Effect of Hookworm Elimination and Vitamin A Intervention on Iron Status of Preschool Children in Sichuan, China
Condition: Anemia; Worm Infections
MeSH terms: Helminthiasis
Study type: Interventional
Phase: Phase 4

Summary: 
      The present study is intended to supplement the preschool anemic children with vitamin A
      capsule and de-hookworm administration in poverty Sichuan province. We eventually expect our
      study can provide a cost-effective, safe and more beneficial public health strategy to manage
      the anemia status of preschool children in poverty area.
    

Detailed description: 
      Subjects and ethical approval This randomized, control and double-blinded cohort study was
      performed in Dayi, Pixian and Meishan country, Sichuan Province, western China, which are
      suburbs of Chengdu city with a low class of socioeconomic status, from March 2012 to
      September 2014 and approximately about 216 anemic preschool children aged 3-6 years were
      randomly recruited from nine kindergartens of the three countries for the study during
      intervention period. The eligibility criteria for participation were as follows: 1) apparent
      health; 2) Hb concentration <110 g/l but not <80 g/l; 3) C-reaction protein (CRP) <10 mg/L;
      4) parental or guardian approval of participation in all aspects of the study; and 5)
      parental/guardian agreement to avoid the additional use of vitamin and mineral supplements
      and de-hookworm administration during the trial. Children with Hb<80 g/l and /or CRP >10 mg/l
      were sent to hospital with special treatment.

      We conducted a census in each regional kindergarten to determine which households included an
      eligibility preschool children. Then field health workers conducted a family survey to
      determine which children was included. Eligible families were visited by a field worker who
      explained the protocol, answered questions, and obtained written informed consent from
      parents/guardians. The enrollment and research plan were reviewed and approved by the
      institutional ethics committee of the Chengdu Women's and Children's Central Hospital of
      Chongqing Medical University in Sichuan province, China. The present study complied with the
      code of ethics of the World Medical Association (Declaration of Helsinki).

      The primary objective for the present study was to measure the change in serum Hb before and
      after intervention. A sample size of about 60 anemic preschool children per group was
      required to detect an absolute difference of 10 g/L of Hb concentration among three
      intervention groups after supplementation with 95% power and α= 0.05 for a two-sided
      two-sample t-test. To allow for 20% rate of dropout over the duration of the study, we
      initially planed to recruit about 72 anemic children per group (totally 216). We estimated
      that the prevalence of anemia of preschool children in locality was about 16%[17], eventually
      about 1350 children were recruited into an initial Hb screening study before intervention and
      about 450 for each group.

      Intervention All eligible anemic children were randomly divided into three groups: Group 1
      was received no intervention as control group; Group 2 was received 400 mg single-dose
      albendazole administration and Group 3 was received a 200,000 IU vitamin A capsule combined
      400 mg single-dose albendazole once initially. For ethical reason, all of the children in
      control group were given a single-dose albendazole at the end of study. Immediately after
      recruitment, children in one class were assigned a study number that had been previously
      randomly assigned to the intervention or control group with fixed, equal allocation to each
      group prepared by a third party. The RAND function of Excel (Microsoft, Redmond, WA, USA) was
      used to generate computer randomly permutated codes. The physicians, nurses, field health
      workers, parents, children and laboratory personnel were blinded to the treatment assignment
      of each child throughout the study period. The data manager, statistician, and all
      investigators remained blinded to group assignments until the end of data analysis. The total
      duration of intervention and evaluation were six months. Vitamin A capsule and albendazole
      tablet were provided by Sichuan Pearl Pharmaceutical Co., Ltd.

      Compliance Compliance of albendazole tablet and vitamin A capsule were monitored using
      recording tables, in which teachers recorded whether the child consumed "all" or "none" of
      the albendazole tablet and vitamin A capsule. To avoid exchange of albendazole tablet and
      vitamin A capsule by classmates, the three groups were physically separated by being moved to
      opposite corners of the classroom. Distribution and consumption of the albendazole tablet and
      vitamin A capsule took place under close supervision; children in group 2 and group 3 were
      not allowed to leave the classroom or return to their original seats before they had finished
      eating their albendazole tablet and vitamin A capsule. The distribution of tablets was
      performed by nursery managers, but not health care workers and nursery teachers. Information
      on the acceptability of the albendazole tablet and vitamin A capsule was obtained by a short
      questionnaire after administered.

      Questionnaire interview A 30-minute questionnaire was conducted by a trained interviewer
      after recruitment. The questionnaire included questions on demographic information
      (children's age, sex), educational levels of main caregivers ( who were at least responsible
      for the half of care time of children), monthly family income, use of vitamin/mineral
      supplement before trial and food frequency recall (the frequency of deep-colored vegetables
      and milk, liver and egg).

      Anthropometric measurements Anthropometric examinations were conducted by the same trained
      anthropometric nurse at baseline and follow-up (6-mo) time points using standardized
      techniques to eliminate intra-examiner error. Duplicate measurements were performed for all
      children. The inter-examiner coefficient of variation of weight and height for each examiner
      in each group was less than 5%. Weight was recorded using a weighing scale (100Med, Beijing,
      China) to the nearest 100 g with subjects in minimal clothing and bare feet. Similarly,
      height was measured in the standard position by a height scale (Haode, Guangzhou, China) to
      the nearest 0.1 cm. By using reference data from World Health Organization (WHO; 2005), the
      Z-scores were calculated for height for age (HAZ), weight for height (WHZ), and weight for
      age (WAZ). All indices were computed using Anthro (2005) for the personal computer, as
      recommended by the WHO (http://www.who.int/childgrowth/software/en/).

      Blood sample collection and biochemical assessment At the beginning and at 3 and 6 month
      after intervention, three blood samples (about 1 mL) were collected by venipuncture of an
      antecubital vein from each subject before breakfast in hospital. A quarter of a milliliter
      was drawn into a container containing heparin to measure Hb by the hemoglobincyanide method
      (Maker, Chengdu, China). The interassay variation was lower than 5% and the intra-assay
      variation was lower than 10%. The blood samples were immediately stored at 4° C to prevent
      micro-hemolysis and were separated within 5 h. The remaining blood was centrifuged at 3000g
      for 5 min at room temperature. The centrifuged serum samples were divided into aliquots and
      immediately transported to the laboratory and stored at -20°C. The concentrations of serum
      ferritin (SF) were measured using a commercial enzyme-linked immunosorbent assay (ELISA)
      (Sunbiote, Shanghai, China). Serum soluble transferrin receptor (sTfR) was measured by
      microparticle-enhanced immunoassay (Sunbiote, Shanghai, China). CRP was measured by
      particle-enhanced immunoturbidimetry (Sunbiote, Shanghai, China). Serum retinol concentration
      was determined by using high-performance liquid chromatography. Serum retinol was measured by
      experienced examiners in the Pediatric Laboratory of Chongqing Medical University and the
      other biochemical indices in Clinical Laboratory Center of Chengdu Women & Children's Central
      Hospital.
    

Intervention name(s): ZENTEL; ZENTEL and Vitamin A Soft Capsules
Intervention type(s): Drug; Drug
Intervention description(s): Children in Group 2 (n=62) received 400 mg single-dose albendazole (helmintic treatment); Children in Group 3 (n=60) received a 200,000 IU vitamin A capsule combined with 400 mg single-dose albendazole once initially
Other intervention name(s): albendazole; albendazole and vitamin A
Intervention MeSH terms: Vitamins; Vitamin A; Albendazole; Retinol palmitate
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment