Impact of iron fortification on the geospatial patterns of malaria and non-malaria infection risk among young children: a secondary spatial analysis of clinical trial data from Ghana

Abstract

Objectives: Patterns of infection among children with varying levels of iron status in a malaria endemic area may vary spatially in ways requiring integrated infection and iron deficiency control programmes. The objective of this secondary analysis was to determine the geospatial factors associated with malaria and non-malaria infection status among young Ghanaian children at the end of a 5-month iron intervention trial.

Design: Cluster-randomised controlled trial.

Setting: Rural Ghana PARTICIPANTS: 1943 children (6-35 months of age) with geocoded compounds.

Interventions: Point-of-use fortification with micronutrient powders containing vitamins and minerals with or without iron.

Primary and secondary outcome measures: Generalised linear geostatistical models with a Matern spatial correlation function were used to analyse four infection response variables, defined using different combinations of inflammation (C-reactive protein, CRP >5 mg/L) and malaria parasitaemia. Analyses were also stratified by treatment group to assess the independent effects of the iron intervention.

Results: The by-group and combined-group analyses both showed that baseline infection status was the most consistent predictor of endline infection risk, particularly when infection was defined using parasitaemia. In the No-iron group, age above 24 months and weight-for-length z-score at baseline were associated with high CRP at endline. Higher asset score was associated with a 12% decreased odds of endline infection, defined as CRP >5 mg/L and/or parasitaemia (OR 0.88, 95% credible interval 0.78 to 0.98), regardless of group. Maps of the predicted risk and spatial random effects showed a defined low-risk area around the District centre, regardless of how infection was defined.

Conclusion: In a clinical trial setting of iron fortification, where all children receive treated bed nets and access to malaria treatment, there may be geographical variation in the risk of infection with distinct high-risk and low-risk areas, particularly around municipal centres.

Trial registration number: clinicaltrials.gov, NCT01001871.

Keywords: Community child health; Geographical mapping; Nutrition.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1

Predicted probabilities (left) and residual spatial variation (right) from the final combined-group models for the odds of inflammation (CRP>5 mg/L) and/or any malaria parasitaemia (A); the odds of inflammation (CRP > 5 mg/L) without malaria parasitaemia (B); the risk of malaria parasitaemia with concurrent fever (axillary temperature >37.5°C—or history of reported fever within 48 hours) (C) and the odds of malaria parasitaemia with or without fever (D). Darker colour indicates higher risk at endline. Background © Stamen Design.

Figure 2

Elevation (metres) across the study area. Green colour indicates higher elevation.