infants and young children in Zimbabweby Tatenda Geraldine MupfudzeA dissertation submitted to the Bloomberg School of Public Health, Johns Hopkins University, in fulfillment of requirements for the degree of Doctor of PhilosophyBaltimore, MarylandMarch 2014ABSTRACTIron metabolism is very dynamic over the first year of life. Anemia is common in sub-Saharan African infants, particularly in the context of HIV infection. Hepcidin, a peptide hormone whose synthesis is simultaneously regulated by iron status and the innate immune system, has evolved as the master regulator of iron metabolism, thereby linking iron homeostasis, inflammation, infection and anemia. However little is known about normal hepcidin values in infancy, its role in the pathogenesis of anemia during infancy or its role in the pathology of HIV infection or exposure. Plasma hepcidin concentrations were higher in 3-month-old (median 9.7 ng/mL [IQR 2.5, 19.3]), than in 6-month-old (4.5 ng/mL [IQR 0.5, 7.3]) and 12-month-old infants (1.9 ng/mL [IQR 0.7, 6.2)]) (p<0.001, Kruskal–Wallis) among healthy, non-anemic Zimbabwean infants with normal iron parameters at 3 (n=60), 6 (n=47) and 12 (n=40) months of age. The correspondingly lower levels of plasma hepcidin at 6 and 12 months in healthy non-anemic infants is likely a physiologic response to mobilize iron stores and increase iron absorption to prevent anemia. Plasma hepcidin concentrations were higher in HIV-infected compared to HIV exposed uninfected (HEU) and HIV-unexposed groups throughout infancy and correlated with levels of plasma ferritin and C- reactive protein (CRP). HEU infants also had higher levels of plasma hepcidin and inflammation (alpha-1-acid glycoprotein (AGP) and CRP) compared to HIV unexposed infants. Overall, anemia had no effect on plasma hepcidin concentrations during infancy except in HIV unexposed infants. Plasma hepcidin declined with age in all groups; girls had higher plasma hepcidin concentrations than boys. Plasma hepcidin concentrations appear to be driven by inflammation in infants, as has been shown in adults. We did not find a significant association between infant and young child feeding (IYCF) indicators and hemoglobin levels in children 6-24 months using data from the 2010-11 Zimbabwe Demographic and Health Survey. However, Water, Sanitation and Hygiene (WASH) practice indicators were associated with hemoglobin levels in young Zimbabwean children adjusting for biological and social factors and warrant further investigation in randomized controlled trials. Committee of readersDr. William Moss, Department of Epidemiology Professor and Chair of CommitteeDr. David Sullivan, Department of Molecular Microbiology and ImmunologyAssociate ProfessorDr. Jean H. Humphrey, Department of International HealthProfessor and Thesis Project AdvisorDr. Lawrence H. Moulton, Department of International HealthProfessorPREFACEHepcidin, a peptide hormone whose synthesis is simultaneously regulated by iron status and the innate immune system, has evolved as the master regulator of iron metabolism, linking iron homeostasis, inflammation, infection and anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAwODwvWWVh
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Galesloot et al, 2011) effectively blocking iron efflux from duodenal enterocytes, hepatocytes, the placenta and macrophages PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZW1ldGg8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Nemeth et al, 2004; Nemeth et al, 2004; Drakesmith& Prentice, 2012). Since its discovery in 2000 there is burgeoning evidence that hepcidin measurements may reflect the dynamic iron metabolism typical of infancy. Rehu et al reported elevated plasma hepcidin in cord blood ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
0902-4441 (Linking)</isbn><accession-num>20528904</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Rehu et al, 2010) consistent with hemoglobin values that are highest at birth and decreased erythropoiesis during the first stage of iron nutrition. Neonatal serum hepcidin concentrations were comparatively lower in preterm infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWxsZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Muller et al, 2012) using the same assay, consistent with lower iron stores in preterm infants and a greater demand for iron compared to full term infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Rehu et al, 2010; Muller et al, 2012). A trial on the effects of iron supplementation reported increased serum hepcidin concentration over time in infants who were supplemented but not in the placebo group, consistent with higher iron stores and hemoglobin levels in the supplemented group PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Berglund et al, 2011). We are only aware of one study in the literature that looks at the association between hepcidin and infection in infants and they reported a 4-fold increase in serum hepcidin concentrations in very low birth weight infants with compared to those without late onset neonatal sepsis ADDIN EN.CITE <EndNote><Cite><Author>Wu</Author><Year>2013</Year><RecNum>322</RecNum><DisplayText>(Wu<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>322</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">322</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wu, T. W.</author><author>Tabangin, M.</author><author>Kusano, R.</author><author>Ma, Y.</author><author>Ridsdale, R.</author><author>Akinbi, H.</author></authors></contributors><auth-address>Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.</auth-address><titles><title>The utility of serum hepcidin as a biomarker for late-onset neonatal sepsis</title><secondary-title>The Journal of pediatrics</secondary-title><alt-title>J Pediatr</alt-title></titles><periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></periodical><alt-periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></alt-periodical><pages>67-71</pages><volume>162</volume><number>1</number><edition>2012/07/17</edition><keywords><keyword>Age of Onset</keyword><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Biological Markers/blood</keyword><keyword>C-Reactive Protein/analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Very Low Birth Weight</keyword><keyword>Male</keyword><keyword>Predictive Value of Tests</keyword><keyword>Sepsis/*blood/*diagnosis</keyword></keywords><dates><year>2013</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1097-6833 (Electronic)
0022-3476 (Linking)</isbn><accession-num>22796049</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>;(Wu et al, 2013) inline with hepcidin’s role in inflammation/infection. Although limited these studies suggest that hepcidin is associated with changes that have been described in infant iron nutrition and in the presence of infection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWh1PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012; Young et al, 2012; Wu et al, 2013). These studies suggest that hepcidin could be useful as an indicator of iron status in infants however normative hepcidin values have not been described over the course of infancy and the role of hepcidin in other infectious conditions, in particular HIV, have not yet been fully characterized PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWh1PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012; Young et al, 2012; Wu et al, 2013).The main objective of this study was to describe normative plasma hepcidin values in infancy and to determine the independent effects of HIV status, anemia and age on hepcidin concentrations during the first year of life. We also felt it necessary to determine if infant and young child feeding (IYCF) and water, sanitation and hygiene (WASH) indicators were associated with hemoglobin levels in infants and young children using nationally representative data. In Chapter 2, we present normative values of plasma hepcidin generated from infants enrolled in the ZVITAMBO Vitamin A trial who had: a gestational age >37 weeks, birth weight > 2500g and never had abnormal iron indicators (i.e. hemoglobin < 105 g/L at 3 and 6 months and < 100g/L at 12months, serum ferritin < 12μg/l, sTfR > 8.3mg/L), inflammation (i.e. AGP > 1g/L or CRP> 5mg/L) or an acute illness (diarrhea, fever, in the prior week or measles in the prior 3 months) at 3, 6 and 12 months of age. In Chapter 3, we characterize plasma hepcidin levels and inflammatory and iron status indicators in six groups of infants selected at 3, 6 and 12 months of age, based on HIV and anemia status: HIV-unexposed non-anemic infants (Group 1-Chapter 2), HIV-unexposed anemic infants (Group 2); HIV-exposed uninfected non-anemic infants (Group 3); HIV-exposed uninfected anemic infants (Group 4); HIV-infected non-anemic infants (Group 5) and HIV-infected anemic infants (Group 6). We describe the independent effects of HIV status, anemia and age on plasma hepcidin concentrations during the first year of life.In Chapter 4, we examine the hypothesis that IYCF indicators will not be associated with hemoglobin because the iron-rich IYCF indicator primarily or solely counts intake of natural foods and so does not reflect iron consumption at levels that are relevant to infants iron needs.? We also examine the hypothesize that WASH indicators that reflect fecal exposure among infants will be associated with hemoglobin levels during infancy based on our hypothesized causal pathway through Schitosomiasis, soil transmitted helminths (STH) and environmental enteropathy (EE), elevated hepcidin and anemia of inflammation in children aged 6-24 months using data from the 2010-11 Zimbabwe Demographic and Health Survey.To my mother and father, the epitome of love, grace and kindness,who gave me roots to know where home is and wings to fly away. And to my brother, who reminds me not to take anything too seriously.ACKNOWLEDGEMENTSI’m grateful for the experiences that made this journey harder and easier than it needed to be. Without the former, this experience would have been less significant and less life affirming. Without the latter, I would not have found the will to continue. I would like to thank the following people for their support and contributions to my dissertation project and thesis.Dr. Jean H. Humphrey, my thesis advisor, for her unlimited support, kindness and patience. For guiding me through my dissertation and allowing me to own my work.Dr. Andrew J. Prendergast, for playing a leading role in my dissertation and teaching me how to “tell a story from the numbers.” For his infectious enthusiasm. Dr. Lawrence H. Moulton, who served on my committees and contributed toward the study design, analysis and writing of my dissertation project and for allowing me to glean from his expertise in biostatistics.Dr. Rebecca J. Stoltzfus, an expert in anemia, who taught me apply myself and to think critically about my research. Dr. Parul Christian, my academic advisor for her guidance and support.Dr. Keith West, for wanting nothing more than for me to succeed and for his kindness and generosity.Dr. Kerry Schulze, her expertise in nutrition assessment and for serving on both my oral committees.Dr. Taha Taha, for his expertise in epidemiology and HIV research.Ms. Sandra Rukobo and the lab team, for their teamwork and meticulous work in analyzing samples for the study and making me feel like “a real scientist.”The entire ZVITAMBO Project staff; for their tireless work in data collection and in the creation of an archive that enabled my work. A special thanks to Bernard Chasekwa and Robert Ntozini, for helping me put together and analyze the dataset for my study.Finally, I would like to thank all the ZVITAMBO mothers and their babies whose samples are still being used more than a decade later to answer pertinent public health questions.TABLE OF CONTENTSABSTRACT……………………………………………………………………………iiPREFACE……………………………………………………………………………ivACKNOWLEDGEMENTS…………………………………………………………..viiiLIST OF TABLES…………………………………………………………………...xiiLIST OF FIGURES…………………………………………………………………..xiiiChapter 1: INTRODUCTION…..……………………………………………………1Research objectives….………………………………………………………………….…1Specific aims………………………………………………………..……………..5Background and significance……………………………………………………………...7Research design………………………………………………………..………………...44Chapter 2: HEPCIDIN DECREASES OVER THE FIRST YEAR OF LIFE IN HEALTHY AFRICAN INFANTS………………………………………...…………….49 ABSTRACT………………………………………………………………………….......50INTRODUCTION……………………………………………………………………….50METHODS…………………………………………………………………………........51RESULTS AND DISCUSSION………………………………………………………....54CONCLUSION……………………………………………………………………...…...56Chapter 3: ELEVATED HEPCIDIN CONCENTRATIONS IN HIV INFECTED AND HIV EXPOSED ZIMBABWEAN INFANTS AND THE ROLE OF HEPCIDIN IN THE PATHOGENESIS OF ANEMIA IN INFANTS…………………………...………61ABSTRACT…………………………………………………………………………..….62INTRODUCTION…………………………………………………………………….…63METHODS…………………………………………………………………………........66RESULTS…………………………………………………………………………..........70DISCUSSION………………………………………………………………………......100CONCLUSION…………………………………………………………..………...…...105Chapter 4: THE RELATIONSHIP BETWEEN INFANT AND YOUNG CHILD FEEDING (IYCF) INDICATORS, WATER SANITATION AND HYGIENE (WASH) INDICATORS AND HEMOGLOBIN LEVELS AMONG YOUNG ZIMBABWEAN CHILDREN…………………………………………………………………………….106ABSTRACT………………………………………………………………………….....107INTRODUCTION……………………………………………………………………...108METHODS…………………………………………………………………………......112RESULTS…………………………………………………………………………........118DISCUSSION…………………………………………………………………………..120CONCLUSION…………………………………………………………………………123Chapter 5:CONCLUSIONS AND RECOMMENDATIONS……………………..148Conclusions………………………………………………………..…………………....148Recommendations for future research………………………………………………….152APPENDIX:Ethical review………………………………………………………..…153BIBLIOGRAPHY………………………………………………………..……………..163CURRICULUM VITAE………………………………………………………..………180LIST OF TABLESStages in the development of iron deficiency…………………………………....11Advantages and limitations of hepcidin assays………………………………….17Review of Hepcidin studies………………………………………………….…..30Iron content of unfortified food sources.………………………………………...432.1 Baseline characteristics of healthy, non-iron-deficient, non-anemic Zimbabwean infants at 3, 6 and 12-months of age……….………………………………….…573.1 Characteristics of 3-month-old infants………………………………………..….733.2 Characteristics of 6-month-old infants…………………………………………...803.3 Characteristics of 12-month-old infants………………………………………….873.4 Results of linear regression analyses for log plasma hepcidin concentrations (ng/mL)…………………………………………………………………………..954.1Definitions of WHO-recommended Infant and Young Child Feeding (IYCF) indicators..…………………………………………………………………..…..1244.2Sample Characteristics.…..……………………………………………….…….1264.3Prevalence of Infant and Young Child Feeding Practices and Water Sanitation and Hygiene indicators among 6-24 month old Zimbabwean children whose mothers were interviewed, Zimbabwe Demographic Health Survey 2010- 2011……………………………………………………………………………..1304.4Univariate and multivariate models of potential risk factors for low hemoglobin among children 6-24 months (Zimbabwe Demographic Health Survey 2010-2011)………..………………….……………………………………………….133LIST OF FIGURES1.1Hepcidin and Iron metabolism in infancy…………………………………………31.2 Iron metabolism in infancy………………………………………..………………91.3Percentage change in APP in response to inflammation/infection…………..…..131.4Hypothesized causal pathway linking fecal contamination and Environmental Enteropathy (EE) through poor WASH practices with anemia………………….391.5The ZVITAMBO trail project profile including the Hepcidin sub-study…….….482.1 Plasma hepcidin concentrations in healthy non-anemic infants by age and gender…………………………………………………………………………….603.1 Relationships between hepcidin and other biomarkers..……...……………….....98Chapter 1INTRODUCTIONResearch objectivesAnemia is a serious public health problem affecting 2 billion people worldwide, particularly infants and young children in developing countries where its etiology is multifactorial PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb2tlc2h3YXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (WHO.; Lokeshwar et al, 2011; Milman, 2011). Anemia in infancy is associated with impaired cognitive and behavioral development PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWx0ZXI8L0F1dGhvcj48WWVhcj4xOTk0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Walter et al, 1989; Walter, 1994; Rao& Georgieff, 2002), impaired oxygen transport ADDIN EN.CITE <EndNote><Cite><Author>Cullis</Author><Year>2011</Year><RecNum>915</RecNum><DisplayText>(Cullis, 2011)</DisplayText><record><rec-number>915</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">915</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cullis, J. O.</author></authors></contributors><auth-address>Department of Haematology, Salisbury NHS Foundation Trust, Salisbury, UK. jonathan.cullis@salisbury.nhs.uk</auth-address><titles><title>Diagnosis and management of anaemia of chronic disease: current status</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><pages>289-300</pages><volume>154</volume><number>3</number><edition>2011/05/28</edition><keywords><keyword>Algorithms</keyword><keyword>Anemia/*diagnosis/etiology/therapy</keyword><keyword>Antimicrobial Cationic Peptides/antagonists & inhibitors/physiology</keyword><keyword>Chronic Disease</keyword><keyword>Diagnosis, Differential</keyword><keyword>Erythropoietin/therapeutic use</keyword><keyword>Humans</keyword><keyword>Iron/therapeutic use</keyword></keywords><dates><year>2011</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1365-2141 (Electronic)
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ADDIN EN.CITE.DATA (Drakesmith& Prentice, 2012). The molecular control of hepcidin is part of the innate immune response to pathogens and is stimulated by IL-6, IL-22, type I interferons, toll-like receptor (TLR) ligands, and the endoplasmic reticulum stress response PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA (Drakesmith& Prentice, 2012). Hepcidin synthesis is stimulated by elevated plasma iron concentration, infection and/or inflammation, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Kroot et al, 2010; Galesloot et al, 2011). A limited number of studies have characterized hepcidin during infancy, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWh1PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012; Wu et al, 2013) and none have studied infants in developing countries where the prevalence of anemia and infectious disease are both high. Specifically, only one study to date has reported hepcidin levels in HIV-infected adults, and none have described hepcidin in HIV-infected children. We designed the hepcidin study to characterize normative plasma hepcidin concentrations in healthy non-anemic Zimbabwean infants and to determine the independent effects of HIV infection/ exposure and anemia on hepcidin concentrations in infancy. Understanding normative hepcidin levels in this age group will allow us to understand the hormonal regulatory mechanisms that allow healthy infants to avoid developing anemia. We set out to measure plasma hepcidin concentrations and to characterize normative values in healthy, non-anemic, Zimbabwean infants. We used an algorithm developed by Kroot et al to generate hepcidin consensus values, to allow for harmonization with different hepcidin assays PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012). Secondly, we determined plasma hepcidin levels in anemic and non-anemic infants in the context of HIV infection and exposure to better understand the pathophysiology underlying this highly prevalent condition of global health importance. The multifactorial etiology of anemia in developing countries motivated us to conduct an epidemiological data analysis of the Zimbabwe Demographic and Health Survey (ZDHS) to better understand the primary processes implicated in the pathogenesis of anemia in developing countries. We hypothesized that indicators of Water Sanitation and Hygiene (WASH) would be associated with anemia in young children because conditions of poor WASH are associated with Schistosomiasis, soil-transmitted helminths (STHs) and environmental enteropathy (EE). Furthermore, since most natural dietary sources of iron are not iron-concentrated enough to meet dietary iron requirements in 6 month – 3 year old children, and fortified infant foods are practically non-existent in Zimbabwe, we hypothesized that indicators of infant feeding practices would not be associated with anemia in this population PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Lind et al, 2004; Baker& Greer, 2010; Domellof, 2011). Figure 1.1. Hepcidin and Iron metabolism in infancy. Hepcidin binds to ferroportin, the only known mammalian iron exporter, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Kroot et al, 2010; Galesloot et al, 2011). Specific aimsThe specific aims of this study are presented in the corresponding chapters:Chapter 2Estimate reference intervals for plasma hepcidin for non-anemic healthy infants at three ages (3, 6 and 12 months) where non-anemic healthy is defined as: gestational age at birth >37 weeks; birth weight > 2500 g; hemoglobin ≥ 105 g/L at 3 and 6 months and ≥ 100 g/L at 12 months; plasma ferritin ≥ 12 μg/L; soluble transferrin receptor (sTfR) ≤ 8.3 mg/L; AGP < 1 g/L and CRP < 5 mg/L at 3, 6, and 12 months of age; and no history of diarrhea or fever in the week prior or measles in 3 months prior to blood drawing at 3, 6, and 12 months of age from a well-characterized cryopreserved archive of plasma collected from HIV negative mother infants pairs participating in the ZVITAMBO study in Harare Zimbabwe (1998-2001). Chapter 3Characterize the independent associations between HIV status, anemia and hepcidin concentration in infants, by measuring plasma hepcidin concentrations in cryopreserved samples from the ZVITAMBO trial collected from 6 groups of infants: HIV-unexposed non-anemic (chapter 2), HIV-unexposed anemic, HIV-exposed uninfected (HEU) non-anemic, HEU anemic,?HIV-infected non-anemic; HIV-infected anemic?at 3, 6, 12 months. Infants were classified as HIV unexposed if the mother and infant pair were HIV negative at delivery and did not seroconvert during the trial period; HEU infants were born to HIV positive mothers but were HIV negative at delivery and did not seroconvert during the trial period. HIV infected infants were infected intrauterine (IU), intrapartum (IP) or postnatal (PN). Anemia was defined by hemoglobin ≤ 105 g/L at 3 and 6 months and ≤ 100g/L at 12 months.Determine the correlation between plasma hepcidin and other biomarkers: plasma ferritin and CRP. Chapter 4Test the hypothesis that indicators of poor environmental sanitation and personal hygiene that reflect fecal exposure among infants will be associated with hemoglobin levels during infancy based on our hypothesized causal pathway through Schistosomiasis, STHs and EE. Together with the hypothesis that IYCF indicators will not be associated with hemoglobin levels because the iron-rich IYCF indicator lacks specificity with regard to iron consumption among infants and young children in Zimbabwe using data from the 2010-11 Zimbabwe Demographic and Health Survey.Background and significanceAnemiaAnemia is a serious public health problem affecting 2 billion people worldwide particularly infants and children. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxtYW48L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Walter et al, 1989; Walter, 1994; Rao& Georgieff, 2002). Infancy is a key period for brain development and hence iron uptake is at its peak during infancy ADDIN EN.CITE <EndNote><Cite><Author>Taylor</Author><Year>1990</Year><RecNum>2070</RecNum><DisplayText>(Taylor& Morgan, 1990)</DisplayText><record><rec-number>2070</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2070</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Taylor, E. M.</author><author>Morgan, E. H.</author></authors></contributors><auth-address>Department of Physiology, University of Western Australia, Nedlands.</auth-address><titles><title>Developmental changes in transferrin and iron uptake by the brain in the rat</title><secondary-title>Brain research. Developmental brain research</secondary-title><alt-title>Brain Res Dev Brain Res</alt-title></titles><pages>35-42</pages><volume>55</volume><number>1</number><edition>1990/08/01</edition><keywords><keyword>Aging/*metabolism</keyword><keyword>Animals</keyword><keyword>Brain/growth & development/*metabolism</keyword><keyword>Iron/*pharmacokinetics</keyword><keyword>Rats</keyword><keyword>Rats, Inbred Strains</keyword><keyword>Transferrin/*pharmacokinetics</keyword></keywords><dates><year>1990</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0165-3806 (Print)
0165-3806 (Linking)</isbn><accession-num>2208639</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Taylor& Morgan, 1990). Iron is required for myelination of nerve fibers, energy metabolism, and is a cofactor for enzymes involved in neurotransmitter synthesis ADDIN EN.CITE <EndNote><Cite><Author>Shaw</Author><Year>2011</Year><RecNum>124</RecNum><DisplayText>(Shaw& Friedman, 2011)</DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">124</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shaw, J. G.</author><author>Friedman, J. F.</author></authors></contributors><auth-address>Public Health Program, Division of Biology and Medicine, Brown University, Providence, RI 02912, USA.</auth-address><titles><title>Iron deficiency anemia: focus on infectious diseases in lesser developed countries</title><secondary-title>Anemia</secondary-title><alt-title>Anemia</alt-title></titles><pages>260380</pages><volume>2011</volume><edition>2011/07/09</edition><dates><year>2011</year></dates><isbn>2090-1275 (Electronic)
2090-1267 (Linking)</isbn><accession-num>21738863</accession-num><urls><related-urls><url>;(Shaw& Friedman, 2011). Iron metabolism in infancyIron metabolism is very dynamic during infancy, with iron requirements 10-fold higher than in adults, because of rapid infant growth ADDIN EN.CITE <EndNote><Cite><Author>Tolentino</Author><Year>2007</Year><RecNum>129</RecNum><DisplayText>(Tolentino& Friedman, 2007)</DisplayText><record><rec-number>129</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">129</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tolentino, K.</author><author>Friedman, J. F.</author></authors></contributors><auth-address>Center for International Health Research at Rhode Island Hospital and Department of Pediatrics, Brown University Medical School, Providence, Rhode Island, USA.</auth-address><titles><title>An update on anemia in less developed countries</title><secondary-title>The American journal of tropical medicine and hygiene</secondary-title><alt-title>Am J Trop Med Hyg</alt-title></titles><periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></periodical><alt-periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></alt-periodical><pages>44-51</pages><volume>77</volume><number>1</number><edition>2007/07/11</edition><keywords><keyword>Anemia/*epidemiology/etiology/*prevention & control</keyword><keyword>Anemia, Iron-Deficiency/epidemiology</keyword><keyword>Anemia, Sickle Cell/epidemiology</keyword><keyword>Cost of Illness</keyword><keyword>Developing Countries</keyword><keyword>HIV Infections/epidemiology</keyword><keyword>Humans</keyword><keyword>Malaria/epidemiology</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0002-9637 (Print)
0002-9637 (Linking)</isbn><accession-num>17620629</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Tolentino& Friedman, 2007). The average term infant triples in body weight within the first year and body iron almost doubles ADDIN EN.CITE <EndNote><Cite><Author>Dallman</Author><Year>1980</Year><RecNum>2089</RecNum><DisplayText>(Dallman, 1980)</DisplayText><record><rec-number>2089</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2089</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dallman, P. R.</author></authors></contributors><titles><title>Inhibition of iron absorption by certain foods</title><secondary-title>American journal of diseases of children</secondary-title><alt-title>Am J Dis Child</alt-title></titles><pages>453-4</pages><volume>134</volume><number>5</number><edition>1980/05/01</edition><keywords><keyword>Ascorbic Acid/pharmacology</keyword><keyword>Biological Availability</keyword><keyword>Breast Feeding</keyword><keyword>Food, Fortified</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant Food</keyword><keyword>*Infant Nutritional Physiological Phenomena</keyword><keyword>Iron/*metabolism</keyword></keywords><dates><year>1980</year><pub-dates><date>May</date></pub-dates></dates><isbn>0002-922X (Print)
0002-922X (Linking)</isbn><accession-num>7377148</accession-num><urls><related-urls><url>;(Dallman, 1980). Iron metabolism in infancy can be divided into 3 stages (Figure 1.2). The term infant has on average 75 mg/kg total body iron at birth, 25% of which is in iron stores PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYW88L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Rao& Georgieff, 2002). Hemoglobin concentration is highest at birth, followed by a rapid decline in hemoglobin due to decreased erythropoiesis and shorter red blood cell lifespan, with a nadir between 6 and 8 weeks ADDIN EN.CITE <EndNote><Cite><Author>Dallman</Author><Year>1987</Year><RecNum>203</RecNum><DisplayText>(Dallman, 1987)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dallman, P. R.</author></authors></contributors><titles><title>Iron deficiency and the immune response</title><secondary-title>The American journal of clinical nutrition</secondary-title><alt-title>Am J Clin Nutr</alt-title></titles><periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></periodical><alt-periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></alt-periodical><pages>329-34</pages><volume>46</volume><number>2</number><edition>1987/08/01</edition><keywords><keyword>Anemia, Hypochromic/*immunology</keyword><keyword>Animals</keyword><keyword>*Antibody Formation</keyword><keyword>Humans</keyword><keyword>*Immunity, Cellular</keyword><keyword>Infection/immunology</keyword><keyword>Iron/administration & dosage/deficiency</keyword><keyword>Neutrophils/immunology</keyword><keyword>Nutritional Requirements</keyword><keyword>Phagocytosis</keyword></keywords><dates><year>1987</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0002-9165 (Print)
0002-9165 (Linking)</isbn><accession-num>3303900</accession-num><work-type>Research Support, U.S. Gov't, P.H.S.
Review</work-type><urls><related-urls><url>;(Dallman, 1987) while iron stores increase due to recycling of senescent erythrocytes ADDIN EN.CITE <EndNote><Cite><Author>Domellof</Author><Year>2011</Year><RecNum>2297</RecNum><DisplayText>(Domellof, 2011)</DisplayText><record><rec-number>2297</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2297</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Domellof, M.</author></authors></contributors><auth-address>Department of Clinical Sciences, Pediatrics, Umea University, Sweden. magnus.domellof@pediatri.umu.se</auth-address><titles><title>Iron requirements in infancy</title><secondary-title>Annals of nutrition & metabolism</secondary-title><alt-title>Ann Nutr Metab</alt-title></titles><periodical><full-title>Annals of nutrition & metabolism</full-title><abbr-1>Ann Nutr Metab</abbr-1></periodical><alt-periodical><full-title>Annals of nutrition & metabolism</full-title><abbr-1>Ann Nutr Metab</abbr-1></alt-periodical><pages>59-63</pages><volume>59</volume><number>1</number><edition>2011/11/30</edition><keywords><keyword>Anemia, Iron-Deficiency/prevention & control</keyword><keyword>Animals</keyword><keyword>Child Development</keyword><keyword>Evidence-Based Practice</keyword><keyword>Guidelines as Topic</keyword><keyword>Health Promotion</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Iron/metabolism</keyword><keyword>Iron, Dietary/*administration & dosage/therapeutic use</keyword><keyword>Neurogenesis</keyword><keyword>Nutrition Policy</keyword><keyword>*Nutritional Requirements</keyword></keywords><dates><year>2011</year></dates><isbn>1421-9697 (Electronic)
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ADDIN EN.CITE.DATA (Dallman et al, 1980). Endogenous iron stores become depleted in the third stage, which occurs around 3 months of age in preterm and 4 months of age in term infants and dietary iron is needed to maintain hemoglobin concentrations. Endogenous iron stores become depleted earlier in low birth weight infants due to a more rapid rate of postnatal growth and the third stage of iron metabolism begins earlier than in term infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb3J0ZW48L0F1dGhvcj48WWVhcj4xOTY0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Gorten& Cross, 1964; Lundstrom et al, 1977). Insufficient dietary iron during the third stage of iron nutrition is associated with a decline in hemoglobin concentration and a rising prevalence of iron deficiency anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWxsbWFuPC9BdXRob3I+PFllYXI+MTk4MDwvWWVhcj48
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ADDIN EN.CITE.DATA (Dallman et al, 1980).Figure 1.2. Iron metabolism in infancy. Stages I, II and III of iron nutriture. Mean values for hemoglobin (g/dL) and reticulocyte count (%) for term and preterm infants. (Reproduced from PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWxsbWFuPC9BdXRob3I+PFllYXI+MTk4MDwvWWVhcj48
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ADDIN EN.CITE.DATA (Dallman et al, 1980)).Development of iron deficiency Reduced storage iron in the presence of normal levels of transport iron and hemoglobin is the first stage in the development of iron deficiency (Table 1.1) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZW5kdDwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZW5kdDwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Vendt et al, 2007). Iron deficient erythropoiesis, the second stage of iron deficiency, is marked by exhaustion of iron stores, decreased transferrin saturation and limited iron supply to the bone marrow. Limited iron for heme synthesis leads to accumulation of erythrocyte protoporphyrin, a heme precursor in the red blood cells ADDIN EN.CITE <EndNote><Cite><Author>Gibson</Author><Year>1990</Year><RecNum>4483</RecNum><DisplayText>(Gibson, 1990)</DisplayText><record><rec-number>4483</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4483</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gibson, R.S.</author></authors></contributors><titles><title>Assessment of iron status. In: Principles of nutritional assessment. Oxford, United Kingdom: Oxford University Press</title></titles><pages>349-376</pages><dates><year>1990</year></dates><urls></urls></record></Cite></EndNote>(Gibson, 1990). However hemoglobin levels usually remain in the normal range until the third stage and characterize iron deficiency anemia (IDA). Exhaustion of iron stores, depressed levels of circulating iron, microcytic and hypochromic anemia characterize IDA, the third stage of iron deficiency. Hence to identify IDA both hemoglobin an indicator of anemia and two indicators of iron deficiency such as low erythrocyte mean cell volume (MCV), low ferritin, high zinc protoporphyrin (ZPP) and/ high sTfR (Breymann et al, 2011; Domellof et al, 2007) are needed. The WHO for example defines IDA in infants as a combination of hemoglobin < 110 g/L, ferritin < 12 ?g/L and sTfR > 8.3 mg/L PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJ2YWxobzwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA (WHO., 2001; Carvalho et al, 2010) to reflect functional impairment, tissue avidity for iron, and iron storage, respectively in determining IDA ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2001</Year><RecNum>4442</RecNum><DisplayText>(WHO., 2001; WHO/CDC., 2007)</DisplayText><record><rec-number>4442</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4442</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title>Iron deficiency anaemia: assessment, prevention and control. A guide for programme managers , accessed September 2011</title></titles><dates><year>2001</year></dates><urls></urls></record></Cite><Cite><Author>WHO/CDC.</Author><Year> 2007</Year><RecNum>826</RecNum><record><rec-number>826</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">826</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO/CDC.</author></authors></contributors><titles><title>Assessing the iron status of populations. Second edition, including Literature Reviews. Geneva: WHO; ? ,accessed May 2011).</title></titles><dates><year> 2007</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2001; WHO/CDC., 2007), together with the use of acute phase protein in areas with high rates of infection ADDIN EN.CITE <EndNote><Cite><Author>WHO/CDC.</Author><Year> 2007</Year><RecNum>826</RecNum><DisplayText>(WHO/CDC., 2007)</DisplayText><record><rec-number>826</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">826</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO/CDC.</author></authors></contributors><titles><title>Assessing the iron status of populations. Second edition, including Literature Reviews. Geneva: WHO; ? ,accessed May 2011).</title></titles><dates><year> 2007</year></dates><urls></urls></record></Cite></EndNote>(WHO/CDC., 2007). Iron depletionIron-deficient erythropoiesisIron deficiency anemiaPlasma ferritin (μg/L)?????Transferrin saturation (%)Normal??sTfRNormal???RBC protoporphyrin (μg/dL)Normal???Hemoglobin g/dLNormalNormal?ErythrocytesNormalNormalMicrocytic/ HypochromicTable 1.1: Stages in the development of iron deficiency. Adapted from ADDIN EN.CITE <EndNote><Cite><Author>Herbert</Author><Year>1987</Year><RecNum>4484</RecNum><DisplayText>(Herbert, 1987)</DisplayText><record><rec-number>4484</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4484</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Herbert, V.</author></authors></contributors><titles><title>Recommended dietary intakes (RDI) of iron in humans</title><secondary-title>The American journal of clinical nutrition</secondary-title><alt-title>Am J Clin Nutr</alt-title></titles><periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></periodical><alt-periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></alt-periodical><pages>679-86</pages><volume>45</volume><number>4</number><edition>1987/04/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Intestinal Absorption</keyword><keyword>Iron/*administration & dosage/adverse effects/metabolism</keyword><keyword>Lactation</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nutritional Requirements</keyword><keyword>Nutritive Value</keyword><keyword>Pregnancy</keyword></keywords><dates><year>1987</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0002-9165 (Print)
0002-9165 (Linking)</isbn><accession-num>3565294</accession-num><work-type>Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.</work-type><urls><related-urls><url>;(Herbert, 1987).Iron BiomarkersSoluble transferrin receptors (sTfR) are present on the surfaces of every iron incorporating cell and facilitate uptake of iron into the cell ADDIN EN.CITE <EndNote><Cite><Author>Beguin</Author><Year>2003</Year><RecNum>4477</RecNum><DisplayText>(Beguin, 2003)</DisplayText><record><rec-number>4477</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4477</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beguin, Y.</author></authors></contributors><auth-address>Department of Medicine, Division of Hematology, University of Liege, CHU Sart Tilman, 4000 Liege, Belgium. yves.beguin@chu.ulg.ac.be</auth-address><titles><title>Soluble transferrin receptor for the evaluation of erythropoiesis and iron status</title><secondary-title>Clinica chimica acta; international journal of clinical chemistry</secondary-title><alt-title>Clin Chim Acta</alt-title></titles><periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></periodical><alt-periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></alt-periodical><pages>9-22</pages><volume>329</volume><number>1-2</number><edition>2003/02/19</edition><keywords><keyword>Animals</keyword><keyword>Erythropoiesis/*physiology</keyword><keyword>Humans</keyword><keyword>Iron/*blood</keyword><keyword>Nutritional Status</keyword><keyword>Receptors, Transferrin/*metabolism</keyword></keywords><dates><year>2003</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-8981 (Print)
0009-8981 (Linking)</isbn><accession-num>12589962</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Beguin, 2003). Increased sTfR indicates functional iron deficiency, increased erythropoiesis and increased iron needs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmV5bWFubjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+
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ADDIN EN.CITE.DATA (Breymann, 2002; Lewis et al, 2007; Jain et al, 2010). However sTfR is affected by the rate of erythropoiesis, which varies by age hence age cutoffs are still needed PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdW5nJmFwb3M7dTwvQXV0aG9yPjxZZWFyPjIwMDk8L1ll
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdW5nJmFwb3M7dTwvQXV0aG9yPjxZZWFyPjIwMDk8L1ll
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ADDIN EN.CITE.DATA (Beguin, 2003; Kung'u et al, 2009). Ferritin is the most frequently used indicator of iron status. In healthy individuals a ferritin concentration of 1 μg/L (between 20-300 μg/L) is equivalent to ≈10 mg of storage iron ADDIN EN.CITE <EndNote><Cite><Author>Gibson</Author><Year>1990</Year><RecNum>4483</RecNum><DisplayText>(Gibson, 1990)</DisplayText><record><rec-number>4483</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4483</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gibson, R.S.</author></authors></contributors><titles><title>Assessment of iron status. In: Principles of nutritional assessment. Oxford, United Kingdom: Oxford University Press</title></titles><pages>349-376</pages><dates><year>1990</year></dates><urls></urls></record></Cite></EndNote>(Gibson, 1990). Although low plasma ferritin is a reliable index of iron deficiency in the absence of inflammation, ferritin is a positive acute phase protein and thus normal or raised values maybe observed in deficient individuals in the presence of inflammation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3RpbjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Totin et al, 2002). Therefore to avoid misclassification of iron biomarkers in epidemiological or clinical studies, the WHO recommends measurement of an acute phase protein (APP) to aid in the interpretation of iron status indicators in areas with high rates of infection.Acute Phase ProteinsThe acute phase response (APR) is an innate immune response to inflammation triggered by cytokines including interleukin-1 (IL-1), tumour necrosis factor-alpha (TNF-a) and IL-6 ADDIN EN.CITE <EndNote><Cite><Author>Northrop-Clewes</Author><Year>2008</Year><RecNum>4853</RecNum><DisplayText>(Northrop-Clewes, 2008)</DisplayText><record><rec-number>4853</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4853</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Northrop-Clewes, C. A.</author></authors></contributors><auth-address>Division of Nutrition and Physical Activity, International Micronutrient Malnutrition Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA. christine.clewes@mrc-hnr.cam.ac.uk</auth-address><titles><title>Interpreting indicators of iron status during an acute phase response--lessons from malaria and human immunodeficiency virus</title><secondary-title>Annals of clinical biochemistry</secondary-title><alt-title>Ann Clin Biochem</alt-title></titles><periodical><full-title>Annals of clinical biochemistry</full-title><abbr-1>Ann Clin Biochem</abbr-1></periodical><alt-periodical><full-title>Annals of clinical biochemistry</full-title><abbr-1>Ann Clin Biochem</abbr-1></alt-periodical><pages>18-32</pages><volume>45</volume><number>Pt 1</number><edition>2008/02/16</edition><keywords><keyword>Acquired Immunodeficiency Syndrome/*blood</keyword><keyword>Acute-Phase Reaction/*blood</keyword><keyword>Animals</keyword><keyword>Ferritins/blood</keyword><keyword>Humans</keyword><keyword>Iron/*blood</keyword><keyword>Malaria/*blood</keyword></keywords><dates><year>2008</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0004-5632 (Print)
0004-5632 (Linking)</isbn><accession-num>18275670</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Northrop-Clewes, 2008). Iron metabolism and iron status is influenced by infection and inflammation through the APR, obscuring the interpretation of iron biomarkers most notably ferritin a positive acute phase protein (APP), as the host modifies iron metabolism to make iron less available to pathogens. APPs frequently used in epidemiological and clinical studies include CRP, AGP and a-1-antichymotrypsin (ACT) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXdhdDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Rawat et al, 2009). CRP increases rapidly within the first 5 hours of infection and peaks between 24 and 48 hours after infection followed by a rapid decline (Figure 1.3). AGP rises more slowly and peaks between 3–5 days after infection, and remains elevated in different infections PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXdhdDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Thurnham et al, 2005; Northrop-Clewes, 2008; Rawat et al, 2009). Figure 1.3. Percentage change in APP in response to inflammation/infection. (Reproduced from ADDIN EN.CITE <EndNote><Cite><Author>Northrop-Clewes</Author><Year>2008</Year><RecNum>4853</RecNum><DisplayText>(Northrop-Clewes, 2008)</DisplayText><record><rec-number>4853</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4853</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Northrop-Clewes, C. A.</author></authors></contributors><auth-address>Division of Nutrition and Physical Activity, International Micronutrient Malnutrition Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA. christine.clewes@mrc-hnr.cam.ac.uk</auth-address><titles><title>Interpreting indicators of iron status during an acute phase response--lessons from malaria and human immunodeficiency virus</title><secondary-title>Annals of clinical biochemistry</secondary-title><alt-title>Ann Clin Biochem</alt-title></titles><periodical><full-title>Annals of clinical biochemistry</full-title><abbr-1>Ann Clin Biochem</abbr-1></periodical><alt-periodical><full-title>Annals of clinical biochemistry</full-title><abbr-1>Ann Clin Biochem</abbr-1></alt-periodical><pages>18-32</pages><volume>45</volume><number>Pt 1</number><edition>2008/02/16</edition><keywords><keyword>Acquired Immunodeficiency Syndrome/*blood</keyword><keyword>Acute-Phase Reaction/*blood</keyword><keyword>Animals</keyword><keyword>Ferritins/blood</keyword><keyword>Humans</keyword><keyword>Iron/*blood</keyword><keyword>Malaria/*blood</keyword></keywords><dates><year>2008</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0004-5632 (Print)
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ADDIN EN.CITE.DATA (Kung'u et al, 2009), although there is some evidence that sTfR is influenced by inflammation in HIV infected adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXdhdDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Rawat et al, 2009).HepcidinOriginally named liver-expressed antimicrobial peptide (LEAP-1) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmFuY2hpbmk8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy
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ADDIN EN.CITE.DATA (Krause et al, 2000; Park et al, 2001; Pigeon et al, 2001), hepcidin is considered the major regulator of iron metabolism PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Kroot et al, 2010; Galesloot et al, 2011; Pasricha et al, 2011; Troutt et al, 2012). Hepcidin, a 25-amino acid peptide hormone is secreted by hepatocytes as an 84-amino-acid pre-prohepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QaWdlb248L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Pigeon et al, 2001) encoded by the human hepcidin gene (HAMP; OMIM 606464), which contains three exons and is located on chromosome 19q13.1 ADDIN EN.CITE <EndNote><Cite><Author>Franchini</Author><Year>2010</Year><RecNum>133</RecNum><DisplayText>(Franchini<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>133</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">133</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Franchini, M.</author><author>Montagnana, M.</author><author>Lippi, G.</author></authors></contributors><auth-address>Servizio di Immunoematologia e Medicina Trasfusionale, Dipartimento di Patologia e Medicina di Laboratorio, Azienda Ospedaliero-Universitaria di Parma, Italy. mfranchini@ao.pr.it</auth-address><titles><title>Hepcidin and iron metabolism: from laboratory to clinical implications</title><secondary-title>Clinica chimica acta; international journal of clinical chemistry</secondary-title><alt-title>Clin Chim Acta</alt-title></titles><periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></periodical><alt-periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></alt-periodical><pages>1565-9</pages><volume>411</volume><number>21-22</number><edition>2010/07/14</edition><keywords><keyword>Antimicrobial Cationic Peptides/*metabolism/physiology</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Iron/*metabolism</keyword><keyword>Iron Metabolism Disorders/diagnosis/etiology/*metabolism</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov 11</date></pub-dates></dates><isbn>1873-3492 (Electronic)
0009-8981 (Linking)</isbn><accession-num>20620132</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Franchini et al, 2010). The prohormone is converted into a 64 amino acid prohepcidin during export from the cytoplasm and further posttranslationally converted into hepcidin-25 amino acid ADDIN EN.CITE <EndNote><Cite><Author>Wessling-Resnick</Author><Year>2008</Year><RecNum>1923</RecNum><DisplayText>(Wessling-Resnick, 2008)</DisplayText><record><rec-number>1923</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">1923</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wessling-Resnick, M.</author></authors></contributors><auth-address>Harvard School of Public Health, USA.</auth-address><titles><title>The irony of host defense</title><secondary-title>Blood</secondary-title><alt-title>Blood</alt-title></titles><periodical><full-title>Blood</full-title><abbr-1>Blood</abbr-1></periodical><alt-periodical><full-title>Blood</full-title><abbr-1>Blood</abbr-1></alt-periodical><pages>460</pages><volume>112</volume><number>3</number><edition>2008/07/25</edition><dates><year>2008</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>1528-0020 (Electronic)
0006-4971 (Linking)</isbn><accession-num>18650460</accession-num><work-type>Comment</work-type><urls><related-urls><url>;(Wessling-Resnick, 2008). Further processing generates two smaller N-terminal truncated isoforms (hepcidin-20 and -22) whose biological function has not yet been determined PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXJrPC9BdXRob3I+PFllYXI+MjAwMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Park et al, 2001; Ganz et al, 2008; Grebenchtchikov et al, 2009). The peptide hormone is a member of the defensins family, a group of small cationic, antibiotic peptides that form part of the innate immune system ADDIN EN.CITE <EndNote><Cite><Author>Ganz</Author><Year>1995</Year><RecNum>1961</RecNum><DisplayText>(Ganz& Lehrer, 1995)</DisplayText><record><rec-number>1961</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">1961</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ganz, T.</author><author>Lehrer, R. I.</author></authors></contributors><auth-address>Department of Medicine, University of California School of Medicine, Los Angeles 90024-1736, USA.</auth-address><titles><title>Defensins</title><secondary-title>Pharmacology & therapeutics</secondary-title><alt-title>Pharmacol Ther</alt-title></titles><pages>191-205</pages><volume>66</volume><number>2</number><edition>1995/05/01</edition><keywords><keyword>Amino Acid Sequence</keyword><keyword>Animals</keyword><keyword>*Anti-Infective Agents</keyword><keyword>Blood Proteins/*biosynthesis/chemistry/*immunology</keyword><keyword>Defensins</keyword><keyword>Humans</keyword><keyword>Molecular Sequence Data</keyword><keyword>Neutrophils/chemistry/*immunology/metabolism</keyword><keyword>Phagocytes/chemistry/immunology</keyword></keywords><dates><year>1995</year><pub-dates><date>May</date></pub-dates></dates><isbn>0163-7258 (Print)
0163-7258 (Linking)</isbn><accession-num>7667395</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Ganz& Lehrer, 1995). Hepcidin regulates iron influx into the plasma by regulating tissues involved in iron absorption, storage, transport and recycling of iron from senescent erythrocytes: duodenal enterocytes, hepatocytes, the placenta and macrophages PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Franchini et al, 2010; Galesloot et al, 2011). Hepcidin binds to ferroportin the only known mammalian iron exporter, inducing its internalization and lysosomal degradation, thereby effectively blocking iron efflux from macrophages, the placenta and hepatocytes; and attenuating iron absorption by duodenal enterocytes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmViZW5jaHRjaGlrb3Y8L0F1dGhvcj48WWVhcj4yMDA5
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ADDIN EN.CITE.DATA (Grebenchtchikov et al, 2009; Pasricha et al, 2011). Hepcidin synthesis is physiologically increased by elevated plasma iron concentration PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZW1ldGg8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Kroot et al, 2010; Galesloot et al, 2011). Decreased hepcidin concentrations result in the release of macrophage iron and increase duodenal iron absorption ADDIN EN.CITE <EndNote><Cite><Author>Nemeth</Author><Year>2006</Year><RecNum>2007</RecNum><DisplayText>(Nemeth& Ganz, 2006)</DisplayText><record><rec-number>2007</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2007</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nemeth, E.</author><author>Ganz, T.</author></authors></contributors><auth-address>Departments of Medicine and Pathology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA. enemeth@mednet.ucla.edu</auth-address><titles><title>Regulation of iron metabolism by hepcidin</title><secondary-title>Annual review of nutrition</secondary-title><alt-title>Annu Rev Nutr</alt-title></titles><pages>323-42</pages><volume>26</volume><edition>2006/07/20</edition><keywords><keyword>Antimicrobial Cationic Peptides/genetics/metabolism/*physiology</keyword><keyword>Hemochromatosis/genetics/metabolism</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Inflammation/complications/metabolism</keyword><keyword>Iron/*metabolism</keyword><keyword>Iron Metabolism Disorders/metabolism</keyword></keywords><dates><year>2006</year></dates><isbn>0199-9885 (Print)
0199-9885 (Linking)</isbn><accession-num>16848710</accession-num><work-type>Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Review</work-type><urls><related-urls><url>;(Nemeth& Ganz, 2006). Hepcidin deficiency is the cause of iron overload in most hereditary hemochromatosis and contributes to iron overload in β-thalassemia and other iron-loading anemia types PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Kroot et al, 2009). Two types of hepcidin assays are currently available for research use: immunoassays based on anti-hepcidin antibodies, and mass spectrometric assays (MS) that detect the characteristic mass of the active 25 amino acid hepcidin species ADDIN EN.CITE <EndNote><Cite><Author>Ganz</Author><Year>2011</Year><RecNum>2599</RecNum><DisplayText>(Ganz& Nemeth, 2011)</DisplayText><record><rec-number>2599</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2599</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ganz, T.</author><author>Nemeth, E.</author></authors></contributors><auth-address>Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California 90095, USA. TGanz@mednet.ucla.edu</auth-address><titles><title>Hepcidin and disorders of iron metabolism</title><secondary-title>Annual review of medicine</secondary-title><alt-title>Annu Rev Med</alt-title></titles><pages>347-60</pages><volume>62</volume><edition>2010/10/05</edition><keywords><keyword>Aging/metabolism</keyword><keyword>Anemia/metabolism</keyword><keyword>Animals</keyword><keyword>Antimicrobial Cationic Peptides/agonists/antagonists & inhibitors/*metabolism</keyword><keyword>Cation Transport Proteins/metabolism</keyword><keyword>Female</keyword><keyword>Hepatocytes/metabolism</keyword><keyword>Humans</keyword><keyword>Inflammation/metabolism</keyword><keyword>Interleukin-6/metabolism</keyword><keyword>Iron/*metabolism</keyword><keyword>Iron Metabolism Disorders/drug therapy/*metabolism</keyword><keyword>Iron, Dietary/metabolism</keyword><keyword>Kidney Diseases/metabolism</keyword><keyword>Male</keyword><keyword>Mice</keyword><keyword>Neoplasms/metabolism</keyword><keyword>Transferrin/metabolism</keyword></keywords><dates><year>2011</year></dates><isbn>1545-326X (Electronic)
0066-4219 (Linking)</isbn><accession-num>20887198</accession-num><work-type>Research Support, Non-U.S. Gov't
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Galesloot et al, 2011), enzyme immunoassay (EIA) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Berglund et al, 2011) and radioimmunoassay (RIA) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmViZW5jaHRjaGlrb3Y8L0F1dGhvcj48WWVhcj4yMDA5
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ADDIN EN.CITE.DATA (Kroot et al, 2009). Hence there is currently no gold standard assay, each approach offering relative advantages and caveats (Table 1. 2). Immunoassays are limited by the hepcidin’s highly conserved “compact hairpin,” structure with four disulfide bonds among eight cysteine residues which restricts the number of antigenic epitopes ADDIN EN.CITE <EndNote><Cite><Author>Castagna</Author><Year>2010</Year><RecNum>2602</RecNum><DisplayText>(Castagna<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>2602</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2602</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castagna, A.</author><author>Campostrini, N.</author><author>Zaninotto, F.</author><author>Girelli, D.</author></authors></contributors><auth-address>Department of Clinical and Experimental Medicine, University of Verona, Verona, Italy. annalisa.castagna@univr.it</auth-address><titles><title>Hepcidin assay in serum by SELDI-TOF-MS and other approaches</title><secondary-title>Journal of proteomics</secondary-title><alt-title>J Proteomics</alt-title></titles><pages>527-36</pages><volume>73</volume><number>3</number><edition>2009/08/18</edition><keywords><keyword>Antimicrobial Cationic Peptides/*analysis/blood</keyword><keyword>Clinical Laboratory Techniques</keyword><keyword>Homeostasis/physiology</keyword><keyword>Humans</keyword><keyword>Iron/metabolism</keyword><keyword>Models, Biological</keyword><keyword>Serum/*chemistry</keyword><keyword>Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization/*methods</keyword></keywords><dates><year>2010</year><pub-dates><date>Jan 3</date></pub-dates></dates><isbn>1876-7737 (Electronic)</isbn><accession-num>19683083</accession-num><work-type>Research Support, Non-U.S. Gov't
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ADDIN EN.CITE.DATA (Galesloot et al, 2011). It is, however, worth noting that such isoforms are rare in reference healthy populations PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Galesloot et al, 2011). Advantages of immunoassays include: a lower limit of detection, lower cost, high-throughput and potential for wide application in clinical settings compared to MS.Mass spectrometry-based methods on the other hand are often semi-quantitative due to competition during binding steps, and variations in ionization efficiency unless a proper internal standard is used PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008) and require skilled personnel. AssayAdvantagesLimitationsImmunoassaysLow limit of detectionLow cost High-throughputLack specificity for hepcidin isoformsMass spectrometry-based methodsCan distinguish between hepcidin isoformsProvide semi-quantitative measurements unless a proper internal standard is usedRely on expensive equipment that is not widely available Require skilled personnel. Table 1.2 Advantages and limitations of hepcidin assaysAn interim solution is an algorithm generated from the medians of duplicate native samples obtained by 2 highly correlated methodsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012). The algorithm can be used to generate hepcidin consensus values (HEPCON1) for 13 ‘‘well performing’’ assays (within sample variation (reliability) < 10% of the total variance and a spearman rank correlations > 0.90 with the other assays) from an initial list of 11 MS PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb2JvbGQ8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Murao et al, 2007; Murphy et al, 2007; Kobold et al, 2008; Swinkels et al, 2008; Ward et al, 2008; Altamura et al, 2009; Bansal et al, 2009; Li et al, 2009; Crockett et al, 2010; Kroot et al, 2010; Anderson et al, 2011) and 10 immunoassays PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (De Domenico et al, 2008; Ganz et al, 2008; Busbridge et al, 2009; Grebenchtchikov et al, 2009; Koliaraki et al, 2009; Butterfield et al, 2010; Kroot et al, 2010; Schwarz et al, 2011; Kroot et al, 2012). A caveat however is that these algorithms have not yet been applied by the general research community and may be less reliable in the low and high hepcidin concentration range PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012).Relationship between hepcidin and iron and inflammatory biomarkersA limited number of studies have characterized the association between hepcidin and markers of infection, inflammation and iron status in humans. However studies have consistently reported a strong correlation between hepcidin and ferritin, the most important correlate of hepcidin concentration in healthy adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bc2hieTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Schulze et al, 2008; Swinkels et al, 2008; Ashby et al, 2009; Galesloot et al, 2011) preterm infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWxsZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Muller et al, 2012) and among low birth weight infants (6 weeks, 12 weeks and 6 months-old) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Berglund et al, 2011). A 1% change in serum ferritin (μg/L) for example was associated with a 0.81% and 0.85% change in hepcidin concentration (nmol/L), in men and women respectively, in adjusted linear regression models in a large population based study in the Netherlands PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Galesloot et al, 2011). Both hepcidin and ferritin are positive APP and respond similarly to inflammation and changes in iron stores. However, hepcidin responses take place on the time scale of a few hours peaking 6 hours after infection, whereas changes in ferritin concentrations are much slower peaking 24 to 48 hours after initiation of inflammation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012). Although IL-6 triggers both CRP and hepcidin synthesis, studies on the correlations between hepcidin and CRP are inconsistent. A positive association between hepcidin and CRP has been reported in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Galesloot et al, 2011) and neonates with sepsis, making it a useful biomarker for diagnosing late onset neonatal sepsis ADDIN EN.CITE <EndNote><Cite><Author>Wu</Author><Year>2013</Year><RecNum>322</RecNum><DisplayText>(Wu<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>322</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">322</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wu, T. W.</author><author>Tabangin, M.</author><author>Kusano, R.</author><author>Ma, Y.</author><author>Ridsdale, R.</author><author>Akinbi, H.</author></authors></contributors><auth-address>Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.</auth-address><titles><title>The utility of serum hepcidin as a biomarker for late-onset neonatal sepsis</title><secondary-title>The Journal of pediatrics</secondary-title><alt-title>J Pediatr</alt-title></titles><periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></periodical><alt-periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></alt-periodical><pages>67-71</pages><volume>162</volume><number>1</number><edition>2012/07/17</edition><keywords><keyword>Age of Onset</keyword><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Biological Markers/blood</keyword><keyword>C-Reactive Protein/analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Very Low Birth Weight</keyword><keyword>Male</keyword><keyword>Predictive Value of Tests</keyword><keyword>Sepsis/*blood/*diagnosis</keyword></keywords><dates><year>2013</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1097-6833 (Electronic)
0022-3476 (Linking)</isbn><accession-num>22796049</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>;(Wu et al, 2013). However hepcidin was not correlated with CRP in preterm infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWxsZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Muller et al, 2012). Hepcidin was modestly associated with AGP but not CRP in pregnant Bangladeshi women PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1bHplPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1bHplPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE.DATA (Schulze et al, 2008). The inconsistent results may be due to the fact that hepcidin and CRP have different time course of synthesis: hepcidin concentrations change much faster and have been reported to peak 6 hours after initiation of inflammation in contrast to CRP concentrations that peaks between 24 to 48 hours after initiation of inflammation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWxsZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Northrop-Clewes, 2008; Schulze et al, 2008; Muller et al, 2012; Wu et al, 2013).Hepcidin studies in infancyGiven the pivotal role of hepcidin in understanding and characterizing iron metabolism in infancy, studies quantifying hepcidin levels across infancy are warranted. Establishing normative values of plasma hepcidin in healthy growing infants is particularly important because of the dynamic hematological changes associated with infancy. However a limited number of studies have characterized hepcidin levels in infancy and the use of different assays often precludes comparisons across studies.Only one study has described reference values for hepcidin in cord blood. Rehu et al reported plasma hepcidin median (geometric mean concentration (GMC) range) 78.4 (20.5 and 231.9 ng/mL) using an ELISA from Intrinsic Life Sciences, CA, USA among 137 healthy full term infants (37- 44 weeks gestation) in Finland ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
0902-4441 (Linking)</isbn><accession-num>20528904</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Rehu et al, 2010) (Table 1.2). The study excluded newborns with anemia, iron deficiency, increased erythropoiesis, inflammation and iron overload as defined by hemoglobin ≤ 145 g/L, transferrin saturation ≤ 30%, erythropoietin (EPO) > 97.5th percentile, CRP ≥ 10 mg/L and serum ferritin > 1153.3 μg/L in cord blood, respectively ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
0902-4441 (Linking)</isbn><accession-num>20528904</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Rehu et al, 2010). A second study using the same assay reported similar hepcidin levels (median (SD) 61.7 (77.0 μg/L)) among 19 neonates at birth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Zb3VuZzwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Young et al, 2012). The high hepcidin levels reported by both these studies are consistent with the very high hemoglobin levels and slow rate of erythropoiesis during the first stage of iron nutrition.Neonatal serum hepcidin concentrations were lower in a study among 31 preterm infants (23-32 weeks gestation) GMC (95% CI) 48.5 (33.0-71.3 ng/mL) at 35 days postnatal (IQR: 26-48 days) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWxsZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Muller et al, 2012) using the same assay. This is consistent with lower iron stores in preterm infants and a greater demand for iron compared to full term infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Rehu et al, 2010; Muller et al, 2012). A trial on the effects of iron supplementation with 1 or 2 mg/kg of iron daily from 6 weeks to 6 months of age among 285 low birth weight infants (between 2000 and 2500 g) reported mean (SD) hepcidin 12.2 ng/mL (1.8 ng/mL) at 6 weeks using an ELISA from Bachem CA, USA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Domellof et al, 2002; Hicks et al, 2006). Hence these results offer a possible mechanism through which infants adapt iron absorption to iron status. Hepcidin levels were lower in low birth weight infants compared to normal birth weight infants ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
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ADDIN EN.CITE.DATA (Kroot et al, 2009).We are only aware of one study in the literature in which the association between hepcidin and infection in infants was examined. Wu et al reported 4-fold higher levels of hepcidin concentrations in very low birth weight (VLBW) infant with late onset neonatal sepsis compared to VLBW infants without late onset neonatal sepsis and similar hepcidin concentrations between the two groups after therapy using capture enzyme-linked immunosorbent assay ADDIN EN.CITE <EndNote><Cite><Author>Wu</Author><Year>2013</Year><RecNum>322</RecNum><DisplayText>(Wu<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>322</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">322</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wu, T. W.</author><author>Tabangin, M.</author><author>Kusano, R.</author><author>Ma, Y.</author><author>Ridsdale, R.</author><author>Akinbi, H.</author></authors></contributors><auth-address>Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.</auth-address><titles><title>The utility of serum hepcidin as a biomarker for late-onset neonatal sepsis</title><secondary-title>The Journal of pediatrics</secondary-title><alt-title>J Pediatr</alt-title></titles><periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></periodical><alt-periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></alt-periodical><pages>67-71</pages><volume>162</volume><number>1</number><edition>2012/07/17</edition><keywords><keyword>Age of Onset</keyword><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Biological Markers/blood</keyword><keyword>C-Reactive Protein/analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Very Low Birth Weight</keyword><keyword>Male</keyword><keyword>Predictive Value of Tests</keyword><keyword>Sepsis/*blood/*diagnosis</keyword></keywords><dates><year>2013</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1097-6833 (Electronic)
0022-3476 (Linking)</isbn><accession-num>22796049</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>;(Wu et al, 2013). Although limited, these studies suggest that hepcidin is influenced by both iron nutriture and infection in preterm and low birth weight infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWh1PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012; Young et al, 2012; Wu et al, 2013)..Hepcidin studies in adultsA number of hepcidin studies have been conducted in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Swinkels et al, 2008; Grebenchtchikov et al, 2009; Galesloot et al, 2011). Ganz et al created a reference for plasma hepcidin concentration in adult men and women and reported a 5% to 95% range of 29 to 254 ng/mL median 112 ng/mL in men (n=65) and 17 to 286 ng/mL median 65 ng/mL in women (n=49) using the first competitive ELISA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Grebenchtchikov et al, 2009). However, a study using SELDI-TOF MS did not find a significant difference in hepcidin concentrations between men and women PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Td2lua2VsczwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+
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ADDIN EN.CITE.DATA (Swinkels et al, 2008).Galesloot et al extended these findings using a similar competitive ELISA to Ganz et al PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Grebenchtchikov et al, 2009).Hepcidin concentrations were constant over age in men median (2.5th and 97.5th percentiles): 7.8 nM (0.6 - 23.3 nM) but were higher in postmenopausal compared to premenopausal women (4.1 nM (0.4 - 19.7 nM) in women < 55 years and 8.5 nM (1.2-24.8 nM) in women > 55 years) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Galesloot et al, 2011). Galesoot et al reported lower median hepcidin concentrations compared to Ganz et al and found a less pronounced difference in hepcidin concentrations between men and women PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Galesloot et al, 2011). Although the difference in absolute hepcidin values obtained by different assays precludes the comparison of hepcidin concentrations across different assays, among studies using the Ganz assay, hepcidin concentrations in infants are consistently lower compared to those in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Rehu et al, 2010; Muller et al, 2012; Young et al, 2012). These infant studies included cord blood samples from healthy term infants ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
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ADDIN EN.CITE.DATA (Muller et al, 2012). This is consistent with higher iron needs in infants compared to adults particularly in preterm infants. We would expect hepcidin concentrations to be even lower in older infants as erythropoiesis increases and the infant becomes dependent on exogenous iron in the 2nd and 3rd stage of iron nutrition respectively.Chapter 2 characterizes hepcidin levels in healthy non-anemic infants at 3 ages (3, 6 and 12 months), in the 2nd and 3rd stages of iron nutriture, when anemia is more prevalent, as erythropoiesis increases and the infant becomes dependent on exogenous supply of iron, respectively. Older infants are particularly vulnerable to anemia through mechanisms described above, however anemia has been described as early as 3 months. By selecting healthy non-anemic infants, we describe hepcidin levels that are apparently associated with effective mobilization of iron stores and adequate absorption of dietary iron. The role of hepcidin in anemia of inflammation Hepcidin’s role as part of the innate immune system is associated with anemia of inflammation. Anemia of inflammation is defined as a mild-to-moderate, normochromic/ normocytic anemia associated with a chronic inflammatory, infectious or neoplastic illness and altered iron homeostasis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4xOTgzPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Lee, 1983; Weiss, 2002; Jain et al, 2010; Cullis, 2011). Anemia of inflammation is induced by a stimulated innate immune system through mechanisms mediated by inflammatory cytokines, acute phase proteins and hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWlzczwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Weiss, 2002; Means, 2004; Weiss& Goodnough, 2005; Weiss, 2009). The hypoferremia associated with anemia of inflammation is caused primarily by iron sequestration into reticuloendothelial macrophages PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2xlbnRpbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy
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ADDIN EN.CITE.DATA (Lee, 1983; Tolentino& Friedman, 2007). Increased uptake and retention of iron within cells of the reticuloendothelial system leads to a diversion of iron from the circulatory system into storage sites of the reticuloendothelial system ADDIN EN.CITE <EndNote><Cite><Author>Weiss</Author><Year>2005</Year><RecNum>4118</RecNum><DisplayText>(Weiss& Goodnough, 2005)</DisplayText><record><rec-number>4118</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4118</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weiss, G.</author><author>Goodnough, L. T.</author></authors></contributors><auth-address>Department of General Internal Medicine, Clinical Immunology and Infectious Diseases, Medical University of Innsbruck, Innsbruck, Austria. guenter.weiss@uibk.ac.at</auth-address><titles><title>Anemia of chronic disease</title><secondary-title>The New England journal of medicine</secondary-title><alt-title>N Engl J Med</alt-title></titles><periodical><full-title>The New England journal of medicine</full-title><abbr-1>N Engl J Med</abbr-1></periodical><alt-periodical><full-title>The New England journal of medicine</full-title><abbr-1>N Engl J Med</abbr-1></alt-periodical><pages>1011-23</pages><volume>352</volume><number>10</number><edition>2005/03/11</edition><keywords><keyword>*Anemia/diagnosis/etiology/physiopathology/therapy</keyword><keyword>Animals</keyword><keyword>Blood Transfusion</keyword><keyword>*Chronic Disease</keyword><keyword>Erythroid Precursor Cells/physiology</keyword><keyword>Erythropoietin/blood/physiology/*therapeutic use</keyword><keyword>Homeostasis/physiology</keyword><keyword>Humans</keyword><keyword>Iron/metabolism/*therapeutic use</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar 10</date></pub-dates></dates><isbn>1533-4406 (Electronic)
0028-4793 (Linking)</isbn><accession-num>15758012</accession-num><work-type>Research Support, Non-U.S. Gov't
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ADDIN EN.CITE.DATA (Weiss& Goodnough, 2005; Drakesmith& Prentice, 2008; Xu et al, 2010). Proinflammatory cytokines interleukin-1 (IL-1) and tumor necrosis factor α (TNF- α) induce ferritin synthesis, iron acquisition and iron storage by the reticuloendothelial system ADDIN EN.CITE <EndNote><Cite><Author>Weiss</Author><Year>2002</Year><RecNum>4122</RecNum><DisplayText>(Weiss, 2002)</DisplayText><record><rec-number>4122</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weiss, G.</author></authors></contributors><auth-address>Department of Internal Medicine, University Hospital, Anichstr 35, A-6020 Innsbruck, Austria. guenter.weiss@uibk.ac.at</auth-address><titles><title>Pathogenesis and treatment of anaemia of chronic disease</title><secondary-title>Blood reviews</secondary-title><alt-title>Blood Rev</alt-title></titles><pages>87-96</pages><volume>16</volume><number>2</number><edition>2002/07/20</edition><keywords><keyword>Anemia/diagnosis/*etiology/therapy</keyword><keyword>Chronic Disease</keyword><keyword>Erythropoiesis</keyword><keyword>Humans</keyword><keyword>Immunity, Cellular</keyword><keyword>Inflammation/complications</keyword><keyword>Iron Metabolism Disorders</keyword></keywords><dates><year>2002</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0268-960X (Print)
0268-960X (Linking)</isbn><accession-num>12127952</accession-num><work-type>Research Support, Non-U.S. Gov't
Review</work-type><urls><related-urls><url>;(Weiss, 2002). Hepcidin synthesis is stimulated by TNF-α and IL-6 ADDIN EN.CITE <EndNote><Cite><Author>De Domenico</Author><Year>2007</Year><RecNum>2728</RecNum><DisplayText>(De Domenico<style face="italic"> et al</style>, 2007)</DisplayText><record><rec-number>2728</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2728</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>De Domenico, I.</author><author>Ward, D. M.</author><author>Kaplan, J.</author></authors></contributors><auth-address>Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84106, USA.</auth-address><titles><title>Hepcidin regulation: ironing out the details</title><secondary-title>The Journal of clinical investigation</secondary-title><alt-title>J Clin Invest</alt-title></titles><periodical><full-title>The Journal of clinical investigation</full-title><abbr-1>J Clin Invest</abbr-1></periodical><alt-periodical><full-title>The Journal of clinical investigation</full-title><abbr-1>J Clin Invest</abbr-1></alt-periodical><pages>1755-8</pages><volume>117</volume><number>7</number><edition>2007/07/04</edition><keywords><keyword>Animals</keyword><keyword>Antimicrobial Cationic Peptides/genetics/*metabolism</keyword><keyword>Bone Morphogenetic Proteins/metabolism</keyword><keyword>*Gene Expression Regulation</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Iron/*metabolism</keyword><keyword>Membrane Proteins/metabolism</keyword><keyword>Signal Transduction</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0021-9738 (Print)
0021-9738 (Linking)</isbn><accession-num>17607352</accession-num><work-type>Comment
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ADDIN EN.CITE.DATA (Lee, 1983; Means& Krantz, 1992; Means, 2000). Hepcidin contributes to anemia of inflammation primarily through its effects on ferritin, ADDIN EN.CITE <EndNote><Cite><Author>Means</Author><Year>2004</Year><RecNum>2585</RecNum><DisplayText>(Means, 2004)</DisplayText><record><rec-number>2585</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2585</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Means, R. T., Jr.</author></authors></contributors><auth-address>Hematology/Oncology Division, Department of Medicine, Ralph H. Johnson VA Medical Center and the Medical University of South Carolina, 903 CSB, 96 Jonathan Lucas Street, Charleston, SC 29425, USA. meansr@musc.edu</auth-address><titles><title>Hepcidin and anaemia</title><secondary-title>Blood reviews</secondary-title><alt-title>Blood Rev</alt-title></titles><pages>219-25</pages><volume>18</volume><number>4</number><edition>2004/10/27</edition><keywords><keyword>Anemia/*etiology</keyword><keyword>Animals</keyword><keyword>Antimicrobial Cationic Peptides/blood/*physiology/urine</keyword><keyword>Ferritins/blood</keyword><keyword>Humans</keyword><keyword>Iron/metabolism</keyword><keyword>Liver/chemistry/metabolism</keyword></keywords><dates><year>2004</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0268-960X (Print)
0268-960X (Linking)</isbn><accession-num>15501550</accession-num><work-type>Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.
Review</work-type><urls><related-urls><url>(03)00066-3</electronic-resource-num><language>eng</language></record></Cite></EndNote>(Means, 2004) which is typically elevated in anemia of inflammation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWFuczwvQXV0aG9yPjxZZWFyPjIwMDQ8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Lee, 1983; Means, 2004). Cytokines and acute-phase proteins (IFN-γ, IFN-α, TNF-α and IL-1) also inhibit the growth and differentiation of erythroid progenitor cells ADDIN EN.CITE <EndNote><Cite><Author>Weiss</Author><Year>2009</Year><RecNum>2730</RecNum><DisplayText>(Weiss, 2009)</DisplayText><record><rec-number>2730</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2730</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weiss, G.</author></authors></contributors><auth-address>Department of Internal Medicine I, Clinical Immunology and Infectious Diseases, Medical University, Anichstr. 35, A-6020 Innsbruck, Austria. guenter@i-med.ac.at</auth-address><titles><title>Iron metabolism in the anemia of chronic disease</title><secondary-title>Biochimica et biophysica acta</secondary-title><alt-title>Biochim Biophys Acta</alt-title></titles><pages>682-93</pages><volume>1790</volume><number>7</number><edition>2008/09/13</edition><keywords><keyword>Anemia/diet therapy/*metabolism</keyword><keyword>Chronic Disease</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Inflammation/metabolism/*physiopathology</keyword><keyword>Interferon-gamma/antagonists & inhibitors</keyword><keyword>Iron/*metabolism</keyword><keyword>Macrophages/metabolism</keyword><keyword>Monocytes/metabolism</keyword><keyword>Receptors, Transferrin/physiology</keyword></keywords><dates><year>2009</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0006-3002 (Print)
0006-3002 (Linking)</isbn><accession-num>18786614</accession-num><work-type>Research Support, Non-U.S. Gov't
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ADDIN EN.CITE.DATA (Clark et al, 2002; Totin et al, 2002; Belperio& Rhew, 2004; Adetifa et al, 2006; Bolton-Moore et al, 2007; Bong et al, 2007; 2008; Marazzi et al, 2008; Wamalwa et al, 2010). Anemia in HIV infection is caused by multiple mechanisms including: the direct action of HIV on bone marrow cells, adverse reactions to antiretroviral therapy, opportunistic infections, vitamin B12 and iron deficiency anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2xlbnRpbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy
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ADDIN EN.CITE.DATA (Semba& Gray, 2001; Totin et al, 2002; Tolentino& Friedman, 2007; Adetifa& Okomo, 2009). However anemia of inflammation is thought to be the predominant cause of anemia in HIV infected patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2xlbnRpbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy
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ADDIN EN.CITE.DATA (Semba& Gray, 2001; Totin et al, 2002; Tolentino& Friedman, 2007; Adetifa& Okomo, 2009).Hepcidin as a pathogenic factor in HIV infectionApart from mediating anemia of inflammation, iron sequestration in reticuloendothelial macrophages through hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxsZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Xu et al, 2010). Elevated hepcidin concentration may protect the host against iron-dependent extracellular pathogens by decreasing iron supply to extracellular pathogens; however, elevated hepcidin concentration may also promote the growth and survival of iron dependent intracellular micro-organism such as HIV and Mycobacterium tuberculosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWlzczwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PFJl
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ZT4A
ADDIN EN.CITE.DATA (Weiss, 2005; Weiss& Goodnough, 2005; Galesloot et al, 2011; Kroot et al, 2011). HIV infection of macrophages is an important component of HIV pathogenesis and survival of HIV patients correlates inversely with higher iron stores in bone marrow macrophages PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5YdTwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA (Xu et al, 2010). Mycobacterium tuberculosis requires iron to grow and target macrophages to acquire iron PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAwODwvWWVh
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ADDIN EN.CITE.DATA (Boelaert et al, 2007). Hepcidin Studies in HIV InfectionHowever, only one study has reported hepcidin levels in HIV-infected individuals. They reported median (IQR) hepcidin concentration of 25.1 ng/mL (6.4–39.7) in 188 Rwandan HIV-positive women without ferroportin mutations using a monoclonal antibody immunoassay PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h3YXJ6PC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48
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ADDIN EN.CITE.DATA (Schwarz et al, 2011; Masaisa et al, 2012). While a smaller cohort of 12 women with a ferroportin mutation (Q248H mutation in the gene SLC40A1) associated with resistance to hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXNhaXNhPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Masaisa et al, 2012), had a median hepcidin concentration of 3.3 ng/mL (IQR 1.3-7.5). HIV exposure The large success of Prevention of Mother-to-Child Transmission (PMTCT) of HIV responses in the most affected African countries means that an increasing number of HIV exposed uninfected (HEU) infants are being born PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaWx0ZWF1PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA (Filteau, 2009). More than 18% of infants for example will be HEU if MTCT is reduced to 10% in countries with an antenatal HIV prevalence of more than 20% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaWx0ZWF1PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA (Marinda et al, 2007; Kumwenda et al, 2008; Filteau, 2009). HEU infants have reduced growth, increased rates of infections and higher mortality than HIV-unexposed infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFwaXJvPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Thea et al, 1993; Brahmbhatt et al, 2006; Otieno et al, 2006; Makasa et al, 2007; Marinda et al, 2007; McNally et al, 2007; Shapiro et al, 2007). Several studies have also highlighted immune abnormalities in HEU infants; however, the relationship between specific cytokine abnormalities and increased morbidity and mortality is still unclear PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DbGVyaWNpPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48
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ADDIN EN.CITE.DATA (Coovadia& Bland, 2007; Marinda et al, 2007). HEU infants are also exposed to infections carried by immune-compromised parents PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJpbmRhPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJpbmRhPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Marinda et al, 2007). Furthermore, increased vulnerability to anemia has been associated with infant exposure to maternal ART PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcnlkZW4tUGV0ZXJzb248L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA (Le Chenadec et al, 2003; Feiterna-Sperling et al, 2007; Dryden-Peterson et al, 2011; Ziske et al, 2013) in HEU infants.Chapter 3 characterizes the independent effects of HIV status, anemia and age on hepcidin concentration in infants from a well-defined cohort in Zimbabwe. Normative hepcidin values established in chapter 2 serve as the reference group in chapter 3. The study reported in chapter 3 of this thesis is, to our knowledge, the first to characterize hepcidin concentrations in HIV-infected sub-Saharan African infants, who are at particularly high risk of anemia.Table 1.3: Review of Hepcidin Studies.AssayStudy populationInclusion criteriaHepcidin concentrationCoefficient of variation (CV)Referencesc-ELISA (serum)Intrinsic Life Sciences 19 pregnant women (16-32 years)19 neonates (cord blood) median gestational age 39.9 weeks range 36.0-41.6 weeksHealthy, nonsmoking females with uncomplicated pregnancies were included. Participants were excluded if they had diabetes, underlying malabsorption diseases or medical conditions known to affect Fe homeostasisMedian (SD) at delivery:Mothers9.30 (50.1?g/L)Neonates61.7 (77.0 ?g/L)Intra-assay CV 5-19%Inter-assay CV 12%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Zb3VuZzwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Young et al, 2012)c-ELISA (Bachem)11 post malarial children mean age 28.1 months16 non malarial anemia children mean age 28.7 months (n=48)Post malarial anemia was defined by a fever and peripheral parasitemia. Non malarial anemia was defined by the absence of fever in the previous 7 days and no record of clinical malaria episodes or antimalarial treatment Mean ± SEDay 1 of Fe supplementationPost malarial anemia 25.5 ± 7.4 ng/mLNon malarial anemia12.8 ± 5.8 ng/mLDay 15 of Fe supplementationPost malarial anemia 16.3 ± 5.3 ng/mLNon malarial anemia17.5 ± 4.7 ng/mLNot providedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QcmVudGljZTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA (Prentice et al, 2012)c-ELISA (Bachem)100 Kenyan children aged 6 months to 10 years with acute malariaChildren with fever (> 38.5°C), anemia, and P. falciparum parasitemia were included. Children treated with antimalarials during the week before admissions were excluded. Median (IQR) baseline: 8.57 (1.00-39.05) ng/mL, one week after treatment: 1.69 (0-6.31) ng/mL one month after treatment: 0.43 (0.37-0.75) ng/mL Not provided ADDIN EN.CITE <EndNote><Cite><Author>Casals-Pascual</Author><Year>2012</Year><RecNum>1018</RecNum><DisplayText>(Casals-Pascual<style face="italic"> et al</style>, 2012)</DisplayText><record><rec-number>1018</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">1018</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Casals-Pascual, C.</author><author>Huang, H.</author><author>Lakhal-Littleton, S.</author><author>Thezenas, M. L.</author><author>Kai, O.</author><author>Newton, C. R.</author><author>Roberts, D. J.</author></authors></contributors><auth-address>Wellcome Trust Centre for Human Genetics, Roosevelt Drive, Oxford OX3 7BN, UK. ccasals@well.ox.ac.uk</auth-address><titles><title>Hepcidin demonstrates a biphasic association with anemia in acute Plasmodium falciparum malaria</title><secondary-title>Haematologica</secondary-title><alt-title>Haematologica</alt-title></titles><periodical><full-title>Haematologica</full-title><abbr-1>Haematologica</abbr-1></periodical><alt-periodical><full-title>Haematologica</full-title><abbr-1>Haematologica</abbr-1></alt-periodical><pages>1695-8</pages><volume>97</volume><number>11</number><edition>2012/06/13</edition><dates><year>2012</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1592-8721 (Electronic)
0390-6078 (Linking)</isbn><accession-num>22689680</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Casals-Pascual et al, 2012)c-ELISA(Intrinsic Life Sciences, CA, USA)44 very low birth weight (VLBW) infants Mean (SD) birth weight 885 (245) g and mean gestational age was 26.2 (1.7) weeks. 21 healthy term infants mean (SD) birth weight 3297 (348) g and mean gestational age was 38.8 (1.2) weeks.Infants born with congenital anomalies, twin–twin transfusion syndrome, placenta abruption, or immediate postnatal hemoglobin level <10 g/dL on admission were excluded. Sepsis was defined post hoc as a positive blood culture and/or antibiotic therapy for 5 or more days in infants with clinical signs of infection.Range of hepcidin 26.8-67.7 ng/mL in healthy term infants.Infants without sepsis (means 43.9 ng/mL, CV 13.7%) infants with sepsis with negative blood cultures mean 99.2 ng/mL, CV 22.4%) infants with sepsis with positive blood cultures (mean 244.8 ng/mL, CV 10.7%)Intra-assay CV 5-19%Inter-assay CV 12% ADDIN EN.CITE <EndNote><Cite><Author>Wu</Author><Year>2013</Year><RecNum>322</RecNum><DisplayText>(Wu<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>322</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">322</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wu, T. W.</author><author>Tabangin, M.</author><author>Kusano, R.</author><author>Ma, Y.</author><author>Ridsdale, R.</author><author>Akinbi, H.</author></authors></contributors><auth-address>Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.</auth-address><titles><title>The utility of serum hepcidin as a biomarker for late-onset neonatal sepsis</title><secondary-title>The Journal of pediatrics</secondary-title><alt-title>J Pediatr</alt-title></titles><periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></periodical><alt-periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></alt-periodical><pages>67-71</pages><volume>162</volume><number>1</number><edition>2012/07/17</edition><keywords><keyword>Age of Onset</keyword><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Biological Markers/blood</keyword><keyword>C-Reactive Protein/analysis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Very Low Birth Weight</keyword><keyword>Male</keyword><keyword>Predictive Value of Tests</keyword><keyword>Sepsis/*blood/*diagnosis</keyword></keywords><dates><year>2013</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1097-6833 (Electronic)
0022-3476 (Linking)</isbn><accession-num>22796049</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>;(Wu et al, 2013)c-ELISA(Intrinsic Life Sciences, CA, USA)191 pregnant women and their full term babies (gestational age 37-42 weeks)Reference ranges were calculated in 116 mothers and 137 cord blood samplesPregnant women with Hb ≤ 110 g/L, % hypochromic red blood cells ≥ 3.4%, ferritin > 64 ?g/L, Erythropoietin (EPO) > 97th percentile, CRP >10 mg/LNew born infants with cord blood Hb ≤ 145 g/L, ferritin > 115.3 ?g/L transferrin saturation ≤ 30%, EPO > 97th percentile, CRP>10 mg/LReference ranges Geometric mean (5th and 95th percentile)Pregnant women at term 10.6 (< 5.0 - 58.8 ng/mL)Cord blood 72.3 (< 5.0-231 ng/mL)Intra-assay CV 5-19%Inter-assay CV 12% ADDIN EN.CITE <EndNote><Cite><Author>Rehu</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText>(Rehu<style face="italic"> et al</style>, 2010)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rehu, M.</author><author>Punnonen, K.</author><author>Ostland, V.</author><author>Heinonen, S.</author><author>Westerman, M.</author><author>Pulkki, K.</author><author>Sankilampi, U.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Eastern Finland, Eastern Finland Laboratory Centre (ISLAB), Kuopio, Finland. mari.ervasti@uef.fi</auth-address><titles><title>Maternal serum hepcidin is low at term and independent of cord blood iron status</title><secondary-title>European journal of haematology</secondary-title><alt-title>Eur J Haematol</alt-title></titles><pages>345-52</pages><volume>85</volume><number>4</number><edition>2010/06/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Female</keyword><keyword>Ferritins/blood</keyword><keyword>Fetal Blood/*chemistry</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*blood</keyword><keyword>Iron/*blood</keyword><keyword>Maternal-Fetal Exchange</keyword><keyword>Pregnancy/*blood</keyword><keyword>Reference Values</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1600-0609 (Electronic)
0902-4441 (Linking)</isbn><accession-num>20528904</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Rehu et al, 2010)c-ELISA2998 participants from the general population, 48% maleMedian age in men and women 63 and 54 years respectivelyReferences were created by excluding subjects who were pregnant, had an Alanine transaminase (ALT) > 50 U/L, CRP > 10 mg/L, epidermal growth factor receptor (eGFR) < 60 Ml/min/1.73 m2, used iron supplements, were anemic or had a BMI > 30 kg/m2Reference ranges median (2.5th and 97.5th percentiles) per 5 year age group were constant in men 7.8 nM (0.6-23.3 nM)Women < 55: 4.1 nM (0.4-19.7 nM) and Women > 55: 8.5 nM (1.2-24.8 nM) Intra-assay CV 6.3%Inter-assay CV 11.9%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Galesloot et al, 2011)EIA kit S-1337; Bachem 285 healthy Low Birth weight babies between 6 weeks and 6 months. 49% were boys, 56% were preterm mean gestational age 36.5 ± 1.9 weeksBirth weight 2000-2500 g, no disease symptoms at inclusion, no chronic disease, no previous blood transfusion, no history of iron supplementation12.2 ± 1.8 ng/mL at 6 weeks19.9 ± 2.1 ng/mL at 6 months in iron supplemented infants and 13.0 ± 2.6ng/mL in placebo groupDetection range of 0 to 25 ng/mLCV not providedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZXJnbHVuZDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Berglund et al, 2011)EIA Bachem kitPatients with vasculitic disease (ANCA-AAV) and healthy controls Not provided92.93 ± 15.37 ng/mL in patients 15.43 ± 2.11ng/mL in healthy controls Not provided ADDIN EN.CITE <EndNote><Cite><Author>Konopásek</Author><Year>2011</Year><RecNum>320</RecNum><DisplayText>(Konopásek<style face="italic"> et al</style>, 2011)</DisplayText><record><rec-number>320</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">320</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pavel Konopásek</author><author>Petr Prˇikryl</author><author>Jana Vávrová</author><author>Vladimír Tesarˇ</author><author>Emanuel Necˇas</author><author>Martin Vokurka</author></authors></contributors><titles><title>Hepcidin levels in patients with ANCA-AAV</title><secondary-title>Clinical and Experimental Immunology</secondary-title></titles><periodical><full-title>Clinical and experimental immunology</full-title><abbr-1>Clin Exp Immunol</abbr-1></periodical><pages>88</pages><volume>164 (Supp. 1)</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(Konopásek et al, 2011)EIA Bachem kit UK134 recipients of heart allografts Prevalent heart allograft recipients 24.98 ± 9.79 ng/mL in anemic patients 20.59 ± 9.59 ng/mL in non anemic patients Not providedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcnp5Ynlsb3dza2k8L0F1dGhvcj48WWVhcj4yMDEwPC9Z
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ADDIN EN.CITE.DATA (Przybylowski et al, 2010)ELISA using recombinant functional hepcidin 25-His peptide 32 healthy controls7 patients with HJV associated juvenile hemochromatosis10 patients with IDA7 patients with Hodgkin’s LymphomaNot providedMean hepcidin Healthy controls – 42.7 ?g/LPatients with juvenile hemochromatosis - 12.8 ?g/LPatients with IDA- 15.7 ?g/LPatients with Hodgkin’s Lymphoma-116.7 ?g/LIntra- and inter-assay CV ranged from 8-15% and 5-16% respectivelyPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb2xpYXJha2k8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy
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ZE5vdGU+
ADDIN EN.CITE.DATA (Koliaraki et al, 2009)C-ELISA(Ganz lab)Healthy volunteers 18-81 years, 65 men and 49 women from the USA and ItalyNormal health history based on local standards, hemoglobin, serum iron, total iron binding capacity, ferritin, serum transferrin receptor and CRP5-95%range (median)29-254 ng/mL (112 ng/mL) in men17-286 ng/mL (65 ng/mL) in womenIntra-assay CV 5-19% Inter-assay CV mean and median 12 and 7% respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008) Radioimmunoassay (RIA)RIA (Bachem)47 Normal patients samples40 patients with ulcerative colitis15 patients with IDA45 patients with chronic kidney disease (CKD) not requiring dialysis95 patients with CKD requiring dialysisNot providedReference range of 1.1-55 ng/mL in normal patientsIntra-assay CV 5.8-7.2% Inter-assay CV 6.7-7.6% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXNicmlkZ2U8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy
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ADDIN EN.CITE.DATA (Busbridge et al, 2009)c-RIA (Bachem)61 patients with Inflammatory Bowel Disease (IBD) (mean age 44.03 years)25 healthy controls (mean age 36.02 years)Not providedMean hepcidin in IBD was 6.13 ng/ml compared to 15.3 ng/ml in healthy controls p=0.009Intra-assay CV 2.7- 7.2%Inter-assay CV 2.4 - 4.7%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bcm5vbGQ8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Arnold et al, 2009)RIA Grebenchtchikov et al, 2009 Lab(Developed RIA instead of a sandwich ELISA because of the size of hepcidin)64 healthy individuals29 men35 womenNot providedMedian (range)Men at 9 am: 5.77 (0.37 - 29.15 ?g/l) Women at 9 am: 3.60 (0.25-12.56?g/l)Men at 4pm: 15.59 (0.26 - 40.63 ?g/l)Women at 4 pm- 5.89 (0.18-19.11 ?g/l)Intra- and inter assay CVs of 4.4% and 6.2% respectively(Currently has the lowest limit of detection - 0.02 ?g/l)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmViZW5jaHRjaGlrb3Y8L0F1dGhvcj48WWVhcj4yMDA5
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ADDIN EN.CITE.DATA (Grebenchtchikov et al, 2009)Sandwich ELISA (Butterfield et al Lab)34 Cancer patients76 rheumatoid arthritis patients 100 Healthy volunteers (18-64, mean 37 years, 50 women)Not providedMedian (25-75% range)Cancer patients 54.8 (23.2-93.5 ?g/L)Rheumatoid arthritis patients 10.6 (5.9-18.4 ?g/L) Healthy volunteers 1.20 (0.42-3.07 ?g/L)Intra-assay CVs were 3.4%, 4.5%, 3.5% for human serum samples containing 0.16, 4.5, and 15.1 ?g/L of hepcidinPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXR0ZXJmaWVsZDwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll
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ADDIN EN.CITE.DATA (Butterfield et al, 2010)Mass Spectrometry (MS)Liquid Chromatography (LC-MS/MS)LC-MS/MS12 healthy controls (24-50 years, 6 males, 6 females)12 patients with hereditary hemochromatosis (32-65 year old males)6 patients with systemic infection and inflammation (45-61 years, 4 males, 2 females)15 patients with sickle cell anemia (32-65 years, 8 males, 7 females)Not providedMean Hepcidin5.2 ± 1.92 nmol/mmol creatinine -1 in controls 0.55 ± 0.52 nmol/mmol creatinine -1 in patients with hemochromatosis26.5 ± 14.5 nmol/mmol creatinine -1 in patients with inflammation< 10%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYW5zYWw8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Bansal et al, 2009)LC-MS/MS231 apparently healthy adults partitioned into age groups 18-30, 31-50, 51-70 and > 70 years with 21-37 people per group“Apparently healthy adults”Reference values Females aged 18-50 years: 0.4 - 9.2 nmol/L Females > 50 years: 0.7-16.8 nmol/L Males ≥ 18 years 1.1-15.6 nmol/LMedian (range) 3.2 (0.4-15.3 nmol/L)Inter-assay CV ≤ 5%, Total variation ≤ 7.6% ADDIN EN.CITE <EndNote><Cite><Author>Itkonen</Author><Year>2012</Year><RecNum>5179</RecNum><DisplayText>(Itkonen<style face="italic"> et al</style>, 2012)</DisplayText><record><rec-number>5179</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5179</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Itkonen, O.</author><author>Parkkinen, J.</author><author>Stenman, U. H.</author><author>Hamalainen, E.</author></authors></contributors><auth-address>Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland. outi.itkonen@hus.fi</auth-address><titles><title>Preanalytical factors and reference intervals for serum hepcidin LC-MS/MS method</title><secondary-title>Clinica chimica acta; international journal of clinical chemistry</secondary-title><alt-title>Clin Chim Acta</alt-title></titles><periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></periodical><alt-periodical><full-title>Clinica chimica acta; international journal of clinical chemistry</full-title><abbr-1>Clin Chim Acta</abbr-1></alt-periodical><pages>696-701</pages><volume>413</volume><number>7-8</number><edition>2012/01/10</edition><keywords><keyword>Antimicrobial Cationic Peptides/*blood</keyword><keyword>Chromatography, Liquid/*methods</keyword><keyword>Enzyme-Linked Immunosorbent Assay</keyword><keyword>Humans</keyword><keyword>Reference Standards</keyword><keyword>Tandem Mass Spectrometry/*methods</keyword></keywords><dates><year>2012</year><pub-dates><date>Apr 11</date></pub-dates></dates><isbn>1873-3492 (Electronic)
0009-8981 (Linking)</isbn><accession-num>22222553</accession-num><work-type>Validation Studies</work-type><urls><related-urls><url>;(Itkonen et al, 2012)95 apparently healthy adultsMedian (range) 5.7 (1.4-35.9 nmol/L)Not calculatedLC-MS/MS10 healthy individual subjectsNot providedMedian plasma and serum hepcidin levels of 4.9 and 3.6 ng/mL respectively in healthy males and median plasma and serum levels of 2.8 and 3.6 ng/mL in women Inter-assay CV range 11.0-15.3% ADDIN EN.CITE <EndNote><Cite><Author>Murphy</Author><Year>2007</Year><RecNum>5180</RecNum><DisplayText>(Murphy<style face="italic"> et al</style>, 2007)</DisplayText><record><rec-number>5180</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5180</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Murphy, A. T.</author><author>Witcher, D. R.</author><author>Luan, P.</author><author>Wroblewski, V. J.</author></authors></contributors><auth-address>Department of Drug Disposition Bioproducts, Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN 46285, USA. atm@</auth-address><titles><title>Quantitation of hepcidin from human and mouse serum using liquid chromatography tandem mass spectrometry</title><secondary-title>Blood</secondary-title><alt-title>Blood</alt-title></titles><periodical><full-title>Blood</full-title><abbr-1>Blood</abbr-1></periodical><alt-periodical><full-title>Blood</full-title><abbr-1>Blood</abbr-1></alt-periodical><pages>1048-54</pages><volume>110</volume><number>3</number><edition>2007/04/17</edition><keywords><keyword>Animals</keyword><keyword>Antimicrobial Cationic Peptides/*blood/urine</keyword><keyword>Chromatography, Liquid</keyword><keyword>Chronic Disease</keyword><keyword>Humans</keyword><keyword>Inflammation/blood</keyword><keyword>Liver/metabolism</keyword><keyword>Mice</keyword><keyword>Protein Precursors/blood/urine</keyword><keyword>Sensitivity and Specificity</keyword><keyword>*Tandem Mass Spectrometry</keyword></keywords><dates><year>2007</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0006-4971 (Print)
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Q2l0ZT48L0VuZE5vdGU+AG==
ADDIN EN.CITE.DATA (Cercamondi et al, 2010)Matrix-assisted laser desorption/ionization time of flight MS (MALDI)-TOF MS)MALDI-TOF MS (Bruker Daltonics) Indonesian school children, aged 5-15 years73 with Asymptomatic P. falciparum, 18 with Asymptomatic P.vivax and 17 controlsAsymptomatic parasitemia was defined as asexual P. falciparum or P. vivax parasitemia in the absence of fever (temperature ≤ 37.9°C) and of clinical signs or symptoms suggestive of malaria or another infectious disease.Serum hepcidinP. falciparum 5.2 nMP.vivax 5.6 nMControls 3.1 nMInter-assay CV- 2.7%Intra-assay CV-6.5%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kZSBNYXN0PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kZSBNYXN0PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPn==
ADDIN EN.CITE.DATA (de Mast et al, 2010)MALDI-TOF MS62 female and 64 healthy male pediatric patients and 86 HIV-negative adults malesNot provided11.7 ng/mL in pediatric samples 16.1 ng/mL in adult malesInter-day CV- 14.83%Intraday CV – 18.48%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNvbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Anderson et al, 2011)Surface-enhanced laser desorption/ionization time of flight (SELDI)-TOF MSSELDI-TOF MS 181 African children less than 16 years, 93 male, mean age was 8 yearsChildren were excluded if they had received antibiotics or specific treatment for H.pylori in the preceding month, had a diagnosis of immunodeficiency or active tuberculosis, or is H.pylori fecal antigen was not performedUrinary hepcidin levels Median (IQR)25 children with IDA -0.1 (0.05 - 0.6 nmol/mmol Cr156 children without IDA- 3.0 (0.9 - 6.7 nmol/mmol Cr)Intra-assay CV 6.1-7.3% Inter-assay CV 7.9-10.9% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGVyaWFuPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE.DATA (Cherian et al, 2008)SELDI-TOF MS199 patients in Ghana (86 children, 82 adults, and 31 pregnant women) with malaria 79.1%, 82.9%, and 90.3% anemic, respectivelySubjects were eligible for the study if they were diagnosed with P. falciparum malaria, were not admitted for transfusion, had a hemoglobin level > 50 g/L, and had no evidence of cerebral malaria.Hepcidin (intensity/mmol creatinine) median (25th and 75th percentile)Children 4.2 (1.4, 9.5)Adults 0.7 (0.3, 3.6)Pregnant women 0.7 (0.2, 5.9)Not providedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3dhcmQ8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Howard et al, 2007)Weak cation-exchange chromatography and SELDI-TOF MS synthetic analog hepcidin-24 of hepcidin-25 was used as an internal standard 33 men over 40 yearsNot providedRange 0 to 7.8 nmol/LIntra-assay CV 3.5%Inter-assay CV 7.5% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2U8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Roe et al, 2009)SELDI-TOF MS hepcidin-24 peptide (Peptide International) was used as an internal reference standard. Children 2 months to 13 years in TanzaniaFebrile at admission (axillary temperature, > 37.5°C), P. falciparum (i.e., with detection of at least 125 parasites/200 white blood cells, a negative HIV test result, a negative blood culture result, anemia (Hb level, < 10 g/dL), and no history of iron therapy in the preceding 3 weeksMedian (IQR) Urinary hepcidin level, nmol/mmol creatinine 177.5 (91.9–376.4) on admissionNot providedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kZSBNYXN0PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA (de Mast et al, 2009)SELDI-TOF MS23 healthy volunteers (12 men, 11 women)Normal values for complete blood count (CBC), serum iron, transferrin saturation, ferritin, CRP, sTfR, liver function tests,All volunteers 5.3 nmol/l (3.5-8.3 nmol/l) Men 7.2 nmol/l (3.3-16.0 nmol/l)Women 3.9 nmol/l (2.7-5.4 nmol/l) p=0.139Intra-assay CV 5.7-11.7% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Td2lua2VsczwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+
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ADDIN EN.CITE.DATA (Swinkels et al, 2008)Etiology of Anemia in developing countries Primary processes implicated in the pathogenesis of anemia in developing countries include: 1) inadequate iron intake; 2) iron deficiency caused by extra-corporeal blood loss due to Schistosomiasis and soil-transmitted helminths (STHs): hookworm, and Trichuris trichiura infection and 3) anemia of inflammation resulting from high rates of infectious diseases, as well as subclinical infections and inflammation including malaria and HIV.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2xlbnRpbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy
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ADDIN EN.CITE.DATA (Weatherall, 1990; Stoltzfus et al, 1997; Friedman et al, 2005; Tolentino& Friedman, 2007; Midzi et al, 2010). Recently, the prevalent subclinical gut disorder termed environmental enteropathy (EE) has been hypothesized to contribute to anemia of inflammation, even in the absence of clinical disease ADDIN EN.CITE <EndNote><Cite><Author>Prendergast</Author><Year>2012</Year><RecNum>4579</RecNum><DisplayText>(Prendergast& Kelly, 2012)</DisplayText><record><rec-number>4579</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4579</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Prendergast, A.</author><author>Kelly, P.</author></authors></contributors><auth-address>Centre for Paediatrics and Centre for Digestive Diseases, Blizard Institute, Queen Mary University of London, United Kingdom. a.prendergast@qmul.ac.uk</auth-address><titles><title>Enteropathies in the developing world: neglected effects on global health</title><secondary-title>The American journal of tropical medicine and hygiene</secondary-title><alt-title>Am J Trop Med Hyg</alt-title></titles><periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></periodical><alt-periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></alt-periodical><pages>756-63</pages><volume>86</volume><number>5</number><edition>2012/05/05</edition><keywords><keyword>*Developing Countries</keyword><keyword>HIV Enteropathy/diagnosis/*epidemiology/therapy</keyword><keyword>Humans</keyword><keyword>Intestinal Diseases/diagnosis/*epidemiology/therapy</keyword><keyword>Morbidity</keyword><keyword>Public Health</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1476-1645 (Electronic)
0002-9637 (Linking)</isbn><accession-num>22556071</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Prendergast& Kelly, 2012). Environmental Enteropathy (EE)EE is a subclinical intestinal pathology that is ubiquitous among people living in unhygienic conditions. EE results from chronic fecal-oral transmission of microorganisms (Figure 1.4) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA (Lunn et al, 1991; Campbell et al, 2003). Intestinal permeability studies in infants with EE demonstrated that both absorptive and barrier functions of the small bowel mucosa were compromised. EE may result in anemia through impaired digestive/absorptive and barrier functions of the small intestine PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+
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ZT4A
ADDIN EN.CITE.DATA (Campbell et al, 2003). EE in Gambian infants was also associated with chronic, low level immunostimulation, including raised lymphocyte and platelet counts, CRP, and plasma immunoglobulins PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+
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ZT4A
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+
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ZT4A
ADDIN EN.CITE.DATA (Campbell et al, 2003). Reduced absorptive capacity and subclinical malabsorption of carbohydrates PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZXVzY2g8L0F1dGhvcj48WWVhcj4xOTcyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Keusch, 1972; Northrop-Clewes et al, 1997), fat and vitamin B12 ADDIN EN.CITE <EndNote><Cite><Author>Lindenbaum</Author><Year>1966</Year><RecNum>4580</RecNum><DisplayText>(Lindenbaum<style face="italic"> et al</style>, 1966)</DisplayText><record><rec-number>4580</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4580</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lindenbaum, J.</author><author>Alam, A. K.</author><author>Kent, T. H.</author></authors></contributors><titles><title>Subclinical small-intestinal disease in East Pakistan</title><secondary-title>British medical journal</secondary-title><alt-title>Br Med J</alt-title></titles><periodical><full-title>British medical journal</full-title><abbr-1>Br Med J</abbr-1></periodical><alt-periodical><full-title>British medical journal</full-title><abbr-1>Br Med J</abbr-1></alt-periodical><pages>1616-9</pages><volume>2</volume><number>5530</number><edition>1966/12/31</edition><keywords><keyword>Adult</keyword><keyword>Body Weight</keyword><keyword>Folic Acid/pharmacology</keyword><keyword>Humans</keyword><keyword>Intestinal Absorption/drug effects</keyword><keyword>Malabsorption Syndromes/*epidemiology</keyword><keyword>Pakistan</keyword><keyword>Social Conditions</keyword><keyword>Tetracycline/pharmacology</keyword><keyword>Vitamin B 12/metabolism</keyword><keyword>Xylose/metabolism</keyword></keywords><dates><year>1966</year><pub-dates><date>Dec 31</date></pub-dates></dates><isbn>0007-1447 (Print)
0007-1447 (Linking)</isbn><accession-num>5926127</accession-num><urls><related-urls><url>;(Lindenbaum et al, 1966) has also been observed in EE. 0000Figure 1.4. Hypothesized causal pathway linking fecal contamination and Environmental Enteropathy (EE) through poor WASH practices with anemia. Adapted from ADDIN EN.CITE <EndNote><Cite><Author>Prendergast</Author><Year>2012</Year><RecNum>4579</RecNum><DisplayText>(Prendergast& Kelly, 2012)</DisplayText><record><rec-number>4579</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4579</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Prendergast, A.</author><author>Kelly, P.</author></authors></contributors><auth-address>Centre for Paediatrics and Centre for Digestive Diseases, Blizard Institute, Queen Mary University of London, United Kingdom. a.prendergast@qmul.ac.uk</auth-address><titles><title>Enteropathies in the developing world: neglected effects on global health</title><secondary-title>The American journal of tropical medicine and hygiene</secondary-title><alt-title>Am J Trop Med Hyg</alt-title></titles><periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></periodical><alt-periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></alt-periodical><pages>756-63</pages><volume>86</volume><number>5</number><edition>2012/05/05</edition><keywords><keyword>*Developing Countries</keyword><keyword>HIV Enteropathy/diagnosis/*epidemiology/therapy</keyword><keyword>Humans</keyword><keyword>Intestinal Diseases/diagnosis/*epidemiology/therapy</keyword><keyword>Morbidity</keyword><keyword>Public Health</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1476-1645 (Electronic)
0002-9637 (Linking)</isbn><accession-num>22556071</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Prendergast& Kelly, 2012). Schistosomiasis and soil transmitted helminths Poor WASH practices are associated with fecal exposure which can contain over 50 known pathogens including Schistosomiasis and STHs ADDIN EN.CITE <EndNote><Cite><Author>Brown</Author><Year>2013</Year><RecNum>5338</RecNum><DisplayText>(Brown<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>5338</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brown, J.</author><author>Cairncross, S.</author><author>Ensink, J. H.</author></authors></contributors><auth-address>Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.</auth-address><titles><title>Water, sanitation, hygiene and enteric infections in children</title><secondary-title>Archives of disease in childhood</secondary-title><alt-title>Arch Dis Child</alt-title></titles><periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></periodical><alt-periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></alt-periodical><pages>629-34</pages><volume>98</volume><number>8</number><edition>2013/06/14</edition><keywords><keyword>Child</keyword><keyword>*Child Welfare</keyword><keyword>Dysentery/*epidemiology/etiology</keyword><keyword>Gastroenteritis/*epidemiology/etiology</keyword><keyword>Humans</keyword><keyword>*Hygiene</keyword><keyword>Risk Factors</keyword><keyword>*Sanitation</keyword><keyword>*Water</keyword><keyword>*Water Supply</keyword></keywords><dates><year>2013</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1468-2044 (Electronic)
0003-9888 (Linking)</isbn><accession-num>23761692</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Brown et al, 2013). Hence Schistosomiasis (S. haematobium and S. mansoni) and STHs: hookworm, Trichuris trichiura and Ascaris lumbricoides infection are endemic in developing countries with poor WASH practices ADDIN EN.CITE <EndNote><Cite><Author>Hotez</Author><Year>2005</Year><RecNum>4566</RecNum><DisplayText>(Hotez<style face="italic"> et al</style>, 2005)</DisplayText><record><rec-number>4566</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4566</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hotez, P. J.</author><author>Bethony, J.</author><author>Bottazzi, M. E.</author><author>Brooker, S.</author><author>Buss, P.</author></authors></contributors><auth-address>Department of Microbiology and Tropical Medicine, The George Washington University, Washington, DC, USA. mtmpjh@gwumc.edu</auth-address><titles><title>Hookworm: "the great infection of mankind"</title><secondary-title>PLoS medicine</secondary-title><alt-title>PLoS Med</alt-title></titles><periodical><full-title>PLoS medicine</full-title><abbr-1>PLoS Med</abbr-1></periodical><alt-periodical><full-title>PLoS medicine</full-title><abbr-1>PLoS Med</abbr-1></alt-periodical><pages>e67</pages><volume>2</volume><number>3</number><edition>2005/03/24</edition><keywords><keyword>Cost of Illness</keyword><keyword>Helminth Proteins/immunology</keyword><keyword>Hookworm Infections/*epidemiology/etiology/*prevention & control</keyword><keyword>Humans</keyword><keyword>*Infection Control</keyword><keyword>Poverty</keyword><keyword>Sanitation</keyword><keyword>Vaccines</keyword><keyword>*World Health</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1549-1676 (Electronic)
1549-1277 (Linking)</isbn><accession-num>15783256</accession-num><work-type>Research Support, N.I.H., Extramural
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ADDIN EN.CITE.DATA (Stoltzfus et al, 2004; Kung'u et al, 2009). Schistosomiasis is among the top 14 out patient treated diseases in Zimbabwe PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWR6aTwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Midzi et al, 2011) with overall mean prevalence of S. haematobium, S. mansion and STHs of 20.8%, 9.0% and 6.0% respectively and prevalence rates of S. haematobium, up to 70% in some regions of the country PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYXlsb3IgUDwvQXV0aG9yPjxZZWFyPjE5ODU8L1llYXI+
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ADDIN EN.CITE.DATA (Taylor P, 1985; Chandiwana et al, 1988; Midzi et al, 2011) (available from, the Ministry of Health and Child Welfare (MoHCW) of Zimbabwe ). 29.6% of Zimbabwean households have access to improved toilet facilities ADDIN EN.CITE <EndNote><Cite><Year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</Year><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). 20.3%, 9.3% and 6.0% of individuals infected with S. haematobium, S. mansoni and STHs respectively had a toilet at home (available from MoHCW of Zimbabwe).Infant and young child feeding practicesIron requirements are high during the second half of infancy as endogenous iron stores become depleted and the infant is no longer self-reliant for iron to meet the needs for erythropoiesis and growth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Lind et al, 2004; Baker& Greer, 2010; Domellof, 2011). Because of the large iron stores at birth, the Adequate intake (AI) and Recommended Dietary Allowance (RDA) for iron in term infants during the first 6 months of life is only 0.27 mg/day (equivalent to the amount provided by breastmilk for an exclusively breast fed infant). Between 7-12 months of age, when stores at birth are mostly depleted yet growth remains rapid, iron requirements increase to 11 mg/day (a 40-fold increase over the first half of infancy); this requirement is almost 10 times higher per kg bodyweight, that of an adult male (0.9 - 1.3 mg/kg body weight in 6-12 mo infant vs. 0.14 mg/kg body weight requirement of adult male PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Domellof, 2011; World Health Organization, Food and Agriculture Organization of the United Nations 2004). During the 1-3 year age period, requirements decrease to 7 mg/d, which is still much greater than the adult requirement in mg/Kg body weight terms (0.35 mg/kg body weight) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWtlcjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWtlcjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Baker& Greer, 2010; World Health Organization, Food and Agriculture Organization of the United Nations 2004). Hence, the period between 6 months and 3 years of age when infants have depleted birth stores yet still grow rapidly, and which coincides with transition from breast milk to the family diet represents a particularly vulnerable period for infants to develop anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ab25ncm9uZTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+
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ADDIN EN.CITE.DATA (Zongrone et al, 2012). This is especially true for infants in developing countries where complementary foods are largely plant based and high in substances that inhibit iron absorption and rarely include meat, poultry or iron fortified cereal or formula ADDIN EN.CITE <EndNote><Cite><Author>Dewey</Author><Year>2003</Year><RecNum>3994</RecNum><DisplayText>(Dewey, 2003)</DisplayText><record><rec-number>3994</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">3994</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dewey, K. G.</author></authors></contributors><auth-address>Department of Nutrition and Program in International Nutrition, University of California, Davis, CA 95616-8669, USA. kgdewey@ucdavis.edu</auth-address><titles><title>Nutrient composition of fortified complementary foods: should age-specific micronutrient content and ration sizes be recommended?</title><secondary-title>The Journal of nutrition</secondary-title><alt-title>J Nutr</alt-title></titles><periodical><full-title>The Journal of nutrition</full-title><abbr-1>J Nutr</abbr-1></periodical><alt-periodical><full-title>The Journal of nutrition</full-title><abbr-1>J Nutr</abbr-1></alt-periodical><pages>2950S-2S</pages><volume>133</volume><number>9</number><edition>2003/09/02</edition><keywords><keyword>*Aging</keyword><keyword>Diet</keyword><keyword>*Food, Fortified</keyword><keyword>Humans</keyword><keyword>Micronutrients/*administration & dosage</keyword><keyword>*Nutrition Policy</keyword><keyword>*Nutritional Requirements</keyword></keywords><dates><year>2003</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0022-3166 (Print)
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ADDIN EN.CITE.DATA (Arimond et al, 2008; WHO., 2008 ). Iron sources are divided into heme and non-heme. Heme iron is found in animal foods that originally contained hemoglobin and is more bioavailable while plant sources make up non-heme iron. Very good sources of heme iron (≥ 3.5 mg per serving) include chicken liver (9.9 mg/3oz) and beef liver (5.6 mg/3oz) and very good sources of non-heme iron include fortified formula (10-12.8 mg/L) and fortified baby cereal (4.5-18 mg) (Table 1.3). While good sources of heme iron include beef (≥ 2.1 mg per serving). Thus, with the possible exception of chicken liver, only foods that are specially fortified for infants will meet infant iron requirements: natural dietary sources of iron are not iron-concentrated enough to provide 11 mg elemental iron in the small volumes consumed by infants. For example, to meet this requirement, an infant would need to consume 400 g red meat, 700 g chicken, 11 eggs, or 6 cups of cooked legumes daily.Hence the provision of iron-fortified weaning foods or low dose iron supplements is advocated by the WHO and UNICEF PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdG9sdHpmdXM8L0F1dGhvcj48WWVhcj4xOTk4PC9ZZWFy
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ADDIN EN.CITE.DATA (Stoltzfus, 1998; Stoltzfus et al, 2004). However there are no national iron supplementation programs for infants and young children and national consumption foods fortified in the home with a micronutrient powder containing iron or a lipid based nutrient supplement (LNS) containing iron is practically non-existent ADDIN EN.CITE <EndNote><Cite><Year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</Year><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). Hence we hypothesize that the key IYCF indicator “consumption of iron-rich/iron- fortified food for children 6-23 months” is not associated with hemoglobin levels in Zimbabwean children because the iron-rich IYCF indicator lacks specificity with regard to iron consumption Amount needed/day to meet Fe needsFood sourceElemental Iron (mg/100 g)7-12 moRDA: 11 mg/day12-36 moRDA: 7 mg/dayAnimal liver/ organ meat 8-25100 g (3 oz)100 g (3 oz)Red Meat 2.5400 g (13 oz)300 g (8 oz)Chicken1.5730 g (24 oz)500 g (14 oz)Fish0.71 600 g (47 oz)1 000 g (30 oz)Beans, peas, lentils, nuts, peanuts 2.16 cups cooked3.5 cups cookedEgg1.011 eggs7 eggsTable 1.4. Iron content of unfortified food sources PEVuZE5vdGU+PENpdGU+PFllYXI+VVMgRGVwYXJ0bWVudCBvZiBBZ3JpY3VsdHVyZSwgQWdyaWN1
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ADDIN EN.CITE.DATA (Baker& Greer, 2010; US Department of Agriculture, Agricultural Research Service., 2013) Chapter 4 tests the hypothesis that WASH indicators that reflect fecal exposure among infants will be associated with hemoglobin levels during infancy based on our hypothesized causal pathway through Schistosomiasis, STHs and EE. We also test the hypothesis that IYCF indicators will not be associated with hemoglobin because the iron-rich IYCF indicator lacks specificity with regard to iron consumption Research DesignChapters 2 and 3 utilized data and stored samples from ZVITAMBO, a randomized controlled trial of maternal and neonatal vitamin A supplementation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006). The ZVITAMBO trail recruited a total of 14,110 mother-infant pairs from 14 maternity clinics and hospitals in greater Harare between November 1997 and January 2000 (Figure 1.5). Pairs were recruited within 96 h of delivery at maternity clinics and hospitals in Harare and were eligible if neither the mother nor the baby had an acutely life threatening condition and the infant was a singleton with birth weight >1500 g and the mother planned to stay in Harare after delivery. Written, informed consent was obtained from mothers. A 2×2 factorial design was used in the study, and all pairs were randomized ≤ 96 h after delivery to one of 4 treatment groups. The treatment groups were Aa, Ap, Pa, and Pp, where “A” was maternal vitamin A supplementation (400,000 IU), “P” was maternal placebo, “a” was infant vitamin A supplementation (50,000 IU), and “p” was infant placebo. Hemoglobin was measured in a 34% subsample of infants (Anemia sub-study), over-selecting for those born to HIV-positive women, for a total of 2314 and 535 infants born to HIV-positive and HIV-negative women, respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Miller et al, 2003). Mothers and their babies were followed-up at 6 wk, 3 mo and every 3 mo until 12 mo of age by study midwives in a study clinic or at home. Blood was collected at recruitment and follow-up, and Hb measured in baseline samples and repeated in infant samples from 3 mo of age onward. A sample of 907 infants was recruited from the Anemia sub-study into the Hepcidin sub-study. We conducted a cross-sectional study of 3, 6 and 12mo infants. For each respective age, 6 groups of infants were selected, based on HIV and anemia status: HIV-unexposed non-anemic infants (Group 1), HIV-unexposed anemic infants (Group 2); HIV-exposed uninfected non-anemic infants (Group 3); HIV-exposed uninfected anemic infants (Group 4); HIV-infected non-anemic infants (Group 5) and HIV-infected anemic infants (Group 6). Infants were classified as HIV unexposed if mother-infant pair was HIV negative at delivery and did not seroconvert during the trial period; HEU infants were born to HIV positive mothers but were HIV negative at delivery and did not seroconvert during the trial period. HIV infected infants were infected intrauterine, intrapartum or postnatal. Anemia was defined by a hemoglobin measurement <105 g/L at 3 and 6 months, or <100 g/L at 12 months; these criteria were modified from those of the World Health Organization because of the growing literature supporting lower hemoglobin cut-offs in infancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+
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ADDIN EN.CITE.DATA (Domellof et al, 2002; Miller et al, 2003; Eneroth et al, 2011). Further recruitment criteria were applied to group 1 to generate normative hepcidin values in chapter 2: gestational age > 37 weeks; birth weight > 2500 g; absence of iron-deficiency anemia (defined as hemoglobin >105 g/L at 3 mo and 6 mo, or > 100 g/L at 12 mo; plasma ferritin >12 ?g/L; and soluble transferrin receptor (sTfR) < 8.3 mg/L); absence of inflammation (defined as AGP <1g/L and CRP < 5 mg/L); absence of acute illness (defined as diarrhea or fever in preceding week, or measles in preceding 3 months). Indicators of iron (sTfR and ferritin) and inflammatory (CRP and AGP) status and hepcidin were measured in cryopreserved samples at 3, 6 and 12 months. Chapter 4 presents a secondary analysis of data collected in the 2010-2011 Zimbabwe Demographic Health Survey, available on the Demographic Health Survey website ADDIN EN.CITE <EndNote><Cite><RecNum>2271</RecNum><DisplayText>(Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2271</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2271</key></foreign-keys><ref-type name="Dataset">59</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011.( , accessed 15 December 2012).</title></titles><dates><year>Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>(Zimbabwe National Statistics Agency & ICF International Inc., 2012). The Zimbabwe Demographic Health Survey collected information from a nationally representative probability sample of all 10 Zimbabwean provinces using a stratified, two-stage cluster design yielding 9,756 households and a household response rate of 96%. Hemoglobin testing was carried out among children aged 6-59 months and was successfully measured in 80% of eligible children. We analyzed data from children 6-24 months of age for whom age-appropriate IYCF indicators could be constructed from available data. The initial population comprised 1741 children. Our analysis was restricted to the youngest child in a household in this age range with an available hemoglobin measurement, whose mother was interviewed. Hence 51 and 314 children were excluded because they were the older child in a household with more than one child between 6 and 24 months and because they did not have a valid hemoglobin measurement respectively. 105 children were excluded from the multivariate analysis because they were not “de jure” household members or lacked information on included variables. Therefore, 1376 children were selected and studied in the univariate analysis and 1271 children were included in the multivariate analysis. -68580022860048,806 eligibility data available0048,806 eligibility data available-685800114300015,232 not eligible8,571 lived outside Harare3,428 medically ineligible1,353 twin births1,308 birth weight <1500g461 other111 reason for ineligibility not known0015,232 not eligible8,571 lived outside Harare3,428 medically ineligible1,353 twin births1,308 birth weight <1500g461 other111 reason for ineligibility not known434340011430017,584 eligibility not assessed12,799 admitted and discharged on Sunday or a holiday4,166 discharged before nurse had time to assess eligibility0017,584 eligibility not assessed12,799 admitted and discharged on Sunday or a holiday4,166 discharged before nurse had time to assess eligibility137160057150066,390 deliveries documented by study0066,390 deliveries documented by study27432008763000012573007620000274320064770002743200-3810001485900137160048,806 eligibility data available0048,806 eligibility data available1485900-11430069,874 total deliveries0069,874 total deliveries161290093726019,329 declined consent135 consent status not recorded0019,329 declined consent135 consent status not recorded-10160013716000127000082296001270000-9144001270048006033,574 eligible0033,574 eligible274320013970000160020089408014,110 consented and randomized into four supplementation groups0014,110 consented and randomized into four supplementation groups-34290038608000525780038608000274320015748000354330038608000160020038608000-34290038608000Random Allocation-5715001117603523 assigned to Pp group,Mother PLInfant PL003523 assigned to Pp group,Mother PLInfant PL43434001117603528 assigned to Aa group,Mother VAInfant VA003528 assigned to Aa group,Mother VAInfant VA11430001117603529 assigned to Ap group,Mother VAInfant PL003529 assigned to Ap group,Mother VAInfant PL27432001117603530 assigned to Pa group,Mother PLInfant VA003530 assigned to Pa group,Mother PLInfant VA3886200102616000-1028700408940003771900980440Protocol B4625 HIV- mother00Protocol B4625 HIV- mother2514600-990600914400980440Protocol A4501 HIV+ mother4701 HIV- mother283 HIV indeterminate at time of selection00Protocol A4501 HIV+ mother4701 HIV- mother283 HIV indeterminate at time of selection12573002809240907 selected into Hepcidin sub-study00907 selected into Hepcidin sub-study-125730015519406619 remain in Protocol A but not selected into Anemia sub-study006619 remain in Protocol A but not selected into Anemia sub-study Selection Program 4572004800602842 selected into Anemia sub-study002842 selected into Anemia sub-study14859001371600-114300251460002514600838200Figure 1.5. The ZVITAMBO trial profile including the Hepcidin sub-studyHepcidin decreases over the first year of life in healthy African infants Tatenda G. Mupfudze1, 2, Rebecca J. Stoltzfuz3, Sandra Rukobo2, Lawrence H. Moulton1, Jean H. Humphrey1, 2 Andrew J. Prendergast1, 2,4 and the SHINE Project Team1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; 3Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; 4Queen Mary, University of London, UK.Corresponding author: Tatenda G. Mupfudze, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, Maryland, USA. Email: tmupfudz@jhsph.eduShort title: Hepcidin In InfancyABSTRACTIron metabolism is very dynamic over the first year of life. Hepcidin is the master regulator of iron metabolism, but little is known about normal hepcidin values in infancy. We selected healthy, non-anemic Zimbabwean infants with normal iron parameters at 3 (n=60), 6 (n=47) and 12 (n=40) months of age and measured hepcidin, soluble transferrin receptor, ferritin, α1-acid glycoprotein and C-reactive protein on stored plasma samples. Hepcidin concentrations were higher in 3-month-old (median 9.7 ng/mL [IQR 2.5, 19.3]), than in 6-month-old (4.5 ng/mL [IQR 0.5, 7.3]) and 12-month-old infants (1.9 ng/mL [IQR 0.7, 6.2)]) (p<0.001, Kruskal–Wallis). Hepcidin concentrations were non-significantly higher in girls than boys in each age group, and were lower than those reported in adults, supporting the higher metabolic need for iron in infancy. Hepcidin decline during infancy is likely a physiologic response to mobilize iron stores and increase iron absorption to prevent anemia. 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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Kroot et al, 2010; Galesloot et al, 2011; Pasricha et al, 2011; Troutt et al, 2012). Hepcidin binds to ferroportin, the only known mammalian iron exporter, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Galesloot et al, 2011) inducing its degradation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZW1ldGg8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Nemeth et al, 2004; De Domenico et al, 2007; Troutt et al, 2012) and inhibiting the release of iron by macrophages and hepatocytes; and attenuates iron absorption by duodenal enterocytes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmViZW5jaHRjaGlrb3Y8L0F1dGhvcj48WWVhcj4yMDA5
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ADDIN EN.CITE.DATA (Kroot et al, 2010; Galesloot et al, 2011). Infants are at high risk of developing anemia, particularly in developing countries; however, little is known about circulating hepcidin levels over the first year of life, even in healthy infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWh1PC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rehu et al, 2010; Berglund et al, 2011; Muller et al, 2012; Wu et al, 2013). We set out to measure plasma hepcidin concentrations and to characterize normative values in healthy, non-anemic, Zimbabwean infants. METHODSThe current study utilized data and stored samples from the ZVITAMBO trial, a randomized controlled trial of maternal and neonatal vitamin A supplementation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006). 14,110 mother-infant pairs were recruited within 96 hours of delivery at maternity clinics and hospitals in Harare, Zimbabwe, between November 1997 and January 2000. Maternal-infant pairs were eligible if neither the mother nor infant had an acute life-threatening condition and the infant was a singleton with birth weight >1500 g. Follow-up was conducted at 6 weeks, 3 months and every 3 months thereafter, until the child was 12-24 months old. Hemoglobin was measured using the HemoCue hemoglobinometer (HemoCue, Mission Viejo, CA) in a 34% subsample of infants, over selecting for babies born of HIV positive women, for a total of 2314 and 535 infants born to HIV positive and negative women respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Miller et al, 2003). Written informed consent was obtained from the mother at recruitment. The original ZVITAMBO trial and this sub-study were approved by the Medical Research Council of Zimbabwe and the Committee on Human Research of The Johns Hopkins Bloomberg School of Public Health.Study subjects for hepcidin studyHIV unexposed infants with a hemoglobin measurement were selected at 3, 6 and 12 months of age based on the following criteria: gestational age >37 weeks; birth weight >2500 g; absence of iron-deficiency anemia (defined as hemoglobin >105 g/L at 3 and 6 months, or >100 g/L at 12 months; plasma ferritin >12 ?g/L; and soluble transferrin receptor (sTfR) < 8.3 mg/L); absence of inflammation (defined as alpha-1 acid glycoprotein (AGP) <1g/L and C-reactive protein (CRP) < 5 mg/L); absence of acute illness (defined as diarrhea or fever in the preceding week, or measles in the preceding 3 months). This yielded a sample size of 139 infants with three cross-sectional groups at 3mo (n=60), 6mo (n=47) and 12mo (n=40), with 132 infants contributing data at one time point, 6 infants contributing data to 2 time-points and one infant contributing data to all three time-points. The criteria used to diagnose anemia were modified from those of the World Health Organization ADDIN EN.CITE <EndNote><Cite><RecNum>324</RecNum><DisplayText>(WHO., 2011)</DisplayText><record><rec-number>324</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">324</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title>Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, (WHO/NMH/NHD/MNM/11.1) (, accessed 15 May 2013).</title></titles><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2011) because of the growing literature supporting lower hemoglobin cut-offs in infancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+
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ADDIN EN.CITE.DATA (Domellof et al, 2002; Miller et al, 2003; Eneroth et al, 2011).Laboratory assays Plasma samples were stored at -70°C until analysis, with freeze-thaw cycles kept to a minimum. Soluble transferrin receptor concentration was measured by enzyme immunoassay (Ramco Laboratories Inc, Houston, TX), with mean intra-assay coefficient of variation (CV) 5.4% and inter-assay CV 4.4%. Plasma ferritin was measured by enzyme immunoassay (Ramco Laboratories Inc, Houston, TX), with mean intra-assay CV 8.4% and inter-assay CV 8.3%. Plasma AGP and CRP were measured by ELISA (R&D Systems Inc, Minneapolis, MN), with manufacturer-reported intra-assay mean CV of 6.1% and 5.9%, respectively, and inter-assay mean CV of 6.5% and 7.4%, respectively. Hepcidin was measured in plasma by competition ELISA, using the hepcidin-25 (human) enzyme immunoassay kit (S-1337; Bachem, San Carlos, CA) with detection range between 0.02 and 25 ng/mL, according to the manufacturer’s protocol. Plasma samples were diluted 1 in 4 in supplied standard diluent (peptide-cleared human serum). Standards were run in duplicate and samples in triplicate. Samples giving readings outside the linear region of the curve were re-run at alternative dilutions. The intra-assay CV was mean 6.3% (range 5.7 - 6.9%), and inter-assay CV was 6.3%.Statistical analysisBaseline and iron variables are reported as median with interquartile range (IQR), or mean with standard deviation (SD). Comparisons between groups were made using Kruskal–Wallis, ANOVA and regression analysis. Hepcidin values below the detection limit of 0.02 ng/mL were imputed using the limit of detection (LOD)/√2, thereby assigning a value of 0.014 ng/mL to avoid zero values dropping out when data were log transformed in regression analysis ADDIN EN.CITE <EndNote><Cite><Author>Barr</Author><Year>2006</Year><RecNum>339</RecNum><DisplayText>(Barr<style face="italic"> et al</style>, 2006)</DisplayText><record><rec-number>339</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">339</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barr, D. B.</author><author>Landsittel, D.</author><author>Nishioka, M.</author><author>Thomas, K.</author><author>Curwin, B.</author><author>Raymer, J.</author><author>Donnelly, K. C.</author><author>McCauley, L.</author><author>Ryan, P. B.</author></authors></contributors><auth-address>National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. dbarr@</auth-address><titles><title>A survey of laboratory and statistical issues related to farmworker exposure studies</title><secondary-title>Environmental health perspectives</secondary-title><alt-title>Environ Health Perspect</alt-title></titles><periodical><full-title>Environmental health perspectives</full-title><abbr-1>Environ Health Perspect</abbr-1></periodical><alt-periodical><full-title>Environmental health perspectives</full-title><abbr-1>Environ Health Perspect</abbr-1></alt-periodical><pages>961-8</pages><volume>114</volume><number>6</number><edition>2006/06/09</edition><keywords><keyword>*Agriculture</keyword><keyword>Humans</keyword><keyword>*Occupational Exposure</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2006</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0091-6765 (Print)
0091-6765 (Linking)</isbn><accession-num>16760001</accession-num><work-type>Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Barr et al, 2006). Hepcidin consensus values (hepcon1) were calculated using the algorithm developed by Kroot et al, to enable interpretation across studies where different assays are used PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012). All statistical analyses were performed with STATA version 12 (StataCorp, College Station, TX).RESULTS AND DISCUSSIONAt 3, 6 and 12 months of age, 60, 47 and 40 infants, respectively, met the eligibility criteria and had sufficient plasma volume. Infant baseline characteristics are shown in Table 2.1. Mean (SD) hemoglobin in 3, 6 and 12-month infants was 117.9 (13.4), 118.0 (9.4) and 117.1 (11.8) g/L, respectively. Ferritin was lower at older age groups (p< 0.001; Kruskal–Wallis test).Hepcidin concentrations were higher in 3-month-old infants (median 9.7 ng/mL [IQR 2.5, 19.3]), than in infants at 6 months (4.5 ng/mL [IQR 0.5, 7.3]) and 12 months (1.9 ng/mL [IQR 0.7, 6.2)]) (p<0.001; Kruskal–Wallis test; Table 1). Hepcidin was undetectable in one infant at 6 months of age. Hepcon1 values were median (IQR) 6.2 (0.6, 13.7), 2.2 (-1.0, 4.4) and 0.1 (-0.8, 3.5) in 3, 6 and 12 month infants, respectively. Hepcidin concentrations were higher in girls than boys in each age group, but sex differences were not significant in univariate regression analysis and after adjustment for age (Figure 2.1).Iron metabolism is very dynamic in infancy, with hemoglobin and plasma ferritin concentrations falling dramatically after birth as the breakdown of fetal red blood cells exceeds the formation of new red blood cells ADDIN EN.CITE <EndNote><Cite><Author>Dallman</Author><Year>1987</Year><RecNum>203</RecNum><DisplayText>(Dallman, 1987)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dallman, P. R.</author></authors></contributors><titles><title>Iron deficiency and the immune response</title><secondary-title>The American journal of clinical nutrition</secondary-title><alt-title>Am J Clin Nutr</alt-title></titles><periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></periodical><alt-periodical><full-title>The American journal of clinical nutrition</full-title><abbr-1>Am J Clin Nutr</abbr-1></alt-periodical><pages>329-34</pages><volume>46</volume><number>2</number><edition>1987/08/01</edition><keywords><keyword>Anemia, Hypochromic/*immunology</keyword><keyword>Animals</keyword><keyword>*Antibody Formation</keyword><keyword>Humans</keyword><keyword>*Immunity, Cellular</keyword><keyword>Infection/immunology</keyword><keyword>Iron/administration & dosage/deficiency</keyword><keyword>Neutrophils/immunology</keyword><keyword>Nutritional Requirements</keyword><keyword>Phagocytosis</keyword></keywords><dates><year>1987</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0002-9165 (Print)
0002-9165 (Linking)</isbn><accession-num>3303900</accession-num><work-type>Research Support, U.S. Gov't, P.H.S.
Review</work-type><urls><related-urls><url>;(Dallman, 1987). Anemia prevalence therefore tends to increase over infancy as endogenous supplies of iron become depleted and dietary intake is insufficient to meet demands. We show for the first time in healthy, non-anemic infants that hepcidin concentrations decrease over infancy, with most of the drop in hepcidin occurring between 3 and 6 months. This is presumably a physiologic response to mobilize iron stores and absorb more dietary iron, thus preventing iron deficiency anemia. Comparison of these infant values with adult values is complicated by the variation between hepcidin assays currently in use; hence we also provided hepcidin consensus values for future comparisons PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Galesloot et al, 2011). Konopasek et al. reported mean (SD) hepcidin concentration of 15.43 (2.11) ng/mL in healthy adults, using the same assay ADDIN EN.CITE <EndNote><Cite><Author>Konopásek</Author><Year>2011</Year><RecNum>320</RecNum><DisplayText>(Konopásek<style face="italic"> et al</style>, 2011)</DisplayText><record><rec-number>320</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">320</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pavel Konopásek</author><author>Petr Prˇikryl</author><author>Jana Vávrová</author><author>Vladimír Tesarˇ</author><author>Emanuel Necˇas</author><author>Martin Vokurka</author></authors></contributors><titles><title>Hepcidin levels in patients with ANCA-AAV</title><secondary-title>Clinical and Experimental Immunology</secondary-title></titles><periodical><full-title>Clinical and experimental immunology</full-title><abbr-1>Clin Exp Immunol</abbr-1></periodical><pages>88</pages><volume>164 (Supp. 1)</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(Konopásek et al, 2011). Infant values therefore appear lower than those reported in adults, supporting the higher metabolic need for iron in infancy compared to adulthood. Sex and age differences in hepcidin levels have been observed in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Emond et al, 1996; Thorisdottir et al, 2011) and the lower hepcidin concentrations among boys might be a physiologic response to inherently lower iron stores in infancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbW9uZDwvQXV0aG9yPjxZZWFyPjE5OTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Emond et al, 1996; Thorisdottir et al, 2011). Further studies are needed to determine hepcidin levels in anemic infants to better understand the pathophysiology underlying this highly prevalent condition of global health importance. Table 2.1: Baseline characteristics of healthy, non-iron-deficient, non-anemic Zimbabwean infants at 3, 6 and 12-months of age1,2,3 Baseline Characteristics3-month-old infants6-month-old infants12-month-old infants(N=60)(N=47)(N=40)Infant characteristicsMale sex1, 46.7 (28)46.8 (22)52.5 (21)Gestational age, weeks2 39.6 (1.2)39.7 (1.2)39.5 (1.2)Birth weight, g23105 (376)3186 (359)3230 (459)Apgar score at 5 minutes310 (10, 10)10 (9, 10)10 (10, 10)Hemoglobin at blood sampling, g/L2117.9 (13.4)118.0 (9.4)117.1 (11.8)Ferritin at blood sampling, ?g/l344.1(27.9, 103.6)25.2 (17.6, 42.7)22.2 (15.9, 32.9)Soluble transferrin receptor at blood sampling, mg/L35.71 (4.61, 6.67)5.91 (4.55, 6.44)6.00 (3.94, 6.74)AGP at blood sampling, g/L30.35 (0.27, 0.48)0.51 (0.30, 0.61)0.49 (0.39, 0.63)CRP at blood sampling, mg/L30.21 (0.11, 0.91)0.32 (0.13, 1.17)0.54 (0.18, 1.20)Hepcidin at blood sampling, ng/mL39.7 (2.5, 19.3)4.5 (0.5, 7.3)1.9 (0.7, 6.2)Hepcidin consensus valuesa at blood sampling36.2 (0.6, 13.7)2.2 (-1.0, 4.4)0.1 (-0.8, 3.5)WAZ at birth2-0.42 (0.79)-0.24 (0.75)-0.18 (0 .95)WAZ at blood sampling2-0.07 (0.91)-0.07 (1.09)-0.39 (1.23)LAZ at birth20.13 (0.90)0.11 (0.71)0.32 (1.44)LAZ at blood sampling2-0.32 (0.83)-0.36 (1.23)-0.84 (1.36)Neonatal vitamin A treatment1, b51.7 (31)55.3 (26)52.5 (21)Maternal vitamin A treatment1, b55.0 (33)48.9 (23)50.0 (20)Maternal and household CharacteristicsMaternal Education, years311 (9, 11)11 (9, 11)11 (9, 11)Mothers Employed116.7 (10)10.9 (5)15.0 (6)Maternal MUAC, cm226.4 (2.8)25.9 (2.4)26.6 (2.7)Household income per month, US dollars31220 (801, 1693.5)1220 (855, 1830)1221 (879, 2103)1Values are % (n)2Values are mean (SD)3Values are median (IQR)aHepcidin consensus values were calculated using the algorithm Y= -1.36 + 0.78*hepcidinPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012)bIn the ZVITAMBO trial, mother-infant pairs were randomized within 96 h of birth to one of 4 treatment groups (Aa, Ap, Pa, Pp), where ‘A’ was maternal vitamin A supplementation (400,000 IU), ‘P’ was maternal placebo, ‘a’ was infant vitamin A supplementation (50,000 IU) and ‘p’ was infant placebo. Full details of the trial have been published elsewherePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006).WAZ: weight-for-age Z-score; LAZ: length-for-age Z-score; MUAC: Mid-upper arm circumference, SD: standard deviation, IQR: interquartile rangeFigure 2.1. Plasma hepcidin concentrations in healthy non-anemic infants by age and gender. The boxes indicate the 25th and 75th percentiles and the horizontal line indicates the median. Differences by sex are non-significant in both univariate regression analysis and after adjusting for age (p=0.224).Elevated hepcidin levels in HIV infected and HIV exposed Zimbabwean infants and the role of hepcidin in the pathogenesis of anemia in infants Tatenda G. Mupfudze1, 2, Rebecca J. Stoltzfus3, Sandra Rukobo2, Lawrence H. Moulton1, Jean H. Humphrey1, 2 Andrew J. Prendergast1, 2,4 and the SHINE Project Team1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe*; 3Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; 4Centre for Paediatrics, Blizard Institute, Queen Mary University of London, UK.*Site where laboratory work was conductedCorresponding author: Tatenda G. Mupfudze, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, Maryland, USA. Email: tmupfudz@jhsph.edu Phone: +263 (0) 4850732/3 Fax: +263 (0) 4850734Short title: Hepcidin in the pathogenesis of infant anemia Key words: Anemia, infants, hepcidin, inflammation, HIVABSTRACTAnemia is common in sub-Saharan African infants, particularly in the context of HIV infection. Hepcidin is the major hormone regulating iron metabolism but its role in the pathogenesis of anemia during infancy is unclear. The aim of this study was to characterize hepcidin concentrations in anemic and non-anemic infants and in HIV-infected and HIV-exposed uninfected (HEU) infants. Archived plasma samples from HIV-unexposed (n=289), HEU (n=354) and HIV-infected (n=264) anemic and non-anemic Zimbabwean infants at 3, 6 and 12mo of age were used to measure hepcidin, ferritin, transferrin receptor, α-glycoprotein (AGP) and C-reactive protein (CRP) by ELISA. We undertook multivariate analysis of hepcidin, HIV and anemia status, adjusting for sex and age. Hepcidin concentrations were higher in HIV-infected compared to HEU and HIV-unexposed groups throughout infancy and higher in HEU compared to HIV-unexposed infants. Hepcidin concentrations were correlated with levels of ferritin and CRP. Overall, anemia was not associated with hepcidin concentrations during infancy, except in HIV-unexposed infants. Hepcidin declined with age in all groups; girls had higher hepcidin concentrations than boys. Plasma hepcidin concentrations are positively associated with inflammation in infants, as has been shown in adults. Future studies should explore whether elevated hepcidin contributes to the pathogenesis of HIV infection in infancy. INTRODUCTIONAnemia is a serious public health problem affecting 2 billion people worldwide, particularly infants in developing countries PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxtYW48L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Clark et al, 2002; Totin et al, 2002; Belperio& Rhew, 2004; Adetifa et al, 2006; Bolton-Moore et al, 2007; Bong et al, 2007; Gibb, 2008; Marazzi et al, 2008; Wamalwa et al, 2010). The cause of anemia is likely multifactorial, but the pathophysiology has not been well described in HIV-infected children ADDIN EN.CITE <EndNote><Cite><Author>Calis</Author><Year>2008</Year><RecNum>2139</RecNum><DisplayText>(Calis<style face="italic"> et al</style>, 2008)</DisplayText><record><rec-number>2139</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2139</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Calis, J. C.</author><author>van Hensbroek, M. B.</author><author>de Haan, R. J.</author><author>Moons, P.</author><author>Brabin, B. J.</author><author>Bates, I.</author></authors></contributors><titles><title>HIV-associated anemia in children: a systematic review from a global perspective</title><secondary-title>AIDS</secondary-title><alt-title>Aids</alt-title></titles><periodical><full-title>AIDS</full-title><abbr-1>Aids</abbr-1></periodical><alt-periodical><full-title>AIDS</full-title><abbr-1>Aids</abbr-1></alt-periodical><pages>1099-112</pages><volume>22</volume><number>10</number><edition>2008/06/06</edition><keywords><keyword>Adolescent</keyword><keyword>Anemia/epidemiology/*virology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>HIV Infections/*complications/epidemiology</keyword><keyword>Hematocrit</keyword><keyword>Hemoglobins/metabolism</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Infant</keyword><keyword>Prevalence</keyword><keyword>Tropical Climate</keyword><keyword>World Health</keyword></keywords><dates><year>2008</year><pub-dates><date>Jun 19</date></pub-dates></dates><isbn>1473-5571 (Electronic)
0269-9370 (Linking)</isbn><accession-num>18525255</accession-num><work-type>Editorial
Meta-Analysis
Research Support, Non-U.S. Gov't
Review</work-type><urls><related-urls><url>;(Calis et al, 2008). Furthermore, exposure to maternal HIV infection, even in the absence of infection, is associated with increased morbidity and mortality in early life: HIV-exposed uninfected (HEU) infants have higher mortality, increased rates of infections, impaired growth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFwaXJvPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Thea et al, 1993; Brahmbhatt et al, 2006; Makasa et al, 2007; Marinda et al, 2007; McNally et al, 2007; Shapiro et al, 2007) and increased vulnerability to anemia has been associated with infant exposure to maternal ART PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcnlkZW4tUGV0ZXJzb248L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA (Le Chenadec et al, 2003; Feiterna-Sperling et al, 2007; Dryden-Peterson et al, 2011; Ziske et al, 2013) in HEU infants.Hepcidin, a peptide hormone whose synthesis is simultaneously regulated by iron status and the innate immune system, has evolved as the master regulator of iron metabolism, linking iron homeostasis, inflammation, infection and anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAwODwvWWVh
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ADDIN EN.CITE.DATA (Drakesmith& Prentice, 2008; Drakesmith& Prentice, 2012). The molecular control of hepcidin is part of the innate immune response to pathogens through IL-6, IL-22, type I interferons, toll-like receptor (TLR) ligands, and the endoplasmic reticulum stress response PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA (Drakesmith& Prentice, 2012). Hepcidin synthesis is stimulated by elevated plasma iron concentration, infection and/or inflammation, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Grebenchtchikov et al, 2009; Galesloot et al, 2011) effectively blocking iron efflux from duodenal enterocytes, hepatocytes, the placenta and macrophages PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZW1ldGg8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Nemeth et al, 2004; Nemeth et al, 2004; Drakesmith& Prentice, 2012). Lowering circulating iron levels is an adaptive innate defense mechanism against iron-dependent extracellular organisms; however, diverting iron towards macrophages may enhance proliferation of intracellular organisms such as HIV and Mycobacterium tuberculosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFrZXNtaXRoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA (de Monye et al, 1999; Gordeuk et al, 2001; Montaner et al, 2006; Boelaert et al, 2007; Drakesmith& Prentice, 2012). Only one study to date has reported hepcidin levels in HIV-infected adults, and none have described hepcidin in HIV-infected children. A limited number of studies have characterized hepcidin during infancy, when prevalence of anemia is high even in the absence of HIV exposure, particularly in developing countries. We recently described hepcidin concentrations in healthy Zimbabwean infants ADDIN EN.CITE <EndNote><Cite><Author>Mupfudze</Author><Year>2013</Year><RecNum>4411</RecNum><DisplayText>(Mupfudze<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>4411</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4411</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mupfudze, T. G.</author><author>Stoltzfus, R. J.</author><author>Rukobo, S.</author><author>Moulton, L. H.</author><author>Humphrey, J. H.</author><author>Prendergast, A. J.</author></authors></contributors><auth-address>Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe. tmupfudz@jhsph.edu.</auth-address><titles><title>Hepcidin decreases over the first year of life in healthy African infants</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><edition>2013/10/12</edition><dates><year>2013</year><pub-dates><date>Sep 20</date></pub-dates></dates><isbn>1365-2141 (Electronic)
0007-1048 (Linking)</isbn><accession-num>24112078</accession-num><work-type>Letter</work-type><urls><related-urls><url>;(Mupfudze et al, 2013). In the current study, we aimed to characterize the independent associations between HIV status, anemia and age with hepcidin concentration in infants using archived samples from a well-defined cohort in Zimbabwe. We hypothesized that hepcidin levels are progressively elevated in HEU and HIV infected infants compared to HIV unexposed infants and are not able to distinguish between anemic and non-anemic infants in the presence of inflammation characteristic of HEU and HIV infected infants. METHODSThe current study used data and stored samples from ZVITAMBO, a randomized controlled trial of maternal and neonatal vitamin A supplementation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006). Briefly, 14110 mother-infant pairs were recruited within 96 hours of delivery at maternity clinics and hospitals in Harare, Zimbabwe, between November 1997 and January 2000. Mother-infant pairs were eligible if neither had an acute life-threatening condition and the infant was a singleton with birth weight >1500 g. Follow-up was conducted at 6 weeks, 3 months and every 3 months thereafter, until the child was 12-24 months old. Demographic and obstetric data were collected through questionnaires at recruitment. Gestational age was assessed using the method of Capurro ADDIN EN.CITE <EndNote><Cite><Author>Capurro</Author><Year>1978</Year><RecNum>2157</RecNum><DisplayText>(Capurro<style face="italic"> et al</style>, 1978)</DisplayText><record><rec-number>2157</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2157</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Capurro, H.</author><author>Konichezky, S.</author><author>Fonseca, D.</author><author>Caldeyro-Barcia, R.</author></authors></contributors><titles><title>A simplified method for diagnosis of gestational age in the newborn infant</title><secondary-title>The Journal of pediatrics</secondary-title><alt-title>J Pediatr</alt-title></titles><periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></periodical><alt-periodical><full-title>The Journal of pediatrics</full-title><abbr-1>J Pediatr</abbr-1></alt-periodical><pages>120-2</pages><volume>93</volume><number>1</number><edition>1978/07/01</edition><keywords><keyword>Evaluation Studies as Topic</keyword><keyword>*Gestational Age</keyword><keyword>Humans</keyword><keyword>*Infant, Newborn</keyword><keyword>Methods</keyword></keywords><dates><year>1978</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0022-3476 (Print)
0022-3476 (Linking)</isbn><accession-num>650322</accession-num><urls><related-urls><url>;(Capurro et al, 1978). Maternal mid-upper arm circumference (MUAC) and height were measured within 96 hours of delivery; maternal weight was measured at 6 weeks postpartum. Infant weight and height were measured using an electronic scale (Seca Model 727, Hanover, MD, USA), and length board (ShorrBoard, Olney, MD, USA), respectively, using methods described by Gibson (Gibson, 1990). Weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) Z-scores were calculated using WHO Anthro version 3.0.1.Mothers were tested for HIV at enrolment by two parallel ELISAs (HIV 1.0.2 ICE [Murex Diagnostics]; GeneScreen HIV 1/2 [Sanofi Diagnostics Pasteur]); discordant results were resolved by Western blot (HIV Blot 2.2; Genelabs Diagnostics). The last available sample from each infant was tested for HIV (by serology for samples collected at ≥18 months of age; by PCR for samples collected <18 months, using Amplicor HIV-1 DNA test version 1.5 [Roche Diagnostics]). If the last available sample was negative, the child was classified as HIV-uninfected; if the last available sample was positive, the child was classified as HIV-infected and prior samples were tested to determine the timing of infection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006). Hemoglobin was measured using the HemoCue hemoglobinometer (HemoCue, Mission Viejo, CA) in a 34% subsample of infants, over-selecting for those born to HIV-positive women, for a total of 2314 and 535 infants born to HIV-positive and HIV-negative women, respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Miller et al, 2003). Caregivers of infants with hemoglobin < 70 g/L were encouraged to take the child to a health facility for assessment. The trial was conducted prior to availability of cotrimoxazole prophylaxis or ART in Zimbabwe.Written informed consent was obtained from mothers at recruitment. The original ZVITAMBO trial and this sub-study were approved by the Medical Research Council of Zimbabwe and the Committee on Human Research of The Johns Hopkins Bloomberg School of Public Health. Study subjects for hepcidin study We conducted a cross-sectional study of 3, 6 and 12mo infants. For each respective age, 6 groups of infants were selected, based on HIV and anemia status: HIV-unexposed non-anemic infants (Group 1), HIV-unexposed anemic infants (Group 2); HIV-exposed uninfected non-anemic infants (Group 3); HIV-exposed uninfected anemic infants (Group 4); HIV-infected non-anemic infants (Group 5) and HIV-infected anemic infants (Group 6). Anemia was defined by a hemoglobin measurement < 105 g/L at 3 and 6 months, or < 100 g/L at 12 months; these criteria were modified from those of the World Health Organization because of the growing literature supporting lower hemoglobin cut-offs in infancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+
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ADDIN EN.CITE.DATA (Domellof et al, 2002; Miller et al, 2003; Eneroth et al, 2011). A total of 907 infants met the above criteria and had sufficient plasma volume available (> 120 μL). We therefore had three cross-sectional cohorts at ages 3, 6 and 12mo; 736 infants contributed data to one time-point, 153 infants to 2 time-points and 18 infants contributed data to all three time-points. Laboratory assays Plasma samples were stored at -70°C until analysis. Soluble transferrin receptor (sTFR) concentration was measured by enzyme immunoassay (Ramco Laboratories Inc, Houston, TX), with mean intra-assay coefficient of variation (CV) 5.4% and inter-assay CV 4.4%. Plasma ferritin was measured by enzyme immunoassay (Ramco Laboratories Inc, Houston, TX), with mean intra-assay CV 8.4% and inter-assay CV 8.3%. Plasma α-glycoprotein (AGP) and C-reactive protein (CRP) were measured by ELISA (R&D Systems Inc, Minneapolis, MN), with intra-assay mean CV of 6.1% and 5.9%, respectively, and inter-assay mean CV of 6.5% and 7.4%, respectively. Hepcidin was measured in plasma by competition ELISA, using the hepcidin-25 (human) enzyme immunoassay kit (S-1337; Bachem, San Carlos, CA) with detection range between 0.02 and 25 ng/mL, according to the manufacturer’s protocol. Plasma samples were diluted 1 in 4 in supplied standard diluent (peptide-cleared human serum). Standards were run in duplicate and samples in singlicate. Samples giving readings outside the linear region of the curve were re-run at alternative dilutions. The intra-assay CV was mean 6.3% (range 5.7 - 6.9%), and inter-assay CV was 6.3%. Hepcidin levels in healthy non-anemic HIV-unexposed infants (Group 1) were previously published by our group as normative values ADDIN EN.CITE <EndNote><Cite><Author>Mupfudze</Author><Year>2013</Year><RecNum>4411</RecNum><DisplayText>(Mupfudze<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>4411</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4411</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mupfudze, T. G.</author><author>Stoltzfus, R. J.</author><author>Rukobo, S.</author><author>Moulton, L. H.</author><author>Humphrey, J. H.</author><author>Prendergast, A. J.</author></authors></contributors><auth-address>Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe. tmupfudz@jhsph.edu.</auth-address><titles><title>Hepcidin decreases over the first year of life in healthy African infants</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><edition>2013/10/12</edition><dates><year>2013</year><pub-dates><date>Sep 20</date></pub-dates></dates><isbn>1365-2141 (Electronic)
0007-1048 (Linking)</isbn><accession-num>24112078</accession-num><work-type>Letter</work-type><urls><related-urls><url>;(Mupfudze et al, 2013). Statistical analysisBaseline and iron variables are reported as median with interquartile range (IQR), or mean with standard deviation (SD). Comparisons between groups were made using Kruskal–Wallis and Mann-Whitney tests for skewed data and chi-square test for categorical data. Ferritin and hepcidin values below the detection limits of 0.59 μg/L and 0.02 ng/mL, respectively, were imputed using the limit of detection (LOD)/√2, thereby assigning a value of 0.42 μg/L for ferritin and 0.014 ng/mL for hepcidin ADDIN EN.CITE <EndNote><Cite><Author>Barr</Author><Year>2006</Year><RecNum>339</RecNum><DisplayText>(Barr<style face="italic"> et al</style>, 2006)</DisplayText><record><rec-number>339</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">339</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barr, D. B.</author><author>Landsittel, D.</author><author>Nishioka, M.</author><author>Thomas, K.</author><author>Curwin, B.</author><author>Raymer, J.</author><author>Donnelly, K. C.</author><author>McCauley, L.</author><author>Ryan, P. B.</author></authors></contributors><auth-address>National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. dbarr@</auth-address><titles><title>A survey of laboratory and statistical issues related to farmworker exposure studies</title><secondary-title>Environmental health perspectives</secondary-title><alt-title>Environ Health Perspect</alt-title></titles><periodical><full-title>Environmental health perspectives</full-title><abbr-1>Environ Health Perspect</abbr-1></periodical><alt-periodical><full-title>Environmental health perspectives</full-title><abbr-1>Environ Health Perspect</abbr-1></alt-periodical><pages>961-8</pages><volume>114</volume><number>6</number><edition>2006/06/09</edition><keywords><keyword>*Agriculture</keyword><keyword>Humans</keyword><keyword>*Occupational Exposure</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2006</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0091-6765 (Print)
0091-6765 (Linking)</isbn><accession-num>16760001</accession-num><work-type>Research Support, N.I.H., Extramural
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ADDIN EN.CITE.DATA (Kroot et al, 2012). Iron (ferritin and transferrin receptor) and inflammatory biomarkers (AGP and CRP) and hepcidin were log transformed prior to inclusion in multivariate analysis and correlation analysis. The associations of HIV and anemia status with plasma hepcidin concentration were assessed in a multivariate model adjusting for age and sex. All statistical analyses were performed using STATA version 12 (StataCorp, College Station, TX).RESULTS 3-month-old infants HIV-unexposed: Among 3-month old HIV-unexposed infants, those who were anemic were more stunted, had significantly higher plasma concentrations of CRP and hepcidin compared to those who were not anemic (Table 3.1). HEU: Among 3-month-old HEU infants, those with anemia had lower birth weight, lower median concentrations of plasma hepcidin and ferritin, and a higher proportion had ferritin <12 ?g/L compared to those without anemia. HIV-infected: Amongst 3-month-old HIV-infected infants, those who were anemic had mothers with lower weight and BMI and reduced household income, compared to non-anemic infants. Plasma concentrations of AGP, CRP, ferritin and hepcidin were elevated in HIV-infected compared to other groups of 3-month-old infants, but no biomarkers were significantly different between anemic and non-anemic HIV-infected infants. 6-month-old infants HIV-unexposed: HIV-unexposed infants who became anemic by 6 mo of age had a lower birthweight and were more stunted at birth than non-anemic infants (Table 3.2). Hepcidin was significantly higher in anemic compared to non-anemic infants. There was evidence of both iron deficiency and inflammation in anemic infants at 6 months: almost half of anemic infants had ferritin <12 μg/L and CRP levels were higher in anemic compared to non-anemic infants.HEU: Amongst HEU infants, those who were anemic at 6 mo of age had lower gestational age and birthweight and had mothers with lower weight and BMI compared to non-anemic infants. Moreover, among HEU infants who were anemic at 6 months of age compared to those who were not, mean concentration of sTfR was higher, but no significant differences were detected between the groups in median concentrations of plasma ferritin, CRP, AGP or hepcidin.HIV-infected: Mean plasma concentrations of AGP, CRP, sTfR, ferritin and hepcidin were higher among HIV-infected infants compared to all other infant groups. Within HIV-infected infants, those with anemia at 6 mo of age had higher mean sTfR concentrations compared to those without anemia at 6 months; no other significant differences were detected between the anemic and non-anemic groups in the other iron indices measured or in any baseline or 6 month maternal or infant characteristics. 12-month-old infants HIV-unexposed: Among 12-month old HIV-unexposed infants, those who were anemic were more stunted at birth and had lower birth weight compared to non-anemic infants (Table 3.3). There was a greater degree of iron deficiency among HIV-unexposed infants at 12 mo compared to earlier ages. Hepcidin was lower in anemic compared to non-anemic infants, consistent with predominantly iron-deficiency anemia in this anemic group.HEU: Among HEU infants, those who were anemic at 12 mo had lower birth weight and were more likely to be male compared to non-anemic HEU infants. Anemic HEU infants had higher levels of sTfR and lower levels of ferritin. Of note, however, more than half of infants who were not anemic also had ferritin concentrations in the iron-deficient range (<12 μg/L). Levels of hepcidin and inflammatory biomarkers (AGP and CRP) were similar between anemic and non-anemic HEU infants.HIV-infected: Among HIV-infected infants, those who were anemic at 12 mo were born to mothers with lower weight, BMI and MUAC, were more stunted at birth and had lower birth weight compared to non-anemic infants. The majority of anemic infants acquired HIV infection intrapartum or in utero. As at younger ages, hepcidin was elevated in HIV-infected infants compared to other groups, but levels were not significantly different between anemic and non-anemic HIV-infected infants. Levels of CRP were also significantly higher in anemic compared to non-anemic infants. Characteristics associated with HIV exposure status across all age groupsAcross HIV-unexposed, HIV-exposed and HIV-infected groups, infants were progressively more underweight and stunted, both at birth and throughout infancy. There was a general trend towards higher AGP, CRP and hepcidin across HIV-unexposed, HEU and HIV-infected infant groups, and maternal hemoglobin tended to decline progressively across groups.Table 3.1. Characteristics of 3-month-old infants CharacteristicHIV-Negative MotherHIV-positive MotherNon-infected infantsInfected infantsNon-anemicN= 60AnemicN= 61Non-anemicN=69AnemicN=67Non-anemicN=50AnemicN=66Maternal factorsAge, years2 27 (6)24 (6) a27 (5) b26 (5) b28 (5) b, d26 (5) bHemoglobin, g/L3135(128, 137)133(126, 140)123 (115, 129) a, b125 (113, 130) a, b117 (113, 128) a, b111 (91, 127) a, b, c, dHeight, m31.62(1.57, 1.66)1.60(1.56, 1.64)1.59 (1.55, 1.63) a1.59(1.56, 1.64)1.60(1.57, 1.63)1.60(1.56, 1.65)Weight at 6 weeks postpartum, kg361.0(55.6, 70.5)62.8(56.1, 75.0)58.0 (53.5, 64.4) b58.8 (49.5, 67) b63.0 (55.4, 83.2) c, d56.5 (52.8, 63.3) a, b, d, eBMI323.6(20.8, 25.8)25.1(21.5, 27.2)22.8(21.6, 25.5)22.5(20.6, 24.5) b23.7 (21.8, 28.8) d21.8(20.3, 23.7) b, eMaternal MUAC, cm226.4(2.8)25.8(2.7)25.89(2.6)25.6(3.4)26.4(2.8)25.6(2.4)CD4 count, per microliter3N/AN/A384(223, 558)380(209, 522)378(271, 535)319(179, 580)Viral load, copies per ml3 N/AN/A7367(3061, 38032)20641(1335, 88481)13910(4534, 35073)26481(10200, 100052) cVitamin A treatment? 155 (33)53 (32)45 (31)43 (29)56 (28)59 (39)Education, years311 (9, 11)11 (9,11) a11 (9,11)10 (9,11)11 (9,11)10 (8,11)Mothers Employed116.7 (10)11.5 (7)18.8 (13)20.9 (14)18.0 (9)24.2 (16)Household income per month, US dollars31220 (801, 1694)913(730, 1455)914 (704,1546)913 (629, 2033)1994 (913, 2992)918 (412, 1369)Infant characteristicsMale sex1 47 (28)48 (29)42 (29)58 (39)40 (20)47(31)Gestational age, weeks2 39.6 (1.2)39.7 (1.1)39.5 (1.3)39.2 (1.6)39.1 (1.4)39.0 (1.3) a, bBirth weight, g23105 (376)3065 (304) 3023 (429)2838 (457) a, b, c2906 (495) a, b 2879 (513) a, b WAZ at birth2-0.42 (0.79)-0.50 (0.66)-0.60 (0.94)-1.07 (0.94) a, b, c-1.07 (1.09) a, b-0.88 (1.12) a, bWAZ at 3 mo2-0.07 (0.91)-0.26 (0.88)-0.50 (1.07) a-0.81 (1.39) a, b -1.44 (1.42) a, b, c, d-1.72 (1.36) a, b, c, d LAZ at birth20.13 (0.90)-0.14 (1.03)-0.37 (1.04) a-0.69 (1.04) a, b-0.69 (1.36) a-0.39 (1.21) aLAZ at 3 mo2-0.32 (0.83)-0.95 (1.04) a-0.79 (1.39) a-1.21 (1.36) a-1.57 (1.17) a, b, c-1.93 (1.50) a, b, c, dBreastfeeding pattern at 3 months1Exclusive26.7 (16)11.5 (7)14.5 (10)14.9 (10)12.0 (6)6.1 (4) a, bPredominant40.0 (24)41.0 (25)53.6 (37)47.8 (32)50.0 (25)69.7 (46)Mixed20.0 (12)29.5 (18)24.6 (17)20.9 (14)18.0 (9)15.2 (10)Timing of infection1IP16.0 (8)31.8 (21)IU56.0 (28)51.5 (34)PN28.0 (14)16.7 (11)Infant mortality1000012 (6) a, b, c, d25.76 (17) a, b, c, dNeonatal vitamin A treatment? 152 (31)44 (27)39 (27)61 (41) c50 (25)58 (38) cInfant Biomarkers at 3monthsHemoglobin, g/L2117.9 (13.4)92.6 (13.7) a118.6 (10.5) b90.1 (16.6) a, c116.6 (8.0) b, d89.4 (13.7) a, b, eHepcidin, ng/mL39.7 (2.5, 19.3)14.7 (6.8, 29.5) a14.3 (8.1, 28.4) a10.3 (3.7, 24.0) c20.3(8.5, 40.0) a, d23.9 (7.9, 42.9) a, b, dHepcidin consensus values ψ 6.2(0.6, 13.7)10.1 (3.9, 21.7) a 9.8 (4.9, 20.8) a6.7(1.5, 17.4) c14.4 (5.3, 29.8) a, d17.3 (4.8, 32.1) a, b, d Ferritin, ?g/l344.10 (27.94, 103.55)49.25 (28.68, 91.76)66.57 (42.79, 100.44)51.09 (25.51, 74.87) c104.98 (39.80, 194.28) a, b, c, d116.74 (55.84, 351.15) a, b, c, dFerritin < 12?g/l 10 8.20 (5) a4.35 (3)10.45 (7) a0 b, d0 b, dSoluble transferrin receptor, mg/L35.71 (4.61, 6.69)5.96(5.25, 7.32)7.25 (5.48, 8.71) a, b6.96 (5.65, 8.2) a, b8.50 (6.64, 12.14) a, b, c, d9.11 (6.77, 12.03) a, b, c, dSoluble transferrin receptor > 8.3mg/L1014.75 (9) a31.88 (22) a, b23.88 (16) a54.00 (27) a, b, c, d63.64 (42) a, b, c, dCRP, mg/L30.21(0.11, 0.91)0.45(0.18, 3.05) a0.46 (0.21, 1.33) a0.95 (0.22, 3.04) a1.4 (0.70, 5.39) a, b, c3.06 (0.84, 10.40) a, b, c, dAGP, g/L30.35 (0.27,0.48)0.32 (0.23, 0.53)0.55 (0.37, 0.74)0.59 (0.40, 0.87) a, b0.67 (0.53, 1.04) a, b, c0.74 (0.51, 1.15) a, b, c, dWAZ: weight-for-age Z-score, LAZ: length-for-age Z-score, MUAC: Mid-upper arm circumference, SD: standard deviation, IQR: interquartile range 1Values are % (n), 2Values are mean (SD), 3Values are median (IQR)*All characteristics measured <96 hours of delivery except where notedψ Hepcidin consensus values were calculated using the algorithm Y= -1.36 + 0.78*hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012)?In the ZVITAMBO trial, mother-infant pairs were randomized within 96 h of birth to one of 4 treatment groups (Aa, Ap, Pa, Pp), where ‘A’ was maternal vitamin A supplementation (400,000 IU), ‘P’ was maternal placebo, ‘a’ was infant vitamin A supplementation (50,000 IU) and ‘p’ was infant placebo. Full details of the trial have been published elsewherePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006).For all variables, pair-wise comparisons were made by Mann-Whitney test and superscript letter denotes a raw p<0.05 for the difference between that group and:a HIV unexposed non anemic infants b HIV unexposed anemic infants c HIV exposed uninfected non anemic infants d HIV unexposed uninfected anemic infants e HIV infected non anemic infants Table 3.2. Characteristics of 6-month-old infantsCharacteristicHIV-Negative MotherHIV-positive MotherNon-infected infantsInfected infantsNon-anemicN= 47AnemicN= 66Non-anemicN=66AnemicN=65Non-anemicN=33AnemicN=69Maternal factorsAge, years2 24 (5)25 (6)26 (5)26 (4)27 (5) a, b27 (5) a, bHemoglobin, g/L3136(132, 142)137 (128, 144.5)125 (118, 133) a, b122 (109, 134) a, b128 (117, 132) a, b123 (113, 128) a, bHeight, m31.59(1.56, 1.65)1.58(1.55, 1.63)1.59(1.55, 1.64)1.59(1.54, 1.65)1.62(1.57, 1.68)1.60(1.57, 1.66)Weight at 6 weeks postpartum, kg361.5(53.0, 70.0)58.3(53.0, 68.0)61.0(54.7, 65.4)57.3 (49.0, 66.2) c62.5(52.0, 66.5)60.0(55.0, 69.3)BMI323.4(20.5, 25.6)23.2(20.2, 26.2)24.1(21.8, 26.3)21.3 (20.0, 23.8) c21.8(19.5, 25.2)22.7(20.7, 27.3)Maternal MUAC, cm225.9 (2.4)26.0 (3.3)27.1 (3.5) a, b26.1 (2.5)25.5 (2.5) c26.1 (3.1)CD4 count, per microliter3N/AN/A403(295, 550)437(250, 619)386(190, 452)333(268, 453)Viral load, copies per ml3 N/AN/A9380(2552, 34063)5970(1565, 65289)27783(6493, 82959)23517 (8850, 79113) dVitamin A treatment? 149(23)47 (31)52 (36)40 (27)42 (14)54 (37)Education, years311 (9, 11)10 (9,11)11 (9,11)10 (9,11)11 (9,11)10 (9,11)Mothers Employed110.9 (5)19.7 (13)21.7 (15)33.8 (23)27.3 (9)18.8 (13)Household income per month, US dollars31220(855, 1830)913(610, 1322) a881(503, 1555)949(711, 1815)1763.00 (855, 2253) b, d970(671, 1902)Infant characteristicsMale sex1 47 (22)59 (39)52 (36)44 (30)55 (18)55 (38)Gestational age, weeks2 39.7 (1.2)39.5 (1.1)39.5 (1.4)38.7 (1.6) a, b, c39.3 (1.4) d39.2 (1.2) dBirth weight, g23186 (359)3068 (386) a3008 (451.04) a2818 (497) a, b3053 (452) d2960 (457) a, dWAZ at birth2-0.24 (0.75)-0.53 (0.80)-0.74 (0.97) a-1.12 (0.97) a, b, c-1.12 (1.20) d-0.57 (1.02) aWAZ at 6 mo2-0.07 (1.09)-0.20 (1.17)-0.45 (1.15) a, b,-0.27 (1.27)-1.25 (1.70) a, b, c, d-1.30 (1.38) a, b, c, dLAZ at birth20.11 (0.71)-0.29 (1.09)-0.13 (0.96)-0.42 (0.96) a-0.42 (1.31) a-0.53 (1.13)LAZ at 6 mo2-0.36 (1.23)-0.79 (1.08)-0.85 (1.19) a-1.00 (1.27) a-1.13 (1.61) a-1.63 (1.25) a, b, c, dBreastfeeding pattern at 3 months1Exclusive17.0 (8)10.6 (7)9.1 (6)9.2 (6)6.1 (2) 5.8 (4)Predominant36.2 (17)51.5 (34)51.5 (34)47.7 (31)39.4 (13)56.5 (39)Mixed14.9 (7)19.7 (13)16.7 (11)20.0 (13)24.2 (8)11.6 (8)Timing of infection1IP24.2 (8)36.2 (25)IU39.4 (13)37.7 (26)PN36.4 (12)26.1 (18)Infant mortality101.52 (1)006.06 (2) c, d10.14 (7) a, b, c, dNeonatal vitamin A treatment? 155 (26)47 (31)54 (37)40 (27)52(17)57 (39)Infant Biomarkers at 6 monthsHemoglobin, g/L2118.0 (9.4)971.6 (13.2) a118.0 (12.7) b87.7 (17.5) a, c116.3 (13.7) b, d91.0 (11.7) a, cHepcidin, ng/mL34.5(0.5, 7.3)7.9 (1.6, 22.7) a7.6 (3.2, 13.3) a6.1 (1.2, 14.7) a7.5 (4.3, 39.2) a, d10.0(1.6, 25.6) aHepcidin consensus values ψ32.2(-1.0, 4.4)4.8 (-0.1, 16.3) a4.6 (1.11, 9.0) a3.4(-0.4, 10.1) a4.5 (2.0, 29.2) a, d6.4 (-0.1, 18.6) aFerritin, ?g/l325.15 (17.64, 42.67)13.16 (6.69, 25.08) a17.48 (9.32, 30.68) a12.36 (7.06, 22.76) a37.20 (17.17, 115.28) b, c, d30.69 (14.93, 52.84) b, c, dFerritin < 12?g/l10 46.97 (31) a34.85 (23) a46.15 (30) a12.12 (4) a, b, c, d17.39 (12) a, b, c, dSoluble transferrin receptor, mg/L35.91 (4.55, 6.44)6.81 (5.68, 8.68) a7.51 (6.06, 8.28) a8.69 (6.96, 10.96) a, b, c7.45 (6.46, 9.81) a8.66 (7.20, 11.34) a, b, c, eSoluble transferrin receptor > 8.3mg/L1032.31 (21) a24.24 (16) a55.38 (36) a, b, c36.36 (12) a56.52 (39) a, b, cCRP, mg/L30.32 (0.13, 1.17)2.33 (0.49, 7.52) a2.08 (0.44, 7.03) a1.97 (0.51, 6.06) a3.10 (0.62, 7.69) a4.64 (1.79, 14.00) a, b, c, dAGP, g/L30.50(0.30, 0.61)0.40 (0.27, 0.57)0.67 (0.47, 0.90) a, b0.68 (0.51, 0.84) a, b0.77 (0.58, 1.02) a, b0.81 (0.60, 1.20) a, b, c, dWAZ: weight-for-age Z-score, LAZ: length-for-age Z-score, MUAC: Mid-upper arm circumference, SD: standard deviation, IQR: interquartile range 1Values are % (n), 2Values are mean (SD), 3Values are median (IQR)*All characteristics measured <96 hours of delivery except where notedψ Hepcidin consensus values were calculated using the algorithm Y= -1.36 + 0.78*hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012)?In the ZVITAMBO trial, mother-infant pairs were randomized within 96 h of birth to one of 4 treatment groups (Aa, Ap, Pa, Pp), where ‘A’ was maternal vitamin A supplementation (400,000 IU), ‘P’ was maternal placebo, ‘a’ was infant vitamin A supplementation (50,000 IU) and ‘p’ was infant placebo. Full details of the trial have been published elsewherePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006).For all variables, pair-wise comparisons were made by Mann-Whitney test and superscript letter denotes a raw p<0.05 for the difference between that group and:a HIV unexposed non anemic infants b HIV unexposed anemic infants c HIV exposed uninfected non anemic infants d HIV unexposed uninfected anemic infants e HIV infected non anemic infants Table 3.3. Characteristics of 12-month-old infantsCharacteristicHIV-Negative MotherHIV-positive MotherNon-infected infantsInfected infantsNon-anemicN= 40AnemicN= 66Non-anemicN=69AnemicN=68Non-anemicN=68AnemicN=66Maternal factorsAge, years2 26 (6)24 (6)25 (5)25 (4) b27 (5) b26 (5) bHemoglobin, g/L3141 (130, 142)133 (125, 142)129 (113, 136) a, b125 (115, 135) a, b127 (116, 138) a, b125 (114, 130) a, bHeight, m31.61(1.54, 1.65)1.59(1.55, 1.62)1.61(1.57, 1.66)1.60(1.55, 1.66)1.61 (1.58, 1.65) b1.59(1.55, 1.63)Weight at 6 weeks postpartum, kg361.0(53.3, 68.5)58.0(53.0, 63.5)60.3(56.0, 65.8)58.2(51.0, 63.5)61.5 (55.0, 74.4) d56.4 (52.2, 63.0) eBMI323.4(21.0, 26.1)22.6(20.5, 26.6)23.1(21.3, 25.2)22.1(20.7, 25.0)23.5(21.7, 28.4) d22.2(20.1, 24.3) eMaternal MUAC, cm226.6 (2.7)25.7 (2.7)26.2 (3.3)26.1 (2.4)27.1 (3.4) a, b25.1 (2.4) d, eCD4 count, per microliter3N/AN/A385(187, 556)493(261, 576)341(289, 417)375(212, 563)Viral load, copies per ml3 N/AN/A6399(1734, 40323)4635g(1282, 29643)14269(6015, 69921)24697 (8484, 119308) c, dVitamin A treatment? 150.0 (20)54.6 (36)52.2 (36)50.0 (34)39.7 (27)50.0 (33)Education, years311 (9, 11)11 (9, 11)11 (9, 11)11 (9, 11)11 (9, 11)10 (9, 11)Mothers Employed115.0 (6)18.2 (12)18.8 (13)17.7 (12)19.1 (13)18.2 (12)Household income per month, US dollars31221 (879, 2103)913(676, 1322)933(529, 1831)917 (575.5, 1576) b1017(680, 1526)1164(711, 2426)Infant characteristicsMale sex1 53(21)62 (41)42 (29) b66 (45) c47 (32) d52 (34)Gestational age, weeks2 39.5 (1.2)39.4 (1.1)39.2 (1.6)39.1 (1.6)39.1 (1.3)39.1 (1.4)Birth weight, g23230 (459)2995 (359) a2973 (427)2853 (420) a, c3020 (498) d2883 (466) aWAZ at birth2-0.18 (0.95)-0.69 (0.78) a-0.72 (1.01) a-1.04 (1.01) a-1.04 (0.96) a, d-0.64 (1.13) aWAZ at 12 mo2-0.39 (1.23)-0.58 (0.92)-0.45 (1.19)-0.71 (1.37)-1.45 (1.32) a, b, c, d-2.00 (1.49) a, b, c, d, eLAZ at birth20.32 (1.44)-0.19 (0.96) a-0.30 (1.16) a-0.63 (1.16) a, b-0.63 (1.17) d-0.17 (1.36) aLAZ at 12 mo2-0.84 (1.36)-1.22 (0.96)-0.88 (1.10)-1.16 (1.70)-1.71 (1.14) a, b, c, d-2.32 (1.34) a, b, c, d, eTiming of infection1IP13.2 (9)19.7 (13) eIU36.8 (25)54.6 (36)PN50.0 (34)25.8 (17)Infant mortality1001.45 (1)05.88 (4) b12.12 (8) a, b, c, dNeonatal vitamin A treatment? 152.5 (21)51.5 (34)55.1 (38)58.8 (40)42.7 (29)53.0 (35)Infant Biomarkers at 12 monthsHemoglobin, g/L2117.1 (11.8)89.4 (11.2) a116.4 (10.1) b83.2 (15.4) a, b, c112.2 (14.7) a, b, c, d84.0 (13.7) a, b, eHepcidin, ng/mL31.90(0.73, 6.17)0.89 (0.01, 3.88) a0.82 (0.12, 5.21)0.98 (0.01, 2.98) a3.87 (0.72, 12.52) b, c, d2.56 (0.25, 13.98) b, c, dHepcidin consensus values ψ 30.12 (-0.79, 3.45)-0.66 (-1.35, 1.67) a-0.72 (-1.27, 2.71)-0.60 (-1.35, 0.97) a1.66 (-0.80, 8.40) b, c, d0.64 (-1.16, 9.54) b, c, dFerritin, ?g/l322.21(15.86, 32.85)3.19 (0.61, 15.56) a9.00 (4.44, 18.37) a, b4.68 (1.74, 16.61) a, c, d19.35 (9.37, 39.99) b, c, d18.83 (8.71, 55.77) b, c, dFerritin < 12?g/l10 71.21 (47) a59.42 (41) a73.53 (50) a32.35 (22) a, b, c, d40.91 (27) a, b, c, dSoluble transferrin receptor, mg/L36.00 (3.94, 6.74)6.71 (4.93, 9.16) a6.21 (4.41, 8.00)8.42 (6.61,10.82) a, b c6.99 (5.15,8.76) a, d9.68 (6.18,15.30) a, b, c, eSoluble transferrin receptor > 8.3mg/L10 36.92 (24) a21.74 (15) a, b50.00 (33) a, c29.41 (20) a, d56.92 (37) a, b, c, eCRP, mg/L30.54 (0.18, 1.20)1.43 (0.44, 5.52) a0.84 (0.16, 3.98)1.40 (0.28,4.64) a2.64 (0.79,7.08) a, c, d4.75 (1.81,14.80) a, b, c, d, eAGP, g/L30.49 (0.38, 0.63)0.57 (0.42, 0.79)0.65 (0.45, 0.89) a0.62 (0.45,0.96) a0.85 (0.57,1.14) a, b, c, d1.03 a, b, c, d, g(0.57,1.57)WAZ: weight-for-age Z-score, LAZ: length-for-age Z-score, MUAC: Mid-upper arm circumference, SD: standard deviation, IQR: interquartile range 1Values are % (n), 2Values are mean (SD), 3Values are median (IQR)*All characteristics measured <96 hours of delivery except where notedψ Hepcidin consensus values were calculated using the algorithm Y= -1.36 + 0.78*hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9vdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Kroot et al, 2012)?In the ZVITAMBO trial, mother-infant pairs were randomized within 96 h of birth to one of 4 treatment groups (Aa, Ap, Pa, Pp), where ‘A’ was maternal vitamin A supplementation (400,000 IU), ‘P’ was maternal placebo, ‘a’ was infant vitamin A supplementation (50,000 IU) and ‘p’ was infant placebo. Full details of the trial have been published elsewherePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006).For all variables, pair-wise comparisons were made by Mann-Whitney test and superscript letter denotes a raw p<0.05 for the difference between that group and:a HIV unexposed non anemic infants b HIV unexposed anemic infants c HIV exposed uninfected non anemic infants d HIV unexposed uninfected anemic infants e HIV infected non anemic infants Determinants of hepcidin levels during infancy To characterize the main determinants of hepcidin concentrations during infancy, we undertook multivariate analysis of hepcidin, HIV and anemia status, adjusting for age and sex (Table 3.4). Log hepcidin concentrations were 42% higher in HEU infants compared to HIV-unexposed infants, after adjusting for anemia status, age and sex (p=0.017); among HIV-infected infants log hepcidin concentrations were 176% higher than in HIV-unexposed infants (p<0.001). Overall, anemia status was not associated with hepcidin concentrations during infancy; however, infant age modified the association between anemia and hepcidin. Anemic 3 mo infants had 62% higher hepcidin levels compared to non-anemic 3 mo infants (p=0.02), with the same trend seen in 6 mo infants. However, at 12 mo of age, differences in hepcidin were observed in the opposite direction (p<0.001), with lower hepcidin levels in anemic compared to non-anemic infants. Hepcidin levels were progressively lower with age in each group, with 44% and 84% decreases in 6 mo and 12 mo non-anemic infants, respectively, compared to 3 mo non-anemic infants (p=0.008 and p<0.0001, respectively) and 62% and 94% lower hepcidin levels in 6 mo and 12 mo anemic infants respectively, compared to 3 mo anemic infants (p<0.001 and p<0.001, respectively, 2.d.f.). Overall, girls had 83% higher hepcidin concentrations than boys (p<0.001) during infancy. Taken together, age, sex and HIV status were the main determinants of hepcidin levels during infancy.Table 3.4. Results of linear regression analyses for log plasma hepcidin concentrations (ng/mL) Univariate modelMultivariate modelβ95% CIP-valueβ95% CIP-valueSexBoysRGirls2.081.59, 2.72< 0.0011.821.44, 2.31<0.001 HIV statusHIV unexposedRHIV exposed0.141.00, 1.920.0511.421.07, 1.900.02HIV infected2.571.84, 3.60<0.0012.762.05, 3.72<0.001AnemiaNon-anemicRAnemic-0.970.74, 1.270.818 1.621.08, 2.420.02Age3 monthsR6 months0.440.32, 0.59<0.0010.560.36, 0.860.00812 months0.090.07, 0.13<0.0010.160.11, 0.24<0.001Interaction:6 months × Anemic0.680.38, 1.220.19Interaction:12 months × Anemic0.360.20, 0.64<0.001*The dependent variable hepcidin was log-transformed before inclusion in the models. Thus, the β values express the percentage change in hepcidin (ng/mL) that is associated with each group compared to the reference group.Associations between haematological biomarkersWe next undertook analyses to explore the relationships between hepcidin and other hematological biomarkers (Fig 3.1). We assessed the relationship between hepcidin, ferritin and CRP within HIV-unexposed, HEU and HIV-infected infant groups at each age. Anemic and non-anemic infants were combined within each group in order to extend the ranges of hepcidin, ferritin and CRP concentrations. Hepcidin was positively correlated with both ferritin and CRP in all groups at each age (p<0.001 for all correlations). In all infant groups, hepcidin was more strongly correlated with ferritin than with CRP (Fig 3.1).r=0.64r=0.73r=0.55r=0.35r=0.32r=0.27Figure 3.1. Relationships between hepcidin and other biomarkersCorrelation of hepcidin with ferritin and CRP in HIV-unexposed, HIV-exposed uninfected (HEU) and HIV-infected infants. Values for non-anemic (empty) and anemic (solid) infants (p<0.001 for all Pearson correlations). Hepcidin, ferritin and CRP are expressed on a log scale.DISCUSSIONThis study is, to our knowledge, the first to characterize hepcidin concentrations in HIV-infected and HIV-exposed infants, and focused specifically on sub-Saharan African infants, who are at particularly high risk of anemia. We show, first, that hepcidin levels are strikingly elevated in HIV-infected infants throughout the first year of life; second, that HIV-exposed uninfected infants have higher hepcidin levels than HIV-unexposed infants; third, that hepcidin levels in infancy are related to inflammatory biomarkers, which are elevated in HEU and HIV-infected infants; fourth, that hepcidin overall is not strongly associated with anemia during infancy in the context of HIV; fifth, that hepcidin concentrations are progressively lower at 6 and 12 months compared to 3 months; and, sixth, that hepcidin levels are higher in girls than boys. Hepcidin concentrations were markedly elevated in HIV-infected infants from as early as 3 months of age, and remained high throughout infancy. HIV infection is characterized by immune activation, and we found a direct relationship between hepcidin and levels of inflammatory biomarkers in infants, as others have found in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYW56PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Schwarz et al, 2011). They reported median (IQR) hepcidin concentration of 25.1 ng/mL (6.4–39.7) in 188 Rwandan HIV-positive women without ferroportin mutations, whilst a smaller cohort of 12 women with a ferroportin mutation (Q248H mutation in the gene SLC40A1), associated with resistance to hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXNhaXNhPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ZT5=
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ZT5=
ADDIN EN.CITE.DATA (Masaisa et al, 2012), had a median hepcidin concentration of 3.3 ng/mL (IQR 1.3-7.5). Despite the depressed hepcidin concentration, they observed elevated ferritin in HIV-positive women with the ferroportin mutation and concluded that the increased availability of iron may explain the higher prevalence of opportunistic infections, including pulmonary tuberculosis and Pneumocystis jiroveci pneumonia, in this group compared to HIV-positive women without the ferroportin mutation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXNhaXNhPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Montaner et al, 2006; Boelaert et al, 2007; Drakesmith& Prentice, 2012). Anemia is a risk factor for mortality in pediatric HIV infection and is likely to reflect advanced disease; consistent with this, HIV-infected infants were more likely to be underweight and stunted in this cohort. The expansion of prevention of mother-to-child transmission (PMTCT) interventions in countries with high HIV prevalence means that an increasing number of HEU infants are being born in sub-Saharan Africa PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaWx0ZWF1PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA (Thea et al, 1993; Brahmbhatt et al, 2006; Otieno et al, 2006; Makasa et al, 2007; Marinda et al, 2007; McNally et al, 2007; Shapiro et al, 2007). In addition, several studies have cited hematologic toxicity and increased risk of anemia in HEU infants associated with exposure to maternal ART PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aaXNrZTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Paul et al, 2005; Feiterna-Sperling et al, 2007; Dryden-Peterson et al, 2011; Ziske et al, 2013). Poor maternal health and suboptimal infant feeding practices may contribute to increased rates of illness and impaired nutritional status PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJpbmRhPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Clerici et al, 2000; Kuhn et al, 2001). We observed elevated hepcidin and markers of inflammation (AGP and CRP) in HEU compared to HIV-unexposed infants. This suggests that exposure to maternal immune activation in utero may lead to low-grade inflammation in HEU infants and may partially contribute to the poor growth, increased morbidity and mortality consistently reported in HEU infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFwaXJvPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Thea et al, 1993; Brahmbhatt et al, 2006; Otieno et al, 2006; Makasa et al, 2007; Marinda et al, 2007; McNally et al, 2007; Shapiro et al, 2007). However it should be noted that maternal ART was not available in Zimbabwe at the time of the study. If inflammation contributes to anemia in HEU infants, it does not appear to be driven by elevated hepcidin levels in this group. Interpretation of anemia in HEU infants at 3 mo of age in this cohort was complicated by the finding that a higher proportion of anemic infants were randomized to vitamin A supplementation at birth in the ZVITAMBO trial. Although vitamin A supplementation in HEU infants was not associated with increased mortality in the present analysis, it was associated with increased mortality in the main trial PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey et al, 2006). Although anemic HEU infants had lower ferritin at 3 mo, it is not clear what the cause of anemia was, as only 10.5% of anemic 3 mo infants had ferritin in the iron-deficient range and there was no evidence of increased inflammation. We cannot exclude the possibility, therefore, that anemia in this group was a marker of ill health, and may be on the causal pathway to mortality. At 6 mo and 12 mo of age, ferritin was in the iron-deficient range in 50-75% of anemic HEU infants, suggesting a high prevalence of iron deficiency anemia in this group with increasing age, similar to our findings in HIV-unexposed infants. Hepcidin concentrations declined with age in all groups. This is presumably a physiological response to mobilize iron stores and absorb more dietary iron, since endogenous iron becomes depleted between 3-4 months and dietary iron is needed to maintain hemoglobin concentrations PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWxsbWFuPC9BdXRob3I+PFllYXI+MTk4MDwvWWVhcj48
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ADDIN EN.CITE.DATA (Dallman et al, 1980). Girls had higher hepcidin concentrations than boys, as we have previously described for healthy non-anemic infants ADDIN EN.CITE <EndNote><Cite><Author>Mupfudze</Author><Year>2013</Year><RecNum>4411</RecNum><DisplayText>(Mupfudze<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>4411</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4411</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mupfudze, T. G.</author><author>Stoltzfus, R. J.</author><author>Rukobo, S.</author><author>Moulton, L. H.</author><author>Humphrey, J. H.</author><author>Prendergast, A. J.</author></authors></contributors><auth-address>Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe. tmupfudz@jhsph.edu.</auth-address><titles><title>Hepcidin decreases over the first year of life in healthy African infants</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><edition>2013/10/12</edition><dates><year>2013</year><pub-dates><date>Sep 20</date></pub-dates></dates><isbn>1365-2141 (Electronic)
0007-1048 (Linking)</isbn><accession-num>24112078</accession-num><work-type>Letter</work-type><urls><related-urls><url>;(Mupfudze et al, 2013). Boys have been found to be more prone to anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaG9yaXNkb3R0aXI8L0F1dGhvcj48WWVhcj4yMDExPC9Z
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ADDIN EN.CITE.DATA (Emond et al, 1996; Thorisdottir et al, 2011) and lower hepcidin concentrations among male infants might be a physiological response to reduced iron stores PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbW9uZDwvQXV0aG9yPjxZZWFyPjE5OTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Emond et al, 1996; Thorisdottir et al, 2011). Sex and age differences in hepcidin levels have also been reported in adults PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Cook et al, 1976; Koziol et al, 2001; Galesloot et al, 2011). Anemia had no overall association with hepcidin concentrations during infancy in multivariate analyses. However, among specific subgroups of infants, anemia did appear to be associated with hepcidin concentrations. Elevated hepcidin in anemic 3 mo HIV-unexposed infants may be explained by the elevated CRP levels observed in this group, although the reasons for low-grade inflammation in these apparently healthy infants is unclear. At 6 mo of age, anemia among HIV-unexposed infants appeared to be driven by a combination of inflammation and iron deficiency, but by 12mo anemia was mainly due to iron deficiency and hepcidin levels were low, as has been observed in classical iron deficiency. In the HEU group, both ferritin and hepcidin were lower in anemic compared to non-anemic infants at 3mo of age, suggesting a physiological hormonal response through hepcidin in response to lower iron stores. However, hepcidin was not useful in distinguishing anemic from non-anemic 6 mo and 12 mo HEU infants, or HIV-infected infants at any age. Hepcidin, like ferritin, is an acute phase protein and thus normal or raised hepcidin levels may be observed in anemic individuals in the presence of inflammation, as was characteristic of HEU and HIV-infected infants in this cohort. Hepcidin levels were more strongly correlated with ferritin than with CRP in all groups of infants. Hepcidin and ferritin have been shown to respond similarly to changes in inflammation and storage of iron and ferritin has been shown to be most strongly associated with hepcidin in other studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Galesloot et al, 2011).This is the first study to characterize hepcidin levels in the context of pediatric HIV infection and exposure, and one of the few studies to describe hepcidin in infants. A strength of this study is the unique cohort of African infants who were recruited prior to ART availability and therefore represent a well-characterized natural history cohort. A limitation of this study is the absence of viral load and CD4 data in HIV-infected infants, so it was not possible to ascertain how hepcidin is related to HIV disease progression in infants. Although we assayed samples at 3, 6 and 12 months, the cross-sectional nature of our study limits our ability to make inferences about the trajectory of hepcidin over the first year of life. In summary, hepcidin concentrations are related to inflammatory status in infants, as in adults, and HIV-infected infants therefore have high levels of hepcidin; HEU infants have higher levels of inflammation and hepcidin than HIV-unexposed infants. Overall, differences in hepcidin did not explain anemia during infancy, except in young HIV-unexposed infants. Hepcidin concentrations progressively declined over the first year of life, and girls had higher levels of hepcidin than boys. Future studies should further explore the role of hepcidin in the pathogenesis of HIV infection, in particular whether sequestration of iron in macrophages may contribute to HIV disease progression, particularly in perinatally infected infants. The relationship between Infant and Young Child feeding (IYCF) indicators, Water Sanitation and Hygiene (WASH) indictors and hemoglobin levels among young Zimbabwean children Tatenda G. Mupfudze1, 2, Rebecca J. Stoltzfus3, Lawrence H. Moulton1, Andrew Jones4, Bernard Chasekwa1, Mduduzi Mbuya1, Andrew J. Prendergast1, 2,5, Jean H. Humphrey1, 2 and the SHINE Project Team1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; 3Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; 4Centre for Paediatrics, Blizard Institute, Queen Mary University of London, UK. 5Department of Environmental Health Sciences, University of Michigan School of Public HealthCorresponding author: Tatenda G. Mupfudze, Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, Maryland, USA. Email: tmupfudz@jhsph.edu Phone: +263 (0) 4850732/3 Fax: +263 (0) 4850734Short title: IYCF, WASH and infant anemiaKey words: Anemia, infants, water, hygiene sanitation, complementary feedingAbstractAnemia affects 2 billion people worldwide, particularly young children in developing countries. Substantial research has demonstrated that dietary iron deficiency and subclinical and clinical infections are important causes of pediatric anemia. It has recently been proposed that environmental enteropathy (EE) may cause prevalent systemic inflammation in young children, that EE suppresses iron absorption and erythropoiesis, and that EE is caused by poor water, sanitation and hygiene (WASH). Using the 2010-11 Zimbabwe Demographic Health Survey (ZDHS), we tested the hypothesis that WASH indicators that reflect fecal exposure are associated with lower hemoglobin (Hb) in children 6-24 mo of age (n=1271). We controlled for WHO infant and young child feeding (IYCF) indicators, including the iron-rich food indicator, and hypothesized that these would not be associated with Hb due to lack of accuracy with regard to iron nutrition.? Continuous regression analysis with survey weights and survey-specific commands were applied to account for the complex multistage cluster sampling survey design. We found that two WASH indicators (uncontained child stool disposal, and absence of soap at handwashing station) were associated with lower hemoglobin levels, but found no association between any of the WHO IYCF indicators and Hb in multivariate analysis. Our findings are consistent with the hypothesized role of poor WASH as a contributing cause of pediatric anemia in low-income settings. Further studies are needed to elucidate the role of WASH interventions of risk of anemia in infants and young children. IntroductionAnemia is a serious public health problem affecting 2 billion people worldwide; particularly young children in developing countries, where its causes are multifactorial PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb2tlc2h3YXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (WHO.; Lokeshwar et al, 2011; Milman, 2011). In Zimbabwe the prevalence of anemia is 71%, 74% and 68% among 6-8 month-olds, 9-17 month-olds, and 18-24 month-olds, respectively ADDIN EN.CITE <EndNote><Cite><Year>Zimbabwe National Statistics Agency & ICF International Inc., 2012</Year><RecNum>2271</RecNum><DisplayText>(Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2271</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2271</key></foreign-keys><ref-type name="Dataset">59</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011.( , accessed 15 December 2012).</title></titles><dates><year>Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>(Zimbabwe National Statistics Agency & ICF International Inc., 2012) and has remained relatively constant over the past 5 years ADDIN EN.CITE <EndNote><Cite><Year>Central Statistics Office (CSO) [Zimbabwe] & Macro International Inc., 2007</Year><RecNum>2270</RecNum><DisplayText>(Central Statistics Office (CSO) [Zimbabwe] & Macro International Inc., 2007)</DisplayText><record><rec-number>2270</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2270</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Zimbabwe Demographic and Health Survey 2005-2006.( accessed 15 December 2012).</title></titles><dates><year>Central Statistics Office (CSO) [Zimbabwe] & Macro International Inc., 2007</year></dates><urls></urls></record></Cite></EndNote>(Central Statistics Office (CSO) [Zimbabwe] & Macro International Inc., 2007). Anemia in infancy is associated with impaired cognitive and behavioral development PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWx0ZXI8L0F1dGhvcj48WWVhcj4xOTk0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Walter et al, 1989; Walter, 1994; Rao& Georgieff, 2002), impaired oxygen transport ADDIN EN.CITE <EndNote><Cite><Author>Cullis</Author><Year>2011</Year><RecNum>915</RecNum><DisplayText>(Cullis, 2011)</DisplayText><record><rec-number>915</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">915</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cullis, J. O.</author></authors></contributors><auth-address>Department of Haematology, Salisbury NHS Foundation Trust, Salisbury, UK. jonathan.cullis@salisbury.nhs.uk</auth-address><titles><title>Diagnosis and management of anaemia of chronic disease: current status</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><pages>289-300</pages><volume>154</volume><number>3</number><edition>2011/05/28</edition><keywords><keyword>Algorithms</keyword><keyword>Anemia/*diagnosis/etiology/therapy</keyword><keyword>Antimicrobial Cationic Peptides/antagonists & inhibitors/physiology</keyword><keyword>Chronic Disease</keyword><keyword>Diagnosis, Differential</keyword><keyword>Erythropoietin/therapeutic use</keyword><keyword>Humans</keyword><keyword>Iron/therapeutic use</keyword></keywords><dates><year>2011</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1365-2141 (Electronic)
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ADDIN EN.CITE.DATA (Weatherall, 1990; Stoltzfus et al, 1997; Friedman et al, 2005; Tolentino& Friedman, 2007; Midzi et al, 2010). Recently, the prevalent subclinical gut disorder termed environmental enteropathy (EE) has been hypothesized to contribute to anemia of inflammation, even in the absence of clinical disease ADDIN EN.CITE <EndNote><Cite><Author>Prendergast</Author><Year>2012</Year><RecNum>4579</RecNum><DisplayText>(Prendergast& Kelly, 2012)</DisplayText><record><rec-number>4579</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4579</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Prendergast, A.</author><author>Kelly, P.</author></authors></contributors><auth-address>Centre for Paediatrics and Centre for Digestive Diseases, Blizard Institute, Queen Mary University of London, United Kingdom. a.prendergast@qmul.ac.uk</auth-address><titles><title>Enteropathies in the developing world: neglected effects on global health</title><secondary-title>The American journal of tropical medicine and hygiene</secondary-title><alt-title>Am J Trop Med Hyg</alt-title></titles><periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></periodical><alt-periodical><full-title>The American journal of tropical medicine and hygiene</full-title><abbr-1>Am J Trop Med Hyg</abbr-1></alt-periodical><pages>756-63</pages><volume>86</volume><number>5</number><edition>2012/05/05</edition><keywords><keyword>*Developing Countries</keyword><keyword>HIV Enteropathy/diagnosis/*epidemiology/therapy</keyword><keyword>Humans</keyword><keyword>Intestinal Diseases/diagnosis/*epidemiology/therapy</keyword><keyword>Morbidity</keyword><keyword>Public Health</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1476-1645 (Electronic)
0002-9637 (Linking)</isbn><accession-num>22556071</accession-num><work-type>Review</work-type><urls><related-urls><url>;(Prendergast& Kelly, 2012). Chronic fecal-oral transmission of microorganisms may be the primary cause of EE, a subclinical intestinal pathology ubiquitous among people living in unhygienic conditionsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey, 2009). EE may contribute to the high rates of anemia among infants and young children in developing countries through impaired digestive/absorptive and barrier functions of the small intestine PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+
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ADDIN EN.CITE.DATA (Cook et al, 1969; Carneiro Chaves et al, 1981) and increased inflammation and permeability . The characteristic distorted gut architecture compromises the intestinal barrier, reduces absorptive capacity and increased intestinal permeability, enabling microbial translocation which leads to chronic systemic inflammation (Figure 1) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA (Ukabam et al, 1986; Iqbal et al, 1996; Humphrey, 2009; Prendergast& Kelly, 2012). Chronic systemic inflammation may result in anemia of inflammation through mechanisms mediated by inflammatory cytokines, acute phase proteins and hepcidin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XZWlzczwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Weiss, 2002; Means, 2004; Weiss& Goodnough, 2005; Weiss, 2009). Schistosomiasis infection (S. haematobium and S. mansoni) and STHs: hookworm, Trichuris trichiura and Ascaris lumbricoides, are also endemic in developing countries with poor Water Sanitation and Hygiene (WASH) practices ADDIN EN.CITE <EndNote><Cite><Author>Hotez</Author><Year>2005</Year><RecNum>4566</RecNum><DisplayText>(Hotez<style face="italic"> et al</style>, 2005)</DisplayText><record><rec-number>4566</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4566</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hotez, P. J.</author><author>Bethony, J.</author><author>Bottazzi, M. E.</author><author>Brooker, S.</author><author>Buss, P.</author></authors></contributors><auth-address>Department of Microbiology and Tropical Medicine, The George Washington University, Washington, DC, USA. mtmpjh@gwumc.edu</auth-address><titles><title>Hookworm: "the great infection of mankind"</title><secondary-title>PLoS medicine</secondary-title><alt-title>PLoS Med</alt-title></titles><periodical><full-title>PLoS medicine</full-title><abbr-1>PLoS Med</abbr-1></periodical><alt-periodical><full-title>PLoS medicine</full-title><abbr-1>PLoS Med</abbr-1></alt-periodical><pages>e67</pages><volume>2</volume><number>3</number><edition>2005/03/24</edition><keywords><keyword>Cost of Illness</keyword><keyword>Helminth Proteins/immunology</keyword><keyword>Hookworm Infections/*epidemiology/etiology/*prevention & control</keyword><keyword>Humans</keyword><keyword>*Infection Control</keyword><keyword>Poverty</keyword><keyword>Sanitation</keyword><keyword>Vaccines</keyword><keyword>*World Health</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1549-1676 (Electronic)
1549-1277 (Linking)</isbn><accession-num>15783256</accession-num><work-type>Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.</work-type><urls><related-urls><url>;(Hotez et al, 2005), affecting over 2 billion people, 5–10% of whom are children under 24 months of age ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2005</Year><RecNum>5122</RecNum><DisplayText>(WHO., 2005)</DisplayText><record><rec-number>5122</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title>The Millenium Development Goals. The evidence is in: deworming helps meet the Millenium Development Goals accessed November 2013</title></titles><dates><year>2005</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2005). Children 12-24 months who are at highest risk for anemia often acquire their first STH infection during the same time period PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdW5nJmFwb3M7dTwvQXV0aG9yPjxZZWFyPjIwMDk8L1ll
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ADDIN EN.CITE.DATA (Taylor P, 1985; Chandiwana et al, 1988; Midzi et al, 2011) (available from, the Ministry of Health and Child Welfare (MoHCW) of Zimbabwe ). Only 29.6% of Zimbabwean households have access to improved toilet facilities ADDIN EN.CITE <EndNote><Cite><Year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</Year><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012) and 20.3%, 9.3% and 6.0% of individuals infected with S. haematobium, S. mansoni and STHs respectively had a toilet at home (available from MoHCW of Zimbabwe )Dietary iron deficiency also contributes to pediatric anemia. Dietary iron requirements are extremely high during the second half of infancy when endogenous iron stores become depleted and the infant is no longer self-reliant for iron to meet the needs for erythropoiesis and growth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb21lbGxvZjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA (Lind et al, 2004; Baker& Greer, 2010; Domellof, 2011). The Recommended Dietary Allowance (RDA) for iron among 7 to 12 month old infants is 11mg/day ADDIN EN.CITE <EndNote><Cite><Author>Baker</Author><Year>2010</Year><RecNum>829</RecNum><DisplayText>(Baker& Greer, 2010)</DisplayText><record><rec-number>829</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">829</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baker, R. D.</author><author>Greer, F. R.</author></authors></contributors><titles><title>Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age)</title><secondary-title>Pediatrics</secondary-title><alt-title>Pediatrics</alt-title></titles><periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></periodical><alt-periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></alt-periodical><pages>1040-50</pages><volume>126</volume><number>5</number><edition>2010/10/07</edition><keywords><keyword>Anemia, Iron-Deficiency/*diagnosis/etiology/*prevention & control</keyword><keyword>Bottle Feeding</keyword><keyword>Breast Feeding</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant Formula</keyword><keyword>Infant, Newborn</keyword><keyword>Iron/administration & dosage</keyword><keyword>Male</keyword><keyword>Nutritional Requirements</keyword><keyword>Reference Values</keyword><keyword>Risk Factors</keyword><keyword>United States</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1098-4275 (Electronic)
0031-4005 (Linking)</isbn><accession-num>20923825</accession-num><urls><related-urls><url>;(Baker& Greer, 2010). Except for animal liver and organ meat, even the best natural dietary sources of iron are not iron-concentrated enough to provide 11mg elemental iron in the small volumes consumed by infants. For example, to meet this requirement, an infant would need to consume 400 g red meat, 700 g chicken, 11 eggs, or 6 cups of cooked legumes daily.The median iron consumed by 9-12 and 6-8 month-old infants in formative research among 32 infants from 2 small rural Zimbabwean villages was 3.1 and 1.8 mg/day respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXVsPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Paul et al, 2011). Hence, almost all 9-12 month olds (95%) and a 100% of 6-8 month-old infants did not meet the RDA for iron PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXVsPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Paul et al, 2012). We hypothesize that the key IYCF indicator “consumption of iron-rich/iron- fortified food for children 6-23 months” is not associated with hemoglobin levels in Zimbabwean children because the iron-rich IYCF indicator primarily counts intake of natural foods and so does not reflect iron consumption at levels that are relevant to infants’ iron needs.The objective of this study was to determine if IYCF and WASH indicators are associated with hemoglobin levels in Zimbabwean children aged 6-24 months. We hypothesized that WASH practices are associated with hemoglobin levels in Zimbabwean children, due to the high prevalence of Schistosomiasis, STH and the EE pathway discussed above, but that the WHO IYCF indicators would not be associated with hemoglobin due to lack of specificity with regard to iron consumption. MethodsData and sampleWe used data from the 2010-2011 Zimbabwe DHS (ZDHS), available on the DHS website ADDIN EN.CITE <EndNote><Cite><RecNum>2271</RecNum><DisplayText>(Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2271</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2271</key></foreign-keys><ref-type name="Dataset">59</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011.( , accessed 15 December 2012).</title></titles><dates><year>Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>(Zimbabwe National Statistics Agency & ICF International Inc., 2012). The ZDHS collected information from a nationally representative probability sample of all 10 Zimbabwean provinces using a stratified, two-stage cluster design yielding 9,756 households and a household response rate of 96%. Detailed information on survey design, management, quality control, and major findings is provided in the 2010-2011 ZDHS report ADDIN EN.CITE <EndNote><Cite><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012).Hemoglobin testing was carried out among children aged 6-59 months and was successfully measured in 80% of eligible children. We analyzed data from children 6-24 months of age for whom age-appropriate IYCF indicators could be constructed from available data. The initial population comprised 1741 children. Our analysis was restricted to the youngest child in a household in this age range with an available hemoglobin measurement, whose mother was interviewed. Hence 51 and 314 children were excluded because they were the older child in a household with more than one child between 6 and 24 months and because they did not have a valid hemoglobin measurement respectively. 105 children were excluded from the multivariate analysis because they were not “de jure” household members or lacked information on included variables. Therefore, 1376 children were selected and studied in the univariate analysis and 1271 children were included in the multivariate analysis. VariablesOutcome: The outcome variable hemoglobin (g/dl) was measured using the HemoCue hemoglobinometer (HemoCue, Mission Viejo, CA; ADDIN EN.CITE <EndNote><Cite><Author>Sharman</Author><Year>2000</Year><RecNum>4410</RecNum><DisplayText>(Sharman, 2000)</DisplayText><record><rec-number>4410</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4410</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Sharman, A</author></authors></contributors><titles><title> Anemia testing in population-based surveys: General information and guidelines for country monitors and program managers. Calverton, Maryland USA: ORC Macro.</title></titles><dates><year>2000</year></dates><urls></urls></record></Cite></EndNote>(Sharman, 2000)). Severe, moderate and mild anemia were characterized by hemoglobin levels < 7.0 g/dl; between 7.1g/dl and 9.9g/dl; and between10.0 g/dl and 10.9 g/dl respectively ADDIN EN.CITE <EndNote><Cite><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012).IYCF indicators: The infant and young child feeding indicators were calculated as specified by the WHO Indicators for Assessing Infant and Young Child Feeding Practices ADDIN EN.CITE <EndNote><Cite><RecNum>2258</RecNum><DisplayText>(WHO., 2008 )</DisplayText><record><rec-number>2258</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2258</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part I: Definitions, (, accessed 15 May 2013).
</title></titles><dates><year>2008 </year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008 ) (Table 4.1). Early initiation of breast-feeding, (i.e. the child was put to the breast within the first hour of birth) was measured based on maternal recall. Continued breast-feeding at 1 and 2 years of age was assessed in children age 12-15 months and 20-23 months, respectively and introduction of solid, semi-solid or soft foods was assessed in infants aged 6-8 months. The above indicators assessing small subsets of children were not included in multivariate analysis. Consumption of iron-rich foods, bottle-feeding and age-appropriate breastfeeding (the child received breast milk as well as solid or semi-solid foods) in the previous 24 hours was assessed using a 24-hour recall in all children age 6-23 months. Minimum dietary diversity (MDD) was defined as consumption of foods from 4 or more of the following 7 foods groups: i) grains, roots, tubers; ii) legumes and nuts; iii) dairy products; iv) flesh foods (meat, fish, poultry, organ); v) eggs; vi) vitamin A-rich fruits and vegetables, and vii) other fruits and vegetables. The minimum meal frequency (MMF) was estimated by counting the number of times solid, semi-solid, or soft foods were consumed in the previous 24 hours. The MMF for breastfed infants 6–8 months and 9-23 months old is 2 and 3 meals per day respectively, with 1–2 additional snacks as desired ADDIN EN.CITE <EndNote><Cite><RecNum>2273</RecNum><DisplayText>(WHO/PAHO., 2003)</DisplayText><record><rec-number>2273</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2273</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO/PAHO. </author></authors></contributors><titles><title>Guiding Principles for Complementary Feeding of the Breastfed Child. (, accessed December 2012)</title></titles><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>(WHO/PAHO., 2003). The MMF for non-breastfed children 6-23 months is 4 meals and 1-2 cups of “milk feeds” (infant formula, milk or yogurt) per day ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2008</Year><RecNum>5050</RecNum><DisplayText>(WHO., 2008)</DisplayText><record><rec-number>5050</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5050</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part II: Measurement, , pdf accessed 15 May 2013).</title></titles><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008). The minimum acceptable diet (MAD) was estimated from the MDD and the MMF: consumption of 2 and 3 meals per day with 1–2 additional snacks as desired ADDIN EN.CITE <EndNote><Cite><RecNum>2273</RecNum><DisplayText>(WHO/PAHO., 2003)</DisplayText><record><rec-number>2273</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2273</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO/PAHO. </author></authors></contributors><titles><title>Guiding Principles for Complementary Feeding of the Breastfed Child. (, accessed December 2012)</title></titles><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>(WHO/PAHO., 2003) by breastfeeding 6–8 months and 9-23 months old infants respectively, and 4 meals and 1-2 cups of “milk feeds” per day for non-breastfeeding children 6-23 months old together with the consumption of 4 or more of the above 7 foods groups ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2008</Year><RecNum>5050</RecNum><DisplayText>(WHO., 2008)</DisplayText><record><rec-number>5050</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5050</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part II: Measurement, , pdf accessed 15 May 2013).</title></titles><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008). The key IYCF indicator in our analysis, “Consumption of iron-rich/iron- fortified food for children 6-23 months” is defined by the WHO as the consumption of an iron-rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home. Iron rich foods include organ meats, meat (beef, pork, lamb, chicken, etc.), fish and seafood or any processed/cured products made from the above ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2008</Year><RecNum>5050</RecNum><DisplayText>(WHO., 2008)</DisplayText><record><rec-number>5050</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5050</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part II: Measurement, , pdf accessed 15 May 2013).</title></titles><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008). Suitable iron-fortified foods include: iron fortified infant/toddler formula, commercially fortified foods specially designed for infants and young children which contain iron, or foods fortified in the home with a micronutrient powder containing iron such as sprinkles or a lipid-based nutrient supplement (LNS) containing iron ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2008</Year><RecNum>5050</RecNum><DisplayText>(WHO., 2008)</DisplayText><record><rec-number>5050</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5050</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part II: Measurement, , pdf accessed 15 May 2013).</title></titles><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008). Iron-fortified foods and products included in the WHO indicator are adapted to reflect iron-fortified foods available in a particular context ADDIN EN.CITE <EndNote><Cite><Author>WHO.</Author><Year>2008</Year><RecNum>5050</RecNum><DisplayText>(WHO., 2008)</DisplayText><record><rec-number>5050</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5050</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>WHO.</author></authors></contributors><titles><title> Indicators for assessing infant and young child feeding practices - Part II: Measurement, , pdf accessed 15 May 2013).</title></titles><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(WHO., 2008). There are no national iron supplementation programs for infants and young children. Hence information on consumption of foods fortified in the home with a micronutrient powder containing iron or a LNS containing iron was not collected, because national use is practically non-existent ADDIN EN.CITE <EndNote><Cite><Year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</Year><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). The indicator “Consumption of iron-rich/iron- fortified food for children 6-23 months” was constructed from the following food groups: 1) liver, heart, other organs; 2) meat (beef, pork, lamb, chicken, etc.); 3) fish and shellfish; 4) baby formula and 5) fortified baby food.WASH Indicators: Sanitary conditions were classified as improved or unimproved depending on the type of toilet facility and whether it was shared with other households ADDIN EN.CITE <EndNote><Cite><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). Toilets that flush or pour flush into a piped sewer system, septic tank, or pit latrine; ventilated improved pit (VIP) latrines or Blair toilets; and pit latrines with a slab were classified as improved, provided only one household used the toilet facility ADDIN EN.CITE <EndNote><Cite><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). Households that shared a toilet facility, had no toilet or used an open pit were classified as non-improved. Disposal of the youngest child’s stools was classified as contained if the child used a toilet or latrine, the stool was rinsed into a toilet or latrine or the stool was buried. Stool that was left in the open/not disposed of, thrown into garbage or into a drain or ditch was classified as uncontained ADDIN EN.CITE <EndNote><Cite><RecNum>2269</RecNum><DisplayText>( Zimbabwe National Statistics Agency & ICF International Inc., 2012)</DisplayText><record><rec-number>2269</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2269</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title> Zimbabwe Demographic and Health Survey 2010-2011. (, accessed 15 December 2012).</title></titles><dates><year> Zimbabwe National Statistics Agency & ICF International Inc., 2012</year></dates><urls></urls></record></Cite></EndNote>( Zimbabwe National Statistics Agency & ICF International Inc., 2012). Interviewers observed household handwashing stations and gathered information on the availability of soap or detergent and water in households where the handwashing place was observed. Data were categorized into: soap present at handwashing station; no soap present at handwashing station; no handwashing station; handwashing station not observed because permission was denied or for other reasons.The main source of drinking water was classified as being from an “improved source” (e.g. piped water source, borehole, protected well or if it was treated regardless of the water source) or from a “non-improved source” (e.g. open well, pond or stream) according to the WHO/UNICEF Joint Monitoring Program (JMP) for Water and Sanitation categorizations ADDIN EN.CITE <EndNote><Cite><RecNum>2272</RecNum><DisplayText>(WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation)</DisplayText><record><rec-number>2272</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">2272</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title> ( , accessed December 2012)</title></titles><dates><year>WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation</year></dates><urls></urls></record></Cite></EndNote>(WHO / UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation).AnalysesData analyses were conducted using Stata 12 statistical software STATA version 12 (StataCorp, College Station, TX). Survey weights and survey-specific commands (svy in Stata 12) were applied to account for the complex multistage cluster sampling survey design and to appropriately correct standard errors for all analyses. Descriptive analyses were first conducted to present general information on the study population. Continuous regression analysis was used to assess the association between hemoglobin and possible risk factors. Factors that were significant in univariate analysis were included in the multivariate models. In addition, a number of potential confounding factors were included in the multivariate model at the child level (age, sex, birth weight and whether the child had ever received vitamin A supplements) and at the maternal level (maternal hemoglobin), which were likely to influence the hemoglobin status of children. Covariance matrices were used to assess multi-collinearity among independent variables in the models. The DHS wealth index includes some WASH-related variables as assets ADDIN EN.CITE <EndNote><Cite><Author>S. O. Rutstein and K. Johnson</Author><Year>2004</Year><RecNum>4409</RecNum><DisplayText>(S. O. Rutstein and K. Johnson, 2004)</DisplayText><record><rec-number>4409</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4409</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>S. O. Rutstein and K. Johnson, MEASURE DHS+, ORC Macro, Calverton, Maryland, USA</author></authors></contributors><titles><title>The DHS Wealth Index (, accessed 15 December 2012).
</title></titles><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>(S. O. Rutstein and K. Johnson, 2004) and was collinear with disposal of child’s stool; hence it was not added to the multivariate model and maternal education was used as a proxy for wealth in the multivariate model.ResultsSample CharacteristicsThe mean (SD) age was 14.0(0.1) months (Table 4.2). The prevalence of low birth weight (< 2500g) and stunting (height-for-age-z-score < -2) was 5.5 and 29.2%, respectively. Mean maternal hemoglobin was 12.9 (SD 1.7) g/dL. In our analytic sample, 29.6% (CI 95%: 26.8; 32.6%) children 6-24 months had mild anemia; 42.2% (CI 95%: 38.9; 44.9%) had moderate anemia and 1.8% (CI 95%: 1.1; 2. 7 %) had severe anemia. More than three-quarters of infants and young children (76.5%) lived in rural areas; two-thirds of mothers (65.0%) had a secondary education or were not currently working (66.9%). Prevalence of infant and young child feeding practices and WASH indicatorsBreastfeeding was common, with the prevalence of ever breastfeeding; continued breastfeeding at one year; early breastfeeding initiation (<1 hour after birth) and age-appropriate breastfeeding (the child received breast milk as well as solid or semi-solid foods in the previous 24 hours among 6-23 months-olds) 98.7%, 88.6%, 75.1% and 69.1%, respectively (Table 4.3). However, the mean percentage of children who consumed food with the MDD, MMF and the MAD from the previous day’s 24 hour dietary recall was low: 21.3, 37.1 and 11.2% respectively. Less than half of children (41.1%) had consumed an iron-rich or iron fortified food in the prior 24-hours. Baby formula, fortified baby food, liver and other organ meat, meat and fish accounted for 1.8%; 9.5%; 11.3%; 24.6%; 1.4% respectively (groups not mutually exclusive)In terms of WASH indicators, 80.5% households had an improved household source of drinking water; however, only 29.6% households had improved sanitary conditions. Factors associated with hemoglobin levels in children Controlling for maternal, child and household characteristics, uncontained disposal of the youngest child’s stools and having no soap at the household handwashing station remained associated with 0.22 and 0.37 g/dL lower hemoglobin concentrations, respectively (β=-0.22, p=0.04 and β=-0.37, p=0.003 respectively) after controlling for maternal, child and household characteristics (Table 4.4). However neither the key IYCF “consumption of iron rich/iron fortified food” nor any of the other IYCF indicators was associated with hemoglobin levels. Other factors associated with hemoglobin levels in multivariate analysis were sex, birth weight, maternal hemoglobin, maternal tertiary education and residing in Matabeleland North province. DiscussionUsing nationally representative data, we examined the association between IYCF and WASH indicators and hemoglobin levels among the 6-24 month old children. None of the WHO IYCF indicators were associated with hemoglobin levels in multivariate analysis. However, two WASH indicators (uncontained disposal of the child’s stool, and absence of soap at the household handwashing station) were associated with lower hemoglobin levels in multivariate analysis. Two important barriers to fecal-oral transmission in children are thought to be safe disposal of children's stools and hand washing with soap/detergent after fecal contact PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdW1waHJleTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
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ADDIN EN.CITE.DATA (Humphrey, 2009). Hand washing with soap before feeding children and after disposal of child’s stools can interrupt the transmission of fecal-oral microbes ADDIN EN.CITE <EndNote><Cite><Author>Brown</Author><Year>2013</Year><RecNum>5338</RecNum><DisplayText>(Brown<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>5338</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brown, J.</author><author>Cairncross, S.</author><author>Ensink, J. H.</author></authors></contributors><auth-address>Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.</auth-address><titles><title>Water, sanitation, hygiene and enteric infections in children</title><secondary-title>Archives of disease in childhood</secondary-title><alt-title>Arch Dis Child</alt-title></titles><periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></periodical><alt-periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></alt-periodical><pages>629-34</pages><volume>98</volume><number>8</number><edition>2013/06/14</edition><keywords><keyword>Child</keyword><keyword>*Child Welfare</keyword><keyword>Dysentery/*epidemiology/etiology</keyword><keyword>Gastroenteritis/*epidemiology/etiology</keyword><keyword>Humans</keyword><keyword>*Hygiene</keyword><keyword>Risk Factors</keyword><keyword>*Sanitation</keyword><keyword>*Water</keyword><keyword>*Water Supply</keyword></keywords><dates><year>2013</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1468-2044 (Electronic)
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ADDIN EN.CITE.DATA (Kaltenthaler et al, 1991). One other study among Ethiopian children also reported an association between unclean hands and anemia ADDIN EN.CITE <EndNote><Cite><Author>Mahmud</Author><Year>2013</Year><RecNum>5320</RecNum><DisplayText>(Mahmud<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>5320</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5320</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mahmud, M. A.</author><author>Spigt, M.</author><author>Mulugeta Bezabih, A.</author><author>Lopez Pavon, I.</author><author>Dinant, G. J.</author><author>Blanco Velasco, R.</author></authors></contributors><auth-address>Department of Medical Microbiology and Immunology, College of Health Sciences, Mekelle University, Ethiopia. muheab2008@</auth-address><titles><title>Risk factors for intestinal parasitosis, anaemia, and malnutrition among school children in Ethiopia</title><secondary-title>Pathogens and global health</secondary-title><alt-title>Pathog Glob Health</alt-title></titles><periodical><full-title>Pathogens and global health</full-title><abbr-1>Pathog Glob Health</abbr-1></periodical><alt-periodical><full-title>Pathogens and global health</full-title><abbr-1>Pathog Glob Health</abbr-1></alt-periodical><pages>58-65</pages><volume>107</volume><number>2</number><edition>2013/05/21</edition><dates><year>2013</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>2047-7732 (Electronic)</isbn><accession-num>23683331</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Mahmud et al, 2013).Open defecation by infants and young children is acceptable in many resource-constrained cultures PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZZWFnZXI8L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Yeager et al, 1999; Brown et al, 2013). For example, less than a quarter of children under five-years in Lima, Peru used a toilet ADDIN EN.CITE <EndNote><Cite><Author>Yeager</Author><Year>1999</Year><RecNum>5358</RecNum><DisplayText>(Yeager<style face="italic"> et al</style>, 1999)</DisplayText><record><rec-number>5358</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5358</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yeager, B. A.</author><author>Huttly, S. R.</author><author>Bartolini, R.</author><author>Rojas, M.</author><author>Lanata, C. F.</author></authors></contributors><auth-address>Instituto de Investigacion Nutricional, Lima, Peru. byeager@iin.sld.pe</auth-address><titles><title>Defecation practices of young children in a Peruvian shanty town</title><secondary-title>Social science & medicine</secondary-title><alt-title>Soc Sci Med</alt-title></titles><periodical><full-title>Social science & medicine</full-title><abbr-1>Soc Sci Med</abbr-1></periodical><alt-periodical><full-title>Social science & medicine</full-title><abbr-1>Soc Sci Med</abbr-1></alt-periodical><pages>531-41</pages><volume>49</volume><number>4</number><edition>1999/07/22</edition><keywords><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Defecation</keyword><keyword>Diarrhea/epidemiology</keyword><keyword>Feces</keyword><keyword>Female</keyword><keyword>Health Behavior</keyword><keyword>*Health Promotion</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Interviews as Topic</keyword><keyword>Male</keyword><keyword>Peru/epidemiology</keyword><keyword>Poverty</keyword><keyword>Sanitation/*methods</keyword></keywords><dates><year>1999</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0277-9536 (Print)
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ADDIN EN.CITE.DATA (Ziegelbauer et al, 2012). However safe disposal of children’s stools has received relatively little attention in sanitation programs ADDIN EN.CITE <EndNote><Cite><Author>Brown</Author><Year>2013</Year><RecNum>5338</RecNum><DisplayText>(Brown<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>5338</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">5338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brown, J.</author><author>Cairncross, S.</author><author>Ensink, J. H.</author></authors></contributors><auth-address>Environmental Health Group, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.</auth-address><titles><title>Water, sanitation, hygiene and enteric infections in children</title><secondary-title>Archives of disease in childhood</secondary-title><alt-title>Arch Dis Child</alt-title></titles><periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></periodical><alt-periodical><full-title>Archives of disease in childhood</full-title><abbr-1>Arch Dis Child</abbr-1></alt-periodical><pages>629-34</pages><volume>98</volume><number>8</number><edition>2013/06/14</edition><keywords><keyword>Child</keyword><keyword>*Child Welfare</keyword><keyword>Dysentery/*epidemiology/etiology</keyword><keyword>Gastroenteritis/*epidemiology/etiology</keyword><keyword>Humans</keyword><keyword>*Hygiene</keyword><keyword>Risk Factors</keyword><keyword>*Sanitation</keyword><keyword>*Water</keyword><keyword>*Water Supply</keyword></keywords><dates><year>2013</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1468-2044 (Electronic)
0003-9888 (Linking)</isbn><accession-num>23761692</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Brown et al, 2013). A study by Traore et al highlights the importance of disposal of child’s stool in diarrheal or dysentery infection PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UcmFvcmU8L0F1dGhvcj48WWVhcj4xOTk0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Traore et al, 1994). Our finding of an association between uncontained disposal of the youngest child’s stool and lower hemoglobin levels provides further evidence for the importance of promoting safe disposal of children’s stools. The creation of population-based measures of IYCF practices allows for research on the scale and distribution of inadequate feeding practices and subsequent consequences for child health and survival by capturing the various dimensions of child feeding that occur during the transition from breastfeeding to family diet between 6 and 24 months. All key infant and young child feeding practices were suboptimal except for two breastfeeding practices (early initiation of breastfeeding, and continued breastfeeding at 1 year), introduction of solid/semi-solid foods at 6-8month and prevalence of bottle-feeding. For example while 21.3 and 37.1% of children 6-23months consumed a diet meeting the MDD and the MMF respectively, very few (11.2%) achieved both of these indicators and consumed the MAD. The indicator “consumption of iron-rich/iron- fortified food for children 6-23 months” is meant to reflect iron nutriture; hence it was central to our hypothesis. We hypothesized that receipt of iron fortified food or iron supplementation is more likely to be associated with hemoglobin levels in developing countries. A Community Infant and Young Child Feeding (CIYCF) program is run through the Ministry of Health and Child Welfare (MoHCW). However it focuses on counseling mothers on food based approaches through village health workers and health promoters. Hence consumption of home fortified or LNS is practically non-existent in Zimbabwe. Although baby formula and fortified baby food were included in the key IYCF indicator, only 1.8 and 9.5% of children 6-24 months consumed baby formula or fortified baby food respectively. Consumption of meat accounted for the largest proportion of infants who consumed an iron rich food/ iron fortified food (24.6%). However the iron content is not concentrated enough to meet the RDA for iron in the small volumes consumed by infants. Removing consumption of meat from the IYCF iron indicator in sensitivity analysis resulted in a stronger association with hemoglobin levels that was borderline significant (p=0.069). Hence the wide range of iron content of food included in the IYCF iron indicator may explain the lack of association between the IYCF iron indictor and hemoglobin levels. This study also identified several other risk factors for anemia, which have been previously reported in the literature, confirming internal validity of the data. Boys had lower hemoglobin levels compared to girls, suggesting a greater vulnerability to anemia in males. This physiologic finding has been established in several studiesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbW9uZDwvQXV0aG9yPjxZZWFyPjE5OTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Colomer et al, 1990; De Pee et al, 2002) including our own; in a previous study we reported that maternal hemoglobin concentration predicted anemia in the first year of life PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWxsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Miller et al, 2003). Maternal tertiary education is likely to be a distal factor associated with higher hemoglobin levels, as a proxy for higher income and better child caring practices. Residing in Matebeleland North province was associated with lower hemoglobin levels, likely through geographical and economic disadvantages, being an arid and drought-prone part of the country with historical economic inequalities.Our study has both strengths and limitations. We used nationally representative data and adjusted for several potential confounders at child, maternal and household levels. However, the cross sectional nature of the data collected in the ZDHS limits inferences to associations rather than causality. Although our results are likely applicable to other developing countries, particularly in sub-Saharan Africa, the ability to generalize our results from a single country study is limited. A multicounty study of anemia using DHS data would test whether our findings are generalizable to other settings. A single 24-hour dietary recall used in the creation of IYCF indicators might not be good proxy for dietary patterns in infancy and young childhood PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bcmltb25kPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Arimond& Ruel, 2004). ConclusionIn this cross-sectional study of Zimbabwean children aged 6-24 months two WASH indictors: disposal of child’s stools and presence of soap at handwashing station were associated with hemoglobin levels. However, none of the WHO IYCF indicators, including consumption of iron-rich/iron- fortified food, were associated with hemoglobin levels. Our findings are consistent with the hypothesis that poor WASH conditions may contribute to anemia through infections with Schistosomiasis and STHs, EE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QcmVuZGVyZ2FzdDwvQXV0aG9yPjxZZWFyPjIwMTI8L1ll
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ADDIN EN.CITE.DATA (Midzi et al, 2010; Prendergast& Kelly, 2012) and other clinical infections and inflammation. Further research, including randomized trials of WASH interventions, is needed to further explore the effect of WASH interventions of risk of anemia in infants and young children. Table 4.1. Definitions of WHO-recommended Infant and Young Child Feeding (IYCF) indicatorsIndicatorsDefinitionCore IndicatorsEarly initiation of breast feedingProportion of children born in the last 24 months who were put to the breast within one hour of birthContinued breast-feeding at 1 yearProportion of children 12–15 months of age who are fed breast milkIntroduction of solid, semi-solid or soft foodsProportion of infants 6–8 months of age who receive solid, semi-solid or soft foodsMinimum dietary diversity Proportion of children 6–23 months of age who receive foods from 4 or more food groupsMinimum meal frequencyProportion of breastfed and non-breastfed children 6–23 months of age, who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum number of times or moreMinimum acceptable dietProportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breast milk)Consumption of iron-rich/iron- fortified food for children 6-23 monthsProportion of children 6–23 months of age who receive an iron-rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home.Optional IndicatorsChildren ever breastfedProportion of children born in the last 24 months who were ever breastfed.Continued breast-feeding at 2 yearProportion of children 20–23 months of age who are fed breast milkAge-appropriate breastfeedingProportion of children 6–23 months of age who received breast milk as well as solid or semi-solid foods during the previous day. Bottle feedingProportion of children 0–23 months of age who are fed with a bottle.Table 4.2. Sample Characteristics Child covariatesN% SexMale 68149.6Female69550.4Age in months mean (SD)140.1Birth weight≥ 2500gR129694.5< 2500g805.5Height-for-age-Z score> - 2.0R96770.8≤ -2.0)40929.2Recent diarrheaNo106575.9Yes31124.1Recent feverNo119687.1Yes18012.9Vitamin A supplementationEver received100374.2Never received37025.8Maternal CovariatesMaternal age250.2Mother took iron supplements during pregnancyDid not take iron supplements61546.9Took iron supplements75053.1Number of days mother took iron supplements during pregnancy mean (SD)331.8Maternal Hemoglobin g/dL (continuous)1300.6Maternal Body Mass Index (BMI)< 18.51268.7≥ 18.5 & <2592967.5≥ 25 & <3023617.8≥ 30856.0Maternal educationNo education191.2Primary44931.4Secondary87865.0Tertiary302.3Maternal work statusCurrently working42133.1Not currently working95566.9Household CharacteristicsProvinceManicaland17815.8Mashonaland Central15511.7Mashonaland East17412.6Mashonaland West13810.6Matabeleland North1335.8Matabeleland South1486.1Midlands16614.1Masvingo1189.7Harare9210.0Bulawayo743.7ResidenceUrban31423.5Rural106276.5Wealth quintileLowest35524.4Second30823.0Middle28421.2Fourth26318.9Highest16612.5Table 4.3. Prevalence of Infant and Young Child Feeding Practices and WASH Indicators among 6-24 month old Zimbabwean children whose mothers were interviewed, ZDHS 2010-2011 Infant and Young Child Feeding PracticesN%Core IndicatorsEarly initiation of breastfeeding (6-23 months)≤ 1 hour of birth105175.1 > 1 hour after birth32524.9Continued breastfeeding at 1 year (12-15 months)Breastfeeding15888.6Not breastfeeding2511.4Introduction of solid/ semi solid foods (6-8 months) Introduced20490.2Not introduced269.8Minimum dietary diversity (6-23 months)≥ 4 food groups28021.3< 4 food groups 109678.7Minimum meal frequency (6-23 months)≥ 2 (6-8 months) ≥ 4 (9-24 months)46937.1< 2 (6-8 months) < 4 (9-24 months)84462.9Minimum acceptable diet (6-23 months)Received acceptable diet13411.2Did not receive acceptable diet117988.8Consumption of iron-rich or iron-fortified foods (6-23 months)Yes52841.1No79558.9Optional IndicatorsChild ever breastfed (6-23months)Ever breastfed135498.7Never breastfed221.3Continued breastfeeding at 2 years (20-23 months)Breastfeeding4917.9Not breastfeeding21182.2Age appropriate breastfeeding (6-23 months)Breastfeeding93569.1Not breastfeeding44131.0Drank from bottle with nipple (6-23 months)Child was not bottle fed127993.1Child was bottle fed966.8WASH IndicatorsHousehold source for drinking waterImproved106780.5Not Improved 26619.5Time to source of drinking waterOn premises42833.1≤ 30minutes69253.4> 30minutes20013.5Sanitary conditionsImproved 39229.6Unimproved93369.8Disposal of child’s stoolContained 108980.1Uncontained28419.7Soap/detergent and water at hand washing stationSoap/detergent at hand washing station29821.6No Soap/detergent at hand washing station45330.9No hand washing station1057.9Table 4.4: Univariate and multivariate models of potential risk factors for low hemoglobin among children 6-24 months (ZDHS 2010-2011)Explanatory variableUnivariate1, 2 MultivariateNβ (95% Conf. Interval)P- valueβ (95% Conf. Interval)P-valueChild covariatesSex1376MaleRFemale0.30 (0.15, 0.46)<0.0010.35 (0.19, 0.50)<0.001Age in months (continuous)13760.01 (-0.002, 0.03)0.090.01 (-0.01, 0.02)0.32Birth weight1376≥ 2500gR< 2500g-0.53 (-0.95, -0.11)0.01-0.68 (-1.12, -0.24)0.003Height-for-age-Z score1376> - 2.0R≤ -2.0)-0.12 (-0.31, 0.07)0.22Recent diarrhea1376NoRYes-0.06 (-0.24, 0.11)0.49Recent fever1376NoRYes0.17 (-0.07, 0.40)0.17Vitamin A supplementation1373Ever receivedRNever received-0.23 (-0.44, -0.02)0.03-0.07 (-0.28, 0.14)0.49Maternal CovariatesMother took iron supplements during pregnancy1365Did not take iron supplementsRTook iron supplements-0.06 (-0.22, 0.10)0.47Number of days mother took iron supplements during pregnancy, mean (SD)697-0.001 (-0.004, 0.001)0.36Maternal Hemoglobin (g/dL), mean (SD)13620.01 (0.005, 0.02)<0.0010.01 (0.003, 0.01)<0.01Maternal Body Mass Index (BMI)1376≥ 18.5 & < 25R< 18.5-0.07 (-0.37, 0.23)0.640.01 (-0.28, 0.30)0.95≥ 25 & <300.17 (-0.03, 0.37)0.100.13 (-0.06, 0.32)0.17≥ 300.35 (0.01, 0.69)0.040.22 (-0.12, 0.56)0.21Maternal education1376No educationRPrimary0.11 (-0.5.1, 0.74)0.720.20 (-0.41, 0.80)0.52Secondary0.30 (-0.33, 0.93)0.350.31(-0.30, 0.92)0.32Tertiary1.23 (0.35, 2.1.2)0.011.09 (0.15, 2.0)0.02Maternal work status1376Currently workingRNot currently working-0.09 (-0.26, 0.09)0.32Maternal age at child’s birth in years (continuous)13760.01 (-0.001, 0.03)0.08Household covariatesProvince1376ManicalandRMashonaland Central0.06 (-3.39, 4.50)0.780.05 (-0.33, 0.43)0.79Mashonaland East0.01 (-0.38, 0.39)0.97-0.02 (-0.40, 0.36)0.91Mashonaland West0.25 (-0.16, 0.66)0.230.29(-0.09, 0.68)0.13Matabeleland North-0.59 (-0.99, -0.19)<0.01-0.44 (-0.83, -0.04)0.03Matabeleland South-0.29 (-0.76, 0.18)0.22-0.07(-0.51, 0.38)0.76Midlands-0.01 (-0.38, 0.36)0.98-0.03 (-0.38, 0.32)0.87Masvingo0.26 (-0.18, 0.70)0.250.25 (-0.15, 0.64)0.22Harare0.11 (-0.30, 0.53)0.600.003 (-0.39, 0.40)0.99Bulawayo-0.20 (-0.64, 0.25)0.38-0.32 (-0.77, 0.13)0.17Residence1376UrbanRRural0.01 (-0.18, 0.21)0.89Wealth quintile1376LowestRSecond0.16 (-0.06, 0.38)0.15Middle0.29 (0.06, 0.52)0.02Fourth0.12 (-0.11, 0.35)0.32Highest0.45 (0.18, 0.71)< 0.01Infant and young child feeding practicesEarly initiation of breastfeeding1376≤ 1 hour of birthR> 1 hour after birth0.01 (-0.19, 0.21)0.94Continued breastfeeding at 1 year183BreastfeedingRNot breastfeeding-0.13 (-0.94, 0.68)0.75Introduction of solid, semi-solid or soft foods (6-8 months)230IntroducedRNot introduced0.38 (-0.38, 1.15)0.33Minimum dietary diversity (MDD)1376≥ 4 food groupR< 4 food groups-0.19 (-0.36, -0.01)0.04-0.11 (-0.30, 0.08)0.26Minimum meal frequency (MMF)1313Received MMFRDid not receive MMF-0.11 (-0.29, 0.08)0.26Minimum acceptable diet1313Received acceptable dietRDid not receive acceptable diet-0.30 (-0.53, -0.08)0.008Consumption of iron-rich or iron-fortified foods1323YesRNo-0.12 (-0.29, 0.04)0.14Child ever breastfed1376Ever breastfedRNever breastfed-0.90 (-1.74, -0.06)0.04-0.46 (-1.42, 0.50)0.35Continued breastfeeding at 2 years260BreastfeedingRNot breastfeeding-0.01 (-0.57, 0.55)0.98Age-appropriate breastfeeding1376BreastfeedingRNot breastfeeding0.03 (-0.14, 0.21)0.72Drank from bottle with nipple1376Child was not bottle fedRChild was bottle fed0.21 (-0.09, 0.50)0.16WASH IndicatorsHousehold source of drinking water1333ImprovedRUnimproved0.02 (-0.19, 0.22)0.86Time to source of household drinking water1320On premisesR≤ 30minutesR-0.06 (-0.25, 0.13)0.53> 30minutes0.01 (-0.29, 0.31)0.94Sanitary conditions1333ImprovedRNot Improved-0.08 (-0.26, 0.09)0.34Disposal of child’s stool1376ContainedRNot contained-0.29 (-0.490, -0.08)0.01-0.22 (-0.42, -0.01)0.04Soap/detergent observed at hand washing station1376Soap/detergent observed at hand washing stationRNo soap/detergent observed at hand washing station-0.39 (-0.63, -0.15)0.001-0.37 (-0.61, -0.12)0.003No hand washing station-0.22 (-0.51, 0.07)0.139-0.08 (-0.37, 0.21)0.572Hand washing station not observed for other reasons-0.23 (-0.46, -0.001)0.049-0.22(-0.49, 0.05)0.109 1.Wealth status was dropped from the multivariate model because it was correlated with disposal of child’s stool. 2.1317 children were included in the multivariate model.Chapter 5CONCLUSIONS AND RECOMMENDATIONS5.1ConclusionsChapter 2We show for the first time in healthy, non-anemic infants that hepcidin concentrations decrease over infancy, with most of the drop in hepcidin occurring between 3 and 6 months. This is presumably a physiologic response to mobilize iron stores and absorb more dietary iron, thus preventing iron deficiency anemia.Infant values therefore appear lower than those reported in adults (mean (SD) hepcidin concentration: 15.43 (2.11)) ADDIN EN.CITE <EndNote><Cite><Author>Konopásek</Author><Year>2011</Year><RecNum>320</RecNum><DisplayText>(Konopásek<style face="italic"> et al</style>, 2011)</DisplayText><record><rec-number>320</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">320</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pavel Konopásek</author><author>Petr Prˇikryl</author><author>Jana Vávrová</author><author>Vladimír Tesarˇ</author><author>Emanuel Necˇas</author><author>Martin Vokurka</author></authors></contributors><titles><title>Hepcidin levels in patients with ANCA-AAV</title><secondary-title>Clinical and Experimental Immunology</secondary-title></titles><periodical><full-title>Clinical and experimental immunology</full-title><abbr-1>Clin Exp Immunol</abbr-1></periodical><pages>88</pages><volume>164 (Supp. 1)</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(Konopásek et al, 2011), supporting the higher metabolic need for iron in infancy compared to adulthood. Hepcidin concentrations were higher in girls than boys in each age group, but sex differences were not significant in univariate regression analysis and after adjustment for age, perhaps because of the small sample size. Boys have been observed to be more vulnerable to anemia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaG9yaXNkb3R0aXI8L0F1dGhvcj48WWVhcj4yMDExPC9Z
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ADDIN EN.CITE.DATA (Emond et al, 1996; Thorisdottir et al, 2011). Chapter 3This study is, to our knowledge, the first to characterize hepcidin concentrations in HIV-infected and HIV-exposed infants, and focused specifically on sub-Saharan African infants, who are at particularly high risk of anemia. We show that:Hepcidin concentrations were markedly elevated in HIV-infected infants from as early as 3 months of age, and remained high throughout infancy. Elevated hepcidin levels may simultaneously halt erythropoiesis while promoting the growth and survival of HIV and intracellular co-pathogens such as Mycobacterium tuberculosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb250YW5lcjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+
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ADDIN EN.CITE.DATA (Montaner et al, 2006; Boelaert et al, 2007; Drakesmith& Prentice, 2012).Hepcidin blocks the activity of the iron exporter ferroportin, leading to iron sequestration in macrophages. Consistent with this, we found that ferritin was higher in HIV-infected infants compared to other infant groups, and did not differ between anemic and non-anemic HIV-infected infants, highlighting both the iron sequestration that occurs during HIV infection and the role of ferritin as an acute phase protein. We observed elevated hepcidin and markers of inflammation (AGP and CRP) in HEU compared to HIV-unexposed infants. This suggests that exposure to maternal immune activation in utero may lead to low-grade inflammation in HEU infants and may partially contribute to the poor growth, increased morbidity and mortality consistently reported in HEU infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFwaXJvPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Thea et al, 1993; Brahmbhatt et al, 2006; Otieno et al, 2006; Makasa et al, 2007; Marinda et al, 2007; McNally et al, 2007; Shapiro et al, 2007). However if inflammation contributes to anemia in HEU infants, it does not appear to be driven by elevated hepcidin levels in this group.Anemia had no overall association with hepcidin concentrations during infancy in multivariate analyses except in HIV unexposed infants and young HEU infants (3 month-olds). Elevated hepcidin in anemic 3 mo HIV-unexposed infants may be explained by the elevated CRP levels observed in this group, although the reasons for low-grade inflammation in these apparently healthy infants is unclear. At 6 mo of age, anemia among HIV-unexposed infants appeared to be driven by a combination of inflammation and iron deficiency, but by 12mo anemia was mainly due to iron deficiency and hepcidin levels were low, as has been observed in classical iron deficiency. In the HEU group, both ferritin and hepcidin were lower in anemic compared to non-anemic infants at 3mo of age, suggesting a physiological hormonal response through hepcidin in response to lower iron stores. Hepcidin was not useful in distinguishing anemic from non-anemic 6 mo and 12 mo HEU infants, or HIV-infected infants at any age. Hepcidin, like ferritin, is an acute phase protein and thus normal or raised hepcidin levels may be observed in anemic individuals in the presence of inflammation, as was characteristic of HEU and HIV-infected infants in this cohort. Hepcidin levels were more strongly correlated with ferritin than with CRP in all groups of infants. Hepcidin and ferritin have been shown to respond similarly to changes in inflammation and storage of iron and ferritin has been shown to be most strongly associated with hepcidin in other studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxlc2xvb3Q8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA (Ganz et al, 2008; Galesloot et al, 2011).Hepcidin concentrations declined with age in all groups and girls had higher hepcidin concentrations than boys, extending our findings in healthy non-anemic infants from Chapter 2 ADDIN EN.CITE <EndNote><Cite><Author>Mupfudze</Author><Year>2013</Year><RecNum>4411</RecNum><DisplayText>(Mupfudze<style face="italic"> et al</style>, 2013)</DisplayText><record><rec-number>4411</rec-number><foreign-keys><key app="EN" db-id="d9zx2pxatst9s8er2zlvess75zd9tad9r555">4411</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mupfudze, T. G.</author><author>Stoltzfus, R. J.</author><author>Rukobo, S.</author><author>Moulton, L. H.</author><author>Humphrey, J. H.</author><author>Prendergast, A. J.</author></authors></contributors><auth-address>Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe. tmupfudz@jhsph.edu.</auth-address><titles><title>Hepcidin decreases over the first year of life in healthy African infants</title><secondary-title>British journal of haematology</secondary-title><alt-title>Br J Haematol</alt-title></titles><periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></periodical><alt-periodical><full-title>British journal of haematology</full-title><abbr-1>Br J Haematol</abbr-1></alt-periodical><edition>2013/10/12</edition><dates><year>2013</year><pub-dates><date>Sep 20</date></pub-dates></dates><isbn>1365-2141 (Electronic)
0007-1048 (Linking)</isbn><accession-num>24112078</accession-num><work-type>Letter</work-type><urls><related-urls><url>;(Mupfudze et al, 2013). Chapter 4Using nationally representative data, Two WASH indicators (uncontained disposal of the child’s stool, and absence of soap at the household handwashing station) were associated with lower hemoglobin levels in multivariate analysis, consistent with the high prevalence of Schistosomiasis, STH and the EE pathway hypothesis. However neither the key IYCF indicator “consumption of iron rich/iron fortified foods” or any of the other IYCF indicators were associated and hemoglobin levels in multivariate analysis consistent with the hypothesis that the iron-rich IYCF indicator primarily counts intake of natural foods and so does not reflect iron consumption at levels that are relevant to infants iron needs.?5.2 Recommendations for future researchHepcidin appears to be a useful marker consistent with iron metabolism in infants. However our inferences are limited both by our small sample sizes at 3, 6 and 12 months and the cross sectional nature of our study. There is need for larger studies to establish ‘reference values’ and longitudinal studies across infancy to characterize the trajectory of normative hepcidin values in parison between studies is limited by the lack of congruence in hepcidin measurements from different hepcidin assays, highlighting the need for further studies harmonizing different assays. Although we also reported hepcidin consensus values, their use in the literature is still limited.Future studies should further explore the role of hepcidin in the pathogenesis of HIV infection, in particular whether sequestration of iron in macrophages may contribute to HIV disease progression, particularly in perinatally infected infants. Future studies should further explore the utility of hepcidin measurements in assessing the best time to supplement infants and young children in areas with high rates of infection.Further research, including randomized trials of WASH interventions measuring intestinal permeability, hepcidin levels and anemia is needed to further explore the hypotheses generated by this study.APPENDIXEthical review11 December 2012MRCZ SecretariatMedical Research Council of ZimbabweJosiah Tongogara /Mazowe StreetP.O. Box CY 573CausewayHARAREDear Sir/Madam,RE: REQUEST TO CONDUCT A SUB-STUDY UNDER THE ZVITAMBO “VITAMIN A” TRIAL- MRCZ/A/583We request further permission to:Estimate the reference intervals for plasma hepcidin in (65) non-anemic healthy children at three ages (3, 6 and 12months) and describe the trajectory of plasma hepcidin in the first year of life. The study population will be drawn from children enrolled in the ZVITAMBO Vitamin A trial who had a gestational age >37 weeks, birth weight >2500g and never had abnormal iron indicators (i.e. hemoglobin < 105 g/L at 3 and 6 months and < 100g/L at 12months, serum ferritin < 12?g/l, sTfR > 8.3mg/L), inflammation (i.e. AGP > 1g/L) or an acute illness (diarrhoea, fever, in the prior week or measles in the prior 3 months) at assessment visits at 3, 6 and12 months of age. Evaluate the differences in mean plasma hepcidin associated with HIV exposure, HIV infection and anemia by measuring plasma hepcidin levels in cryopreserved samples from the ZVITAMBO trial collected from five groups of infants (65 infants per group): HIV-unexposed anemic; HIV-exposed uninfected and anemic; HIV-exposed uninfected and non-anemic; HIV-infected and anemic and HIV-infected and non-anemic infants at 3 ages (3, 6, 12months).REASON FOR SUB-STUDYThe ZVITAMBO archive provides us with a well-characterized population of Zimbabwean infants in which to explore the trajectory of plasma hepcidin in the first year of life. Hepcidin plays an important role in iron metabolism, however reference values for plasma hepcidin have not yet been characterized in infants and young children. It is not clear how hepcidin changes over time in infancy in association with the underlying dynamic iron physiology associated with infancy. The second aim allows us to evaluate the role of hepcidin in HIV and anemia. This study will be the first study to evaluate plasma hepcidin concentrations in HIV exposed and infected infants and will add to the body of literature on hepcidin and iron metabolism in infancy. Thank you very much for your on-going support of our work.Yours faithfully________________________________________________Tatenda Geraldine MupfudzePhD Candidate- Johns Hopkins School of Public HealthZvitambo ProjectDecember 13, 2012Elizabeth A SkinnerChairIRB Office Johns Hopkins University Bloomberg School of Public Health615 N. Wolfe Street, E 1100Baltimore, MD 21205RE: Amendment to IRB No. H.22.02.06.27.ARI - Vitamin A Supplementation of Breastfeeding Mothers and Their Neonates at Delivery: Impact on Mother-to-Child HIV Transmission during lactation, HIV Infection Among Women During the Post-partum Year and Infant MortalityDear Ms. Skinner:I am writing to request permission to amend Protocol IRB No. H.22.02.06.27.ARI.Iwould like to carry out the following additional work under the Vitamin A Trial archive:1. Estimate the reference intervals for plasma hepcidin in (65) non-anemic healthy children at three ages (3, 6 and 12 months) and describe the trajectory of plasma hepcidin in the first year of life. The study population will be drawn from children enrolled in the Zvitambo Vitamin A trial who had a gestational age >37 weeks, birth weight >2500g and never had abnormal iron indicators (i.e. hemoglobin < 105 g/L at 3 and 6 months and < 100g/L at 12 months, plasma ferritin < 12?g/l, sTfR > 8.3mg/L), inflammation (i.e. AGP > 1g/L) or an acute illness (diarrhoea, fever, in the prior week or measles in the prior 3 months) at assessment visits at 3, 6 and12 months of age. 2. Evaluate the differences in mean plasma hepcidin associated with HIV exposure, HIV infection and anemia by measuring plasma hepcidin levels in cryopreserved samples from the Zvitambo trial collected from five groups of infants (65 infants per group): HIV-unexposed anemic; HIV-exposed uninfected and anemic; HIV-exposed uninfected and non-anemic; HIV-infected and anemic and HIV-infected and non-anemic infants at 3 ages (3, 6, 12 months).The Zvitambo archive provides us with a well-characterized population of Zimbabwean infants in which to explore the trajectory of plasma hepcidin in the first year of life. Hepcidin plays an important role in iron metabolism, however reference values for plasma hepcidin have not yet been characterized in infants and young children. It is not clear how hepcidin changes over time in infancy in association with the underlying dynamic iron physiology associated with infancy. The second aim allows us to evaluate the role of hepcidin in HIV and anemia. This study will be the first study to evaluate plasma hepcidin concentrations in HIV exposed and infected infants and will add to the body of literature on hepcidin and iron metabolism in infancy.Finally, we also request permission to add Tatenda G. Mupfudze to the research plan as student investigator.Enclosed please find the amendment application and the revised protocol including an outline of the additional areas of study proposed. Thank you very much for your continuing support of our work.Sincerely,Jean Humphrey, Sc.D.Director, Zvitambo1 Borrowdale RoadBorrowdale, HarareZimbabwe3429000ZVITAMBO HIV CARE AND PREVENTION FOR MOTHERS AND CHILDREN IN ZIMBABWE00ZVITAMBO HIV CARE AND PREVENTION FOR MOTHERS AND CHILDREN IN ZIMBABWE14 February 2013MRCZ SecretariatMedical Research Council of ZimbabweJosiah Tongogara/Mazowe StreetP O Box CY 573CausewayHARAREDear Sir/MadamRE: AUTHORISATION TO USE VITAMIN A SAMPLES FOR A SUB-STUDY - PLASMA HEPCIDIN CONCENTRATIONS IN ZIMBABWEAN INFANTSZvitambo Project hereby gives Tatenda Mupfudze, a PhD Candidate at Johns Hopkins School of Public Health permission to use samples from the Vitamin A study stored in the Zvitambo archive for her doctoral research. 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Effect of sanitation on soil-transmitted helminth infection: systematic review and meta-analysis. PLoS medicine 9(1): e1001162.Ziske, J., Kunz, A., Sewangi, J., Lau, I., Dugange, F., Hauser, A., Kirschner, W., Harms, G. & Theuring, S. (2013). Hematological changes in women and infants exposed to an AZT-containing regimen for prevention of mother-to-child-transmission of HIV in Tanzania. PloS one 8(2): e55633.Zongrone, A., Winskell, K. & Menon, P. (2012). Infant and young child feeding practices and child undernutrition in Bangladesh: insights from nationally representative data. Public health nutrition 15(9): 1697-1704.CURRICULUM VITAE TATENDA G. MUPFUDZE615 N Wolfe St Room W2041 Program in Human NutritionBaltimore, MD 21205 Department of International HealthTel: (410) 258 5047 The Johns Hopkins UniversityE-mail: tmupfudz@jhsph.edu Bloomberg School of Public HealthEDUCATION2009-2014 PhD Student, Program in Human Nutrition, Department of International Health. The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 2008 BS, Human Nutrition, University of St. Catherine, MN. PROFESSIONAL EXPERIENCE2009-2011 Graduate Research Assistant, Center for Immunization Research, Johns Hopkins- Baltimore, MD.Responsibilities: Screened and recruited healthy volunteers for early phase 1 clinical trials. Data entry, data management and report generation. 2008-2009 Sr. Community Health Worker, Women Infants and Children (WIC), Minneapolis, MN.Responsibilities: Conducted dietary assessments, and took anthropometric and hematological measurements. Provided nutrition education and counseling to pre- and post-natal women, infants and children below 5years.2009 Community Health Worker, Portico Healthnet, Minneapolis, MN. Responsibilities: Connected uninsured patients with appropriate health insurance coverage. 2006-2008Research Assistant - College of St. Catherine, St. Paul, MN. Responsibilities: Conducted literature reviews. Edited articles for Dr Julie Jones’ nutrition columns in Cereal World Foods and Lipid Technology magazinesHONORS/AWARDS2010 Johns Hopkins, Harry D. Kruse Fellowship in Nutrition2007 The College of St. Catherine, Senate Leadership Scholarship2007The College of St. Catherine, PLEN Leadership ScholarshipMEMBERSHIP 2010 American Society for NutritionPresentations2008“Efficacy of Vitamin A supplementation in reducing infant mortality in Zimbabwe,” Meeting of the Twin Cities District Diet Association, St. Paul MN. Speaker. 2008“Efficacy of Vitamin A supplementation in reducing infant mortality in Zimbabwe,” 91st Annual Meeting of the Minnesota Dietetics Association. Rochester MN. Poster Presentation.ADDITIONAL INFORMATIONPersonal Statement of ResearchMy research interests center on maternal and infant health and the interaction between nutrition, and infectious diseases. My current work is aimed at understanding the risk factors and the mechanisms underlying anemia in infants and young children particularly the role of hepcidin in anemia in areas with a high burden of infection. Specific areas of interest include:Maternal and infant healthAnemia IronHepcidinHIV/AIDSKeywordsMaternal and infant healthAnemiaHepcidinHIV/AIDS ................
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