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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
  1. Ashley M Aimone1,
  2. Patrick Brown1,2,
  3. Seth Owusu-Agyei3,
  4. Stanley H Zlotkin1,4,
  5. Donald C Cole1
  1. 1 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
  2. 2 Departments of Analytics and Informatics, Cancer Care Ontario, Toronto, Canada
  3. 3 Kintampo Health Research Centre, Kintampo, Ghana
  4. 4 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
  1. Correspondence to Dr Ashley M Aimone; ashley.aimone{at}


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, NCT01001871.

  • Nutrition
  • Community child health
  • Geographical mapping

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  • Contributors AMA, SHZ and SO-A conducted the original trial in Ghana. AMA and SO-A coordinated the acquisition of geographical data. AMA conceived and conducted the secondary analysis with substantial contribution from PB. DCC and SHZ were also involved in the conception and design of the secondary analysis, and interpretation of data. AMA drafted the manuscript. All authors read and approved the final manuscript.

  • Funding Funding for this manuscript was provided by AMA’s Doctoral Research Award from the Canadian Institutes of Health Research (CIHR).

  • Competing interests None declared.

  • Ethics approval Kintampo Health Research Center (KHRC) Institutional Ethics Committee, the Ghana Health Service (GHS) Ethical Review Committee, the Hospital for Sick Children Research Ethics Board and the Food and Drugs Authority of Ghana; University of Toronto Health Sciences Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Any unpublished data are available upon request by emailing the corresponding author.

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