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The Proportion of Iron Deficiency Anemia Associated with Active H.Pylori Infection in Low and Middle Income Countries

Introduction to Iron Deficiency Anemia

Despite of global economical and technological development, the anaemia affects many countries of the total world’s population and almost half of this burden resulted in IDA (iron deficiency anaemia). The anaemia deficiency is most common among children under the age of 5 and women, especially pregnant woman. More than one billion people globally are anaemic and the World Health Organisation estimates that 47% of children (0-5 years), 42% expectant female, 30% non- pregnant female and approximately 12.7% of male more than 15 years of age are suffering from iron deficiency anaemia (Chandra, ,2019). This report has mainly concerned with the low economic and middle economic groups of countries those are strongly linked with maternal anaemia and child anaemia.

Iron deficiency leads to low red blood cell levels also called anaemia which delays the growth of unborn babies. Anaemia has several causes that involve complex relations between restrictive or poor diet, improper nutrition, increased iron necessity during pregnancy and other factors including infectious diseases which give a complex challenge to tackle efficiently with the population affected with iron deficiency aneamia (Rahman and Ireen, 2019). H. pylori infection is closely associated with anaemia and usually occurs during early childhood at presently infected more than half population of the world.

As per The World Bank, the world economy classifies the countries into various categories but the main categories are divided in 3 groups: high -income nations, middle – income nations and low-income nations and The World Bank analyzed and ranked these countries on the basis of their GNI or Gross National Income. The low- income nations mean those countries that have gross per capita national income is lower than $1026. On the other hand, middle –income nation refers to those nations that have Gross per capita national income is more than $1026 but less than $12475. The high risk countries where H. pylori related infections occur frequently are mostly related with low and middle income generated countries (Iqbal and Ekmekcioglu, 2019). The risk factors of H. pylori are associated with lower living conditions like over populated nations, countries without clean water supply and under privileged countries. Therefore, in this report the detail discussion will be done on Iron deficiency related to H. pylori in low and middle economic countries with proper findings and conclusion.

Detail Discussion on Iron Deficiency and H. Pylori in Low – Middle Income Countries

In the present economic scenario, the low and middle economic countries face several common obstacles in the current healthcare system. Both communicable and non-communicable diseases has been proved pandemic in these countries because quality of health is at great risk in low income generated nations especially countries like Nigeria, central African republic, Liberia and other regions of Sub-Africa and South –East Asian countries (Armitage and Moretti, 2019). The major health threats for the low income countries are mal nutrition, unsafe water, low hygiene and sanitation and low level of iron intake in diet which leads to severe iron deficiency among young children. This report shows that iron deficiency is a complex factor which challenges many research policies and high-level strategies that are implemented to minimize the burden of anaemia from a large scale of population around the world. In addition to the adverse health affect of iron deficiency anaemia, WHO spends billions of US dollars annually which results to huge loss of human capital on this health risk.

Brief Description on IDA, ID and Anaemia

Anaemia refers to a condition of human body where low red blood cell counts are reported in a regular blood test. Hemoglobin is the protein part of the RBCs and its main function is to carry oxygen throughout the body. If a person suffering from anaemia, a very low level of hemoglobin is diagnosis by a physical practitioner. Anaemia is most common in young children, pregnant woman, older adults, and new-born babies from their birth (Rahman and Ireen, 2019) . Young women are more vulnerable to this disease because of iron deficiency during pregnancy and blood loss from menstruation periods. The symptoms, types and causes of anaemia:

Symptoms of anaemia includes-

  • Problems related to growth in young children
  • Pain in many parts of the body-joints, bones, chest
  • Difficulty inbreathing
  • Headache, dizziness, weakness
  • Cold feet and hands

Types and causes of anaemia-

Mostly 400 types of anaemia detected in the blood test that are divided into groups. They are

  • Production of faulty or low red blood cell counts
  • Severe blood loss
  • Destruction of healthy RBCs (Red Blood cell)

Iron deficiency or ID refers as lower iron content in the body due to any digestive diseases or in very exceptional cases it is cancer. Many times iron deficiency is not easy to diagnosis because a low level of ferritin shows no abnormal condition. So, sometimes it is difficult to differentiate that ID is caused due to chronic anaemia disease or without anaemia (Chandra, 2019) . In such cases proper pathological diagnosis is very important to detect the actual reason of iron deficiency.

Diagnosis of Iron deficiency-

Initial evaluation by taking clinical history, serological tests and urine analysis Physical practitioner may suggest some detail diagnosis such as gastroscopy and colonoscopy are main diagnostic tools to identify the root cause of iron deficiency. In case if both the tests are normal then common treatment of oral iron supplement will be given and if the anaemia comes severe then chances of other disease persist thus further clinical evaluation is needed (Hasan, 2019) .

Iron deficiency anaemia (IDA) refers a situation where the body does not produce adequate substance (hemoglobin) in the RBC (red blood cells) that helps to carry oxygen (Muckenthaler, 2019). The iron deficiency anaemia implies not sufficient of iron in the blood that causes anaemia. In the absence of adequate iron in the blood, human body does not able to produce enough red blood cells that carry oxygen and that resulted to various health problems like tiredness, growth problem, breathlessness and other same problems of anaemic patients.

Symptoms of iron deficiency anemia include:

  • Weakness, tiredness and extreme fatigue
  • Dizziness, headache or lightheadedness
  • Very poor appetite especially in young children and infants
  • Coldness in hands and feet
  • Inflammation or tender tongue

Causes of iron deficiency anemia include

  • Inability to absorb iron
  • Improper nutrition or lack of iron intake per day
  • Severe blood loss
  • Pregnancy

Impact of Iron Deficiency in Young Children in low-Middle Income Countries (LMIC)

Iron deficiency anaemia has become a serious health issue for many countries globally especially for low and middle income countries where problem of mal nutrition is much higher than developed countries. As per estimates provide by WHO, half of patients are anaemic due to iron deficiency in under developed countries (Iqbal and Ekmekcioglu, 2019). It is also proved that the impact of iron deficiency is much more during infancy period and early childhood period as compared to other age of the lifecycle which clearly shows the risk of iron deficiency is started right from pregnancy period because if expectant woman having iron deficiency than the unborn child is directly related to that risk.

The largest number of anaemic persons in South-East Asia including children both in number and proportion shows 66% that is maximum percentage of anemia in children along with 60% of women affected by iron deficiency. Anaemia has been typical problem in Asian countries where middle income nations are higher and so the data shows that 70% children of age under five years are anaemic. In South-East Asia where low income nations are very high young children of age group under two years are suffering from anaemia exceeds 90% (Camaschella, 2019).

The above data clearly shows that the children are more vulnerable to iron deficiency and the major effects of iron deficiency shows in first 6 months of infancy which causes severe brain development problems and more chances of infection throughout the childhood. The major impact persists on young children is that there appetite is overall reduced for many years and this ferocious cycle stops the ultimate growth and brain development in young children (Hasan, 2019).

Primary outcomes -Active status of H. pylori infection

During the previous years, tremendous advancement in scientific technology helps to diagnosis the exact reasons associated with H. pylori infection. Several diseases are closely associated with H. pylori infection including severe iron deficiency. The patients who do not have any other digestive disorders mostly observed iron deficiency anaemia as examiner concluded that low ferritin level shows anaemia which is caused due to internal bleeding or any the reasons of blood loss. The main objective of this section is to study the connection between H. pylori infection and severe iron deficiency levels in young age group of children. The LMIC nations where children frequently get infectious diseases it is noticed that they also may have iron deficiency because of lack of proper nutrition, iron supplements and shortage of fortified healthy cereal based foods which helps in preventing infections like H. pylori , anaemia and other vitamin or mineral deficiency (Muckenthaler, 2019) .

Secondary outcomes- H. pylori infection associated with iron deficiency or no evidence

It is fact that no prominent mechanism is invented to establish the real reason of H. pylori infection in human body and how it mostly affected the young children. Hepcidin helps to regulates metabolism in the body and also synthesis the chances of raise in infection and decline in iron deficiency level (Armitage and Moretti, 2019). In recent research it is observed in school going children that hepcidin level is lower who have iron deficiency but without H .pylori infection and in other side children having normal iron level but are positive with H. pylori infection. Therefore it is not proved that young age children infected with H. pylori infection positively have iron deficiency anaemia.

Effects of H. pylori infection in young children

  1. pylori infection is also known as Campylobacter pylori commonly refer as stomach ulcer is also a main reason of infection in young children. The children effected with H pylori infection may also visible some gastrointestinal diseases (Rahman and Ireen, 2019). This infection if obtained in early childhood and not properly treated with antibiotic treatment, it persists for lifelong. Some paediatric studies show that there is close association of H. Pylori infection with IDA which indicates iron deficiency causes this type of infection in young children. The severe effects of H. Pylori infection in young children are:
  • Severe stomach pain associated with diarrhoea
  • Sudden dizziness
  • Breathlessness
  • Fast heartbeat, flapping of chest
  • Severe liver disorder
  • Upper stomach pain, loss of appetite, Jaundice or other digestive tract infection

Recommendations and Findings of IDA Associated with H. Pylori Infection

Infants and young children are at high risk because infants born with low weight or born prematurely may not get sufficient iron from mother’s milk and risk of iron deficiency. The complication regarding this is growth problem and delayed brain development. It also increases the risk of infections in young children. Pregnant woman is more at risk for iron deficiency during pregnancy. The complication for that involves underweight babies, premature delivery and severe iron deficiency that affect both mother and child. In this report it is find that association of iron deficiency and H. pylori is depends on hepcidin level. Anaemia, Iron deficiency and H. pylori infection are the most common diseases in the young children (Iqbal and Ekmekcioglu, 2019). Some recommendations to prevent iron deficiency in infants and young children are:

  • Mother should take proper nutrition during pregnancy period including iron supplements
  • Breastfeeding is the best source of iron in infants and strongly recommended
  • Young children should take proper diet rich in iron
  • Proper screening of under privileged children and providing appropriate treatment to those children who found anaemic
  • Reducing socio economic distances and provides proper aids to the low and middle income countries
  • Proper examine of food consumed by young children of LMIC and provide proper iron supplement to all age group of children

Analysis of Iron Deficiency Anemia

Anemia occurs when the level of hemoglobin in red blood cells (RBCs) decreases. Generally, Hemoglobin is considered as an RBC protein and it is the main factor behind the supply of oxygen to various tissues of one’s body. However, one of the most common sorts of anemia is Iron deficiency anemia and lack of sufficient mineral iron is the main reason of this anemia. Iron is needed by the human body for making hemoglobin. If one does not have adequate iron in the bloodstream, oxygen will not be received by the rest part of the body. Although the condition may be normal, iron deficiency anemia is unknown. One may experience symptoms year after year without knowing the cause. Among women of childbearing age, the most common cause of iron deficiency anemia is acute urinary or iron deficiency in the blood during pregnancy. Some intestinal diseases that affect a poor diet and how the body absorbs iron can also cause iron deficiency anemia.

Physicians usually treat the condition by changing iron supplements and diets.

Symptoms of iron deficiency anemia

Indications of this sort of anemia might be minor at the initial stage and may be unknown. Rendering to the “American Society of Hematology (ASH)”, maximum number of people cannot be able to understand that they have mild anemia until they have regular blood tests (Baker & Greer 2010).

Symptoms of moderate to severe iron deficiency anemia include:

  • Body Fatigue
  • Weakness
  • Thin skin
  • Giddiness
  • Strange craving for non-food such as soil, ice and clay
  • Trembling or tingling in the legs
  • Swelling or pain in the tongue
  • Cold limbs
  • Fast or irregular heartbeat
  • Fragile nails
  • Headache

Causes of Iron Deficiency Anemia

Rendering to ASH, deficiency of iron is the most common cause of anemia. Many reasons are there due to which iron deficiency can occur in a human body. These comprise:

Insufficient consumption of iron

Consumption of slight amount of iron for a long period of time can cause a deficiency in the human body. Many food items are there which are high in iron, for instances egg, green leafy vegetables and meat. In addition, iron-rich foods might be needed by young children as well as by pregnant women in their day to day diet because iron is important for their development and rapid growth.

Loss of blood or pregnancy due to menstruation

Severe menstrual bleeding during childbirth and hemorrhage are the most common causes of iron deficiency anemia in women of childbearing age.

Internal bleeding

Internal bleeding can be caused by certain conditions and due to which iron deficiency anemia will occur subsequently. Instances comprise gastric ulcer, colon cancer or colon or intestinal polyp. Bleeding in the stomach can as well be caused by the usage of pain reliever in a daily purpose.

Unable to absorb iron

Intestines can be affected either by some surgeries or by certain disorders and it can as well interfere with the way iron is absorbed by the human boy. Amount of iron that can be absorbed by human body might be limited either by intestinal surgery or by celiac disease, for instances, gastric bypass, no matter whether one take enough iron or not in their daily diet (Camaschella, 2015).

Endometriosis

Women with endometriosis may have invisible amounts of blood loss as they are hidden in the abdomen or pelvic region.

Iron deficiency anemia (IDA) is found in 2% to 5% of older men and postmenopausal women in developing countries. This is the most common cause of blood loss from the digestive tract. Also, 5% -12% of IDA occurs in otherwise healthy premenopausal women. IDA is the most common cause of referral to a gastroenterologist (4% -13% referrals), and the cause of this condition involves extensive testing of gastrointestinal bleeding in 5% -10% of IDA patients. It remains unknown. Helicobacter pylori (H. pylori) colonization of the gastric mucosa results in loss of iron intake and may increase iron loss, possibly IDA. In addition, the speculative process by which IDA can be created through H. pylori has recently been reviewed. Furthermore, 4 meta-analyses for evaluating the impact of H. pylori eradication have been published. It is recommended by the suggestion that the absorption of iron is improved by H. pylori removal therapy as this therapy is combined with the administration f iron, and this is more operative in the treatment of IDA. The omission of pylori was more effective.

However, after the completion of oral iron therapy, as well as deterioration of IDA was not restructured after the removal therapy of the H. pylori. Therefore Whether H. pylori infection was the cause of IDA has not yet been established. Maximum amount of intervention studies, which have executed in the terrestrial regions, where H. Pylori infections along with IDA are prevalent and can be IDA’s aetiology could be multifactorial (malnutrition, vitamin deficiency, chronic parasitic infections, malaria). In addition, a number of uncontrolled interventions studies are there in the western countries, showing recovery from anemia after the reduction therapy of H. pylori. With egad to the afore mentioned fact, H. Pylori infection has been identified as a risk factor for IDA. It is recommended by “The British Society of Gastroenterology” that the reduction therapy of H. pylori infections for the patients of IDA along with esophagogastroduodenoscopy and General Colonoscopy can be effective (Pacifico, et al., 2010).

Nevertheless, information relating to the eradication of H. pylori with regards to the adult patients whose iron-deficiency or iron-dependent IDA was previously unknown is unusual and this is why the occurrence of H. pylori infection which is the main reason behind iron deficiency anemia in that context is not known. Iron deficiency anemia (IDA) is a global nutritional problem. Moreover, this is responsible for about half of the world's anemia and most IDA patients who are living in developing countries.

Unexplained or Non-compliance IDA accounts for about 15% in all cases. This is not only assessing challenge but also diagnostic challenge, assigning a number of tests for completing gastrointestinal endoscopy for parasitic insects from stool examination. The word “unexplained IDA” is appropriately applied at the time of failing of the endoscopic gastrointestinal workup for establishing the reason of IDA. Alone with that, the word “refractory IDA” can be applied or a number of patients when they cannot respond to the supplementation of iron, for 4-6 weeks or more sat the dose of at least 100 mg of primary iron (Johnson-Wimbley & Graham 2011).

Childhood anemia is a condition in which the child's body tissues have sufficient amounts of hemoglobin (HB) to supply adequate oxygen. For children aged 6 to 59 months (usually marked as under 5 years of age) the immunity threshold is 11.0 g / dl of HB level (g / dL) and then severe anemia, hereditary or acquired disease persists. The most common cause of anemia in children is low intake of iron-rich foods (such as meat and meat products). These conditions often lead to iron deficiency anemia, which affects about half of all cases of anemia worldwide, with children under 5 being the most affected. Anemia in children under 5 years of age lasts a lifetime, but it is a special case in this population to emphasize the importance of informing multiple patients and mortality. These resistances not only have their highly preventable and curable properties, but also predict potential long-term personal and social consequences.

In addition, Nutritional anemia is the most common global problem in developing countries. It is especially seen in women who give birth to babies, small children and give birth to them during pregnancy and lactation. It is estimated that it affects about two-thirds of pregnant women and half of pregnant women in developing countries. Women will lose enough iron, especially during genital ejaculation. A few more causes of anemia are the spread of malaria and hookworm. Also, mothers who give birth at short intervals due to rapid pregnancy and increased demand for anemia during each delivery become anaemic (Zhu, Kaneshiro & Kaunitz, 2010).

Conclusion on Iron Deficiency Anemia

Helicobacter pylori are estimated to infect the stomach of 50% of the world's population. The rate of transmission from one country to another is proportional to the Human Development Index. Lack of reduction therapy, H. pylori intends to persist in its human host due to the development of peptic ulcer, gastric adenocarcinoma and / or mucus-related lymphoma (MLT). Above the abdomen, further than 50 additional gastric symptoms of H. pylori have been associated with an extensive list of treatable diseases.

The association among the deficiency of iron and H. pylori was defined in the year 1991, when a fifteen year old boy was found to be affected by IDAs and hematological parameters were improved after the reduction therapy of H. pylori. However, the fundamental factors of the connection among the deficiency of iron and H. pylori are not entirely comprehended yet. In addition, competing for dietary iron I reared as the most common factors for H. pylori for causing IDA. With regard to the usual physiological circumstances, homeostasis of iron is strictly regulated. Daily loss of iron which is about 1-2 mg per day can be certainly managed by eating a diet of heme and non-heme iron. Moreover, deficiency of Iron occurs when iron intake is insufficient, iron is poorly absorbed, or iron absorption exceeds the daily small intestine iron loss. In case balance of iron is not maintained by one, eventually stores of iron will be declined as well as iron deficiency anemia will be developed (Short & Domagalski, 2013).

Not only in men but also in premenopausal women IDA s generally attributed to pregnancy and menstrual related iron losses. Nevertheless, it must be considered that chronic gastrointestinal blood loss should as well be well-thought-out in the context of the different diagnosis of anemia among women. It is suggested by the current guidelines that if there is no significant history of non-GI bleeding and confirmed iron deficiency anemia in upper and lower gastrointestinal tract should be assessed in patients. Advanced endoscopy and colonoscopy should be performed to detect potential lesions that may cause chronic gastrointestinal bleeding carcinomas, large adenomas, malignant mucosa, ulcers, vascular lesions, and other magical bleeding. Patients in this group are more likely to have chronic bleeding in the upper gastrointestinal tract than in the colon.

Even though Helicobacter pylori infection is quite common among patients, iron deficiency anemia does not increase in all infected patients. Other bacterial viral factors or host factors may be responsible for increasing iron deficiency anemia. Children and premenopausal women are at risk of iron deficiency due to low iron stores. This is why children along with premenopausal women might as well be susceptible to iron losses H. pylori infection (Habib, et al., 2013).

It is not yet clear whether pylori infection leads to iron deficiency anemia, but several possibilities have been suggested. For example, Helicobacter pylori may contribute to the development of atrophic somatic gastritis. Patients with gastritis with atrophic body may suffer from hypochlorhydria or anhydrochloride and may have poor absorption of iron. Helicobacter pylori competes with the host for iron absorption, leading to iron deficiency anemia.

References for Iron Deficiency Anemia

Baker, R. D., & Greer, F. R. (2010). Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics, 126(5), 1040-1050.

Camaschella, C. (2015). Iron-deficiency anemia. New England journal of medicine, 372(19), 1832-1843.

Habib, H. S. A., Murad, H. A. S., Amir, E. M., & Halawa, T. F. (2013). Effect of sequential versus standard Helicobacter pylori eradication therapy on the associated iron deficiency anemia in children. Indian journal of pharmacology, 45(5), 470.

Johnson-Wimbley, T. D., & Graham, D. Y. (2011). Diagnosis and management of iron deficiency anemia in the 21st century. Therapeutic advances in Gastroenterology, 4(3), 177-184.

Pacifico, L., Anania, C., Osborn, J. F., Ferraro, F., & Chiesa, C. (2010). Consequences of Helicobacter pylori infection in children. World journal of gastroenterology: WJG, 16(41), 5181.

Short, M. W., & Domagalski, J. E. (2013). Iron deficiency anemia: evaluation and management. American family physician, 87(2), 98-104.

Zhu, A., Kaneshiro, M., & Kaunitz, J. D. (2010). Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective. Digestive diseases and sciences, 55(3), 548-559.

Jubran, A.S., Al-Zamely, O.M. and Al-Ammar, M.H., 2019. Estimation of iron oxide nanoparticles on white albino mice induced with iron deficiency anemia. Drug Invention Today, 11(11).

Elstrott, B., Khan, L., Olson, S., Raghunathan, V., DeLoughery, T. and Shatzel, J.J., 2020. The role of iron repletion in adult iron deficiency anemia and other diseases. European journal of haematology, 104(3), pp.153-161.

Muckenthaler, M.U., 2019. Iron deficiency anemia. HemaSphere, 3(S2), p.99.

Hasan, A.A., 2019. Determination Knowledge of Second Stage Student in Nursing College about Blood Iron Deficiency (Anemia). Medico-Legal Update, 19(2), pp.355-361.

Camaschella, C., 2019. Iron deficiency. Blood, 133(1), pp.30-39.

Chandra, J., 2019. Treating Iron Deficiency Anemia. The Indian Journal of Pediatrics, 86(12), pp.1085-1086.

Crowe, S.E., 2019. Helicobacter pylori infection. New England Journal of Medicine, 380(12), pp.1158-1165.

Fang, H.R., Zhang, G.Q., Cheng, J.Y. and Li, Z.Y., 2019. Efficacy of Lactobacillus-supplemented triple therapy for Helicobacter pylori infection in children: a meta-analysis of randomized controlled trials. European journal of pediatrics, 178(1), pp.7-16.

Ibrahim, A., Ali, Y.B., Abdel-Aziz, A. and El-Badry, A.A., 2019. Helicobacter pylori and enteric parasites co-infection among diarrheic and non-diarrheic Egyptian children: seasonality, estimated risks, and predictive factors. Journal of Parasitic Diseases, 43(2), pp.198-208.

Armitage, A.E. and Moretti, D., 2019. The Importance of Iron Status for Young Children in Low-and Middle-Income Countries: A Narrative Review. Pharmaceuticals, 12(2), p.59.

Rahman, S. and Ireen, S., 2019. Groundwater iron has the ground: Low prevalence of anemia and iron deficiency anemia in Bangladesh. The American journal of clinical nutrition, 110(2), pp.519-520.

Iqbal, S. and Ekmekcioglu, C., 2019. Maternal and neonatal outcomes related to iron supplementation or iron status: a summary of meta-analyses. The Journal of Maternal-Fetal & Neonatal Medicine, 32(9), pp.1528-1540.

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