Background: Despite a high prevalence of anemia among nonpregnant Cambodian women, current reports suggest that iron deficiency (ID) prevalence is low. If true, iron supplementation will not be an effective anemia reduction strategy.Objective: We measured the effect of daily oral iron with or without multiple micronutrients (MMNs) on hemoglobin concentration in nonpregnant Cambodian women screened as anemic.Design: In this 2 × 2 factorial, double-blind, randomized trial, nonpregnant women (aged 18-45 y) with hemoglobin concentrations ≤117 g/L (capillary blood) were recruited from 26 villages in Kampong Chhnang province and randomly assigned to receive 12 wk of iron (60 mg; Fe group), MMNs (14 other micronutrients; MMN group), iron plus MMNs (Fe+MMN group), or placebo capsules. A 2 × 2 factorial intention-to-treat analysis with the use of a generalized mixed-effects model was used to assess the effects of iron and MMNs and the interaction between these factors. Results: In July 2015, 809 women were recruited and 760 (94%) completed the trial. Baseline anemia prevalence was 58% (venous blood). Mean (95% CI) hemoglobin concentrations at 12 wk in the Fe, MMN, Fe+MMN, and placebo groups were 121 (120, 121), 116 (116, 117), 123 (122, 123), and 116 (116, 117) g/L, with no iron × MMN interaction (P = 0.66). Mean (95% CI) increases in hemoglobin were 5.6 g/L (3.8, 7.4 g/L) (P < 0.001) among women who received iron (n = 407) and 1.2 g/L (-0.6, 3.0 g/L) (P = 0.18) among women who received MMNs (n = 407). The predicted proportions (95% CIs) of women with a hemoglobin response (≥10 g/L at 12 wk) were 19% (14%, 24%), 9% (5%, 12%), 30% (24%, 35%), and 5% (2%, 9%) in the Fe, MMN, Fe+MMN, and placebo groups, respectively.Conclusions: Daily iron supplementation for 12 wk increased hemoglobin in nonpregnant Cambodian women; however, MMNs did not confer additional significant benefit. Overall, ∼24% of women who received iron responded after 12 wk; even fewer would be likely to respond in the wider population. This trial was registered at clinicaltrials.gov as NCT02481375.

Determining the magnitude of the thalassemia problem in a country is important for implementing a national prevention and control program. In order to acquire accurate thalassemia prevalence data, the gene frequency of alpha- and beta-thalassemia (alpha- and beta-thal) in different regions of a country should be determined. The molecular basis of thalassemia in Cambodia was performed by polymerase chain reaction (PCR)-based techniques in a community-based cross-sectional survey of 1631 unrelated individuals from three regions, Battambang, Preah Vihear and Phnom Penh. Thalassemia mutations were detected in 62.7% of the three studied population of Cambodia. Hb E (HBB: c.79G>A) was the most common beta-globin gene mutation with a frequency ranging from 0.139 to 0.331, while the most frequent alpha-globin gene mutation was the -alpha(3.7) (rightward) deletion (0.098-0.255). The other frequencies were 0.001-0.003 for beta-thal, 0.008-0.011 for alpha-thal-1 (- -(SEA)), 0.003-0.008 for alpha-thal-2 [-alpha(4.2) (leftward deletion)], 0.021-0.044 for Hb Constant Spring (Hb CS, HBA2: c.427T>C) and 0.009-0.036 for Hb Pakse (HBA2: c.429A>T). A regional specific thalassemia gene frequency was observed. Preah Vihear had the highest prevalence of Hb E (55.9%), alpha-thal-2 (24.0%) and nondeletional alpha-thal (15.1%), whereas Phnom Penh had the lowest frequency of thalassemia genes. Interestingly, in Preah Vihear, the frequency of Hb Pakse was extremely high (0.036), almost equivalent to that of Hb CS (0.044). Our results indicate the importance of micromapping and epidemiology studies of thalassemia, which will assist in establishing the national prevention and control program in Cambodia.

BACKGROUND:Ferritin and soluble transferrin receptor (sTfR) concentrations are commonly used to assess iron deficiency (ID); however, they are influenced by multiple factors. OBJECTIVES:We assessed associations between numerous variables and both ferritin and sTfR concentrations in Cambodian women and compared ID prevalence through the use of study-generated correction factors (CFs) for ferritin with those from a published meta-analysis. METHODS:Venous blood from 450 women (aged 18-45 y) was assessed for hemoglobin (Hb), ferritin, sTfR, retinol binding protein, folate, vitamin B-12, C-reactive protein, α-1 acid glycoprotein (AGP), and genetic Hb disorders. Linear regression was used to calculate geometric mean ratios (95% CIs) for ferritin and sTfR concentrations. RESULTS:The variant Hb EE genotype was associated with 50% (14%, 96%) and 51% (37%, 66%) higher geometric mean ferritin and sTfR concentrations, respectively, than was the normal Hb AA genotype; a 1-g/L increase in AGP was associated with 99% (50%, 162%) and 48% (33%, 64%) higher concentrations in the same variables, respectively. ID prevalence in nonpregnant women (n = 420) was 2% (n = 9) with the use of ferritin <15 μg/L and 18% (n = 79) with the use of sTfR >8.3 mg/L as criteria. ID prevalence with the use of sTfR was higher in women with the Hb EE genotype (n = 17; 55%) than in those with the Hb AA genotype (n = 20; 10%); and in women with the Hb AA genotype and chronic inflammation (n = 10; 18%) than in that group of women without chronic inflammation (n = 10; 7%) (P < 0.05). No differences in ID prevalence were found with the use of ferritin between women with Hb EE and AA genotypes (P = 1.0) or by chronic inflammation status (P = 0.32). There were no differences in mean ferritin concentrations among all 450 women when study-generated CFs were compared with those from the meta-analysis (P = 0.87). CONCLUSIONS:Compared with sTfR, ferritin concentrations appear to reflect more accurately true ID in rural Cambodian women. The CFs from a published meta-analysis were appropriate for use in this population with a high prevalence of Hb disorders and inflammation.

Objectives: To evaluate the impact of genetic Hb disorders on the effectiveness of 6 months of daily micronutrient Sprinkles for infants age 6-12 months on anemia.Methods: As part of a randomized controlled effectiveness trial, subjects were screened for genetic Hb disorders at aged 18 months on whole blood using the SEBIA MINICAP analyser, HEMOGLOBIN (E) program, and IC α THAL test to detect major Hb variants and α-thalassemia.Anemia (Hb < 110 g/L) was measured at baseline (age 6 mo), endline (age 12 mo), and at two Conference

Objectives: To evaluate the impact of IYCF education and practices on growth compared to an ecological control. Methods: As part of a randomized controlled effectiveness trial of micronutrient Sprinkles and IYCF education, all mothers received IYCF education. Group and individual sessions were delivered by health staff and trained village health workers. Anthropometry and IYCF were recorded at baseline (age 6 mo), endline (age 12 mo), and at two follow up points (age 18 mo and 24 mo) and compared with same aged children in the same province from the 2005 Cambodia Demographic and Health Survey (CDHS). Conference Abstract Jack et al.; EJNFS, 5(5): 719-720, 2015; Article no.EJNFS.2015.251 720 Results: There was no treatment effect on growth so intervention and control groups were combined. At 6, 12 and 18 mo, 59%, 86% and 73% of children met minimum adequate WHO IYCF practices respectively in the study group compared to 33%, 62% and 47% for CDHS children. Stunting (HAZ <-2) prevalence at 6, 12, 18 and 24 mo was 11%, 19%, 32% and 38% in the study group compared to 11%, 37%, 62%, and 44% for CDHS children. Underweight (WAZ <-2) prevalence at 6, 12, 18 and 24 mo was 14%, 16%, 21% and 26% in the study group compared to 18%, 28%, 37% and 21% for CDHS children. Differences for stunting and underweight were significant (p<0.05) at 12 and 18 mo. Conclusions: IYCF education to study mothers improved IYCF practices and slowed stunting and underweight significantly at 12 and 18 months of age compared to CDHS children. Strengthened IYCF education and practices improved growth in children in this low-income, rural population. © 2015 Jack et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To evaluate the effectiveness of Sprinkles alongside infant and young child feeding (IYCF) education compared with IYCF education alone on anemia, deficiencies in iron, vitamin A, and zinc, and growth in Cambodian infants.Design: Cluster-randomized effectiveness study.Setting: Cambodian rural health district.Participants: Among 3112 infants aged 6 months, a random subsample (n = 1350) was surveyed at baseline and 6-month intervals to age 24 months.Intervention: Daily micronutrient Sprinkles alongside IYCF education vs IYCF education alone for 6 months from ages 6 to 11 months.Main Outcome Measures: Prevalence of anemia; iron, vitamin A, and zinc deficiencies; and growth via biomarkers and anthropometry.Results: Anemia prevalence (hemoglobin level <11.0 g/dL [to convert to grams per liter, multiply by 10.0]) was reduced in the intervention arm compared with the control arm by 20.6% at 12 months (95% CI, 9.4-30.2; P=.001), and the prevalence of moderate anemia (hemoglobin level <10.0 g/dL) was reduced by 27.1% (95% CI, 21.0-31.8; P = .001). At 12 and 18 months, iron deficiency prevalence was reduced by 23.5% (95% CI, 15.629.1; P < .001) and 11.6% (95% CI, 2.6-17.9; P =. 02), respectively. The mean serum zinc concentration was increased at 12 months (2.88 mu g/dL [ to convert to micromoles per liter, multiply by 0.153]; 95% CI, 0.265.42; P =. 03). There was no statistically significant difference in the prevalence of zinc and vitamin A deficiencies or in growth at any time.Conclusions: Sprinkles reduced anemia and iron deficiency and increased the mean serum zinc concentration in Cambodian infants. Anemia and zinc effects did not persist beyond the intervention period.

OBJECTIVE To evaluate the effectiveness of Sprinkles alongside infant and young child feeding (IYCF) education compared with IYCF education alone on anemia, deficiencies in iron, vitamin A, and zinc, and growth in Cambodian infants. DESIGN Cluster-randomized effectiveness study. SETTING Cambodian rural health district. PARTICIPANTS Among 3112 infants aged 6 months, a random subsample (n = 1350) was surveyed at baseline and 6-month intervals to age 24 months. INTERVENTION Daily micronutrient Sprinkles alongside IYCF education vs IYCF education alone for 6 months from ages 6 to 11 months. MAIN OUTCOME MEASURES Prevalence of anemia; iron, vitamin A, and zinc deficiencies; and growth via biomarkers and anthropometry. RESULTS Anemia prevalence (hemoglobin level <11.0 g/dL [to convert to grams per liter, multiply by 10.0]) was reduced in the intervention arm compared with the control arm by 20.6% at 12 months (95% CI, 9.4-30.2; P = .001), and the prevalence of moderate anemia (hemoglobin level <10.0 g/dL) was reduced by 27.1% (95% CI, 21.0-31.8; P < .001). At 12 and 18 months, iron deficiency prevalence was reduced by 23.5% (95% CI, 15.6-29.1; P < .001) and 11.6% (95% CI, 2.6-17.9; P = .02), respectively. The mean serum zinc concentration was increased at 12 months (2.88 μg/dL [to convert to micromoles per liter, multiply by 0.153]; 95% CI, 0.26-5.42; P = .03). There was no statistically significant difference in the prevalence of zinc and vitamin A deficiencies or in growth at any time. CONCLUSIONS Sprinkles reduced anemia and iron deficiency and increased the mean serum zinc concentration in Cambodian infants. Anemia and zinc effects did not persist beyond the intervention period. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000069358.

In Cambodia, many factors may complicate the detection of iron deficiency. In a cross-sectional survey, we assessed the role of genetic hemoglobin (Hb) disorders, iron deficiency, vitamin A deficiency, infections, and other factors on Hb in young Cambodian children. Data on sociodemographic status, morbidity, and growth were collected from children (n = 3124) aged 6 to 59 mo selected from 3 rural provinces and Phnom Penh municipality. Blood samples were collected (n = 2695) for complete blood count, Hb type (by DNA analysis), ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), C-reactive protein, and α(1)-acid glycoprotein (AGP). Genetic Hb disorders, anemia, and vitamin A deficiency were more common in rural than in urban provinces (P < 0.001): 60.0 vs. 40.0%, 58.2 vs. 32.7%, and 7.4 vs. 3.1%, respectively. Major determinants of Hb were age group, Hb type, ferritin, sTfR, RBP, AGP >1.0 g/L (P < 0.001), and rural setting (P < 0.05). Age group, Hb type, RBP, elevated AGP, and rural setting also influenced ferritin and sTfR (P < 0.02). Multiple factors affected anemia status, including the following: age groups 6-11.99 mo (OR: 6.1; 95% CI: 4.3, 8.7) and 12-23.99 mo (OR: 2.7; 95% CI: 2.1, 3.6); Hb type, notably Hb EE (OR: 18.5; 95% CI: 8.5, 40.4); low ferritin (OR: 3.2; 95% CI: 2.2, 4.7); elevated AGP (OR: 1.4; 95% CI: 1.2,1.7); rural setting (OR: 2.3; 95% CI: 1.7, 3.1); low RBP (OR: 3.6; 95% CI: 2.2, 5.9); and elevated sTfR (OR: 2.1; 95% CI: 1.7, 2.7). In Cambodia, where a high prevalence of genetic Hb disorders exists, ferritin and sTfR are of limited use for assessing the prevalence of iron deficiency. New low-cost methods for detecting genetic Hb disorders are urgently required.

Blood counts, hemoglobin (Hb) high performance liquid chromatography ( HPLC), and DNA analyses were performed on 260 children, aged 5 months to 16 years, at Siem Reap to assess the prevalence of thalassemia and other hemoglobinopathies in regional Cambodia. Hemoglobinopathies were present in 134 children (51.5%) with 20 abnormal genotypes identified. alpha-Thalassemia (thal) (35.4%) was the most prevalent disorder and the -alpha(3.7) gene deletion was the most common alpha-globin gene abnormality. The - -(SEA) deletion and nondeletional forms of alpha-thal, Hb Constant Spring [ Hb CS, alpha 142, Term -> Gln, TAA -> CAA (alpha 2)], Hb Pakse [alpha 142, Term -> Tyr, TAA -> TAT (alpha 2)] and triplicated a genes, were also present but at low frequencies. Hb E [beta 26(B8) Glu -> Lys, GAG -> AAG] (28.8%) was the most common beta-globin gene abnormality, whilst beta-thal was only detected in two children (0.8% of cases). Although hemoglobinopathies were common, the majority of abnormalities detected ( heterozygous -alpha(3.7) and Hb E) were not clinically significant. On the basis of these findings, and with the majority of abnormalities being mild, it seems improbable that thalassemia represents a major health burden in this region of Cambodia.

Alpha-thalassaemia and HbE have been reported to occur at high frequency (80%) in children with hypochromic microcytic anaemia from Siem Reap. In addition, HbPS has been reported from this region. The study aims to document the prevalence of anaemia, a- and b- thalassaemia and other haemoglobinopathies in children presenting sequentially to the Angkor Hospital for Children. Two hundred and sixty children between 5 months and 16 years of age were assessed with full blood counts, films, ferritin levels, HPLC, a-globin multiplex PCR and b-globin PCR. 110 anaemic subjects were identified with 61 cases of microcytic anaemia. Six subjects were iron deficient. 163 children (63%) had a haemoglobinopathy. The high prevalence of HbE (29%) in the study population is consistent with previous reports. By comparison b-thalassaemia (0.7%) occurs at lower frequency than previously reported. Alpha-thalassaemia occurs at high frequency (35.4% of subjects), but a large majority of subjects (78%) have a single gene deletion, with double deletions occurring at low frequency (5%). HbPS occurs at low frequency whilst the frequency of triplicated a genes in the survey population is consistent with that described in other populations. Although haemoglobinopathies are common in Cambodian children, the majority of abnormalities (heterozygous HbE and a3.7) are clinically insignificant. Only 2 cases with clinically severe haemoglobinopathy (HbH disease and Eb thalassaemia) were identified.

BACKGROUND AND OBJECTIVES:This study aimed to describe hematologic and molecular characterization of the interaction of hemoglobin (Hb) E and several forms of alpha-thalassemia causing complex thalassemia syndromes in two Cambodian families as well as to establish a rapid polymerase chain reaction (PCR) assay for simultaneous detection of Hb Constant Spring (CS) and Hb Pakse' (PS). DESIGN AND METHODS:Using PCR and DNA sequencing, the alpha- and beta-globin genotypes were examined. Clinical and hematologic data were assessed. A multiplex asymmetric allele-specific PCR for differential diagnosis of HbCS and HbPS was developed and validated. RESULTS:Eight genotypes including heterozygous HbCS, heterozygous HbPS, double heterozygous HbE/HbPS, double heterozygous HbE/alpha-thalassemia 2, triple heterozygous HbE/alpha-thalassemia /HbPS, homozygous HbE/alpha-thalassemia 2, compound alpha-thalassemia 2/HbCS and a hitherto undescribed compound HbCS/HbPS were found in these two families. Genotype-phenotype relationships are discussed and successful application of a multiplex PCR system for differential diagnosis of HbCS and HbPS is described. INTERPRETATION AND CONCLUSIONS:The interaction of several globin gene abnormalities in Cambodian families emphasizes the high frequencies of thalassemia and hemoglobinopathies. Identification of HbPS suggests that this mutation might be common and underestimated among South-east Asian populations. A simplified PCR assay for simultaneous detection of HbCS and HbPS would facilitate characterization of these genotypes in both the clinical setting and population screening programs in the region.